Bridging the gap: Hospital to workplace

Abstract

BACKGROUND:

Work-oriented neurorehabilitation to return to competitive employment after a serious neurologic illness or injury is an interdisciplinary process that begins as soon as pathology has stabilized.

OBJECTIVE:

This bimonthly column provides narratives of anonymized clients in situations that challenge their return-to-work. Each case study is designed for postgraduate education about tools and methods that are appropriate to consider in similar situations.

METHODS:

Through case studies of adults attempting to return to safe and dependable competitive employment, real-world issues are explored that occur at the interface between the client and their employer.

RESULTS:

The current case describes Structured Task Self Appraisal (STSA), a forensic rehabilitation method to collect self-report baseline information concerning the client’s job-relevant functional limitations. STSA guides return-to-work rehabilitation services.

CONCLUSION:

Information concerning the core tasks and important abilities of the client’s target occupation that are immediately available in O*NET can be analyzed in a structured manner to provide the workplace context for rehabilitation.

Keywords

Neurorehabilitation work capacity evaluation cognitive functional capacity work disability competitive employment case study occupational information network O*NET

1 Introduction

Foundational research published recently in this journal [1] validates the practicality and utility of self-report information describing the “gap” between the client’s abilities and their job’s demands. Bridging this gap to focus on return to work involves the interdisciplinary span of responsibility depicted in the Stage Model of Work-Oriented Neurorehabilitation (WON), the most recent version of which is in Table 1 [2].

Table 1
Stage Model of Work-Oriented Neurorehabilitation

Stage Measured by or in terms of … Usual Hierarchy of Professions

8 Earning Capacity Earned income over expected work-life. RC, VE, E, OT

7 Vocational Competence Ability to perform a particular job. RC, VE, OT

6 Employability Ability to become employed in the local labor market. RC, VE, OT

5 Employment Feasibility Ability to perform fundamental work behaviors. OT, VE

4 Occupational Disability Societal & familial consequences of functional limitations. OT, RP, VE, PT, SLP, PMR

3 Functional Limitation Inability to perform component actions and tasks. OT, PT, SLP, VE, NP, RP, PMR

2 Impairment Loss or restriction of person component. N, OT, NP, PT, SLP, PMR

1 Pathology &Diagnosis Imaging, lab studies, observed signs, reported symptoms. N, NR, NP

Stage	Measured by or in terms of …	Usual Hierarchy of Professions
8	Earning Capacity	Earned income over expected work-life.	RC, VE, E, OT
7	Vocational Competence	Ability to perform a particular job.	RC, VE, OT
6	Employability	Ability to become employed in the local labor market.	RC, VE, OT
5	Employment Feasibility	Ability to perform fundamental work behaviors.	OT, VE
4	Occupational Disability	Societal & familial consequences of functional limitations.	OT, RP, VE, PT, SLP, PMR
3	Functional Limitation	Inability to perform component actions and tasks.	OT, PT, SLP, VE, NP, RP, PMR
2	Impairment	Loss or restriction of person component.	N, OT, NP, PT, SLP, PMR
1	Pathology &Diagnosis	Imaging, lab studies, observed signs, reported symptoms.	N, NR, NP

Key: N = Neurologist; NP = Neuropsychologist; NR = Neuroradiologist; OT = Occupational Therapist; PMR = Physical Medicine & Rehabilitation; PT = Physical Therapist; RC = Rehabilitation Counselor; RP = Rehabilitation Psychologist; SLP = Speech and Language Therapist; VE = Vocational Evaluator.

Each stage in the WON process addresses issues that overlap with adjacent stages, as do the primary professionals’ responsibilities. WON professionals begin the process at Stage 3 as soon as pathology and impairment are stabilized and it becomes likely that rehabilitation is necessary. At Stage 3, the patient becomes our client. At each stage, the leadership and makeup of the team adjusts to the client’s needs at that time, gradually becoming more specific about what is necessary for the client to experience safe and dependable employment.

