6. Planning Return to Work

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

Time frame of return to work commencement

It is important to commence discussions with the pre-injury employer at an early stage post-injury to preserve the job opportunity and gather details regarding the client’s job and workplace culture.  However, the timing of work commencement requires more careful consideration. Commencing work too early can be just as problematic as delaying return to work, because the impact of cognitive and personality changes may take some time to become clear.

Graduated return to work programs

Employers do not commonly encounter TBI and will therefore require guidance via a written plan that specifies the schedule of upgrading tasks and hours, specific restrictions and compensatory strategies.

Hours

The routine commences with part-time hours to pre-empt fatigue, with gradual upgrading over time. This process may take months or years and may plateau for some periods before further upgrading is possible.

Compensatory strategies

Compensatory strategies allow clients with cognitive impairment to operate more independently.  General strategies for the return to work program:

  • Schedule more demanding tasks when alert
  • Increase the level of structure within tasks and routine
  • Reduce distractions
  • Double check work
  • Focus on more routine and familiar work
  • Schedule regular feedback
  • Allow extra time to complete tasks
  • Reduce scope of responsibilities
  • Use diary, checklists and written notes

Specific strategies need to be devised for each client, taking the specific workplace factors into account. Workplace personnel are often able to suggest strategies if they have a good understanding of the problem.

Refer to:
Dodson, M.B. (2010). A model to guide the rehabilitation of high-functioning employees after mild brain injury. Work, 36: 449-457.
Mateer, C. A. & Sira, C. S. (2006). Cognitive and emotional consequences of TBI: intervention strategies for vocational rehabilitation. NeuroRehabilitation, 21(4), 315-326

Strategies for clients with limited insight:  

If someone has little insight, then they are unlikely to apply compensatory strategies as the need for these is not agreed upon. Strategies more likely to succeed in these cases will be external (ie environmental modification). However, for those clients with a good level of insight, internal strategies (eg use of checklists) can be considered.

Case examples for poor insight and good insight

Case example for poor insight:

Tom is a clerical worker who sustained an extremely severe TBI. 

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

Workplace changes included: reduced scope of responsibilities reduced hours in his initial return to work, seating Tom in a desk that is away from distracting stimuli (eg. Non-cluttered, quiet, out of frequent foot traffic area), Labelling filing system eg. Colour coded or numerical code.

The VP scheduled regular reviews with Tom and his employer to review performance and plan gradual increases as Tom demonstrated the skills and capacity required.


Case example for good insight:

Emma is a therapist who has sustained a severe TBI. 

As a result of her injury she has difficulty recalling information, reduced speed of thought and difficulty with divided attention tasks. 

She has good insight into these difficulties and was able to discuss the impact in her workplace with the employer and VP and decide useful compensatory strategies.

The compensatory strategies used in the workplace include: audio-recording her sessions so that she can write her notes at a later time, using checklists, breaking larger tasks into smaller steps, using reminders on her phone and computer.  

Emma was able to review her own performance with her employer and contact her VP provider to explore what else could work as her duties increased.

 

More examples of compensatory strategies

Strategies to accommodate for:

Executive functioning
(planning, problem solving, reasoning etc):

  • 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)
  • To assist with impulsivity, train the client to systematically problem solve (identify the problem, identify possible solutions, eliminate unsuitable solutions etc)

Psychological issues:

  • Establish long term and short term goals
  • Flexible scheduling (accommodate appointment needs)
  • Provide education/sensitivity training to co-workers
  • Schedule weekly meetings with supervisor to encourage open communication and feedback

Attention/concentration:

  • Schedule breaks and work when most alert
  • Multiple short breaks
  • Use headset to cancel out background noise
  • Private office or quiet workplace
  • Reduce clutter in the work environment
  • Task management: doing only one thing at a time, wearing earplugs and using the answering machine to avoid interruptions

Memory:

Some types of memory are generally spared post TBI: procedural and semantic (knowledge, learned facts) but not others: episodic (recall of events, experiences) and metamemory (belief about one’s own memory)

  • Restorative approach - memory games/exercises - do not appear to generalise to other situations, and have limited empirical support.
  • Record meetings on audio device
  • Internal compensatory strategies (e.g. word associations)
  • External compensatory strategies (posted lists, labelled file cabinets, calendars, alarms, timers, beeping watches, computer-based reminders, mobile phones and medication organisers.

For Interpersonal/ behaviour changes:
(e.g., disinhibition, impulsivity, socially inappropriate behaviour, and lack of initiation).

  • Environmental modification (identify antecedents/triggers)
  • Establish clear expectations
  • Identify positive reinforcers/rewards
  • Direct, immediate feedback
  • Strategies for initiation (alarms etc)