Work-related traumatic brain injury: A brief report on workers perspective on job and health and safety training,supervision,and injury preventability

1. Introduction

Canadian and American administrative data demonstrate a steady increase (up to 250%) in the number of claims for work-related traumatic brain injury (wrTBI) over the past decade [1, 2]. Although this increase may be partly attributable to greater awareness and recognition of brain injury — research on sport-related traumatic brain injury (TBI) shows a positive relationship between knowledge of TBI and self-reporting behavior [3] — findings from a recent systematic review nonetheless suggest that the rate of wrTBI may be as high as 33.1 per 100,000 workers [4]. The scope of wrTBI is therefore extensive, and wrTBI warrants further study for the purposes of informing injury prevention and management.

Notably, wrTBI is among the most disabling occupational injuries, with even mild wrTBI potentiality causing long-term cognitive, physical, behavioral, and emotional impairments [5]. Such cognitive impairments, as per a recent systematic review, not only increase patient burden, but are also associated with the ability to return-to-work [6]. wrTBI may also influence life satisfaction and perceived self-efficacy post-injury [7], with a scoping review suggesting that brain injury can alter self-and occupational-identity, with ultimate consequences for the ability to return to a previous occupation [8].

Return-to-work rates following moderate-to-severe TBI are low, with a systematic review by van Velzen et al. [9] reporting that only 40.7% and 40.8% of those with an acquired brain injury (including TBI) return to work by 1-and 2-years post-injury, respectively. A number of studies have identified barriers and facilitators of return-to-work following a brain injury [10–13]. Recent thematic analyses suggest that from the patient perspective, return-to-work is influenced by the availability and success of rehabilitation programs, cognitive and social abilities, as well as the motivation to resume occupation [14]. Further, given the documented relationship between employment-related self-efficacy and improved perceived quality of life in TBI patients [15], wrTBI that result in unemployment or underemployment may have negative personal and societal consequences.

Considering the scale, clinical impact, and financial burden of wrTBI, there is an urgent need for evidence-informed wrTBI prevention strategies. However, to date, most of our understanding of wrTBI is based on administrative data, which provides limited insight into workers’perspectives on their injury; this limits our understanding of the factors that cause wrTBI, and how these injuries can be prevented. Further, while evidence on wrTBI in specific industries (such as construction) has accumulated [16–18], there is a dearth of understanding of how sex and gender influences wrTBI vulnerability despite an emerging literature which suggests that there are sex differences in wrTBI risk [19, 20]. This constitutes an important knowledge gap, given that sex-informed analyses are important to redress health inequities and poor health outcomes [21].

We conducted a sequential explanatory mixed-methods study to better understand how the factors that precipitate wrTBI are perceived by injured workers. Our ultimate goal is to facilitate primary and secondary injury prevention in a manner wherein the injured worker perspective would be considered alongside existing administrative and clinical occupational injury data to inform more balanced and multi-perspective wrTBI prevention initiatives and strategies. This paper presents a part of the findings from our sequential mixed-methods study, focusing on a sex-stratified descriptive analysis of workers’ perceptions of job and health and safety training, supervision, and injury management, which are important for informing future prevention efforts.

2. Methods

The study received Research Ethics Board approval, and all participants provided written informed consent.

All participants were referred to an outpatient clinic at a large urban hospital for an assessment for persistent symptoms associated with a work-related head and/or brain injury. This clinic accepts assessment referrals for all work-related head and/or brain injuries sustained within the province of Ontario from the Ontario Workplace Safety and Insurance Board, which, as of January 2016, has a workforce of 6.99 million. Most of the injuries were considered “mild” in terms of severity.

Patients were consecutively recruited (between October 2014 and May 2016) prospectively either in-person or via telephone. Over this time period, 207 in-person patient intake orientations (i.e., brief meetings wherein patients were introduced to the clinical program as well as our research study by a program coordinator) were scheduled, of which 81 were cancelled. Therefore, the research coordinator attended 126 orientations; 79 patients were ultimately recruited in-person via these means. We also contacted and recruited past clinic patients who had previously participated in other wrTBI studies of ours, resulting in the recruitment of an additional 12 patients. Finally, we reviewed the clinic’s administrative records to identify, contact, and recruit injured workers who spoke English as a second language or with limited English proficiency, thereby ensuring that our study did not overlook this often marginalized worker population. These workers were recruited in-person with the assistance of a certified interpreter, or if a family member of said worker agreed to be contacted over the telephone regarding study participation, the participant in question was recruited over the telephone with the assistance of a phone-in certified interpreter. A total of 39 patients who spoke English as a second language were identified by reviewing prior administrative records, of which 10 were recruited by the means outlined above.

Our inclusion criteria were: 1) age ≥18 years and; 2) a referral for work-related head and/or brain injury. No exclusion criteria were applied with respect to injury characteristics (e.g., industry at time of injury).

