Abstract
Introduction
Traumatic Brain Injury (TBI) has a significant negative impact on the vocational outcome of clients. [1] The more chronic the injury and the longer unemployment post-injury persists, the smaller the chance of eventual return to work. [2] According to Huntstiger and Thompson [3], return to work after a moderate to severe brain injury is generally unsuccessful. High unemployment rates have been attributed to emotional, behavioural and neuropsychological changes arising from brain injuries. 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, individuals with a disability or an individual who has injured him/herself are regarded as having problems that require medical-biological intervention, with limited attention given to the difficult process of reintegrating the person with disability back into society, for example, in resuming their worker roles [4]. The medical approach may result in feelings of disempowerment on behalf of the person with a disability with regard to the rehabilitation process [4, 5]. 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 explored the perceptions of occupational therapists in implementing a newly developed vocational rehabilitation model called the Model of Occupational Self Efficacy (MoOS) as a strategy to return the workers who sustained a brain injury to work in the Open Labour Market (OLM).
Literature review
TBI involves a traumatic insult to the brain capable of producing a milieu of psychological, intellectual, emotional, social and vocational challenges [6]. A traumatic brain injury is an acquired brain injury from an outward mechanical force causing temporary or permanent neurological dysfunction, which may result in cognitive, physical and psychosocial impairment [7]. The overall incidence of TBI in developed countries is about 200 per 100, 000 persons annually [7] and according to the Kwazulu Natal Department of Health [8], an estimate of 89, 000 new cases of head injuries are reported in South Africa annually. The majority of these head injuries are due to motor vehicle, bicycle, or vehicle-pedestrian mishaps (more than 50%); falls (approximately 25%) and violence (nearly 20%) [7]. The highest incidence of traumatic brain injury occurs in the 15–24 age group [6]. According to Vuadens [9], 70% of individuals with moderate brain injuries do not return to work and 20% of individuals with mild brain injuries are unemployed. Furthermore, a total of 10% of individuals with brain injury get dismissed from their work due to poor work performance and only 2% are employed on a short term basis, one-year post trauma. It could be argued from the evidence above that a large number of individuals living with TBI are unable to return to the vocational roles they established before injury, and this has a direct association with their volition and self-worth. As a result, the current vocational rehabilitation programme using the MoOS, uses a supportive employment framework in order to enhance the return to work rates of individuals with mild to moderate brain injury.
Return to work is considered an important element of TBI rehabilitation because post TBI employment is a strong predictor of quality of life (QoL). Tsaousides and Gordon [10] conducted a systematic review that focused on the period 1998–2002 and reported that the meaning of employment amongst study participants ranged from financial gains to a means of regaining a place in society. The study further elaborated on employment-related self-efficacy, that an individual’s belief in his or her ability to find or carry out work related tasks successfully may play a role in the relationship between employment and QoL. Furthermore, studies reveal that successful return to work also results in the reduction of secondary disability, and conversely, unsuccessful return to work can lead to poorer psychosocial adjustments and physical ailments [11].
In the 1980’s, the supported employment approach to vocational rehabilitation was developed in the United States of America [12]. This program required the individual with the brain injury to be placed in a community based competitive job with a Job Coach if they were accepted to a program. The Job Coach’s role included one-on-one onsite training, vocational counseling and support, in addition to assisting with job searching, job applications, interviews and employment inductions. Gamble and Moore [13], followed 1073 participants with TBI, of which 78% received supported employment services during the vocational rehabilitation process. Of the participants, 48.6% were competitively employed by the time their cases were closed and 51.4% were not employed. Of the participants who were not employed, 7.3% were provided with supported employment and 92.7% were not provided with supported employment. Of the clients who were provided with supported employment, 67.9% resulted in these clients being placed in competitive employment. However, one criticism related to the supported employment models is that it is expensive to incorporate into practice.