The WON process is driven by the client’s needs. Although Stage 8 seems to be a long way from Stage 3, there is no doubt that the attention of the client and their family is focused on how the pathology and impairment will affect earning capacity. If we signal recognition and respect this central aspect of the client’s circumstance by asking, “What kind of work do you do, and how long have you done that?”, we begin to harness their motivation. This can be facilitated during the initial interview, which is today’s topic.

2 Methods

2.1 Case study selection

The case method context for today’s study is a healthy young adult whose career was jeopardized by a serious accident producing musculoskeletal, cognitive, and psychological impairments. This example helps us appreciate the situation in which a missed diagnosis of concussive traumatic brain injury creates substantial long-term consequences. Our case study’s Emergency Department professionals focused on his painful musculoskeletal injuries, so that a comorbid concussion was not identified, which months later left our client anxious and discouraged about his future.

“Johnny Mac” is a fictitious 35-year-old Surgical Assistant who was 10 years into a successful career when he was injured in a back country rock-climbing accident while on vacation in northern British Columbia. His climbing instructor dislodged a boulder that fell and hit his helmet before causing a displaced fracture of the distal radius and crush injury of the of his right dominant scaphoid. He did not lose consciousness. He one-arm-rappelled and was described on the ground as “agitated and disoriented but otherwise responsive” by the air-evacuation medical crew. Arriving at the hospital two hours after the accident, Johhny’s Glasgow Coma Scale (GCS) was 15/15. He was CT screened for a brain bleed, while the focus was on his painful hand, wrist, and cervical spine. He was observed overnight at the hospital and released to travel home with oral analgesics. Over the next few weeks, he underwent surgery for his fractures while pain was controlled with appropriate opioid cautions.

Johnny’s participation in hand therapy was excellent; he was highly motivated to get back to his career. As his upper extremity symptoms and function improved, he returned to modified work at his hospital, maintaining their “always ready” surgical suite. He continued to experience slight activity-responsive hand pain that he managed with NSAIDs. He did not participate in surgical procedures because bright lights led to a moderate headache, especially when he was fatigued. Along with the headache, Johnny reported to his primary care physician that he was “not quite right” cognitively. “I’m struggling with the pace of work when we get busy, especially late in my shift. I sometimes have to ask instructions to be repeated and I make minor mistakes that I don’t always catch. That’s not like me; I’ve always been spot-on. I’m afraid I could make a real serious mistake if I assisted an unusual or complex procedure.”

Johnny’s physician referred him to a neurologist who confirmed he likely had experienced a concussive traumatic brain injury in the climbing accident. The neurologist was especially concerned about Johnny’s errors in tasks that previously had been routine, both at home and at work. She also wanted to better understand his activity-responsive headache. She offered the opinion that Johnny appeared to be dedicated to his career and was genuinely concerned it might be in jeopardy. She referred Johnny to a consulting neuropsychologist and to a work-oriented neurorehabilitation program, requesting each to address concerns with his safety in the workplace.

2.2 What Should Johnny Expect from Us?

Before we go further in this case study, let’s examine the modern context within which Johnny’s work-oriented neurorehabilitation would unfold in a healthcare system that is properly organized, funded, and staffed.

Since the Rehabilitation professions began to develop in the early 20th century, interdisciplinary clinicians have interacted with scientists within each profession, providing ecological feedback to develop and test hypotheses that extend the biopsychosocial model [3] to include the multifaceted constructs of competitive employment. Beginning with injured World War I combatants returning to civilian life, our clients’ workplaces and the employability criteria imposed by their employers have been our ultimate context.

In the 1960’s the Rehabilitation professions began to actively participate in the international expansion of disabled persons’ civil rights, insisting on adoption of the idea that pathology and impairment do not equal disablement. Our focus has been on the fundamental right to work as necessary for first-class citizenship. In particular, we (and this Journal) have helped to expand the operational definition of “competitive employment” to include reasonable accommodations [4]. No longer can employers in the United States, Canada, Australia, New Zealand, Japan, South Korea, or the European Union demand “I’ll only accept him back to work if he’s 100% ”, without carefully considering the gap-bridging recommendations of Rehabilitation professionals [5].

