Development of employment indicators to advance the quality of spinal cord injury rehabilitation care: SCI-High Project

Figures & data

Figure 1 Employment driver diagram. The impairment branch is common to the 11 SCI-High Project domains. UEMS: Upper-Extremity Motor Score; LEMS: Lower-Extremity Motor Score; NLI: Neurological Level of Injury; AIS: ASIA Impairment Scale; HR: Heart Rate, BP: Blood Pressure; sES: Socioeconomic Status; WPAI: Work Productivity & Activity Impairment; RRTW: Readiness for Return-To-Work IPS: Individual Placement and Support

Table 1 Vocational rehabilitation activities adapted from Ottomanelli et al.⁵⁹.

Time	Type of Vocational Service Activity	Definition	Service Availability
Inpatient Rehabilitation	Orientation	Provide SCI/D Patients with an understanding of how vocational Rehabilitation services work and what supports the vocational rehabilitation counselor will provide	Yes No
	Assessment	Ongoing assessment process that defines the employment status and the stage of readiness for RTW for people who are planning to work	Yes No
	Treatment plan development	Integrate the information gained in the orientation, and assessment session, into the primary clinical team treatment plan for RTW	Yes No
	Referrals for collateral services	Refer to non-integrated, clinical team programs to address job skills training and placement	Yes No
Following Rehabilitation Discharge	Job skills training or education	Provide services, supports, training programs, and/or referrals to other intervention rehabilitation programs that are intended to get the SCI/D patients ready to go to work versus direct job placement with support	Yes No
	Job development	Employer networking and negotiation based on the SCI/D Patients’ interests and preferences	Yes No
	Vocational counseling	Provide office-based or telephone guidance to the SCI/D on how to get and keep jobs; sometimes including interview and interpersonal skills training	Yes No
	Worksite accommodation	Provide information, resources, equipment, or modifications to aid productivity, and determination of supports necessary to secure employment, e.g. schedules, workspace, equipment, personnel support	Yes No
	Job placement	Advocacy, actions, and negotiations with personnel in the employment setting to secure the job and make arrangements for the SCI/D to start the job to start the job	Yes No
	Vocational case management and social skills training	Actions and supports specific to the SCI/D patient’s job development preferences intended to enhance employability, e.g. advocate with family or community resources to assist with transportation to and from work	Yes No
	Employment supports and job coaching	Training and support in the workplace to improve the SCI/D’s comfort, mobility, relationships, personal care, and overall work function	Yes No
	Treatment plan review and revision	Return to the employment and treatment plan to update and reflect on better strategies to attain the stated goal of job placement or retention support	Yes No
	Employment follow-up	Support to both the SCI/D patients and employer/co-workers to safeguard SCI/D patients’ productivity, safety, and satisfaction in addition to employer’s satisfaction	Yes No

Table 2 Outcomes measures considered for inclusion in the employment indicators.

