A pilot study on the operationalization of the Model of Occupational Self Efficacy: A model for the reintegration of persons with brain injuries to their worker roles

Abstract

BACKGROUND:

Traumatic brain injury causes functional limitations that can cause people to struggle to reintegrate in the workplace despite participating in work rehabilitation programmes.

OBJECTIVE:

The aim of the study was to explore, and describe the experiences of individuals with Traumatic Brain Injury regarding returning to work through the use of the model of occupational self-efficacy.

PARTICIPANTS:

In the study 10 individuals who were diagnosed with a mild to moderate brain injury participated in the study.

METHODS:

The research study was positioned within the qualitative paradigm specifically utilizing case study methodology. In order to gather data from the participants, individual interviews and participant observation techniques were used.

RESULTS:

Two themes emerged from the findings of the study theme one reflected the barriers related to the use of the model (i.e. Theme one: Effective participation in the model is affected by financial assistance). The second theme related to the enabling factors related to the use of the model (i.e. Theme two: A sense of normality).

CONCLUSION:

The findings of this study indicated that the Model of Occupational Self Efficacy (MOS) is a useful model to use in retraining the work skills of individual’s who sustained a traumatic brain injury. The participants in this study could maintain employment in the open labour market for a period of at least 12 months and it improved their ability to accept their brain injury as well as adapt to their worker roles. The MOS also provides a framework for facilitating community integration.

Keywords

Occupational therapy Model of Occupational Self Efficacy case study methodology and traumatic brain injury

1 Introduction

An increase in the numbers of individuals who sustained traumatic brain injuries due to motor vehicle accidents, trauma induced by violence and substance abuse, has resulted in more disabled individuals becoming non-productive members in society and inactive in the workplace [1, 2]. Research in the field of brain injury rehabilitation internationally and particularly in South Africa is limited, with the majority of research focusing on the medical model of intervention. In the medical model, the individual with an injury or disability is regarded as having problems that require mainly medical-biological intervention, with little or no attention given to the difficult process of reintegrating the individual with disability back into society, for example, in resuming their worker roles [3]. The medical approach may result in feelings of disempowerment on behalf of the disabled with regard to the rehabilitation process [3, 4]. The lack of success of current rehabilitation interventions could be seen as a result of an inability to generalize outcomes of rehabilitation in a clinical setting to the skills needed to return to work or re-integrate into the community. In the current study the researcher used the Model of Occupational Self Efficacy (MOOSE) [5] as a strategy and rehabilitation model in order to return the injured worker to work in the Open Labour Market (OLM).

2 Literature review

A traumatic brain injury (TBI) can be defined as damage to the brain which occurs as a result of external forces caused by incidents such as assaults, motor vehicle accidents, excluding cerebral vascular accidents and degenerative brain diseases [6]. The highest incidence of traumatic brain injury occurs in the 15–24 age group [7]. According to Vuadens [8], 70% of moderately individual with brain injury do not return to work and 20% of mildly brain injured individuals are unemployed. Furthermore a total of 10% of individuals with brain injury get dismissed from work and only 2% are employed on a short term basis, one year post trauma. The above evidence indicates that a large number of TBI individuals are unable to return to the vocational roles they established before injury, this has a direct association with their volition and self-worth. Cicerone [9] confirms that individuals with brain injury who have failed to return to work have a lowered subjective wellbeing compared to those who have successfully returned to work. According to Cicerone [9], individuals with TBI who are unemployed feel as if they are not competent to perform according to the average work standards, and therefore have a loss of self- esteem and an overall decline in volition and the ability to engage in vocational activities. Due to the latter losses they no longer see themselves as contributing members of society. These individuals with brain injury are no longer able to fill their roles as breadwinners in their families.

In addition to the functional challenges in their everyday lives that TBI patients endure, they also experience a number of barriers to obtain successful vocational outcomes after the acute stages of the injury.

