Practice Evaluation
In response to an increase in requests for vocational interventions to an
outpatient occupational therapy department, an audit was carried out over
a 6-month period to determine the size and nature of this demand and the
outcome of the service provided.
The department provided rehabilitation principally to patients aged 16 to
65 years and, of 118 consecutive referrals, 76 (64%) included requests for
work-related interventions. By the end of the audit period, 46 had returned
to work, 21 were receiving ongoing vocational input and 9 had decided not to
pursue employment. The value of addressing vocational issues within a general
rehabilitation programme at an early stage after injury or illness is discussed.
Occupational Therapy and Vocational
Rehabilitation: an Audit of an Outpatient
Occupational Therapy Service
Lynne Main and Jane Haig
Introduction
Return to work is a recognised goal of rehabilitation
(Johansson and Bernsprang 2001, Corr and Wilmer 2003,
Yorkston et al 2003, Davis and Rinaldi 2004) and, in the
absence of a vocational rehabilitation specialist, the task of
addressing vocational issues often falls to the occupational
therapist. This is appropriate because occupational therapists
have an understanding of the relationship between the
individual’s medical condition, functional abilities,
psychosocial status and work demands (Stuckey 1997).
There are increasing reports of successful projects by the
profession in this area (Sample and Rowntree 1995,
Partridge 1997, Joss 2002, Chappell et al 2003, Brewin
and Hazell 2004, Jackson et al 2004). However, without
specific provision in terms of occupational therapy staff
numbers, there is a danger that interventions will not
meet the patients’ needs.
The Astley Ainslie Hospital, Edinburgh, provides
post-acute rehabilitation for adults mostly aged
16-65 years in a number of specific diagnostic groups,
including neurological conditions, stroke, acquired brain
injury, amputation, cardiac conditions and chronic pain.
The outpatient occupational therapy resource consists
of a 1.8 whole-time equivalent (wte), of which 0.3 wte is
designated for the cardiac service, 0.5 wte for acquired
brain injury and the remaining 1 wte for all other cases.
Patients are seen on an individual and a group basis and
are offered a variety of interventions, including community
living skills, cognitive rehabilitation, physical rehabilitation
and advice on return to work and leisure activities.
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British Journal of Occupational Therapy June 2006 69(6)
Referrals consist of people discharged from inpatient care
and outpatients seen in consultants’ clinics.
The referrals made to the outpatient occupational
therapy service have risen steadily over the last 5 years.
The possible reasons for this include shorter hospital
admissions (Joss 2002), increased survival rates following
an injury or illness (Thurman et al 1999, Howard et al
2001) and the introduction of more community-based
resources aimed at the prevention of acute hospital
admissions. The nature of referrals has also changed, with
an increasing number of people requesting occupational
therapy intervention aimed specifically at return to work.
Such interventions have included an analysis of work
skills, the practice of work-related tasks, advice on a
graded return, adaptations to the workplace or job and
communication with the employer.
This paper describes an audit of the vocational
rehabilitation aspects of the outpatient occupational
therapy service over a 6-month period. The principal aims
were to determine the size and nature of the demand for
return-to-work interventions and to gauge whether these
were effective. For the purpose of the report, the term
‘vocational rehabilitation’ encompasses interventions
aimed at a return to paid employment, voluntary work
and /or further education.
Method
All people referred to the outpatient occupational therapy
service for the 6-month period from October 2002 to
Results
A total of 118 referrals was received by the outpatient
occupational therapy service during the 6-month audit period.
Of these, 76 (64%) patients required interventions related to
return to work and they represent the study population.
Patient data
All patients were aged between 16 and 65 years (mean age
35 years); 51 (67%) were male and 25 (33%) female. The
diagnoses are summarised in Table 1 and the pre-injury
employment status in Table 2.
Table 2. Employment status pre-injury (n = 76)
Employment status
Number of patients
Full time ............................................................................53...................
Part time..............................................................................5...................
Self-employed ......................................................................5...................
Student................................................................................2...................
Unemployed ......................................................................11...................
Vocational interventions
Initial assessment included determining each person’s
employment status at the time of referral to the outpatient
service; the results are given in Table 3. The decision as to
whether or not an individual was considered as ‘ready for
work’ was made by the treating occupational therapist.
This was based on detailed information from the person
regarding the nature of his or her employment and the
therapist’s evaluation of the person’s medical condition,
physical and psychological status and functional abilities.
Table 3. Employment status at time of initial assessment (n = 76)
Employment status
Number of patients
Employed and ready for work .............................................11...................
Employed but not ready for work........................................51...................
Unemployed and ready for work...........................................1...................
Unemployed but not ready for work ...................................10...................
Unlikely to return to work.....................................................3...................