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 [14]. The Occupational therapists’ role with clients with brain injury is to provide intervention that aids the client to resume their previous occupational roles such a worker, homemaker, mother, etc. Occupational therapists provide interventions that remediate and restore impairments that affect an individual’s ability to obtain independence with self-care, work and leisure. The Model of Occupational Self Efficacy by Soeker [15] is a client centered practice model designed to effectively return individuals with brain injury to work. The MoOS consists of 4 stages (see Fig. 1) namely,
A review of the vocational rehabilitation literature indicates that there are no studies in the South African context that have implemented and evaluated a client centered brain injury rehabilitation model. The proposed research aims to explore the experiences of occupational therapists regarding the use of the model in enabling brain injured individuals to return to work after their participation in a vocational rehabilitation programme using the MoOS.
Aim
To explore and describe the experiences of occupational therapists regarding the use of the Model of Occupational Self-Efficacy in returning individuals with brain injury to work.
Objectives
To describe the barriers that Occupational Therapists experience when returning individuals with brain injury to work by utilizing the model of occupational self-efficacy. To describe the enablers that Occupational Therapists experience when returning individuals with brain injury to work by utilizing the model of occupational self-efficacy.
Research design
Qualitative researchers study topics in their natural settings interpreting phenomena in terms of the significance people bring to them [17]. Qualitative research is fundamentally interpretive and includes describing the individual and setting, analyzing data for themes, and eventually drawing conclusions about its meaning [18]. In the current study the researcher utilised an exploratory and descriptive approach. Exploratory research has been described by Mouton and Marais [18] as research that is meant to provide insight to a relatively unknown research area. This type of research is aimed at making clear concepts and constructs of the phenomenon of interest. Polit and Hungler [19] posit that the descriptive approach in research enables the accurate representation of attributes of participants in the research project. To gather accurate data and provide a clear image of the experiences and perceptions of the participants in this study, a descriptive approach was utilized. This approach enabled the researcher to collect data from the participants; they were asked to describe the barriers and facilitatory factors that they experienced relating to the use of the MoOS in practice.
Population and sampling
Five participants were purposively sampled from the registry of occupational therapists that is registered with the Health Professions Council of South Africa and employed in the Western Cape. These participants worked in the Occupational Therapy departments from Tertiary Hospitals, Community Health Centers and Private practice (see Table 1). Patton [20] stated the advantage of purposive sampling lies in selecting information-rich cases. In the context of the current study, the participants were occupational therapists who were exposed to the MoOS and who actively used the model with their clients. Some of the questions that were asked of the participants related their use of the model (see Appendix 1). The inclusion criteria of the study were as follows: The occupational therapists should have a minimum of six months experience in the treatment of clients with traumatic brain injuries. The occupational therapists should have used the MoOS in the rehabilitation of their clients. The therapists should be fluent in English and/or Afrikaans; and the therapists should have a drivers’ license for the purpose of conducting work visits. The exclusioncriteria were: Therapists who had less than six months’ experience in the treatment of clients with traumatic brain injuries.
Data collection
Seale [21], describes face to face interviews as an in-person interview where the interviewer has the advantage of building an interpersonal relationship with the interviewee and thus maximizes the quality of data collected. Data was collected by means of face to face, semi structured interviews. The participants who participated in the study were invited to a seminar where the MoOS was introduced to them as a possible model to return clients with brain injury to work. Individuals who were interested were asked to use the MoOS in practice, they were also provided with training in the use of the model. The occupational therapists were requested to use the MoOS with at least 1 client and was informed that they would be asked to participate in a study that would explore their experiences of the use of the model. As the model had 4 phases, 4 interviews were conducted with each research participant at their place of employment. The duration of the interviews was between 45–60 minutes and one interview was conducted at each phase of the model (see Appendix for the questions asked during the interviews). 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. A member checking interview was also conducted whereby the participants were contacted about the accuracy of the findings related to the current study. Their comments were then taken into consideration and the findings readjusted.
Data analysis
The method of qualitative data analysis as described by Morse and Field [22] was used in this study. The process involved the coding of information, thereafter the organisation of the codes into categories and then the grouping of the categories into themes that described and explored the experience of the participants in this study. Strategies such as credibility, transferability, dependability and confirmability were used in order to ensure the trustworthiness of the data [23]. Credibility was ensured by the dense description of the lived experience of the research participants. 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. 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 and peer examination. 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. Example, some of the biases of the research related to the fact that the participants may experience difficulty in implementing the MoOS with clients who have a poor education level and clients who had a different racial background. These biases are bracketed during the analysis process. Furthermore, the findings of the study did not prove these biases to be true. In the current study, the research findings were purely from the perspective of the participants.
