New Zealand Rehabilitation Association, Inc.

Quality Rehabilitation: An Integral Component of Disability Management as a Strategy Designed to Promote Return to Work Following the Onset of a Significant Disability.

Most return to work programs are conducted in the work place and run by the employer as part of a larger disability management strategy which reflects an organizational commitment to continued employment of those experiencing functional work limitations (1). Disability management may be defined as ‘a work place prevention and remediation strategy that seeks to prevent disability from occurring, or lacking that, to intervene early following the onset of disability, using coordinated, cost conscious, quality rehabilitation services’ (2).

Employer driven programmes tend to view disability as a temporary condition from which an individual will recover with time and after receiving the appropriate treatment (3).  This view is easily justified by the facts as most disability associated with illness and injury is temporary and most people do recover from illness or injury and are able to return to their jobs without significant alteration or accommodation. This is particularly true in organizations which encourage an early return to work accompanied by transitional period of light or alternative duties, shortened work days or work weeks (4, 5, 6). Yet, it is not true in all cases.  Some people will simply never recover from their injury or illness and therefore will be unlikely to return to work if appropriate intervention and/or alterations in the work place are not made available (7). These people are the ones who require the quality rehabilitation service referred to in the definition of disability management used above and will be the focus of this paper. 

Rehabilitation

Rehabilitation may be defined as a process which seeks to limit the disability (i.e., functional limitation) and eliminate the handicap (i.e., disadvantage) resulting from an impairment or interaction between the impairment, disability and the environment (8). Three primary approaches are used to accomplish these goals, including those which (a) seek to reduce the disability itself, (b) change the way tasks are done by teaching new skills and strategies to perform old tasks, and (c) alter the environment or job in such a way that the barriers to successful completion are removed.  

While all rehabilitation programs have similar aims, the focus of their interventions may vary depending on the type of service provided and the philosophy of the provider. In general, those working from a medical model are more likely to focus on changing the individual by treating the impairment, reducing the disability or teaching alternative skills, while those adhering to a social model of disability are more likely to focus on changing the environment to accommodate the needs and abilities of the individual.  These two approaches could in the extreme epitomize poles of intervention where on the one hand the individual is expected to adapt to the demands of the environment or job, while, on other the environment or job is changed to meet the needs and abilities of the individual (9). The reality of most successful return to work programs include all three approaches and occur somewhere in between those two poles, with flexibility of approach and commitment of employer being the key ingredients to a successful program (10, 11, 12 ).

The Process of Rehabilitation

The goal of rehabilitation is to restore an individual’s participation in daily life to that realized before the onset of a disability (13).  In the case of programmes designed to foster a successful return to work, it is to enable the individual to return to their job, workplace and/or routines, as they were experienced before the onset of a disability. Ideally, this would be done without changing the job, the parameters of the job or the setting in which the job is done and without prejudice to career path and opportunity for advancement. However, this is not always possible and flexibility is required to achieve success.  Goals need to be realistic and employers and employees committed to finding appropriate solutions to overcome barriers, which may exist to block the achievement of this goal.

Assessment

The rehabilitation process is one, which involves assessment, planning, implementation, evaluation and follow-up (14). Assessment is crucial, as disability is to a great extent dependent upon the demands of the work place.  Disability is not a general condition, state or inevitable result of an impairment.  Rather it is defined as a lack, loss or reduction of an individual’s ability to perform certain tasks due to impairment (15). Thus, it is situational and is dependent upon the difference between the level of function of the individual and that required of him or her by the task, environment, job or workplace (16). Therefore, assessment of both the individual and the requirements made upon him or her are necessary to establish a plan of action and select interventions which allows for a better fit between the two. 

Roessler and Rumrill state that ‘objective assessments of impediments and enhancements to work are essential to facilitate appropriate modifications in both the work environment and work demands.  With knowledge from such assessments, rehabilitation professionals can work with the person to implement appropriate problem solving solutions that [may] involve environmental and job modifications, adaptations of transportation, increased social and professional support, reduction and/or increased flexibility in work hours, and/or the ability to work at home” (17).

On- going evaluation is necessary to ensure that the interventions are in fact effective and that progress toward the goal is being achieved.  Follow-up is also required as adult career development should be thought as a continuous process of adaptation to an ever-changing workplace (18).

Planning

The rehabilitation process is designed to ensure that each program provided is tailored to meet the specific needs of the person served. Therefore, the goals set, type of interventions used, and amount or length of service provided are situational and dependent upon both the needs of the individual and the demands of the environment.    Schafft and Spjelkavik confirmed the importance of this principle in their review of vocational rehabilitation programs in Norway in which they concluded that “the individual’s support needs in getting and keeping a job must be the deciding factor in choosing which approach to use”. They go on to state that ‘Our assumption is that a standard approach will [consistently] fail to meet the needs of the individual and situation (19). Rather, an individualized approach is required if success is to be achieved.

Implementation

Interventions in the workplace may include training, instruction, education, the use of assertive technology, job accommodation and work site modification (20).  Assistive technology refers ‘to any item, piece of equipment or product system, that is used to increase, maintain or improve functional capacities of individuals with disabilities’ (21).  Assistive technology may be simple or complex, high or low tech. 

Assistive technology is often linked with job accommodation, which includes work site accommodation and the use of aids in the workplace. Job accommodation or restructuring may be defined a “a process through which one combines, eliminates, redistributes, adds, or isolates tasks from one or more jobs within the same job family to form part-time or full-time jobs” (22).  While, work site modification involves changes to the individual’s working environment, work station or work site to make it more functional, comfortable or accessible (23).  

