Return to Work After Brain Injury

Return to Work After Brain Injury

Jeffrey S. Kreutzer, Ph.D.

Virginia Commonwealth University

Medical Center

Pre- and Postinjury Work Statusof Patients Working Postinjury

Brooks, Glasgow

Proportion of Employed Patientsat Varying Times Postinjury

Brooks, Glasgow

Months Postinjury

Return to Work and Job Stability after TBIA TBI Model System Multicenter Analysis

J. Kreutzer, J. Marwitz, W. Walker,et al.Virginia Commonwealth University

Medical Center

Job Stability after TBI

Job Stability after TBI Primary Outcome Measure

Job Stability – operational definition Stably Employed - employed at

all three follow-up intervals (n=44)

Unstably Employed - employed at 1 or 2 of 3 follow-up intervals (n=35)

Unemployed - unemployed at all 3 follow-up intervals (n=50)

Employment and Productivity Status


Employment and Productivity Status


TBIMS Employment Rates 1996 and 2002 Comparisons

Perception of Problems Impeding Return to Work

no transportation bad temper no motivation can’t walk or climb

stairs depression poor vision trouble using limbs

can’t speak properly can't understand

speech memory problems seizures medical illness thinking problems

n=443

Perceived Employment Impediments

Key PointSuccessful Return to Work

holistic approaches work

best

Neurobehavioral ProblemsMost Commonly Reported 5 - 10 Years

Postinjury1. Bored2. Moves slowly3. Frustrated4. Difficulty lifting5. Writes slowly6. Reads slowly7. Poor concentration8. Trouble making

decisions

9. Tired10. Thinks slowly11. Loses train

of thought12. Easily distracted13. Impatient14. Loses balance15. Misunderstood by

othersWitol, Sander, Seel, & Kreutzer

Neurobehavioral ProblemsMost Commonly Reported More Than 10 Years

Postinjury

1. Frustrated2. Forgets reading3. Impatient4. Misunderstood5. Bored6. Loses train of thought7. Reads slowly8. Writes slowly9. Moves slowly

10. Tired11. Thinks slowly12. Thinking of the right

word13. Restless14. Trouble making

decisions15. Trouble following

directions16. Learns slowlyWitol, Sander, Seel, & Kreutzer

Most Commonly Reported Mood Problems*

Symptom 5- 10 yrs 10+ yrsbored 2.57 2.28frustrated 2.40 2.44impatient 2.20 2.33misunderstood 2.14 2.33

*among 15 most commonly reported n=97

Most Commonly Reported Slowness Problems*

*among 15 most commonly reported

Symptom 5-10 yrs 10+ yrsmoving 2.54 2.22writing 2.30 2.24reading 2.34 2.27thinking 2.27 2.19learning 2.11

Employee EvaluationSupervision Issues

Rating

1. Performs routine tasks with little or alwaysno guidance

2. Requires little supervision to alwayscomplete complex tasks

3. Willingly accepts and carries out alwaysassignments

Position Title: Executive Secretary I

Employee EvaluationTime Utilization Issues

Rating1. Able to work effectively against always

tight deadlines2. Performs effectively in pressured always

and tense situations3. Uses time in an efficient and always

productive manner4. Uses the organization’s resources always

effectively to meet deadlines


Employee EvaluationTime Utilization Issues

Rating5. Sets priorities and revises work always

plans to meet deadlines6. Works overtime to make certain always

that deadlines are met7. Punctual always8. Coordinates time away from the always

office in accordance with guidelines

Possible Ratings: Always, Usually, Rarely

Employee EvaluationKnowledge and Creativity

Rating

1. Demonstrates thorough knowledge alwaysand applies to assignments

2. Maintains conscientious effort usuallyto enhance knowledge

3. Provides and applies creative usuallysolutions to assignments


Employee EvaluationPerformance Quality Issues

Rating1. Thorough and accurate in

usuallycompleting assignments

2. Attentive to detailusually

3. Maintains acceptable production usuallyrate without sacrificing quality

4. Reliablealways

Possible Ratings: Always, Usually, Rarely

Employee EvaluationPerformance Quality Issues

Rating5. Answers calls promptly and takes always accurate messages6. Demonstrates good follow-through always

on assignments7. Adapts and copes well with always

changing situations8. Written communication is organized, always

grammatical, and accurate


Rating1. Active in providing phone coverage always

to the team2. Offers assistance to team members always

and supports “team concept”3. Resolves conflict in a professional usually

manner

Performance EvaluationProfessionalism



Recognize that employee evaluations often emphasize performance speed


Some jobs and work environments are more disability-friendly than others

Vocational

Demands and

OutcomeSuccess in higher status occupations is more difficult because of lower error tolerances