Occupational therapy is a profession that offers services that improve, maintain and restore an injured or ill individual‘s ability to engage in occupations such as work related activities, leisure and self-care [10]. The Model of Occupational Self Efficacy advanced by Soeker [11] is an occupational therapy practice model designed to effectively return individuals with brain injury to work. The MOOSE consists of 4 stages (see Fig. 1) namely, Stage One: “A strong personal belief in functional abilities” During this stage the occupational therapist will facilitate a process of introspection and reflection in the client in order to develop new insights into his or her ability to cope in their work and social environment. Stage Two: “Use of Self”. During this stage the occupational therapist continues to act as a facilitator and through a process of introspection and inner strength development, the client reaches a level of autonomy which allows participation in more occupational activities such as activities of daily living, work and leisure. Stage three: “Creation of competency through occupational engagement”. During this stage the client may be referred for vocational rehabilitation and a functional capacity assessment or screening. The client will be asked to identify a difficult workplace scenario, following which the occupational therapist and the client will role play the scenario in order to identify coping strategies for the client. The client will be placed in an actual work setting to practice his or her work skills. Stage four: “Capable individual” is the final stage of the model. During this stage the client will view him or herself as a capable worker and will be able to participate in the worker role with maximum independence and the occupational therapist’ will gradually withdraw from the role facilitator.

The proposed research aims to explore the experiences of individuals with brain injury regarding the use of the model in enabling them to return to work after their participation in a vocational rehabilitation programme using the MOOSE.

2.1 Aim

To explore, and describe the experiences of individuals with TBI regarding returning to work through the use of the model of occupational self-efficacy.

2.2 Objectives

To describe the barriers that individuals with TBI experience when returning to work by the utilization of the model of occupational self-efficacy.

To describe the enablers that individuals with TBI experience regarding returning to work by the utilization of the model of occupational self-efficacy.

2.3 Research design

Within the qualitative paradigm the case study approach was utilized. Qualitative researchers study topics in their natural settings interpreting phenomena in terms of the significance people bring to them [12]. According to Green [13] a qualitative approach starts with a question that the researcher wishes to answer, as a result the researcher obtains contextually rich information from study participants. Maxwell [14] expressed case study research as a detailed investigation of research participants within their context. The aim is to obtain insight into the participants’ behavior and processes that are influenced by their context. A multiple case study design was used in the current study to explore the experiences of Individuals with brain injury regarding the use of the Model of Occupational Self Efficacy, using Yin’s, [15] components of research design which is described by the following process:

A study’s questions, these would be the questions asked during each stage of the model by using semi structured interviews for the purpose of answering the main objectives of the study.

The propositions of the study, these are gained from the theory or mental picture that the researcher has in mind before the results of the study are obtained, the process will then continue to the next step.

Uncovering the units of analysis; the unit of analysis is not just the individual as a case in itself it is also relevant information that would lead the researcher to answer the main objectives and ultimately the research question.

The logic linking the data to the propositions by means of pattern matching whereby similar patterns of information emerge in each case study that is congruent to the researcher’s initial propositions, which were originally obtained by existing theory.

The criteria for interpreting the findings. Pattern matching is the most relevant way to interpret data, as the researcher can compare emergent similar patterns of information to each other, by asking oneself a) what information matched the original propositions of the study and b) what information rivals the original theory, and c) what patterns of information emerge from each case study that can be compared to each other, this is also known as cross –case study analysis.

2.4 Population and sampling

Ten participants were purposively sampled from the statistical records from the Occupational Therapy departments of Tertiary Hospitals and Community Health Centers (see Table 1). Patton [16] states the advantage of purposive sampling lies in selecting information –rich cases. The inclusion and exclusion criteria of the study were as follows:

2.4.1 Inclusion criteria

Participants were diagnosed with either a mild to moderate brain injury according to the Glasgow Coma Scale [17], they must have been living with brain injury for at least one year after the accident. They must have been employed for remuneration before their injury and at least for 3 months thereafter. The participant must have received their full multiple disciplinary team rehabilitation, be able to communicate effectively in English and Afrikaans and be able to understand verbal questions. They were also required to live in Cape Town and be over 18 years old.

2.4.2 Exclusion criteria

Participants who had sustained severe head injuries were excluded as literature revealed that the probability of their reintegrating into the open labour market worker role would be implausible.