Findings
Brief description of how the MoOS was applied in practice
Stage one is called, “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. During this stage the Gibbs cited in Jasper [24] reflective cycle is used with clients in order to enable them to reflect on challenges they experienced with regard to their brain injury, ultimately to enable them to accept the fact that they sustained an injury and that they have the potential to enhance their skills.
Stage two is called “Use of Self.” During this stage, the occupational therapist would continue to act as a facilitator and through a process of introspection and inner strength development, the client would have reached autonomy to participate in more occupational activities, such as activities of daily living, work and leisure. The occupational therapist at this stage will assist the client in identifying the intervention needed in order to enable the client to find employment. If the client requires cognitive remediation or intervention to improve their balance or concentration, then the occupational therapist will provide this intervention. Some activities included gross motor exercises called the infinity walk. Sunbeck [25], indicated that the infinity walk directly helps the two hemispheres of the brain to synapse together, providing the 2 chairs as a pattern so that he could follow properly and have the correct movement. This specific walk was also used to improve the participant’s ability to focus on more than one factor at a time, recall and complete a set of 6 step instructions that could be up or downgraded to the client’s needs.
Stage three is called “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. At this stage the client will be requested to engage in work related tasks in order to improve their ability to work an 8-hour day, familiarize them with working with co-workers and conflict management, and to problem solve.
Stage four is called “Capable individual” and is the final stage of the model. During this stage the client is usually placed in an actual job where they have to work with the tools and equipment required in the job. Prior to the actual placement, the client would have had training on the tasks of the job within a safe environment (i.e. the rehabilitation unit). Thereafter the client is placed in a job in the open labour market where they are provided with on-going training by the occupational therapist who acts as a job coach. During this stage, the occupational therapist is also responsible for arranging meetings with the managers of the workplace and co-workers in order to answer any questions they had with regard to the client’s functional skills or limitations.
NB: At each stage of the model the client’s cognitive ability was assessed via the Montreal cognitive ability screening tool [26]. In addition to the cognitive evaluation, the clients’ functional skills were assessed on an individual basis based on the unique functional challenges that they wanted to overcome.
Barriers related to the use of the model
The main themes that developed from this study were as follows namely, Theme One: Challenges related to the use of the model and Theme Two: The model as an enabler of work skills. These themes will be discussed in relation to the associated categories.
Theme One: Challenges related to the use of the model
“So it’s difficult to get them to buy into it, but once they are in it, they actually like it” (P1)
The above theme describes the participants’ perceptions of the challenges related to the use of the Model of Occupational Self Efficacy. These challenges will be described in the categories that follow.
Limited insight affected participation in the rehabilitation programme
The participants emphasised that the individuals with brain injury (IBI) struggled to initially participate in the rehabilitation processes as described by the MoOS due to their cognitive limitations. The main barrier related to the clients’ level of insight with regard to their functional and cognitive limitations. Some clients could not make the link between true insight and intellectual insight, which ultimately affected their functional performance. These participants mainly had moderate brain injuries performance. A participant said:
“You can see it, but she doesn’t have the ... I struggled the most with her because she didn’t have the link ... she couldn’t make the link between true insight and intellectual insight where she was still under the impression that she can do certain things” (P1)
Limited time available for the completion of rehabilitation programmes
The participants indicated that although the model had a clear process for rehabilitation, a barrier was related to the time available to complete the various phases of the model. The participants indicated that their clients (IBI) struggled to attend all the sessions allocated to them. This caused them great frustration. One participant said:
“I think uhm …perhaps …something that is frustrating is that we’re only seeing her for a few sessions and she also missed a session due to being ill” (P1)
“Because if you do …if you see her every two weeks and she misses a session then you actually see her once a month?” (P2)
Lack of multidisciplinary intervention in the use of the model – practically