Key Point

Vocational Tasks for Persons with Severe Disabilities

Typing & word processing

Computer data entry Photocopying Phone answering Collating & stapling Mail preparation Filing

Packaging & unpacking

Pricing Delivery Light assembly Light cleaning Microfilming Food preparation

Experience tells us that people with even the most severe disabilities can succeed at working -

The personal qualities of successful workers are well known.

Personal qualities are different than work skills.

You have the ability to change the kind of person you are, and to succeed at work.

How

so?

“Am I Ready To Work ?” TestTrue or False?

I know my strengths and limitations.

I have clear goals and focus on making things better.

I keep trying even when things seem difficult.

I try to learn from my mistakes.

“Am I Ready To Work ?” TestTrue or False?

I am willing to admit when I make a mistake.

I am willing to ask for help.

When people ask if I need help, I respond politely.

When people talk, I make sure to listen.

“Am I Ready To Work ?” Test True or False?

When I’m not sure how to do something, I ask.

I look for the positive in other people and situations.

I’m polite and respectful to others. I can learn a lot from other people. I’m thankful when people offer me

constructive feedback.

“Am I Ready To Work ?” Test

True or False? I do my best to be patient with

myself, my goals, and other people.

I pay attention to how I’m feeling. I work hard to control my

discouragement and anger. I think about other people’s

feeling.


I can clearly see the benefits of work.

Outside of work, I try to do things that are good for me.

I choose to spend time with people who can help me reach my goals.


I am an important and responsible member of my treatment team.

I communicate my feelings, needs, concerns, and ideas.

I understand that success at work means more than just doing my job.

Vocational Planning and Counseling

Jeffrey S. Kreutzer, Ph.D., ABPPVCU Health System

Case Planning Issues

Should I choose to help this person find and keep a job?

What goals and time frames are practical?

What do I need to be concerned about or sensitive to?

Client FactorsCharacter, Personality, Intellect,

Skills, and Health

Work ethic, attitude, desire for success Stamina, sleep, pain, and health Transportation independence Stress and frustration tolerance Control of sexual and aggressive impulses Ability to accept diminished skills and

potential

Client FactorsCharacter, Personality, Intellect,

Skills, and Health

Interpersonal and negotiation skills Responsiveness to feedback Neuropsychological functioning Adaptability Loyalty to employer

Client FactorsSituational

Immediate and long-term financial needs

Expense of working Accumulated benefits and

other pressures to remain Consistency between career

plans, hopes, and available options

Retirement plans

Work Responsibilities and Environmental Factors

Dangers Cost of making mistakes Job complexity and demand on

workers Flexibility in scheduling and

assigning responsibilities Organizational stability Noise, distractions, and ambience

Colleague and Supervisor Factors

Presence and level of supervision Morale Attitude toward people with

disabilities and willingness to be supportive

Employee evaluation and feedback system

Competitiveness Tolerance of individual differences

Community Factors Demand for workers Accessibility Presence and types of local

businesses Availability of medical and

rehabilitation resources Cost of living and average wages

Return to WorkAssessment

Jeffrey S. Kreutzer, Ph.D., ABPPVCU Health System

Assessment ComponentsInterview or Questionnaire Format

conditions for return to work

responsibilities schedule safety issues

work environment

relationship with your supervisor

goals and job security

Conditions for Return to Work

Has your doctor or employer set any conditions for your return to work?

If yes, describe conditions……. How long do you feel that you need

before you can return to work part-time? How long do you feel that you need

before you can return to work full-time?

Responsibilities What is your job title? Do you have a

written job description? If yes, please provide a copy.

Is driving required for you to perform your job? Will transportation be an issue if you return to work? How will you get to work?

Describe job responsibilities and indicate most important.

Responsibilities Do you have contact with customers? If

yes, please describe. Do you have contact with other workers?

If yes, please describe. Do you supervise other workers? If yes,

please describe? What equipment do you use on your job?

