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Timothy E, Bourke J, Dunn J, Martin R, Nunnerley J. United and flexible: a collaborative approach to early vocational rehabilitation on a spinal unit. A realist study. Spinal Cord Ser Cases 2023; 9:33. [PMID: 37443167 PMCID: PMC10344866 DOI: 10.1038/s41394-023-00587-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 05/26/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
STUDY DESIGN Qualitative study using realist review. OBJECTIVES To conceptualise how Early Intervention Vocational Rehabilitation (EIVR) functions within inpatient multidisciplinary contexts during spinal cord injury (SCI) rehabilitation. SETTING New Zealand Spinal Unit. METHODS People with newly acquired SCI and members of their rehabilitation team were observed in a range of rehabilitation sessions, team meetings and therapeutic interactions. Participants were also interviewed to explore how EIVR functioned alongside the multidisciplinary team (MDT). Interviews and observations were transcribed, coded and analysed using realist methods. RESULTS We identified three primary contexts which influenced how EIVR was delivered within the MDT: (1) a united approach, (2) a flexible approach, and (3) a hesitant approach. These contexts generated four work-related outcomes for people with SCI; enhanced work self-efficacy, strengthened hope for work, maintained work identity, and the less desirable outcome of increased uncertainty about work. CONCLUSIONS To optimise work outcomes for people after SCI, it is important to consider how EIVR is delivered and integrated within the wider MDT. Such an understanding can also inform the establishment of new EIVR services in different settings. Results suggest that unity, flexibility and clarity between EIVR services and the wider MDT are essential foundations for supporting people with SCI on their journey to employment. SPONSORSHIP This research was funded by Health Research Council NZ grant in partnership with Canterbury District Health Board.
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Affiliation(s)
- Emily Timothy
- Burwood Academy | Hā-i-mano, Christchurch, New Zealand.
| | - John Bourke
- Burwood Academy | Hā-i-mano, Christchurch, New Zealand
- John Walsh Centre for Rehabilitation Research, Northern Sydney Local Health District, St Leonards, NSW, Australia
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jennifer Dunn
- Department of Orthopaedic Surgery and Musculoskeletal Medicine | Te Tari Hāparapara me te Whaiora Ua-kāhiwi, University of Otago, Christchurch, New Zealand
| | - Rachelle Martin
- Burwood Academy | Hā-i-mano, Christchurch, New Zealand
- Rehabilitation Teaching and Research Unit | Te Whare Whakamatūtū, University of Otago, Wellington, New Zealand
| | - Jo Nunnerley
- Burwood Academy | Hā-i-mano, Christchurch, New Zealand
- Department of Orthopaedic Surgery and Musculoskeletal Medicine | Te Tari Hāparapara me te Whaiora Ua-kāhiwi, University of Otago, Christchurch, New Zealand
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Dunn JA, Martin RA, Hackney JJ, Nunnerley JL, Snell DL, Bourke JA, Young T, Hall A, Derrett S. Developing A Conceptual Framework for Early Intervention Vocational Rehabilitation for People Following Spinal Cord Injury. JOURNAL OF OCCUPATIONAL REHABILITATION 2023; 33:179-188. [PMID: 35927599 PMCID: PMC10025215 DOI: 10.1007/s10926-022-10060-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/18/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Early intervention vocational rehabilitation (EIVR) can improve return to work (RTW) outcomes for people with spinal cord injury (SCI). However, mechanisms explaining how and why EIVR works are not well understood. This study aims to develop a conceptual framework describing key mechanisms of EIVR intervention effect following SCI. METHODS We synthesised data from a realist literature review with data from interviews of people with SCI (n = 30), a survey of people with SCI who had received EIVR (n = 37), a focus group of EIVR providers and a focus group of community vocational providers. We first synthesised the literature review and interviews to develop an initial programme theory describing the contexts in which mechanisms are activated to produce EIVR outcomes. Then we used data from the survey and focus groups to further refine the EIVR programme theory. Finally, a conceptual framework was developed to support knowledge dissemination. RESULTS By ensuring consistent messaging across the multi-disciplinary team, EIVR programmes establish and maintain hope that work is possible following injury. Conversations about work allow individuals to determine the priority of work following injury. These conversations can also improve self-efficacy by providing individualized support to envisage pathways toward RTW goals and maintain worker identity. The synthesised study findings highlight the contexts and resources required to trigger activation of these mechanisms. CONCLUSIONS EIVR key mechanisms of effect are not specific to SCI as a health condition, therefore enabling this framework to be applied to other populations who face similar impairments and return to work barriers.