The participants in this study felt that although the MoOS advocates for the involvement of other health professionals, the IBI’s family, and employer, they continue to struggle to get other health professionals and employers involved in the rehabilitation process. The problem they identified related to poor feedback obtained from other health professionals regarding the use of the model as well as whether the other health professionals would consistently continue with the steps as advocated by the model, i.e. a focus on returning the IBI to work. Another concern related to the long waiting period before the IBI is treated by other health professionals, i.e. psychologists and social workers. One participant indicated:
“I haven’t really had feedback from colleagues (i.e. other health professionals) ... not really and then from N himself ... you know ... he’s enjoying his work” (P1)
Another participant indicated:
“Sometimes I just wonder about their work load, like you know would they be able to really assist this client. I mean if we refer this specific client, will they be able to carry on with this process that we’ve now put in motion terms of time.” (P5)
Employer involvement in the return to work process is problematic
The participants in this study were of the opinion that the main barrier to getting the clients employed was a lack of involvement and interest by prospective employers. The participants struggled to get employers to give the IBI an opportunity to put their skills into practice in the open labour market. A participant said:
“Another thing that is difficult ... it is difficult to get employers and outside people to buy into the programme. Coz now when you have these patients, they become restless. Coz it’s going to be two or three weeks, then it’s Christmas again. And we know after Christmas people don’t hire because now they are set. So just trying to push them to get hired before ... before Christmas and getting people ... employers to buy into the project ... just to take note of the project”
It is difficult to implement the model in private practice
Some of the participants in this study were of the opinion that it was difficult to implement the model in a private practice setting. They felt that they did not have the time to implement the model due to the limited time that they had with their clients. This limited time was attributed to the cost involved in providing occupational therapy intervention in a private setting, the IBI’s medical aid usually provides limited funding for rehabilitation services in comparison to funding available for medical consultation by doctors. One participant said:
“Yes, in private it is difficult to make this work practically and from us it took a lot of effort and I’m not sure, I think we put in a lot of extra hours that we’re not getting paid for with this specific client so it makes it very difficult in private because time is money so we’ve really gone out of our way and we’re still not there where we want to be so it’s been very frustrating. Yor I don’t know how much but, but it’s a part time. They must give me more shifts to work.”
Enablers related to the use of the model
Theme Two: The model as an enabler of work skills
The above theme describes the participants’ perceptions of the facilitatory factors related to the use of the Model of Occupational Self Efficacy in practice. These challenges will be described in the categories that follows.
Graded aspect of intervention
The participants in this study indicated that the phases of the model logically related to each other and that it enabled them to grade the activities of their clients (i.e. IBI). The participants indicated that the MoOS was dynamic and it allowed them to fluctuate between the various stages of the model depending on the needs of their clients. One participant said:
“Everything like that. But the model itself has helped a lot because of the clear four stages and the fact that you ... the model is so dynamic and the person is dynamic. So you can actually move ... you can see that patient ... like I said, upgrade, downgrade. Maybe still struggling with memory, a person can move back down. Or do a memory component with him in Stage three. That repetition of tasks, but maybe increase it by three to five steps that he must now remember out of his head. So yes, I would say, it does help.” (P1)
Real life social intervention
The participants in this study indicated that the fact that they could engage in memory enhancing activities that enhanced their cognitive functions facilitated their growth and ultimately their work skills. One participant said:
“Like always tell them, “her name is Shirley, coz her hair is curly”. Then they remember it, coz it’s the visual that is with it. Then we implement it ... then I ask them afterwards, “how do you think you can do that same thing at your house and from you house how do you think you can do it at work” (P1)
“What I noticed in stage three is that they need a lot more social interaction and a lot more real life situations ... so you can role play it in stage two and in stage three it’s where it’s really supposed to happen. And in stage three I worked very well with that department, that I named earlier in the hospital. And they would put him into situations where they ... today we’re doing packing ... .” (P1)
Another participant indicated that engagement in real life work related activities facilitated an improvement in skill.