Describe any training or qualifications to use equipment.

Schedule How many hour per week

are you required to work? Are you required to work overtime? Would you be allowed to work part-time? Are you required to work swing-shifts? How much flexibility would you be allowed

in your schedule to accommodate breaks, doctors appointments, not feeling well?

Safety Concerns Is your job dangerous? If yes, how? Do you use dangerous equipment on

the job? If yes, describe. Do other employees use dangerous

equipment? If yes, describe. Have you or others been injury at work?

If yes, please explain (e.g., how often).

Work Environment Are there other people in the

workplace who have had serious injuries and return to work? If yes, how have they been treated?

Do you have concerns about how you would be received by co-workers if you returned to your previous position? If yes, explain.

Relationship with Your Supervisor

How frequently have you had contact with your supervisor since your injury?

What does your supervisor know about the injury?

What was your relationship with your supervisor like before the injury?

Relationship with Your Supervisor

What feedback has your supervisor given you since your injury?

Has your supervisor offered to change your responsibilities or position so that you can do your job? If yes, how?

Goals and Job Security

What do you see as your biggest challenges in return to work?

Describe your career goals and whether they have changed since the injury.

Do you feel that you will have a secure job if you return to work? If not, why not?

The Potential Family Role

They can ...facilitat

eignoreimpedesabotag

e

The process of ... job

developmentjob matchingplacementmaintenance

Family members often need help understanding the demands of a job ...

I know he can’t remember what day it is

Still, why couldn’t he run a nuclear plant?

Employment Can Increase Family Employment Can Increase Family Members’ Stress LevelsMembers’ Stress Levels

need for transportation assistance

caretaker’s resumption of former work responsibilities

redistribution of injured person’s responsibilities

daily apprehensions about client’s failures or termination

Employment Interference by Family Members

Communicating and emphasizing personal fears about failure

Over-protectiveness - calling employer, following patient, questioning

Telling client he’s too good for the job Demanding better performance Failing to acknowledge client’s gains and

hardships

Skepticism about the value of intervention often increases as a function of time post-injury

Gain an understanding of the family’s

past experiences with rehabilitation professionals

personal expectations for the process and outcome of intervention

Leave the family out ...

When intervention fails and when

the personal problems of the personal problems of family members exceed their family members exceed their potential contribution orpotential contribution or

family members clearly family members clearly indicate a desire to sabotageindicate a desire to sabotage

Employment Enhancement by Family Members

Acknowledging and emphasizing client’s efforts and successes

Encouraging communication Promoting in-home generalization of

cognitive and behavioral interventions

Encouraging abstinence from alcohol

Employment Enhancement by Family Members

Acknowledging personal impact of employment process

Understanding interactions between client, family, and personal goals

Moderating feedback and offers of assistance

Aiding participation in alcohol-free social and recreational opportunities

Building Family Trust Set realistic goals and expectations Acknowledge potential benefits and

limits of intervention Maintain ongoing communication Follow through with agreements

A written program description and contract helps establish and document agreements

Supported Employment Methods

and Models

Jeffrey S. Kreutzer, Ph.D., ABPPVirginia Commonwealth

University Medical Center

Attributes of Employment Models

employees’ level and type of disability nature of supervision and support resources work responsibilities for workers and

supervisors level of compensation and benefits workers’ relationship to host company number of work sites level of community integration and visibility

SupportedEmployment Models

enclave mobile work crew small business sheltered workshop co-worker training center based training individualized supported

employment

Enclave Characteristics

Structure - special training group, 3 - 8 persons working in community based industry

Supervision - permanent, full-time, on site Incentives - pay and benefits based on

productivity; commensurate with other workers Workers - paid by host or support company Supervisor - paid by support company

Enclave Advantages intensive supervision allows hiring persons with

very severe disabilities employee improvement and supervisor fading

not required greater likelihood of co-worker stability and

support supervisor can oversee more than one worker potential for good pay and benefits especially

when host is larger company

Crew - one or two supervisors, 3- 8 persons with disabilities

Operate from a van, frequent traveling to provide contract services at many different sites

Common services - grounds keeping, landscaping, custodial, painting, farm labor, snow removal

Model works well in rural areas and small communities

Mobile Work Crew Characteristics

Mobile Work Crew Characteristics

Some workers not fully productive; increasing supervision and public funding needs