Data were collected by means of a self-report questionnaire packet, including standardized questionnaires as well as questions developed by our research team (consisting of an expert panel of researchers and clinicians in the fields of brain injury and occupational health, as well as relevant industry stakeholders and knowledge users). The standard questionnaires included in the packet were the: Epworth Sleepiness Scale [22], ZOGIM-A [23], Fatigue Severity Scale [24], Sleep and Disordered Breathing Questionnaire [25], Drug Use Questionnaire-10 [26], Alcohol Use Disorders Identification Test [27], and the Safety Climate Scale [28]. The questions developed by our team centered on demographic variables, injury variables (focused on understanding where and how the injury occurred), the extent and satisfication of occupational health and job training, as well as whether or not patients were advised to rest following their injury. The questionnaire also asked whether injured workers perceived their injury to be preventable. The present paper, part of a larger sequential mixed-method study which reports on a broader set of outomces, is focused on the questionnaite items that were generated by our study team, as they provide unique insight into the injured workers’ perspective on occupational brain injury.

All analyses (descriptive analyses were used to characterize the population and present questionnaire responses, and inferential statistics were used to compare questionnaire responses by sex) were conducted in SAS Version 9.3.

3. Results

Our final sample comprised of 102 injured workers. A little over half the sample were male (53.9%) and 54.0% were between the ages of 45–64 (n.b., age was collected as an ordinal and not a continuous variable, thereby precluding the opportunity to report mean age values). The mean time post-injury was 15.9±19.4 months (range 2–132 months), and study participants were employed at their injury position for a mean of 67.9±108.8 months (range 1–492 months). Further, 56.6% reported completing some or all of a college/university program, and 83.1% identified as Caucasian.

In our sample, 38.9% of participants had a prior history of TBI (and were thus being treated for at least their second brain injury), with 37.1% of these participants having sustained the prior TBI at work. At the time of completing the study, nearly two-thirds (63.3%) of participants had returned to work, although the majority of these (42.1%) reported being on modified duties.

Our participants represent a breadth of industries with many from education (21.6%), healthcare (11.4%), and construction and/or landscaping (11.4%); the remainder of injuries were distributed across other industries, neither of which individually comprised more than 10% of injuries in our sample. Most injuries (32.2%) occurred in the winter, followed by fall (25.6%) and spring (24.4%). With respect to injury characteristics, the leading causes of injury in our sample were being struck by and/or against an object or person (55%, of which 14% were assaults), falls (30.3%), and motor vehicle collisions (11%).

Given the focus of the article, we present and discuss findings as they relate to perceived injury preventability, as this is a perspective currently overlooked in the literature (Table 1). While there were no statistically significant differences by sex, findings are sex-stratified as a primary objective of this study was to provide insights into the distribution of injury across men and women, and thus inform sex-specific injury management.

We found that nearly 80% of injured workers self-reported their injuries to be preventable (Table 1), highlighting the scope and potential for injury prevention. It is important to note that most workers were performing their regular job duties at the time of injury, which suggests that the injuries that were perceived to be preventable occurred in the context of normal working conditions. While 84% and 77% of workers were advised to rest and take time-off after their injuries, respectively, less than half (43%) were informed of the risks of re-injury.

More than three-quarters of workers received job training, with 97% and 84% reporting that job training was easy to understand and perceived to be adequate, respectively. In contrast, less than two-thirds of workers received occupational health and safety training; those who did receive this training, however, reported that it was easy to understand. These findings suggest that while most workers consider job and occupational health and safety training easy to understand, there remains a considerable minority of patients who are untrained.

With respect to supervision in the workplace, 46% of workers reported that they were regularly supervised. Two-thirds of these workers reported that they considered supervision to be adequate. Similarly, nearly 70% of workers reported that their supervisor supported following safety rules.

To date, workers’ perspectives on wrTBI prevention within administrative data on wrTBI in Ontario, Canada— as in other parts of the country and abroad— are limited.

As with other brain injuries, wrTBI is regarded as a preventable injury, as injuries caused by, for example, slips, falls, and assaults can be avoided through education (e.g., falls prevention programs) and behavioural adaptations (such as wearing appropriate personal protective equipment) [4]. However, this is the first paper to show that from the perspective of injured workers, wrTBI are considered preventable in 80% of cases (Table 1).

Our findings were stratified by sex, to better understand sex-differences in the lived experience of wrTBI. We considered it important to stratify findings in this way, as there are known sex-differences in rates of work-related injury and illness [29] as well as brain injury outcome [30]; further, our group has previously reported on gender and sex-differences in traumatic brain injury [31–34], suggesting a need for continued investigation into this topic. While we did not find any sex-specific differences with respect to the outcomes reported in this paper, our findings nonetheless highlight two important foci for future wrTBI prevention strategies: training and supervision.