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Affiliation(s)
- Jennifer A Dunn
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand.
| | - R A Martin
- Burwood Academy Trust, Burwood Hospital, Christchurch, New Zealand
- Rehabilitation Teaching and Research Unit, Department of Medicine, University of Otago, Wellington, New Zealand
| | - J J Hackney
- Burwood Academy Trust, Burwood Hospital, Christchurch, New Zealand
| | - J L Nunnerley
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
- Burwood Academy Trust, Burwood Hospital, Christchurch, New Zealand
| | - D L Snell
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | - J A Bourke
- Burwood Academy Trust, Burwood Hospital, Christchurch, New Zealand
- Menzies Health Institute, Griffith University, Queensland, Australia
- Ngāi Tahu Māori Health Research Unit, Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - T Young
- Burwood Academy Trust, Burwood Hospital, Christchurch, New Zealand
| | - A Hall
- New Zealand Spinal Trust, Burwood Hospital, Christchurch, New Zealand
| | - S Derrett
- Ngāi Tahu Māori Health Research Unit, Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
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MARTIN RA, JOHNS JK, HACKNEY JJ, BOURKE JA, YOUNG TJ, NUNNERLEY JL, SNELL DL, DERRETT S, DUNN JA. Early Opportunities to Explore Occupational Identity Change: Qualitative Study of Return-To-Work Experiences After Stroke. J Rehabil Med 2023; 55:jrm00363. [PMID: 36748979 PMCID: PMC9926496 DOI: 10.2340/jrm.v55.4825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/18/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Rates of return-to-work after stroke are low, yet work is known to positively impact people's wellbeing and overall health outcomes. OBJECTIVE To understand return-to-work trajectories, barriers encountered, and resources that may be used to better support participants during early recovery and rehabilitation. PARTICIPANTS The experiences of 31 participants (aged 25-76 years) who had or had not returned to work after stroke were explored. METHODS Interview data were analysed using reflexive thematic analysis methods within a broader realist research approach. RESULTS Participants identified an early need to explore a changed and changing occupational identity within a range of affirming environments, thereby ascertaining their return-to-work options early after stroke. The results articulate resources participants identified as most important for their occupational explorations. Theme 1 provides an overview of opportunities participants found helpful when exploring work options, while theme 2 explores fundamental principles for ensuring the provided opportunities were perceived as beneficial. Finally, theme 3 provides an overview of prioritized return-to-work service characteristics. CONCLUSION The range and severity of impairments experienced by people following stroke are broad, and therefore their return-to-work needs are diverse. However, all participants, irrespective of impairment, highlighted the need for early opportunities to explore their changed and changing occupational identity.
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Affiliation(s)
- Rachelle A. MARTIN
- Burwood Academy Trust, Christchurch,Department of Medicine, University of Otago Wellington
| | | | | | - John A. BOURKE
- Burwood Academy Trust, Christchurch,Ngāi Tahu Māori Health Research Unit, University of Otago, Dunedin
| | | | - Joanne L. NUNNERLEY
- Burwood Academy Trust, Christchurch,Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch
| | - Deborah L. SNELL
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch
| | - Sarah DERRETT
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Jennifer A. DUNN
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago Christchurch
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Martin RA, Nunnerley JL, Young T, Hall A, Snell DL, Hackney JJ, Bourke JA, Derrett S, Dunn JA. Vocational wayfinding following spinal cord injury: In what contexts, how and why does early intervention vocational rehabilitation work? JOURNAL OF VOCATIONAL REHABILITATION 2022. [DOI: 10.3233/jvr-221189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Early intervention vocational rehabilitation (EIVR) is used to optimize return to work (RTW) outcomes for people following spinal cord injury (SCI). However, theoretical clarity is required about how EIVR works, for whom and under what circumstances. OBJECTIVE: To develop a theoretical understanding of how people respond to EIVR following SCI and the contexts in which mechanisms of intervention effect are likely to be activated. METHODS: Realist research methods were used to analyze interviews with 30 participants who had received EIVR following SCI. RESULTS: We conceptualized the reporting of our analyses using a travel metaphor, encapsulating the types and degree of wayfinding support participants required to think about, plan and action their vocational aspirations. Developing, maintaining and enacting hope, supporting self-identity and vocational identity, and focusing on environmental context adaptations required to enact vocational aspirations, appear to be critical mechanisms of intervention effect within EIVR. CONCLUSIONS: Various contexts and mechanisms of EIVR contribute to successful negotiation, achievement and sustainability of RTW outcomes for people following SCI. These theoretical understandings can refine EIVR service provision within SCI rehabilitation and inform how EIVR can improve RTW outcomes for people with acquired neurological conditions in other rehabilitation contexts.