So, how do we help our clients take full advantage of their civil rights to secure safe and dependable competitive employment? It takes an interdisciplinary team. Work-oriented neurorehabilitation is a complex process, and one of the most difficult and demanding experiences of our clients’ lives. Every facet of the client’s life must be addressed by rehabilitation professionals who have expertise in bridging the gap between the client’s immediate experience and the goals they value.

2.3 Development of the interdisciplinary team

In the 1960’s, great strides had been made in treating polio, spinal cord injury [6] and other serious chronic pathologies and impairments [7], but a return-to-work context for rehabilitation was not yet fully established. As an example, hospitalized patients were provided with six weeks of rest and recovery after a myocardial infarction before becoming actively involved in rehabilitation, during which the vocational focus was postponed. This rest and recovery hiatus was counterproductive when return-to-work was the focus [8].

At about this time, the Nagi Model of Disablement [9] ushered in the social ecology context in which modern work-oriented neurorehabilitation is practiced, most recently exemplified in Table 1. Social ecology presupposes meaningful employment as the sine qua non of first-class citizenship and an important resource for independence and satisfying quality-of-life.

The Nagi model described rehabilitation as the process of re-establishing full-fledged citizenship, with the role of patient and client as temporary substitutes for the person’s career role. As this model began to be adopted, interdisciplinary team members shifted our focus to include vocational outcomes and asked the patient, “What kind of work do you do and how long have you done that?” If the patient responded, “I used to be a Teacher, Accountant, or Surgical Assistant”, we recognized that something important was about to be lost. The hospitalized patient’s past tense response suggested an incipient maladaptation to the injury or illness that increased the likelihood of problems such as depression or a learned behavior pattern that we described as the symptom magnification syndrome [10]. At the very least, a past tense response suggested unexplored alternatives and options. To minimize the likelihood of untoward outcomes, early intervention with a proactive focus on appropriate return-to-work goals was necessary, centered around discussions of how the Stage 3 functional limitations might potentially impact re-employment. As we began to rely on our clients as a credible source of information about their job and the shortfalls in their abilities; task-based self-report questionnaires calibrated to work demands became readily available [11]. As part of this, we began to focus on the affordances that are available to the client and could be made available as environmental adaptations and accommodations. We educated ourselves in ergonomics and learning theory and began to educate our clients to look for and take advantage of those affordances. We asked questions such as, “What’s the best way to do this job safely and dependably for you, and economically for your employer?”

The person-centric vocational model of the 1970’s relied on the Dictionary of Occupational Titles (DOT) [12] to explore the match between the patient’s likely functional limitations and the job’s demands. This was useful for functional limitations that stemmed from musculoskeletal impairments affecting walking and lifting and carrying and could be interpreted for cardiorespiratory impairments in terms of energy expenditure, but the cognitive demands of work were not well represented. The inadequacy of this 20th century approach is highlighted by Henly [13] and by Hunt [14], foundational research that identifies the cognitive work capacities as primarily important in modern economies.

2.4 O*NET provides an interdisciplinary bridge

The modern extension of the person-centric work-related shift has resulted in the development of the Work Disability Functional Assessment Battery [15]. The WD-FAB has been recently validated for predicting unemployment by Henly [13], and will have utility in forensic rehabilitation applications that can be improved by linkages to the Occupational Information Network (O*NET). Such linkages will improve the validity and utility of the WD-FAB because the O*NET profiles of approximately 1100 Standard Occupational Classification (SOC) codes contain data that are pertinent to the bridge between the hospital and workplace. The O*NET Content Model in Fig. 1 [16] is organized in six large databases that are searchable by occupational title.

Fig. 1

O*NET content model.

Two of the O*NET databases are especially useful to identify and calibrate the client’s neurorehabilitation goals. The Worker Characteristics database provides both the importance and level of the 52 abilities of workers in each SOC, 21 of which are cognitive abilities.