The actual interventions used varied according to
individual needs and employment status at the time of
initial assessment. Sixty-two (82%) of the 76 patients
were identified as requiring a prevocational treatment
programme in an attempt to improve their readiness for
work. In others, a graded return to work, a change to
the workplace or other measures were advised. Fig. 1
indicates the range of interventions used.
Fig. 1. Occupational therapy intervention (multiple answer,
numbers refer to numbers of patients) (n = 76).
70
Number of patients
March 2003 were assessed to determine whether
return-to-work interventions were required. The trust’s
Quality and Effectiveness Department, which assisted
with the study design and data analysis, stated that no
separate ethical approval was required because the patients’
assessment and treatment would remain the same and all
information would be held by the occupational therapist
delivering the service. The patients were informed that an
audit was being carried out and that any results would
respect anonymity and confidentiality.
A combination of quantitative and qualitative data was
collected. For the former, a proforma sheet was devised
consisting of three sections: patient data (age, diagnosis
and gender); vocational intervention (job evaluation,
workplace assessment, practice of work-related tasks,
graded return and liaison with employer); and outcome at
discharge from occupational therapy (that is, work status).
The qualitative data consisted of a patient questionnaire,
which addressed the individual’s understanding of the
interventions and his or her satisfaction with the service
provided. This questionnaire was issued only to those
whose vocational interventions had been completed by the
end of the audit period. The patient completed this
questionnaire anonymously and sent it directly to the
Quality and Effectiveness Department.
The data from the proforma sheet and the
questionnaire were scanned using the Statistical Package
for Social Sciences (SPSS 2002, Watson 2003) to reduce
any potential for bias and improve reliability.
A small-scale pilot study was completed prior to
commencing the audit project. The aim of this was to
review the brevity and clarity of the questions and the
length of time taken to complete the proforma sheet and
the questionnaire. Both were amended accordingly.
62
60
50
40
30
26
25
20
14
10
4
0
Referral to other Graded return
support services
to work
programme
Prevocational
treatment
programme
Workplace
assessment
Liaison with
employer
Intervention
Table 1. Diagnostic groups (n = 76)
Diagnosis
Number of patients
Brain injury ........................................................................31...................
Cardiac ..............................................................................16...................
Cerebrovascular accident....................................................16...................
Neurological (e.g. Parkinson’s disease,
multiple sclerosis, tumours) ..................................................7...................
Chronic pain ........................................................................5...................
Amputees / locomotor...........................................................1...................
In 26 instances, it was considered appropriate to refer
the person on to other agencies. The key services identified
were Moving into Work (a vocational support service for
patients aged 16-35 years who have an acquired brain injury);
disability employment advisers based at job centres; further
education colleges; and the employer’s occupational health
service. An ‘other’ category was provided for services not
British Journal of Occupational Therapy June 2006 69(6)
289
highlighted on the main list; these included referral to a
community occupational therapist for the provision of
assistive equipment, a pain management programme or a local
day centre. The results of this section are shown in Fig. 2.
Fig. 2. Referral to other support services (multiple answer) (n = 26).
Number of patients
8
7
7
6
6
5
5
5
4
4
period). Twenty-nine (43%) completed the questionnaire
and all were aware that the occupational therapist was
addressing return-to-work issues in therapy sessions. The
patients were asked to identify the specific interventions
received and the results are displayed in Fig. 4.
When asked to rate the occupational therapy sessions
in terms of usefulness regarding assisting their return to
work, 24 (83%) of the 29 patients rated them as very
useful, 2 (7%) as fairly useful, 1 (3%) as not very useful
and 2 (7%) gave no response.
3
Discussion
2
1
0
Moving into
work
College
Disability
employment
advisers
Occupational
health
Other
Service
Outcome at discharge from occupational
therapy
Finally, the employment status at discharge from the
service was determined and this is summarised in Fig. 3.
Fig. 3. Outcome at discharge from occupational therapy (n = 76).
Ongoing
(8)
Decided not to
pursue employment
(9)
Returned to work
(46)
Continued support
from other service
(13)
Questionnaire results
Of the 76 patients in the study, 68 (89%) were issued with
the patient questionnaire (8 patients were excluded because
their treatment was continuing at the end of the audit
Fig. 4. Patients’ understanding of occupational therapy
intervention received (multiple answer) (n = 29).
20
Number of responses
18
18
16
14
13
14
13
12
10
8
8
6
5
4
3
2
0
Visit
Prevocational Contact
treatment employer workplace
programme
Arrange
a graded
return
to work
Suggest
changes
to current
job
Refer to
another
service
Answer given
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British Journal of Occupational Therapy June 2006 69(6)
Other
The audit showed that almost two-thirds of the patients
referred to the outpatient occupational therapy service
required advice and interventions regarding a return to
work. The nature of the interventions varied and included
specific training to improve work skills, a graded return
to employment and changes to the workplace or working
conditions. Negotiating with employers or other agencies
was also often involved. Although vocational issues have
always been accepted as part of the overall remit of the
outpatient occupational therapy service, it has frequently
been perceived as a lesser part of the workload than
interventions aimed at improving basic activities of
daily living skills.