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Affiliation(s)
- Rachelle A. Martin
- Burwood Academy Trust, Christchurch, New Zealand
- Department of Medicine, University of Otago Wellington, Wellington South, New Zealand
| | - Joanne L. Nunnerley
- Burwood Academy Trust, Christchurch, New Zealand
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | | | - Andrew Hall
- New Zealand Spinal Trust, Christchurch, New Zealand
| | - Deborah L. Snell
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | | | - John A. Bourke
- Burwood Academy Trust, Christchurch, New Zealand
- Menzies Health Institute, Griffith University, QL, Australia
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Sarah Derrett
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Jennifer A. Dunn
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
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Dunn JA, Hackney JJ, Martin RA, Tietjens D, Young T, Bourke JA, Snell DL, Nunnerley JL, Hall A, Derrett S. Development of a Programme Theory for Early Intervention Vocational Rehabilitation: A Realist Literature Review. JOURNAL OF OCCUPATIONAL REHABILITATION 2021; 31:730-743. [PMID: 34524575 DOI: 10.1007/s10926-021-10000-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/30/2021] [Indexed: 06/13/2023]
Abstract
Purpose Little is currently known about how early intervention vocational rehabilitation (EIVR) works for people with newly acquired neurological conditions such as traumatic brain injury, acquired brain injury and spinal cord injury. This study aims, from a realist framework, to identify relevant literature and develop an initial programme theory to understand how EIVR might work for people experiencing acquired neurological disability. Realist reviews are ideally placed to address the identified knowledge gap as they assist in gaining a deeper understanding of how the intervention works, for whom it works best, and the contexts that promote the activation of desired outcomes. Methods We used a seven-step iterative process to synthesise literature using a realist approach. The steps included: development of initial programme theory, literature search, article selection, extracting and data organising, synthesis of evidence and programme theory refinement. We performed a literature search using the following databases: Cinahl, Embase, EMcare, Medline, PsychInfo and Scopus. Articles were selected if they contributed to the knowledge describing what is EIVR and how it works in newly acquired neurological conditions. Data were extracted and synthesised to develop a programme theory for EIVR. Results Following screening of 448 references, 37 documents were eligible for data extraction. We developed a refined programme theory of EIVR consisting of three contexts (prioritisation of exploring work options, return to work discussed as an option, and workplace support), nine mechanisms (ensuring rehabilitation teams' culture, fostering hope, exploring options, optimising self-efficacy, maintaining worker identity, staying connected, setting goals, engaging employer, and flexing roles) and three outcomes (confidence in ability to work, psychological adjustment, and engagement in solution focussed options). Conclusions This appears to be the first paper to explore how EIVR works, for whom and in what situations. We have produced a programme theory that may provide an initial understanding of EIVR following acquired neurological conditions.
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Affiliation(s)
- Jennifer A Dunn
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand.
| | | | - Rachelle A Martin
- Burwood Academy Trust, Christchurch, New Zealand
- Department of Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Donna Tietjens
- Wellington Medical and Health Sciences Library, University of Otago, Wellington, Wellington, New Zealand
| | | | - John A Bourke
- Burwood Academy Trust, Christchurch, New Zealand
- Menzies Health Institute, Griffith University, Brisbane, QLD, Australia
- Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Deborah L Snell
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
| | - Joanne L Nunnerley
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, PO Box 4345, Christchurch, 8140, New Zealand
- Burwood Academy Trust, Christchurch, New Zealand
| | - Andrew Hall
- New Zealand Spinal Trust, Christchurch, New Zealand
| | - Sarah Derrett
- Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
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Snell DL, Hackney JJ, Maggo J, Martin RA, Nunnerley JL, Bourke JA, Hall A, Derrett S, Dunn JA. Early vocational rehabilitation after spinal cord injury: A survey of service users. JOURNAL OF VOCATIONAL REHABILITATION 2021. [DOI: 10.3233/jvr-211166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Early vocational rehabilitation following spinal cord injury (SCI) improves return to work (RTW) outcomes, but there is limited information about who benefits from such interventions, why and in what contexts. OBJECTIVE: We aimed to describe demographic and clinical characteristics and RTW outcomes of adults with SCI who received early vocational rehabilitation. We sought to identify key mechanisms of early vocational rehabilitation. METHODS: This is a cross-sectional survey of people with SCI recruited from the New Zealand Spinal Trust Vocational Rehabilitation Service, who had sustained an SCI within the previous five years. RESULTS: Of the 37 people who responded to the survey, 54% returned to paid work (90% of whom retained their pre-injury employment). Those in autonomous roles returned to work faster with greater odds of returning to their pre-injury employer and role. Participants highlighted the importance of feeling hopeful about RTW while still in the spinal unit as a key mechanism of effect within the early vocational intervention. CONCLUSIONS: Findings suggested key mechanisms of early vocational intervention could be framed by models of hope. However, for gains to be optimised, continuity of support beyond the acute stage was suggested as an area for future research.