Members who had additional psychiatric disorders according to the DSM IV, and individuals with multiple disabilities.

3 Data collection during the stages of the model of occupational self efficacy

3.1 Stage one: A strong belief in functional ability

One semi structured interview and participant observation was used during this stage of the model. Study questions at this stage included: 1) Describe the incident, 2) Practically how has the incident changed your life/ circumstances? 3) Emotionally, do you think that your ability to do tasks is different from your ability to do tasks before the accident?

3.2 Stage two: Use of self

One semi structured face to face interview and participant observation was used during this stage of the model. Study questions at this stage included: 1) How did you find the rehabilitation experience so far? 2) What in your opinion was beneficial or not relevant about the experience, 3) How do you think you could use what you were taught practically in a work experience or at home? 4) Do you think you have improved as a worker?

3.3 Stage three: Creation of competency through occupational engagement

One semi structured face to face interview and participant observation was used during this stage of the model. Study questions at this stage included 1) How has the model of occupational self-efficacy assisted you in improving your worker role? 2) If anything what would you change about the model?

3.4 Stage four: Capable individual

One semi structured face to face interview and participant observation was used during this stage of the model. Study questions at this stage included: 1) Describe your experience of the entire rehabilitation process, 2) What aspects of the model were the most beneficial to you?

4 Data analysis

As Salimen, Harra & Lautamo [18] explained, the researcher must utilize multiple case studies and then analyze them individually with a cross case analysis being undertaken in order to understand and amplify similarities’, differences across the cases and ultimately to reveal whether or not the model of occupational self-efficacy is beneficial. Data was analysed using Yin’s [15] analytical strategy of explanation building. In view of this analysis, transcriptions of each interview were coded, categorized and placed into themes in order to conceptualize the information gathered. During the coding process, the researcher utilized observation and field notes to ensure the validity of the study. Strategies such as credibility, transferability, dependability and confirmability were used in order to ensure the trustworthiness of the data [19].

Credibility was ensured by the dense description of the lived experience of the research participants. The descriptions of the lived experience of the participants were audio-recorded as they were talking and the audiotapes were transcribed verbatim to ensure that each participant’s story was captured in their own narrative. Credibility was also ensured by means of member checking whereby a summary of the findings were reviewed by the participants in order to ensure its accuracy. Credibility was also enhanced by triangulation. Triangulation is described as a means of establishing different patterns of agreement based on more than one method of observation, information gathering or the use of more than one data source in order to establish credibility [20]. Within this study triangulation was ensured by the use of more than one method of collecting data, for example, participant observation and semi structured interviews. Each piece of data, when added to the previous data, strengthened or confirmed previous findings thus reinforcing the triangulation of the data. Transferability was ensured by the detailed description of the research methods, contexts, detailed description of the participants and the lived experience of the participants. Dependability was ensured by means of dense descriptions, peer examination and triangulation. The study was documented in such a manner that the readers could follow a decision trail. Confirmability was ensured by the process of reflexivity whereby the researcher’s own biases or assumptions were made apparent by means of a reflexive journal.

5 Data collection

Seale, [21] describes face to face interviews as an in-person interview where the interviewer has the advantage of building an interpersonal relationships IPR with the interviewee and thus maximizes the quality of data collected. Data was collected by means of face to face, semi structured interviews and participant observation methods. The duration of the interviews was between 45–60 minutes and one interview was conducted at each phase of the model. As the model had 4 phases, 4 interviews were conducted with each research participant, using Yin’s [15], 5 steps of research design.

Babbie and Mouton [22] describes participant observation as studying and observing people’s behaviors and attitudes through the researcher immersing him/herself into the subject’s world. The participant observation method was implemented whereby the individual with brain injury was observed during the rehabilitative stages of the model (stage 1-2) as well as when they were employed in the latter stages of the model (stage 3-4). Each participant received work skills training using the self-efficacy model in conjunction with work hardening and cognitive rehabilitation. The researcher conducted the study at a tertiary hospital, the participant‘s home and work environments. The duration of the vocational rehabilitation programme was between 4–6 months.