2.5 Minimum O*NET ability estimates based on job task demands

The Occupation-Specific Information database includes the importance, frequency, and relevance of the core tasks for each SOC. Cross-referencing the client’s information about their job tasks with the client’s self-appraisal of the abilities they find necessary to complete those tasks is the basis of preliminary rehabilitation planning. If the client has adequate tenure in their occupation, confirmation of their pre-injury participation in the occupation’s tasks supports the professional judgment of an adequate level of pre-injury ability [14]. This is an efficient (and inexpensive) alternative to a worksite job analysis to frame functional capacity evaluation or work capacity evaluation [17]. Although it is important to undertake a worksite job analysis as the client’s return-to-work transition becomes imminent, O*NET provides sufficient task-ability data to focus our preliminary neurorehabilitation planning and sets the stage for the initial interview.

3 Procedures

3.1 Initial interview

In the initial interview with Johnny, a Structured Task Self-Appraisal (STSA) was administered. The STSA is an elaboration of the O*NET Job Performance Measure [18, 19]; both are useful. Accessing the O*NET Online Tasks database for Surgical Assistants, the clinician attempts to confirm the client’s occupational category. Table 2 presents an excerpt from a formal printout of Johny’s TSA that is importance-prioritized for the core tasks. Although a formal STSA is advised for forensic consultations, an informal approach in which O*NET Online is reviewed in real-time with the client on a computer screen or tablet is similarly effective for clinical applications.

Table 2
Importance-Prioritized Structured Task Self Appraisal (STSA)

Imp Surgical Assistant Tasks ? Able 1 2 3 4 Unable 5

99 Verify the identity of patient or operative site. Yes X

97 Monitor and maintain aseptic technique throughout procedures. Yes X

93 Cover patients with surgical drapes to create and maintain a sterile operative field. Yes X

93 Participate in positioning patients to provide exposure for the procedure or to protect against nerve or circulation impairment. Yes X

92 Maintain an unobstructed operative field, using surgical retractors, sponges, or suctioning and irrigating equipment. Yes X

91 Prepare and apply sterile wound dressings. Yes X

91 Apply sutures, staples, clips, or other materials to close skin, facia, or subcutaneous wound layers. Yes X

90 Discuss with surgeon the procedure, including methods of exposure, diagnostic or laboratory data, or other needs. Yes X

90 Determine availability of necessary equipment or supplies for operative procedures. Yes X

90 Clamp, ligate, or cauterize blood vessels to control bleeding, using clamps, ligatures, or electrocautery equipment. Yes X

89 Assess skin integrity or other body conditions upon completion of the procedure to determine if damage has occurred. Yes X

88 Assist with patient resuscitation during cardiac arrest or other life-threatening events. Yes X

87 Obtain or inspect sterile or non-sterile surgical equipment, instruments, or supplies. Yes X

87 Operate sterilizing devices. Yes X

86 Pass instruments or supplies to surgeon during procedure. Yes X

83 Monitor patient intra-operative status, including patient position, vital signs, or volume and color of blood. Yes X

81 Assist in the insertion, positioning, or suturing of closed-wound drainage systems. Yes X

Imp	Surgical Assistant Tasks	?	Able 1	2	3	Unable 5
99	Verify the identity of patient or operative site.	Yes	X
97	Monitor and maintain aseptic technique throughout procedures.	Yes		X
93	Cover patients with surgical drapes to create and maintain a sterile operative field.	Yes	X
93	Participate in positioning patients to provide exposure for the procedure or to protect against nerve or circulation impairment.	Yes		X
92	Maintain an unobstructed operative field, using surgical retractors, sponges, or suctioning and irrigating equipment.	Yes	X
91	Prepare and apply sterile wound dressings.	Yes	X
91	Apply sutures, staples, clips, or other materials to close skin, facia, or subcutaneous wound layers.	Yes		X
90	Discuss with surgeon the procedure, including methods of exposure, diagnostic or laboratory data, or other needs.	Yes			X
90	Determine availability of necessary equipment or supplies for operative procedures.	Yes	X
90	Clamp, ligate, or cauterize blood vessels to control bleeding, using clamps, ligatures, or electrocautery equipment.	Yes		X
89	Assess skin integrity or other body conditions upon completion of the procedure to determine if damage has occurred.	Yes	X
88	Assist with patient resuscitation during cardiac arrest or other life-threatening events.	Yes			X
87	Obtain or inspect sterile or non-sterile surgical equipment, instruments, or supplies.	Yes	X
87	Operate sterilizing devices.	Yes	X
86	Pass instruments or supplies to surgeon during procedure.	Yes	X
83	Monitor patient intra-operative status, including patient position, vital signs, or volume and color of blood.	Yes		X
81	Assist in the insertion, positioning, or suturing of closed-wound drainage systems.	Yes		X