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Affiliation(s)
- Deborah L. Snell
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
| | | | - Jasjot Maggo
- Burwood Academy of Independent Living, Christchurch, New Zealand
| | - Rachelle A. Martin
- Burwood Academy of Independent Living, Christchurch, New Zealand
- Department of Medicine, University of Otago Wellington, Wellington South, New Zealand
| | - Joanne L. Nunnerley
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
- Burwood Academy of Independent Living, Christchurch, New Zealand
| | - John A. Bourke
- Burwood Academy of Independent Living, Christchurch, New Zealand
- Menzies Health Institute, Griffith University, Queensland, Australia
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Andrew Hall
- New Zealand Spinal Trust, Christchurch, New Zealand
| | - Sarah Derrett
- Department of Preventive and Social Medicine, University of Otago, Dunedin, New Zealand
| | - Jennifer A. Dunn
- Department of Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, New Zealand
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Mirzoev T, Cronin de Chavez A, Manzano A, Agyepong IA, Ashinyo ME, Danso-Appiah A, Gyimah L, Yevoo L, Awini E, Ha BTT, Do Thi Hanh T, Nguyen QCT, Le TM, Le VT, Hicks JP, Wright JM, Kane S. Protocol for a realist synthesis of health systems responsiveness in low-income and middle-income countries. BMJ Open 2021; 11:e046992. [PMID: 34112643 PMCID: PMC8194331 DOI: 10.1136/bmjopen-2020-046992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
INTRODUCTION Health systems responsiveness is a key objective of any health system, yet it is the least studied of all objectives particularly in low-income and middle-income countries. Research on health systems responsiveness highlights its multiple elements, for example, dignity and confidentiality. Little is known, however, about underlying theories of health systems responsiveness, and the mechanisms through which responsiveness works. This realist synthesis contributes to bridging these two knowledge gaps. METHODS AND ANALYSIS In this realist synthesis, we will use a four-step process, comprising: mapping of theoretical bases, formulation of programme theories, theory refinement and testing of programme theories using literature and empirical data from Ghana and Vietnam. We will include theoretical and conceptual pieces, reviews, empirical studies and grey literature, alongside the primary data. We will explore responsiveness as entailing external and internal interactions within health systems. The search strategy will be purposive and iterative, with continuous screening and refinement of theories. Data extraction will be combined with quality appraisal, using appropriate tools. Each fragment of evidence will be appraised as it is being extracted, for its relevance to the emerging programme theories and methodological rigour. The extracted data pertaining to contexts, mechanisms and outcomes will be synthesised to identify patterns and contradictions. Results will be reported using narrative explanations, following established guidance on realist syntheses. ETHICS AND DISSEMINATION Ethics approvals for the wider RESPONSE (Improving health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam) study, of which this review is one part, were obtained from the ethics committees of the following institutions: London School of Hygiene and Tropical Medicine (ref: 22981), University of Leeds, School of Medicine (ref: MREC19-051), Ghana Health Service (ref: GHS-ERC 012/03/20) and Hanoi University of Public Health (ref: 020-149/DD-YTCC).We will disseminate results through academic papers, conference presentations and stakeholder workshops in Ghana and Vietnam. PROSPERO REGISTRATION NUMBER CRD42020200353. Full record: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020200353.
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Affiliation(s)
- Tolib Mirzoev
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Anna Cronin de Chavez
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Ana Manzano
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Irene Akua Agyepong
- Research and Development Division, Ghana Health Service, Accra, Greater Accra, Ghana
| | - Mary Eyram Ashinyo
- Department of Quality Assurance, Institutional Care Directorate, Ghana Health Service, Accra, Ghana
| | | | | | - Lucy Yevoo
- Research and Development Division, Ghana Health Service, Accra, Greater Accra, Ghana
| | - Elizabeth Awini
- Research and Development Division, Ghana Health Service, Accra, Greater Accra, Ghana
| | - Bui Thi Thu Ha
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | - Trang Do Thi Hanh
- Department of Environmental Health, Hanoi University of Public Health, Hanoi, Viet Nam
| | | | - Thi Minh Le
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | - Vui Thi Le
- Department of Population and Reproductive Health, Hanoi University of Public Health, Hanoi, Vietnam
| | - Joseph Paul Hicks
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - Judy M Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Sumit Kane
- Nossal Institute for Global Health, University of Melbourne Queen's College, Parkville, Victoria, Australia
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