6 Findings

6.1 Barriers related to the operationalizing of the model

6.1.1 Theme One: Effective participation in the model is affected by financial assistance

The above theme describes the participants’ perceptions of the barriers that they experienced in relation to the use of the Model of Occupational Self Efficacy. Financial assistance to and from the hospital where the work skills training took place was expensive. As a result many of the participants were forced to borrow money from their neighbours in order to attend. One participant said:

“I owe people in street, because I don’t have money”

6.2 Money needed to attend work not enough

The participants also emphasised that they struggled to initially maintain employment after they completed the various stages of the model. The main barrier was that they struggled to regularly attend work as they never had enough money to transport them to the workplace. This was exacerbated by the fact that they were paid at the end of month, so they had to pay out money before they received it. A participant said:

“So, now I buy a monthly ticket. I don’t know when the money gonna come.”

6.3 Salary earned during the job is not enough to survive

The participants indicated that although they were employed they struggled to pay for their daily expenses. The fact that they had to do jobs after the injury that did not enable them to earn a good income, caused them great frustration. One participant said:

“I am looking after my mother and father, my brother is not working. I need to earn more money”

“Ja doc I will see, you see its not too much money and then but if there is enough job for me. I can try to work there ne? I‘m working 5 hours I’m started working. Me? I’m getting R 12, I’m getting R12.70”

6.4 Problems with components of function

Despite undergoing rehabilitation using the MOOSE some participants continued to experience difficulty particularly when they had to grip objects. These difficulties were due to poor muscle strength in the affected upper limbs. One participant indicated:

“I also struggle sometimes when I take my my bread to go to into crew room to go eat coz I’m scared the, the glass of the cool drink is gonna fall down.”

“I didn’t try actually but the problem with errr working is this hand.”

“No you see when you do that ice-cream oh … you must press the one container. No I don’t

actually do that because my one hand is working because I’m scared it will fall maybe the

drink”

6.5 Poor support within the household and work place affects work ability

Some of the participants indicated that they received poor support from some of their work colleagues and individuals in their home environments. This poor support tended to affect their motivation levels. A participant said:

“The people at work they are not good, they don’t like it when I get to do certain jobs. The forklift job I like doing but they don’t want me to do it.”

“My family at home does not care I have to give money to my mother and father, sister. No one in my house works.”

6.6 Part time work is not sufficient to enhance one’s worker role

Part time work was regarded as not be helpful in sustaining themselves financially. One participant said:

“Yor I don’t know how much but, but it’s a part time. They must give me more shifts to work.

Ja, doc, … . its too little money (doing the current part time work), but if there is enough (adequate hours) job for me. I can try to work there?

7 Enablers related to the use of the model

7.1 Theme Two: A sense of normality

“I don’t like to maybe to work with people like me, disabled people. I want to, maybe I would like to work with normal people”

7.2 Engagement in real work facilitates growth

The participants in this study indicated that the experience that they got from working in the open labour market helped them improve their work skills. One participant said:

“No, im feeling alright doc, that’s because, when its time to wake up, I wake up at that time. It still feels good mos to work always ne? come to work ya? Just because doc, I always just talk to the people here ne? they make me feel busy”

“I don’t like to maybe to walk with people like me, disabled people. I want to, maybe I would like to work with normal people. They did show me how to make the burgers.”

Another participant said:

“I feel more confident now that that now I can get a job now anywhere now”

7.3 Engagement in educational activity

The participants in this study indicated that the fact that they could engage in educational activity facilitated their growth and ultimately their work skills. One participant said:

“I did actually, Like like I want to study like next year. To maybe going to school again. Some … . my mother was talking like I must … ..study next year.”

“I completed the programme (SETA learnership) in Cape Town it helped me in doing office

job.”

7.4 Enhancing one‘s work motivation through support

The participant’s work motivation greatly improved by participating in work related tasks under the supervision of co-workers. One participant said:

“Like that guy is working there. No like the frying is fine for me like you you, they gonna learn me how to fry, where do you take the chips and then you go fry it all that stuff. But the other stuff is fine.”

“Yes I clean the kitchen. I did learn how to cook but now, but now that … I think they like me to work here. They did show me how to make the burgers.”