Evaluation

It is impossible to know if an intervention is appropriate without evaluating its effectiveness in the work site.  Therefore, ongoing evaluation is necessary to ensure that the intervention provided has the intended affect.  If not, other interventions need be applied and evaluated until either an effective, or ideally, the most effective intervention is employed.

Follow-up

Follow-up is required to ensure that the changes observed in function are maintained over time.  The work environment is ever changing.  Further adaptations may be required to ensure that the employee is able to successfully cope with those changes (24).

Components of a Successful Return to Work Programme

Successful return to work programmes tend to have a number of elements in common.  First of all, they only seem to work where there is a clear commitment on the part of the employer and a corresponding expectation on the part of the employee that return to work is a desirable and realistic goal (25, 26, 27). An early return to or continued contact with one’s place of employment is included (28, 29).  The search for solutions is inclusive with the employee playing a role in both identifying barriers and implementing solutions (30). Change is expected to occur in both the employee and the work place (31).  The approach used is flexible and the interventions employed are individualized to meet the needs of the employee and the demands of the work place (32, 33).  Assessment is an integral part of the process and used to determine the extent of the disability which is recognized as being situational and maintained by a mismatch in the functional ability of the individual and the demands of the environment (34. 35).  Evaluation is ongoing to ensure that the interventions used are effective.  And, follow-up is included to ensure that the changing demands of the work place are effectively met as they arise (36).

References

1. Rosenthal, D and Olsheski, J. Disability management and rehabilitation counseling. Present and future opportunities. Journal of Rehabilitation 1999, 65: (1) 31-38.
2. Akabas, S, Gates, L and Galvin, D.  Disability management: A complete system to reduce costs, increase productivity, meet employment needs and ensure legal compliance: New York: AMACOM, 1992, p 2.
3. Rosenthal and Olsheski, op cit., pp 31-38.
4. Biggs, H, Humphries, S and Flett, R.  Perspectives on vocational rehabilitation: A New Zealand analysis. Journal of Vocational Rehabilitation. 1998: 11 (1) 13-20.
5. Dolan, L. The ACC position regarding return to work. Back to work: The future and the way ahead, Conference Proceedings of the New Zealand Rehabilitation Association Biennial  Conference.  Christchurch: New Zealand Rehabilitation Association, 1997, pp 69-71.
6. Gow, D. Things aren’t always what they seem: Psychosocial aspects of vocational rehabilitation. Conference Proceedings of the New Zealand Rehabilitation Association Biennial Conference. Auckland: New Zealand Rehabilitation Association, 1999, pp 131-134.
7. Roessler, R and Rumrill, P.  Reducing workplace barriers to enhance job satisfaction: An important post-employment service for employees with chronic illness. Journal of Vocational Rehabilitation 1998: 10 (3) 219-228.
8. La Grow, S.  Rehabilitation: A call to limit the definition and expand the possibilities. New Zealand Journal of Disability Studies 1996: 2 (1) 128-135.
9. Schneider, M.  Achieving greater independence through assistive technology, job accommodation and supported employment. Journal of Vocational Rehabilitation 1999:12 (3) 159-164.
10. Beyer, S, Kilsby, M and Shearn, J. The organisation and outcomes of supported employment in Britain.  Journal of Vocational Rehabilitation 1999: 12 (3) 137-141.
11. Schafft, A and Spjelkavik, O.  A Norwegian approach to supported employment: Arbid mid bistand. Journal of Vocational Rehabilitation 1999:12 (3) 147-158.
12. Schneider, op cit, pp 159-164.
13. La Grow, op cit, pp 128-135.
14. Barnes, M and Ward, A.  Textbook of rehabilitation medicine. Oxford: Oxford University Press, 2000. 
15. World Health Organization.  International classification of impairments, disabilities and handicaps. Geneva, Switzerland, World Health Organization. 1980.
16. Schneider, op cit, pp 159-164.
17. Roessler and Rumrill, op cit, p 228.
18. Ibid, pp 219-228.
19. Schafft, and Spjelkavik, op cit, p 156. 
20. Schneider, op cit,  pp 159-164
21. Ibid, p 160.
22. Malik, K.  Job accommodation through job restructuring and environmental modification.  In D. Vandergoot & J. Worall (Eds.), Placement    in rehabilitation: A career development perspective. Baltimore: University Park Press, 1979, p 145.
23. Harkins, D and Moyer, J. Employer relations: Job development, job retention, and job accommodation.  In  J.E. Moore, W.H. Graves and J. Boland Patterson (Eds), Foundations of rehabilitation counseling with persons who are blind or visually impaired . New York: American     Foundation for the Blind, 1997, pp 313-340.
24. Roessler and Rumrill, op cit, pp 219-228.
25. Beyer, Kilsby, and Shearn, op cit., pp 137-144.
26. Schafft and  Spjelkavik, op cit,  pp 147-158.
27. Schneider, op cit, pp 159-164.
28. Dolan, op cit, pp 69-71.
29. Gow, op cit, pp 131-134.
30. Roessler and Rumrill, op cit, pp 219-228.
31. Schneider, op cit, pp 159-164.
32. Beyer, Kilsby and Shearn, op cit, pp. 137-141..
33. Schafft and Spjelkavik, op cit, pp 147-158.
34. Roessler and Rumrill, op cit, pp 219-228.
35. Schneider, op cit, pp 159-164.
36. Roessler and Rumrill, op cit, pp 219-228.