In our sample, approximately one-quarter and one-third of participants did not receive job and occupational health and safety training, respectively. Our findings show that a large portion of employees may be inadequately trained for the job that they are performing, which in turn may increase their risk for injury. As per a systematic review of 22 studies across industries, providing training to employees has been shown to have a positive effect on worker safety practices [35], highlighting the need to mandate training for all workers in all environments. In line with this, a recent systematic review and meta-analysis of 28 studies across multiple industries demonstrated that training has a positive effect on worker attitudes and beliefs with respect to occupational health and safety [36]. However, this meta-analysis also reported that there was limited evidence on the effectiveness of training on health outcomes [36]. As our study found that most workers found both job and health and safety training easy to understand and adequate, together, these findings suggest that training alone may not be sufficient to improve health outcomes [37]; improving the health and safety culture may also be beneficial in improving worker safety [38, 39].

When examining specific industries such as construction, health and safety training has been effective in preventing injuries [40], with more engaging safety training (i.e., training which requires active participation in the form of hands-on activities or behavioral modelling [41]) increasing knowledge acquisition while reducing rates of accidents and injuries to a greater extent than non-interactive seminars. However, our findings suggest that despite legislatively mandated training in Ontario (Occupational Health and Safety Act), workers may not be receiving such training. Therefore, the issue of whether training is effective is secondary to that of whether workers receive training. We therefore suggest that industry-specific regulations be in place to ensure training is provided at the appropriate intervals and frequency and that training involve objective-based learning to increase engagement [42].

Further, our study points to improved supervision as an opportunity to prevent injuries; less than half of all employees in our sample were regularly supervised, and approximately two-thirds of these employees considered their supervision adequate and reported that their supervisor supported following safety rules (Table 1). Accordingly, qualitative research suggests that the relationship between the injured worker and supervisor can become strained following wrTBI [43]. In line with this, qualitative research from our group has demonstrated that managers can be unsupportive of employees following brain injury, and question the legitimacy of their wrTBI and its clinical symptoms [44]. Further, two separate systematic reviews have reported that the compensation system that injured workers engage with can be adversarial [45] or even result in poorer outcomes [46]. Given that injury prevention is multi-faceted with management being a key influencer of workplace safety climate [47], injury prevention and management initiatives should continue to target both employees and employers, managers, and supervisors, and perhaps further engage compensation boards.

Finally, with respect to the final section of (Table 1) on rest and injury management, although the effect of rest following brain injury is currently inconclusive [48], post-wrTBI acute impairments may necessitate rest until symptom resolution, especially in cases where workers are operating machinery or vehicles. Findings from the field of sport-related concussion may shed light into how injuries can be managed; reference to consensus statements from said field may be able to inform injury management [49]. However, these studies typically involve younger athletes, and findings specific to this population may not generalize to working age adults, who are injured through different mechanisms and may have co-morbidities which complicate injury management. For example, a recent systematic review reported a strong negative association between co-morbid psychiatric disorders (such as depression, anxiety, and post-traumatic stress disorder) and return-to-work following an acquired brain injury [50]. Further, this review reported that in patients with a history of psychiatric disorder, the risk of developing a subsequent psychiatric episode was higher following a brain injury [50]. Taken together, these findings suggest that injury management should be specific to the needs and clinical profile of individual patients, and that a single injury management policy may not be adequate. The process of return-to-work after wrTBI requires more detailed and focused population-specific investigation.

5. Limitations

While the use of self-report measures permits an understanding of the injured workers’ experience with brain injury, some were developed by our study team and were not validated psychometrically prior to administration. Further, this study does not capture the employers’ perspective of occupational brain injury, therefore not including the perspective of a key member involved with wrTBI and its management. The lack of longitudinal data also precludes analysis into whether the injured workers’ experience with brain injury and its management changes as they navigate workers’ compensation, rehabilitation, and return-to-work processes.

6. Conclusions

This descriptive study profiles wrTBI in Ontario from the injured workers’ perspective. In doing so, this study was the first to demonstrate that the majority of injured workers consider their injuries to be preventable, suggesting that there may be further opportunity for prevention of brain injury in the workplace. A lack of job and health and safety training may contribute to wrTBI, although additional inferential analyses are required to establish this association. Nontheless, this study provides insight into wrTBI, providing additional perspective that should be considered with designing future prevention measures.

Conflict of interest

The authors have no competing interests to declare

Funding

Ontario Ministry of Labour (13-R-056), CIHR Research Chair in Gender, Work and Health; Alisa Grigorovich gratefully acknowledges funding from the Ontario Ministry of Health and Long-Term Care (Ontario Women’s Health Scholars Award) and from the Canadian Institutes of Health Research (Health System Impact Fellowship).