The first step in his STSA required Johnny to confirm his pre-injury participation in each task. Out of the original set of 28 core tasks in the O*NET Surgical Assistant occupation, he confirmed that 24 were pertinent to his job at the hospital where he works. He reported that he also had been trained and was qualified to perform the four remaining tasks, but “I don’t usually need to do those in my hospital”.

Next, Johnny appraised his current ability to perform each confirmed task compared with his preinjury abilities using a five-point scale from “Able” to “Unable”. Johnny reported there were no tasks he was unable to do or for which he was severely restricted. He identified two tasks for which he was more than slightly restricted.

The final step in the STSA required Johnny to select the tasks for which he has the most concern as he considers returning to work. He identified five of these tasks, shaded in gray.

3.2 Ability identification for neurorehabilitation planning

Because Johnny had adequate tenure in his Surgical Assistant occupation and confirmed most of the occupational tasks as pertinent to his specific job, it was reasonable to conclude that he had adequate abilities for this occupation prior to being injured. Based on this professional judgment, Johnny’s OT turned to the O*NET Online Abilities database for Surgical Assistants. Selection of the abilities to become targets for Johnny’s neurorehabilitation program began with prioritizing the importance of the 52 abilities. For Surgical Assistants, there are 37 abilities with Importance scale scores of 50 or higher. Table 3 presents an excerpt of the 10 most important abilities for Surgical Assistants.

Table 3
Importance-Prioritized Abilities

Imp Level Surgical Assistant Abilities Ability Description

78 57 Oral Comprehension The ability to listen to and understand information and ideas presented through spoken words and sentences.

75 57 Arm-Hand Steadiness The ability to keep your hand and arm steady while moving your arm or while holding your arm and hand in one position.

75 59 Finger Dexterity The ability to make precisely coordinated movements of the fingers of one or both hands to grasp, manipulate, or assemble very small objects.

75 61 Near Vision The ability to see details at close range (within a few feet of the observer).

72 55 Oral Expression The ability to communicate information and ideas in speaking so others will understand.

72 55 Problem Sensitivity The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing that there is a problem.

72 54 Speech Clarity The ability to speak clearly so others can understand you.

69 50 Speech Recognition The ability to identify and understand the speech of another person.

69 54 Visual Color Discrimination The ability to match or detect differences between colors, including shades of color and brightness.

69 54 Written Comprehension The ability to read and understand information and ideas presented in writing.

Imp	Level	Surgical Assistant Abilities	Ability Description
78	57	Oral Comprehension	The ability to listen to and understand information and ideas presented through spoken words and sentences.
75	57	Arm-Hand Steadiness	The ability to keep your hand and arm steady while moving your arm or while holding your arm and hand in one position.
75	59	Finger Dexterity	The ability to make precisely coordinated movements of the fingers of one or both hands to grasp, manipulate, or assemble very small objects.
75	61	Near Vision	The ability to see details at close range (within a few feet of the observer).
72	55	Oral Expression	The ability to communicate information and ideas in speaking so others will understand.
72	55	Problem Sensitivity	The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing that there is a problem.
72	54	Speech Clarity	The ability to speak clearly so others can understand you.
69	50	Speech Recognition	The ability to identify and understand the speech of another person.
69	54	Visual Color Discrimination	The ability to match or detect differences between colors, including shades of color and brightness.
69	54	Written Comprehension	The ability to read and understand information and ideas presented in writing.

