Finding what works: vocational outcomes for Acquired Brain Injury survivors

Introduction

An acquired brain injury (ABI) is a brain injury that happens after birth, in childhood or in adulthood. Acquired Brain Injury (ABI) is the largest traumatic contributor to worldwide death and disability. Globally, an estimated 69 million individuals sustain an ABI each year (Dewan et al., 2018). An estimated 120,000 people in Ireland live with an ABI related disability. 19,000 additional brain injuries occur annually in Ireland (Acquired Brain Injury Ireland, 2018).

Employment Status

Ireland has one of the lowest rates of employment for people with disabilities in the European Union (EU) at 36% compared to 48.1% in the EU (Economic and Social Research Institute, 2021). Among EU-28 countries, Ireland has the fourth lowest employment rate among people with disabilities of working age. Specific to the brain injury population, 54.9% of individuals in community rehabilitation following ABI reported feeling able to find work, however, only 43.7% of this group were employed (Acquired Brain Injury Ireland, 2019). This highlights a significant discrepancy between the number of individuals with brain injuries who feel able to work and those who are employed.

In Ireland, we have strong rights for workers with disabilities. Under employment equality legislation - Employment Equality Acts 1998-2015, people cannot be discriminated against on the ground of disability.  Additionally, employers are obliged to provide reasonable accommodations to allow people to fulfil the duties of their role. Examples of reasonable accommodations include flexible working hours, ensuring the workplace is accessible or supporting the use of assistive technology in the workplace.  Additionally, under the Disability Act 2005, 3% of public jobs must be filled by people with disabilities. 

Supporting people with Acquired Brain Injury into employment

There are also several support schemes available to employers should a member of their team have a disability. In the private sector, if an employer has to make changes to the workspace or purchase specific equipment, they can receive a 'Workplace / Equipment Adaptation Scheme'.  A Wage Subsidy Scheme for non-public sector agencies is available to employ people with disabilities who work between 21 and 39 hours.  All companies in the private sector can access the Disability Awareness Training Scheme to support maintaining working relationships with colleagues with disabilities, amongst other benefits.

Barriers to successful employment outcomes for people with Acquired Brain Injury

However, despite various support schemes available, Ireland continues to experience low employment rates for people with disabilities when compared to our EU counterparts. A complex interplay of factors may impact an individual’s likelihood to Return to Work (RTW) after an ABI. A systematic review of 27 studies found pre-morbid educational level and independence in daily living activities are strongly associated with RTW after ABI (Donker-Cools et al., 2016). A 2016 Irish systematic review found that fatigue was the most common barrier to RTW post-stroke (Horgan et al. 2016).  There is evidence to suggest that coordinated clinically led vocational assessment and rehabilitation leads to improved employment outcomes for people with ABI (Burke et al, 2021). As a service, Step Ahead Plus, have completed two research studies to support our claims. A Research Evaluation of an Acquired Brain Injury-Specific Vocational Rehabilitation Programme (Work4You) Serving the Border, Midlands, and Western Regions of Ireland was carried out by Professor Donal G. Fortune BSc (Hons)., Clin.PsyD., Ph.D. Three out of four participants who entered the Work4You programme returned to productive roles. Participants who did not return to productive roles experienced greater disability. 'Returning to Work after ABI: A mixed method case study' was carried out by the Step Ahead Ability team and has been published by the Journal for Vocational Rehabilitation. This research concluded that work is a meaningful area of rehabilitation after an acquired brain injury and there is evidence that vocational rehabilitation programmes enhance return to work outcomes (Burke et al. 2021).

The Step Ahead Plus Approach

ABI survivors often face challenges returning to work or education due to difficulties such as memory, fatigue, and mobility.  Step Ahead Plus is an occupational therapy led Vocational Assessment (VA) and Vocational Rehabilitation (VR) service for adults with ABIs delivered by Acquired Brain Injury Ireland since 2019. It is a national service, accepting both clinician and self-referrals. The service is delivered in a hybrid model consisting of in person assessment, followed by telehealth rehabilitation. Vocational Rehabilitation Assistants (VRA’s) deliver goal orientated, individualised rehabilitation under the supervision of Occupational Therapists. Interventions include symptom management and strategy development, for example, managing memory difficulties or fatigue in the workplace, training in assistive technology and practical skills such as CV building, and interview skills. At present, Step Ahead Plus comprises one full-time occupational therapist and one part-time occupational therapist, two vocational rehabilitation assistants working two days per week and an employment and training liaison officer who works full-time.

Table 1: Outcomes of the Step Ahead Plus Programme from April 2021 to June 2022

The data above demonstrates the outcomes achieved by those attending the Step Ahead Plus service between April 2021 to June 2022. Of these, 76 received Vocational Assessment (VA) as per service prioritisation guidelines. 42 of those went on to receive Vocational Rehabilitation (VR) and a subsequent discharge assessment. Characteristics of the 42 clients were as follows: 60% (percent) male, 40% (percent) female; mean age 41 years (range: 19-67 years). 71% (percent) of ABIs were non-traumatic in nature. The most common causes of ABI were stroke (n=21), road traffic accident (n=5), and fall (n=5). Upon VA, 12% of clients were actively employed, 42% were on sick leave, and 36% were unemployed.  Following VR, 74% of clients were in employment (full-time (n=24); part-time (n=7)). Additionally, 2 clients entered an education or training programme. These findings demonstrate that with coordinated interventions and support, those who experience ABI in Ireland can be successful in returning to or gaining employment.

Conclusion

The National Strategy and Policy for the Provision of Neuro-Rehabilitation Services in Ireland (2019), recommends that specialist neuro–vocational rehabilitation services should be available to those who require them. Yet, at present, there are limited services nationally providing this input to clients who require it. Step Ahead Plus under Acquired Brain Injury Ireland strongly advocates for the expansion of specialist neuro vocational rehabilitation services.