3. Planning RTW

Returning to work with the pre-injury employer provides the best chance of success following TBI, for several reasons including:

  • often an established relationship exists between employer and employee that may provide for commitment and flexibility in accommodating altered work capabilities
  • the client may feel more comfortable and supported in returning to the familiar social networks in the workplace; and

  • resuming familiar tasks and routine minimises the need for new learning often complicated by memory impairments post TBI.

Some of the practical considerations and strategies for planning return to work are:

Timeframe of return to work commencement

Commencing discussions with the pre-injury employer at an early stage post-injury is important to preserve the job opportunity and gather details regarding the client’s job and workplace culture.  The timing for commencing work requires careful consideration. Commencing work before the client is ready can be just as problematic as delaying return to work.

A structured return to work program

It is uncommon that employers encounter TBI within their workforce and providing guidance via a written return to work plan that specifies the schedule of upgrading tasks and hours, specific restrictions and compensatory strategies will be required to help facilitate a successful outcome. Employers often benefit from empathic support and detailed information to help them understand the person’s functional challenges and how they can best support this.

Hours

Typically, a return to work program commences with part-time hours to manage fatigue, with gradual upgrading over time.  It may be best to avoid consecutive days of work initially. . Upgrading to pre-injury hours, particularly if the client worked full-time prior to the injury, may take an extended period of time. Some clients find they need to amend their long term goal to part-time work. .

Compensatory strategies

Compensatory strategies allow clients with physical, cognitive, behavioural or psychological impairments to operate more independently.  General strategies for return to work include:

  • Commence working part-time and gradually increase hours of work

  • Initially avoid consecutive days of work if possible

  • Allocate work that is most familiar and routine

  • Allow extra time to complete tasks

  • Try to complete one task before moving onto the next

  • Reduce distractions in the work environment

  • Reduce the range of responsibilities in the initial stages to avoid stress

  • Follow a set work structure; review daily goals/priorities with supervisor

  • Use diary, checklists, smart-device prompts/alarms or written notes to assist with memory and organising skills.

Specific strategies will need to be identified individually for each client, considering the impact of the TBI and nature of the job role and workplace.   

 

 

Strategies for managing limited insight:  

Clients experiencing reduced insight into the impact of their injury may be unlikely to identify a need for compensatory strategies.  Providing positive feedback in conjunction with highlighting any issues is recommended through providing practical examples.  Strategies more likely to succeed will be external (i.e. modifying the environment and conditions within which the person works).

Case examples for insight

Tom is an IT technician who sustained a severe TBI. 

As a result of his injury Tom has poor recall of new information, difficulty sustaining his attention, reduced complex planning ability and limited insight into what this means for him when back at work. The employer and vocational provider work together to set up the compensatory strategies needed before Tom can return to work.

Workplace changes include: reduced scope of responsibilities, reduced hours in the initial stages of return to work, seating Tom in a desk that is away from distracting stimuli (eg. non-cluttered, quiet, out of frequent foot traffic area) and use of an internal task-tracking program. The vocational provider schedules regular reviews with Tom and his employer to discuss Tom’s performa.

Emma is a clerical assistant who has sustained a severe TBI. 

As a result of her injury Emma has difficulty recalling information, reduced speed of information processing and difficulty with tasks requiring divided attention. 

Emma has good awareness of these difficulties and was able to discuss potential impacts to  her work performance with the employer and vocational provider and jointly they identified useful compensatory strategies.

The compensatory strategies include: audio-recording meetings so that Emma can write the minutes at a later time, using checklists, breaking larger tasks into smaller steps, using reminders on phone and computer.  

Emma has been able to review her own performance with her employer and contact her vocational provider to explore what other strategies would assist as her duties increased.

More examples of compensatory strategies

Strategis for managing executive functioning impairments including
planning, problem solving, reasoning, decision making:

  • Divide large assignments into smaller steps

  • Schedule weekly meetings with supervisor to track task progress

  • Provide written instructions

  • Task-specific routines (via task analysis and instructions/check list)

  • The use of organisational aids (e.g. written calendars, smart phones)

  • , train the client to systematically problem solve (identify the problem, identify possible solutions, eliminate unsuitable solutions etc.)

  • To assist with impulsivity, train the client in stop, think, act strategies

Strategies for managing attention/concentration difficulties::

  • Schedule breaks and work when most alert

  • Incorporate multiple short breaks into work schedule

  • Use headset/earplugs to cancel out background noise

  • Set up work space in quiet location

  • Reduce clutter in the work environment

  • Task management: perform one task at a time, and redirect calls to an answering machine to avoid interruptions, if suitable option within the workplace.

Strategies for managing memory impairment:

There are different types of memory functions and some may remain unaffected following TBI (e.g., procedural and semantic memory related to knowledge and learned facts). Other types of memory more typically affected by TBI include learning new information and prospective memory (remembering what needs to be done). Memory strategies include:

  • Record meetings on audio device

  • Internal compensatory strategies (e.g. word associations)

  • External compensatory strategies (posted lists, labelled file cabinets, calendars, alarms, timers, computer-based reminders, mobile phones and medication organisers.

Strategies for managing interpersonal/ behaviour changes:

(e.g., disinhibition, impulsivity, socially inappropriate behaviour, and lack of initiation).

  • Environmental modification (identify antecedents/triggers and eliminate where possible)

  • Establish clear expectations

  • Identify positive reinforcers

  • Direct, immediate feedback

  • Strategies for initiation (alarms etc.)

Strategies for managing Psychological issues:

  • Establish long term and short term goals

  • Flexible scheduling (accommodate appointment needs)