7.5 Multi-tasking facilitates success in the workplace

The participants in this study indicated that their work skills improved by means of learning a variety of different work tasks in one work setting. A participant said:

“Ok, so you know, I already working here for the delivery, for stock taking and stocking from the delivery to inside, taking stock and you deliver it inside. Yes I would take the food there. In the counter to take, if they say they say must give that customer. Took the food and then give it to her.”

7.6 Financial assistance facilitates successful completion of programmes

The participants in the study indicated that they struggled to complete their vocational training due to the fact that they did not have enough money to travel to the training centres. They could only complete the programme due to the help of the training centre. One participant said:

“When I, I left at school I tell them (training facility), I don’t have money, so … So, now I buy a monthly ticket (the money was provided by the training programme).

7.7 A sense of responsibility

During the process of completing their rehabilitation, the participants became more independent and took responsibility for their work tasks and for their own development. One participant described how he initiated his work tasks independently as well as how he planned to apply for a new job independently. He said:

“Yes some of the time maybe I come in the morning already then I go inside and then I come put it here, I clean cloth, I take the mop, I mop here polish. “I ‘ll be do, a CV and get my certificated copy, I’ll go and find a job. Ja, there is a local caf $\overset{´}{e}$ .

8 Discussion

In this study the main barriers related to having financial assistance in order to enable individuals with brain injury to initially sustain employment. (Theme One: Effective participation in the model is affected by financial assistance). In a study conducted by Friesen, Yassi and Cooper [23] they verify that the initial assistance after a rehabilitation programme is essential for successful participation in return to work programmes.

In South Africa occupational deprivation is evident in a large section of the population who live in poverty and the disabled who are denied work opportunities despite legislation that is favourable towards them in the workplace [24, 25]. It could be argued that in Africa, poverty could be viewed as a huge barrier that hinders the completion of rehabilitation programmes. As most of the jobs that the clients participate in were regarded as blue collar employment jobs (i.e. jobs requiring low level of education and being very manual in nature), individuals in this study struggled to sustain their families due to the cost of basic food and transport. They needed to earn more money in order to survive, these individuals then ended up looking for other forms of employment in addition to working for their company.

Holzberg [26] indicates that it is common for individual with brain injury to remain dependent on a disability grant or disability benefits from the government. Huang, Shaw and Chen [27] mentions that disability management strategies such as offering modified or temporary alternative work has additional benefits of facilitating workplace reintegration, reducing compensation costs and reflecting the company’s concern for the well-being of its employees. In a study conducted by Soeker, Van Rensburg and Travill [28] they indicate that individual with brain injury seek other forms of employment in order to supplement their income.

Some participants in the current study indicated that they wanted to become entrepreneurs as they felt that they would be able to increase their income by having their own income generating businesses such as selling food and fruit in shops in their communities. However they did not feel competent to leave their employment and take on risks in developing their own income generating business. Unemployment statistics verify that in that 85% of disabled individuals (inclusive of individuals with brain injury) are unemployed South Africa [29].

Ruffolo, Friedland, Dawson, Calantonia and Lindsay [30] indicated that of the 50 individual with brain injury who participated in their study 42% returned to work. They indicated that social interaction, jobs with greater decision latitude and discharge home was associated with return to work. It could therefore be argued that research statistics verify that the percentage of people who successfully maintained their jobs and who went into entrepreneurial type of activities were limited. Most individuals who sustained TBI are employed in sheltered employment settings and that they rarely engage in OLM and self-employment initiatives. Individuals diagnosed with a TBI often present with functional limitations such as balance, speech, problem solving and behaviour problems [29]. These functional limitations often negatively influence their productivity in the workplace.

In the context of this study some of the participants continued to struggle with multi-tasking i.e. the ability to do more than one activity. They were often given one task in the work environment to master before providing them with new tasks. These individuals also took a longer time in order to learn tasks. Furthermore certain jobs that required the use of material and equipment that may hurt the employee, for example operating stoves and machinery, were not encouraged due to poor co- ordination and problem solving abilities.

