Sustaining employment after supported employment in adults with acquired brain injury

Modem Vocational Rehabilitation Programmes support individuals with Acquired Brain Injury (ABI) by using Job coaches who provide support both in placements and employment. This has improved return to work to around 70% compared to around 20 - 50% previously. But the reasons for success of this supportive process are not clear. Quantitative studies have attempted to correlate factors associated with employment, but results have been variable and conflicting. Long term data regarding sustaining employment is sparse. An exploratory study reported that around 26% of those who return to work could not sustain employment. Job coaches reported that this occurred because of dysfunctional interpersonal relationships (misinterpretation of social cues, interpersonal conflict and inappropriate verbalization), substance abuse, criminal activity, poor employment settings and economic disincentives. This study was built on the exploratory data and examined the area of sustaining employment in detail with the aim of developing a conceptual model. A flexible, eclectic design based on multiple case studies was used.. Eight individuals with ABI were purposively selected along with a family member, employer or co-worker and job coach. Triangulation, respondent validation, peer debriefing and reflexivity were used to reduce bias and improve validity. Twenty nine semi-structured interviews were conducted. Transcripts were analysed for topics which were directly linked to sustained employment. Ideas which were directly associated by text were extracted. These concepts were used to develop a conceptual model. Bo-psychological concepts which helped to sustain employment emerged from the research. This included the beneficial use of unconditional motivation, coping skills and pre-injury work and leisure interests. Pre-injury interests also demonstrably improved motivation. Social concepts re-emphasised support from the employer or co-worker, support from the vocational rehabilitation programme and from the work place. An opt-out follow up pattern was proposed i.e. follow up is continued until individuals with ABI choose to opt out. The conceptual model proposes a cyclical continuum rather than a staged and linear approach. It advocates a greater role for employers and co-workers (pre and post-injury) in the process of employment. The conceptual model challenges current practice: it recommends assessments of bio-psychological factors. It advocates greater integration at all levels. It also opens out research challenges in the areas of development of assessment tools for bio-psychological factors, comparison with services available for the unemployed in the general population and transferability of these findings to other projects and similar situations in ABI rehabilitation. It challenges current perceptions by demonstrating that individuals with ABI can be outstanding employees