The success found in the return to employment or
education was encouraging. In 65 cases, jobs or college
placements were kept open for people while they were
attending rehabilitation and 46 of them successfully
returned to their previous vocational pursuit. Another
eight were still receiving input at the end of the audit
period and were expected to be able to get back to their
posts. This would support the argument for early intervention
and speedy placement back into the familiar employment
role whenever possible. As Brewin and Hazell (2004) have
reported, support at an early stage can prevent problems
being encountered on returning to the person’s previous
position. Boschen (1989, p260) emphasised the importance
of early intervention, stating: ‘Timeliness of treatment is
the single most important consideration in rehabilitating
an injured employee.’ Many of the patients in the audit
had themselves prioritised return to work as a goal of
their rehabilitation and the incorporation of vocational
issues in their occupational therapy programme was likely
to encourage active participation. Early return to work,
where possible, may also avoid long periods of inactivity,
with loss of confidence and self-esteem.
The relative success in helping people to return to
employment demonstrated by the audit cannot be
attributed solely to occupational therapy because some
patients received additional input from other allied health
professions, such as physiotherapy and speech and
language therapy, and from neuropsychology. These
professions adopt a team approach wherever possible and
appropriate, but the occupational therapist usually takes
the lead responsibility for coordinating vocational issues.
It was also evident that some individuals were not
successful in returning to, or finding, employment within
the 6-month period that the audit covered. A detailed
investigation of the reasons for this was not possible, but
it was felt that it related principally to the severity of the
individual’s disability. Inevitably, a proportion of patients
with impairments resulting from conditions such as
acquired brain injury or stroke will be unable to return to
employment, even with a change of role or working
conditions. Some patients appropriately opt for retirement
on medical grounds and the occupational therapist’s task
then alters to focus on recreational or other interests as
part of their programme. There were also individuals who
were long-term unemployed which, when coupled with
their newly acquired cognitive and /or physical problems,
made the task of finding employment extremely difficult
in the service currently provided.
As well as providing information about the size and
nature of the demand for vocational rehabilitation, the
audit has demonstrated some of the limitations of the
service. The interventions appropriate to assist people to
return to work, such as negotiations with the employer,
workplace visits and the accurate evaluation of the exact
nature of an individual’s work, are often time consuming.
It is the authors’ opinion that the occupational therapist
working in a post-acute setting is the appropriate person
to assess and advise on occupational matters and it should
be part of the routine service. However, some dedicated
resources are required, principally in terms of an increase
in the therapy time available. An alternative would be to
develop the case for a post that deals exclusively with
employment matters. In the United Kingdom, unlike
some other western countries, specialist vocational
rehabilitation practitioners are scarce and rarely found as
part of the multidisciplinary rehabilitation team. When
available, they are often a separate service to which the
team refers the patient. Prior to this referral, there still
needs to be the assessment and selection of patients for
this service and this is usually an occupational therapist’s
task. This process is also likely to incur delays in the
individual getting back to work.
From the experience with the audit, the authors intend
to modify their practice slightly by giving priority to
identifying and addressing employment issues as soon as
possible. They will also continue to press for increased
staff to improve the quality of the service that they are able
to offer. Finally, it is their intention to continue to audit
the vocational rehabilitation practice but to focus on
particular diagnostic groups, initially acquired brain injury
and stroke, and to take more detailed information
regarding the actual hours of time required per patient to
provide this service.
Conclusion
Return-to-work issues were identified as important in the
rehabilitation programme of two-thirds of those patients
referred to the outpatient occupational therapy service. In
many cases, the timely provision of a range of vocational
interventions assisted in getting people back to employment
or education. It is contended that vocational rehabilitation
can be achieved within a service such as the one audited
and, indeed, that such rehabilitation should be an integral
part of an outpatient occupational therapy service.
Acknowledgements
The authors would like to thank the following people, without whom this
audit would not have been completed: Dr Brian Pentland, Dr Stephen
Smith, Carole Downie, Pauline Hannah, the Clinical Governance Team at
Edenhall Hospital, Caroline Crow and all the patients who agreed to
participate in this audit.
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Authors
Lynne Main, BSc(Hons)OT, Senior Occupational Therapist, Occupational
Therapy Department, Astley Ainslie Hospital, 113 Grange Loan,
Edinburgh EH9 2HL. Email: lynne.main@ipct.scot.nhs.uk
Jane Haig, DipCOT, MSc, Senior Occupational Therapist, Occupational
Therapy Department, Astley Ainslie Hospital, 113 Grange Loan,
Edinburgh EH9 2HL. Email: jane.haig@ipct.scot.nhs.uk