Early vocational intervention for people who have experienced trauma

Currently most vocational rehabilitation services do not commence until after the injured individual has been discharged from inpatient treatment (i.e., for traumatic brain injuries(TBI), spinal cord injuries (SCI) or orthopaedic injuries). We will be recruiting participants to the study early in their inpatient hospital stay, but only after they are medically stable and, in the case of patients with TBI, have emerged from post-traumatic amnesia and are cognitively competent to give consent to participate in the study. If they are randomised to receive the early intervention vocational (EIVR) therapy, discussions will commence immediately after they have given consent to participate in the study, regarding the nature of their pre-injury employment, duties and hours, motivation to return to or engage in work. There will be discussion of current barriers and potential timelines for return to work. These first interactions will focus on establishing rapport, providing an opportunity for the worker role to be acknowledged and understood, introducing the EIVR service, and normalising return to work as an expectation and a goal that can be part of inpatient rehabilitation. When appropriate, permission will be sought from the participant for the EIVRS therapist to contact the employer. The EIVRS service or the participant (where appropriate) will contact the employer to open communication lines and explain the nature of the participant’s injuries, process for return to work and possible timelines for return to the workplace, as well as potential barriers. Options for work adaptations including alternative or modified duties, hours or roles will also be discussed. The timing of this contact with the employer will be a distinguishing feature from treatment as usual as this does not commonly occur until a later stage of vocational rehabilitation. Following early interactions, tailored interventions are customized to the unique circumstances of the individual by the vocational consultant and discussed with the treating therapists. A vocational rehabilitation plan will be prepared to address these issues and motivational interviewing provided to the participant. If deemed necessary, referral will be made for cognitive behavioural therapy to address psychological issues that may impede return to work, such as PTSD, anxiety or depression. The EIVRS clinician will continue to liaise with the treating therapists through attendance at case conferences to review progress towards these goals up to the time of discharge. With the participant’s permission they will also maintain contact with the employer during the rehabilitation process to keep them informed. If the participant is assessed as work ready during the in-patient stay and the employer is agreeable, a graded RTW program may be facilitated by the EIVRS clinician. The EIVRS will be an allied health professional (likely to be an OT) with experience in or knowledge of inpatient trauma rehabilitation, vocational rehabilitation and/or rehabilitation counselling. The EIVRS is planned to be delivered as an in-patient service. On discharge, participants will then have access to the usual vocational services either provided by the facility or a community based specialised vocational services. Access to this service is usually available until a return to work outcome is achieved and is not time limited. The number of EIVRS sessions cannot be specified as this will depend on what is clinically relevant for each individual. It will most likely range, on average, between 5 and 10 sessions over the course of the program. The number of sessions will be documented. Sessions will be face to face however employer contact is likely to be over the phone. Session duration will depend on what is clinically relevant for that individual at that particular time and may vary according to what the patient can tolerate, how complex the work situation is and what the goal of the session is (to establish rapport, obtain a detailed description of the pre-injury role etc). They will most likely range between 20 minutes and 90 minutes, on average. Session timing and duration will be documented. The therapist will contact the employer as early as possible in the inpatient rehabilitation process. However, they will not contact the employer until permission is provided by the patient. The timing of this will vary from one individual to another, but can depend on whether the employer has been asking the patient for information, whether the patient is anxious about their job and the therapist to contact the employer. It will be up to the patient to decide whether they are comfortable with the therapist talking to the employer of whether they prefer to make contact themselves. The time of initiating employer contact will be documented. To monitor fidelity to the intervention, the therapist will keep a record of each session using the EIVRS – session record form. In addition fidelity of the intervention will be monitored using the EVIR therapist activities – monitoring form. The tailored interventions are not part of usual care in most sites as they are not normally provided whilst the patient is an inpatient. The tailored intervention includes contacting patients early while they are inpatients (rather than waiting until they are outpatients). These are the phases of the intervention: i) relationship building, education and information; ii) liaising with employer, family and treating team; iii) establishing and monitoring the return to work program; iv) follow-up Please note, the graded RTW program is part of standard clinical care.