“Uhm ... when we moved onto stage three ... we worked through a lot of self-reflection, problem solving with a realistic work environment. We got him into a position ... a casual position within a company, so it was temporary. He was fully aware of the fact that this was not a permanent position and it was for the purpose of work rehabilitation to see how ... if he was gonna be able to get there by himself using public transport, was he going to be able to take instruction from a manager and understand and execute the tasks” (P2)
Reflection stage aided recovery
The participant’s work motivation greatly improved after they had undergone a period of reflection. The participants in this study indicated that the reflection stage of the model was very important, specifically they viewed it as a measure for their clients to take ownership of their rehabilitation and enhance their goal setting. One participant said:
“With introspection ... he ... it came about that he was very disappointed that he could not complete his grade 12. Uhm ... because of his memory difficulties and ... it wasn’t severe cognitive impairment, but he’s not the same like he used to be, so he struggled with ... with struggled with more academic tasks.”(P1)
Another participant indicated that reflections enabled her to focus on being client-centred rather than being authoritarian in her approach. She said:
What I can say is what I realised I think the previous time when we had our discussion; I think I only saw her one time …I wasn’t sure where we were going …and I think what I realised is we need to do more reflections. I think at this stage I think me and Lezanne is actually pushing the …pushing the …(P5)
Different types of activities aided recovery
The participants in this study were of the opinion that the activities prescribed in relation to the needs of the participants enhanced the sequelae related to the IBI. Deficits such as problems with perception and endurance improved. One participantsaid:
“For stage one, the self-reflection, it’s better for the more lower functioning to have more concrete activities, so we have ... I work a lot out of the cognitive brain work book ... and there’s worksheets in there with like a little man ... and the man is different places on the tree ... so either he is on top of the tree or at the bottom of the tree or swinging somewhere in the middle. And then I would ask them, “so, how do you feel about yourself, how do you see yourself if you were this different types of activities that they prescribed in conjunction with the needs of the man?” And they would colour in the man ... maybe in the middle and I would ask them, “so why the middle man?” and they would say “because I’m not there anymore, like I’m not on the ground anymore, I don’t feel that way anymore, but I still feel I have a long way to go up”. So they can make that man ... As for ... the one that I’ve been struggling with ... like I said she’s much more difficult to handle ... and it’s her, it’s her personalityas well.” (P1)
Another participant indicated that engagement in functional activities enhanced the client’s planning abilities. She said:
“..say if it was ... uhm ... packing boxes ... like maybe taking groceries from the car into the ... into the house ... and then she would take too many packages at once or she’ll take something that she can’t actually carry and then her mother would say “no Liezel, don’t do that, rather take this” or something.” (P2)
Provides practical proof to the employer of the TBI client’s ability
The participants in the study indicated that they incorporated work related practical activities into their rehabilitation programmes. They tried to simulate activities to suit the requirements of the employer’s workplace. They were of the opinion that these types of tasks enabled the employer to see the potential of the IBI. One participant said:
“So that’s what we did yesterday. I saw her yesterday …so I did clerical assessments with her because we are now negotiating with the work” (P5).
Another participant indicated:
“We got him into a position ... a casual position within a company, so it was temporary. He was fully aware of the fact that this was not a permanent position and it was for the purpose of work rehabilitation to see how ... if he was gonna be able to get there by himself using public transport, was he going to be able to take instruction from a manager and understand and execute the tasks.” (P2)
The role of family support
Family support in the context of this study was seen as being essential to the rehabilitation and return to work process. Without this support the IBI struggled to keep their motivation. Within the context of the MoOS, family support was seen as integral to the model in that in all the stages of the model the family could play an important role in motivating the IBI to engage in work tasks. The participant said:
“But ja ... I mean his girlfriend came in who was very supportive. He would tell me ... like he would come in and he would tell me like when there’s a problem ... we built up a relationship to the point ... even if it was a small problem.” (P2)
Another participant indicated that sometimes the IBI could not recognise the support that the family member was trying to offer. However education given to the family from the therapist was essential to keep their motivation levels as they sometimes became frustrated with the IBI. The participant said:
“Yes. And she’s very overprotective. In her eyes ... her mother’s eyes she can just do nothing right to please her mother. That is obviously not the truth ... and with her mother there was a lot of education as well. And I had to show her ways of having more patience, coz her patience was kind of running low as well” (P1)