Many of the participants in this study indicated that they did not have good support at home due to their family members not being interested in the type of work they were doing and the problems they experienced in the workplace. The family members were mainly interested in their financial contribution to the household. Soeker, Van Rensburg and Travill [30] considered the role of families of individuals with brain injury. They could be both supportive and non-supportive. They are supportive when they helped the individual with the brain injury during the period of integration in the community and non - supportive if they did not help the individual with the brain injury re integrate back into the worker role.

Tipton- Burton, McLaughlin and Englander [31] indicated that family members and friends were visible during the acute and sub-acute stages of TBI rehabilitation. The latter would be an example of a family being supportive. However they found that over time, family and friends become progressively less involved, this causes individual with brain injury to develop feelings of isolation. The latter would be an example of an unsupportive family.

Furthermore the participants in the study indicated that some employers were not supportive due to their lack of understanding of the abilities of individuals who had suffered a TBI. Some of the participants reported that their line managers would shout at them and purposely reprimand them in the presence of other co-workers. They felt that they could not trust some of their co-workers as they would often complain about them especially if they felt that the individual with the TBI had a chance of getting promoted in the company.

In a study conducted by Keough and Fisher [33] it was found that often individuals who with brain injury could experience discord with co-workers which could result in the BII experiencing psychosocial stress. An example of discord could be related to co workers becoming frustrated with the fact that sometimes certain jobs were identified specifically for individuals with disability. This often resulted in disputes especially if co-workers (able bodied individuals) were not being promoted for long periods of time in the workplace. Soeker, Van Rensburg and Travill [28] indicated that due to the shortage of jobs, able bodied and individuals with disability had to compete in the same job market. Furthermore the stigma related to having a disability often cause individuals to think that people with disabilities should not be employed in the Open Labour Market.

Many of the individuals in this study worked for fast food restaurants. They were initially employed on a contract basis (i.e. when individuals are in stage 3 and 4 of the rehabilitation stages of the model they are usually placed in a job on a temporary basis. They are often employed for a period of 2- 3 months in order to determine whether they could cope in the OLM). If the employer is happy with their performance then the contract period could be extended. The participants in the study felt that they were often not given many shifts to work, as a result their income was limited. They felt that this was a stressor because they needed to earn more money especially when they had families to support. It could be argued that often employment in the Open Labour Market becomes affected by the availability of jobs, the employers ability to handle the person with disability and the skills required in the job. Van Niekerk [25] states that often the disabled are denied work opportunities despite legislation that is favourable towards them in the workplace.

Some of the facilitatory factors related to the model that aided to participants in returning to work related to the fact that individuals in the study gained a sense of normality especially when returning to paid employment in the Open Labour Market. Johannsson and Tham [34] in their study that focused on the reintegration of individuals with TBI back into the community indicated that employment enabled these individuals to find meaning in life and that it aided with community integration after the injury. Although it is acknowledged that employment in sheltered employment workshops created meaning and purpose in individuals with disabilities lives, it did not facilitate confidence in their abilities.

Individuals in this study indicated that their confidence in work skills improved when they participated in educational activities such as learnership (these are specific courses offered by the South African Department of Labour). Two of the participants in the study completed a 12 month learnership programme, one participant obtained training in basic clerical/administrative work in an office another participant obtained training in domestic cleaning. The other participants in the study were provided with one on one education sessions in which they were educated on coping skills, stress management skills, how to write up a curriculum vitae, communication skills, money management skills etc.

Soeker, Carriem, Joint, Hendrick and Naidoo [35] indicated that the use of life skills in work preparation programmes was essential. Holzberg [26] indicates that supportive employment is characterised by specialized job training and tailored supervision. In a study of 80 participants conducted by Wehman, Sharron, Kregal, Kreutzer, Tran and Cifu [36] the monthly employment ratio increased from 13% before services to 67% after participation in the supportive employment programme. It could therefore be argued that supportive employment programmes greatly improves an individual‘s ability to maintain employment.