In O*NET Online, each ability has a brief definition combined with descriptions of three tasks that serve as behavior anchors arrayed along a gradient of difficulty. Behavior-anchored rating (BAR) scales are reliable and valid methods to quantify abilities [20, 21]. Adopted and refined for the O*NET, BAR scales provide guidance that help bridge the gap between the client’s abilities and their job’s tasks. Selection of Johnny’s likely neurorehabilitation ability targets was facilitated by his OT’s reference to the BAR scores for each ability, as in Fig. 2.

Fig. 2

O*NET oral comprehension behavior scale anchors – surgical assistants.

Selecting these abilities is a two-step process based on professional judgment facilitated by review of the Importance and Level ratings of each ability. First, the Importance rating guides the professional to exclude an ability by reference to the client’s responses to the STSA. In a clinic setting, recognizing that professional time and expense are very limited, only a few of the most important abilities that impose a task limitation will become candidates for rehabilitation. Cross-referencing the standardized ratings of each ability’s importance with Johnny’s description of task limitations he provided in the STSA, his OT identified three abilities to be considered for likely work-oriented neurorehabilitation targets. After an ability is selected to become the early clinical focus, its Level rating is used to set the program goal. The first three ability targets and the standardized scores for both the Importance and the Level of each are depicted in Fig. 3.

Fig. 3

Johnny Mac’s likely neurorehabilitation ability targets.

Because the standardized ratings of the abilities’ levels in Fig. 3 are based on quantified behavior anchors arrayed as benchmarks along a seven-point scale, Johnny’s OT can use the BAR scale markers to derive baseline estimates for each ability in a functional capacity evaluation.

3.3 Ability identification for certain forensic applications

If Johnny’s case involved a personal injury or product liability lawsuit, the STSA described above would require a much more comprehensive abilities profile. In these cases, the O*NET provides a widely acknowledged basis for the occupational context within which the triers of fact will consider the client’s Stage 8 potential loss of earning capacity. This is a key strength of the O*NET-based STSA that the WD-FAB is not designed to offer.

After the STSA confirms the job context within which the client’s lawsuit will be considered, quantification of their abilities and any pre-post injury shortfalls could be linked to the Functional Assessment Constructs Taxonomy [22] through combination of work samples, situational assessments, and the standardized performance tests [23].

4 Discussion and conclusion

Development of an early return-to-work focus is crucial for success of work-oriented neurorehabilitation. During the initial interview with a new client, the Structured Task Self-Appraisal (STSA) provides key components of a solid foundation for the bridge between the hospital and the workplace. Because it is integrated with O*NET, up-to-date information about employment, earnings, job growth, and many other resources become available to the client and professional. In situations in which the client is unable to return to their preinjury career path, information about alternatives is readily available. Because the breadth of information in O*NET supports several stages in the Stage Model of Neurorehabilitation, it is transdisciplinary and useful to the work of each of the core disciplines. Importantly, as a publicly available online resource that the client can use separately from the rehabilitation team, it facilitates their independence by providing information to help clarify and explain the pertinence of their ability strengths and weaknesses that is otherwise not available, except through a professional.

Work-oriented neurorehabilitation assessment will be the focus of our next bimonthly column. Johnny’s case study will be used to describe an evaluation strategy that sets the stage for rehabilitation planning. Using a hypothesis testing approach that gradually becomes more focused, we will begin by assessing his general executive function (GEF), followed by assessment of his general cognitive ability (GCA), leading to assessments focused on Johnny’s three O*NET ability targets. The column also will distinguish among evaluations administered by Occupational Therapists and those administered by Neuropsychologists or Rehabilitation Counselors and provide rationale and examples for each assessment.

Ethical approval

Not applicable.

Informed consent

Not applicable.

Conflict of interest

The author confirms no conflict of interest, monetary or otherwise.

Funding

None to report.

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