Business status typically “not for profit”

Successful marketing and contract negotiation required

Mobile Work Crew Advantages

Contracting allows flexibility based on community needs

Community travel stops facilitate integration

Public work allows citizens to see persons with disabilities working productively

Cost efficient after start up because of low overhead

Small Business or Entrepreneurial Option

Characteristics Workers - eight or less; having most

severe disabilities Supervision, very close with ongoing

behavioral programming Business type - manufacturing or

contractual Single business may be constituted of

several linked sites

Small Business or Entrepreneurial Option

Characteristics Business plan addressees marketing, sales,

production, documentation, quality control Social integration by setting site nearby

other businesses, restaurants, stores, recreation sites

Cost comparable to day treatment or day rehabilitation program

Compared to sheltered workshop - smaller number of employees with greater disabilities

Sheltered Workshop

Workers with severe and varied disabilities Supervisors - usually more than one Close supervision includes behavior

management Work type - light assembly, printing and

duplication, mailing, clerical Incentives - pay less than minimum wage

based on productivity, few benefits if any

Sheltered Workshop

Management - one or more staff may focus entirely on business operations

Single site usually zoned for business or light industry

Common complaints -– workers feel “unproductive” – extreme segregation – limited options for work responsibilities– concerns about poor models for behavior

Co-Worker Training Employment Model

Experienced employees become primary providers of on the job training and support

Employment specialists train experienced employees

Employment specialists serve as consultants, mediators, and data collectors

Center Based Rehabilitation

ReferralReferral

Extensive Assessme

nt

Extensive Assessme

nt

PlacementPlacement

6 – 12 week follow-up

6 – 12 week follow-up

Eliminate Poor Risks

Eliminate Poor Risks

Extensive Vocation

al Training

Extensive Vocation

al Training

Supported Employment

ReferralReferralBrief Holistic

Assessment

Brief Holistic

Assessment

Follow-along long-term

Follow-along long-term

Job Analysis, Matching,

Development

Job Analysis, Matching,

Development

Placement

Placement

interdisciplinary rehabilitation

counseling and behavioral services

case coordination

recreational programs

social programs

substance abuse treatment

Disincentives

Loss of disability income Loss of medical

insurance Fear of stress or failure Loss of “helpless role” Lower pay rate and job

status

Job Analysis Required cognitive, academic, technical,

interpersonal skills Transportation needs and skills Stamina and endurance requirements Health code requirements Level of independence and available

supervision Environment - noise and safety issues

Principles of Shared Responsibility

Include persons with brain injury and their families as equal partners

Develop services by preparing supports not people

Establish and maintain relationships with funding and service agencies

Efforts toward improved quality of life

Job Development Seek available jobs

Contact past and new potential employers

Observation and analysis of job site

Ongoing communication with client, family, and rehabilitation providers

Job matching employers needs with client’s skills and interests

Vocational Tasks for Persons with Severe Disabilities

Typing & word processing

Computer data entry Photocopying Phone answering Collating & stapling Mail preparation Filing

Packaging & unpacking

Pricing Delivery Light assembly Light cleaning Microfilming

New Employer Contacts

Job hotlines Help wanted ads Personal contacts Government vacancy listings Referrals from other employers College career planning and

placement offices

Research indicates that persons with disabilities are

more ...

highly motivated

dependable likely to stay in

their positions longer

than persons without disabilities

Why hire ‘em?

On-Site Intervention Unobtrusive involvement in

training work-related skills Compensatory strategies development Promoting positive collegial and supervisor

relationships Stress inoculation Problem solving interactions

emphasizing positive feedback Phase-out with mastery

Job Adaptation and Support Methods

use assistive devices develop or enhance cues rearrange work environment change task sequence or eliminate

difficult steps arrange for co-worker to complete task

Job Site Enabling

if a work skill or task can be taught - teach it

if it can’t be taught, adapt it if neither teaching nor

adapting are successful, support it

Box 980542, Richmond, VA 23298-0542USA PH 804 828-9055

Jeff Kreutzer [email protected]

Virginia Commonwealth UniversityMedical Center

The National Resource Center for Traumatic Brain Injury www.neuro.pmr.vcu.edu

Documents

Return to Work After Brain Injury