The individuals in this study emphasised that they felt as if they formed part of society when they were working with able bodied individuals doing the same work. It could be argued that when individuals with TBI are employed in the OLM then the stigma related to having a brain injury is reduced in the society. Many of the participants in this pilot study indicated that the fact that they were engaged in work related tasks and that they were expected to work independently to earn a salary gave them a sense of responsibility. The fact that some of the participants were no longer dependent on a disability grant to sustain them also contributed to a greater sense of responsibility.

Individuals in this study emphasised that the fact that they were provided with support by family members and co-workers greatly enhanced their ability to maintain employment in the open labour market. Support in the context of this study was viewed as having a family member accompany the individual with the brain injury to the rehabilitation facility. Also family members initially accompanied some participants to their places of employment in order to assist them in traveling if this was still viewed as a problem. The line managers and human resource managers were viewed as being supportive especially when they adapted the work routine and created a supportive environment for the individual with a brain injury in the workplace. Some line managers would inform co- workers about what the limitations of the individual with the brain injury in order to improve their understanding of why their jobs were adapted slightly e.g. a worker with an elbow flexion contracture was allowed to do tasks where they would only carry beverages to customers but was not allowed to operate a stove. In a study conducted by Holzberg [26] they refer to natural supports such as opportunities for socialization and company sponsored employee assistant programmes as a form of adaptation that enabled the individual with brain injury to maintain employment. It is therefore argued that proper support in the workplace and home environment greatly improves the individuals with a disability/brain injury ability to reintegrate into the workplace as well as create a supportive environment. These supports in the long run enables the individual‘s to sustain employment in the open labour market.

Although some participants were struggling to multi task other participants felt that the exposure to work tasks in the OLM enhanced their work skills. They felt that they could participate in more tasks due to the exposure and skills that they obtained in the various phases of the rehabilitation programme as well as the workplace. According to Soeker [32] an individual‘s ability to multi task contributes to his or her level of confidence and competence. Watt and Penn [37] found that BII’s who had an education of matriculation or less and unskilled were significantly less likely to return to work that those with tertiary education and who had managerial or professional jobs. The researcher in the current study used the steps of occupational self- efficacy in order to improve the client‘s work skills. The research participants indicated that the fact that they were given a R40 (equivalent to $4) per session in order to assist them with transportation costs in traveling to the rehabilitation unit assisted them in regularly attending and completing the rehabilitation programme. According to Stroupe, Smith, Hogan, Andre, Pape, Steiner, Proescher, Huo and Evan [38] the costs related to rehabilitation programmes are expensive and the long term costs related to TBI need to be taken into consideration. It could be argued that an affordable rehabilitation programme as well as the availability of transportation to and from rehabilitation centres increases the value that participants associates with the programme. In the current study the provision of transport or traveling fees contributed to individuals with brain injury completing the rehabilitation programme.

9 Limitations of the study

One major limitation that was identified in this study was the inability to generalise the findings of this study to the larger population due to the inherent nature of qualitative research and the limited number of study participants. Another limitation was the fact that mainly male participants participated in the study. Due to the nature of brain injuries more males tends to be affected with brain injuries than females. Although every attempt was made to include more females in the study only one female participated in the study.

10 Conclusion

This study explored the experiences and perceptions of individuals who sustained a brain injury regarding returning to work after participating in a vocational rehabilitation programme. The vocational rehabilitation programme used the concepts stages of the Model of Occupational Self Efficacy in returning individuals with brain injury to work. Some of the barriers identified in the study included: financial limitations related to access employment and maintenance of employment, problems related to engaging in entrepreneurship projects, problems related to functional limitations due to TBI sequelae and poor support in the home and work environment. Some of the enabling factors included: participation in work in the open labour market facilitates growth, educational activities as part of a training programme enhanced their work skills, the ability to multi task enabled the ability to maintain work in the open labour market and the provision of financial assistance aided the individual with the brain injury to complete rehabilitation programmes. The findings of this study indicated that the Model of Occupational Self Efficacy is a useful model to use in retraining an individual with brain injuries work skills. The participants in this study could maintain employment in the open labour market for a period of at least 12 months and it improved their ability to accept their brain injury as well as adapt to their worker roles. The MOS also provides a framework for facilitating community integration.

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