Multidisciplinary/collaboration with other practitioners
The participants in this study were of the opinion that working together with other health professionals improved the IBI’s ability to return to their worker roles. Referrals to other health practitioners helped improve the IBI’s functional limitations which ultimately enabled them to return to their worker roles. One participant said:
“Because you want your patient to go see the physio if needed, because obviously with the brain injury there’s other things that come with it as well ... . There will sometimes come motor deficits that will come with it, so you’ll need the physio or there will be social issues, so they will need a social worker or the psychologist because, like Neville, he actually at a stage thought that he was schizophrenic because he was hearing voices, but he wasn’t actually hearing voices” (P1)
Some participants were of the opinion that collaboration with other therapists who were skilled in specialised fields enhanced the work skills of IBIs. Example referral to another therapist who specialises in driving skills assessment and retraining was helpful. She said:
“I’ve made contact L (name) at Usebenza (Institution) to assist us with that process so we need at least four sessions so I just want to keep the sessions that we have, but then I also sent through a motivational letter to the medical aid on the 23rd of July to motivate for sessions. So once we’ve got more sessions then I’ll know okay we can carry on with the individual sessions because we’ve got enough sessions for the driving assessment.” (P5)
Discussion
In this study the main barriers identified in the study included: limited Insight of the IBI, limited time to complete rehabilitation, a lack of multidisciplinary intervention and a lack of employer involvement in the return to work process. Some of the enabling factors included: the graded aspect of intervention, real life social intervention, the reflection stage of the model and the role of family support. The participant’s limited insight and time available for the completion of rehabilitation programmes. The participants in this study were of the opinion that if the IBI had problems relating to insight then they would struggle to complete the rehabilitation programme. Research conducted by Holzberg [27], indicated that the client’s level of insight could be seen as a limitation in rehabilitation and the return to work process, they were of the opinion that the clients executive functioning including insight had to be the main focus of intervention. In the current study, Stage 1 of the MoOS was designed to specifically focus on improving the client’s insight and to help them with goal setting. Due to some clients not having enough finances to attend rehabilitation programmes nor the benefits available on their medical aid, many IBI could not attend all the sessions. The model required that the therapist spends on average 10 sessions with the client, however the IBI could not attend all the sessions. According to Soeker [28], attendance of programmes are negatively affected by the IBI’s economic circumstances, most often IBIs spend too little time in these types of programmes due to financial limitations and this ultimately causes them not to improve their functional ability. Although the model promotes a gradual progression through the various stages of the model, external circumstances do limit a client’s potential to complete rehabilitation. As this is a dynamic model, an individual’s progress in treatment is affected by their response to rehabilitation and the nature of their injuries (i.e. presence of co morbid conditions such as multiplefractures).
The participants in this study felt that it was difficult to obtain multi-disciplinary collaboration especially due to other practitioners not being available to provide the necessary rehabilitation. The IBI were placed on waiting lists and often the therapists had to continue with the various stages of the model independently. The Ontario Hospital Association [29], indicated that a critique of the multidisciplinary framework relates to the fact that the professional team does not communicate with each other on a regular basis and that they do not work to frame a common understanding of the health problem and treatment goals. Research shows that collaborative team approaches lead to improved patient care and outcomes, and more effective use of healthresources [29].
This has a negative effect on the rehabilitation outcome i.e. returning the client to work. Researchers have recommended a different strategy called the interdisciplinary strategy, in this strategy the health professionals as well as the client and his/her family focus on the client’s life goal [29]. If the goal is return to work then all the individual health professionals collectively work on this goal by improving the clients’ functional limitations.
Another barrier that affected the return to work process included the lack of involvement and support from the IBI’s employer. This lack of support was seen when the IBI returned to work and when they experienced difficulties in the workplace. In the context of this study employers were very difficult to approach, they never provided feedback pertaining to the availability of jobs and tended to be reluctant to employ people with disabilities in general. In a study conducted by Friesen, Yassi and Cooper [30], they indicated that employers are fundamental to the return to work process of IBI, particularly in the initial stages of employment. Failure to provide support whether in terms of creating an environment of acceptance, providing positive feedback on work performance to measure of reasonable accommodation may negatively affect the IBI’s worker role and period of employment.
The final barrier related to the participant’s ability to implement the model in practice, the participants felt that due to the funding models of medical aid insurance companies, limited funding was available for the IBI to complete their sessions. The medical aid company allocated additional financial benefits for medical intervention by medical doctors and often not enough benefits for rehabilitation. This causes the IBI to not complete their rehabilitation programmes i.e. continue through the steps of the MoOS.
The facilitators within the context of this study were interpreted as the various aspects of the model that the participants felt was useful and enabled the IBI to return to work. The fact that the model presented with a graded process in rehabilitation, enabled the IBI to build on their existing skills. For example, in phase 1 of the model the IBI has to undergo a period of reflection and goal setting. After this has occurred then they can proceed to the next step which is refining their functional ability to return to work i.e. improve their cognitive and or physical ability. A real life social intervention was viewed as facilitator that the MoOS incorporated in rehabilitation. This real life social intervention enabled the IBI to observe their strengths and weaknesses in a practice setting. The participants felt that this social intervention enabled the IBI to develop their own insight in their abilities. Tyerman and Meehan [31], indicated that practice in a real life work situation enables the IBI to develop confidence in their ability. They can then become aware of concerns such as a lack of self-awareness. The participants in this study indicated that the introspection stage of the MoOS enabled the IBI to become aware of their strengths and limitations. This stage was seen as being of vital importance to the model as it served as the platform for client’s centred practice to take place. The Gibbs reflective cycle was seen as useful particularly in relation to the use of journaling. According to Soeker [28], introspection enables an individual to develop goals and become aware of factors that are of importance to him or her. The participants in this study made use of a combination of activities that was used in rehabilitation e.g. journaling, paper based activities such as papier mache, role plays, life skills such as coping skills and assertiveness skills, memory games and work simulation tasks. These activities were sometimes presented in groups or individually and it was modified to suit the needs of the IBI. According to Blundon and Smits [32], table top activities as well as compensatory mechanisms such as the use of memory aids such as diaries, calendars and electronic cuing devises are used to improve the IBI’s cognitive deficits. In addition, the work simulation processes enabled the clients to practice specific work skills in a supervised environment. Stage three of the MoOS advocates the use of work simulated tasks as well as the eventual placement of the individual in a work setting in the open labour market. According to Ross [33], the ultimate outcome of any vocational rehabilitation strategy is the ability of the IBI to sustain their jobs. This in turn will convince employers to employ people with disability and not to view the process of employment as a welfare situation but rather a process that makes good business sense. Family support was seen as a facilitator that enabled the IBI to transfer skills learnt in rehabilitation to the home and work setting. Soeker [34], stated that a supportive family enabled the IBI to adjust to the demands of the workplace, especially when the IBI does not have supportive co-workers. Finally, multi-disciplinary intervention and collaboration was seen as a facilitator in returning individuals with brain injury to work. The fact that the treating health professionals communicated with each other about the clients’ progress as well as the clients’ intentions of returning to work aided the IBI in returning to work. The MoOS places emphasis on the fact that collaboration between health professionals, employer, and the client is essential in the vocational rehabilitation process. In a study conducted by Turner-Stokes [35], they emphasised that the communication between these stakeholders are important in any return to work strategy.
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.
Conclusion
This study explored the experiences and perceptions of occupational therapists that utilised the MoOS as a model to return IBI to work. 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: limited insight of the IBI, limited time to complete rehabilitation, a lack of multidisciplinary intervention and a lack of employer involvement in the return to work process. Some of the enabling factors included: the graded aspect of intervention, real life social intervention, the reflection stage of the model and the role of family support. The findings indicated that the Model of Occupational Self Efficacy is a useful model to use in retraining the work skills of an individual with a brain injury. The participants in this study implemented the model over a period of at least 5 months with one client and it improved their ability to accept their brain injury as well as adapt to their worker roles. The MoOS provides a useful framework for facilitating work integration of individuals diagnosed with brain injury.
Conflict of interest
The author has no conflict of interest to report.
Footnotes
Appendix 1
Acknowledgments
The research project would not have been possible without the financial assistance of the National Research Fund and the Occupational Therapy Departments of the University of the Western Cape as well as Tygerberg Hospital.