Measurement Tool	Tool Description	Items & Scoring
Effort Reward Imbalance (ERI)^Citation60	A standardized, self-report measure for imbalance between work effort and reward	Long form: 22 items Short form: 16 items
	Long form has adequate validity For individuals who are currently working
Readiness for Return-to-Work Scale (RRTW)^Citation39	In Scale A that assesses stages of readiness for RTW, two factors are identified: (1) The RTW inability factor includes items 1, 2, 4, 5 and 13. Persons scoring high on the inability to RTW factor are not considering start of activity or RTW-related behavior. (2) The RTW uncertainty factor includes items 10, 11 and 12. Persons scoring high on the RTW uncertainty factor are considering RTW, but they are uncertain about their possibilities in relation to health and their ability to return to work. In Scale B that assesses stages of readiness for work maintenance, we have also identified two factors: (1) Proactive work maintenance includes items 2, 4 and 9. Persons scoring high on this factor have found strategies to manage work and need less help to stay at work. (2) Uncertain work maintenance includes items 1, 3, 5, 6, 7. Persons scoring high on this factor have a high degree of uncertainty about their ability to continue working.	22-items -13 items for persons not working (Scale A), and 9 items for persons working part time or full-time (Scale B). Five-point ordinal scale (1 = strongly disagree, 5 = strongly agree)
Return-to-Work Self-Efficacy Scale (RTWSE)^Citation61	Three subdomains: (1) the RTWSE Pain subscale, i.e. the ability to cope with pain (pain-tolerate, pain-prevent, pain manage), (2) the RTWSE Supervisor subscale, i.e. the ability to obtain help from supervisor and (3) the RTWSE Co-workers subscale, i.e. the ability to obtain help from coworkers.	Original: 28 Items Other version: 19, 11, 10 Items Five-point scale (0 = not at all certain, 4 = completely certain). The higher the score on the Self-efficacy for RTW Scale, the higher someone’s self-efficacy.
Rheumatoid Arthritis Specific Work Productivity Survey (WPS-RA)^Citation62	Disease-specific questionnaire Assessing the impact of RA on productivity within and outside the home and daily activities during the preceding month. One item of the WPS-RA addresses current labor market participation (that is, “are you currently employed outside the home?”).
Workplace Activity Limitations Scale (WALS)^Citation62,Citation63	Assesses disability/ activity limitation in the workplace due to physical illness Arthritis-related employment activity The scale measures the degree of difficulty with various job-related tasks that tax upper and/or lower limb function (e.g. gripping, crouching), as well as difficulties with commuting, scheduling, concentration, and pace of work.	12 items 4-point Likert type scale range from 0 to 3, where 0 = no difficulty and 3 = not able to do. If the item was not applicable, a score of 0 was given.
Work Instability Scale for Rheumatoid Arthritis (RA-WIS)^Citation64	Disease-specific questionnaire Predicts RTW within 1 year among patients with RA Predicts SAW Shows effectiveness of occupational therapy among patients with Rheumatoid Arthritis
Work Limitations Questionnaire (WLQ-25 /WLQ-16 /WLQ-8)^Citation65	Job impact of chronic health conditions & treatment A range of chronic conditions, including depression, arthritis, cancer, heart disease, diabetes, asthma, musculoskeletal pain, skin conditions and insomnia	Organized into 4 domains: ○ Time management (TM), addresses difficulty with handling a job’s time and scheduling demands (5 items) ○ Physical demands (PD), examines ability to perform job tasks that involve bodily strength, movement, endurance, coordination, and flexibility (6 items) ○ Mental-interpersonal demands (MI), addresses cognitively demanding tasks and on-the-job social interactions (9 items) ○ Output demands (OD), concerns reduced work productivity (5 items)
Work Role Functioning Questionnaire (WRFQ)^Citation64,Citation66,Citation67	A variant of the WLQ and is a work disability measure assesses the degree to which a working individual is experiencing on-the-job limitations* due to his/her health problem. Self-administered (telephone version available) A Describing a number of work demands chosen because of their frequent occurrence in a variety of jobs and their importance identified from the worker’s perspective. Five scales: (1) Work Scheduling Demands, (2) Physical Demands, (3) Mental Demands, (4) Social Demands and (5) Output Demands. Measuring the amount of time, in the past four weeks, a health problem interfered with the ability to perform work demands. Each scale is scored separately, by adding the response of each item, and is mathematically converted to a score varying from 0 (limited all the time) to 100 (never limited).	27 items Five-level scale: 0=difficult all the time, 1= difficult most of the time, 2=difficult half of the time, 3=difficult some of the time and 4=difficult none of the time. Percentage of time anchors the scale at 0, 2 and 4 (100%, 50%, 0%) respectively. The category “does not apply to my job” is also added to the questionnaire to make it applicable to all kinds of jobs.
Work Productivity and Activity Impairment Questionnaire (WPAI)^Citation45	Two versions: ○ General health (WPAI:GH) ○ Specific health problem (WPAI:SHP) (WPAI: SHP) is designed such that it can be modified for any health problem by specifying the disease/condition of interest in the questions Examines the extent of absenteeism, presenteeism, and impairment in daily activities attributable to general health (WPAI: GH) or a specific health problem (WPAI: SHP).	Six questions each with unique response options: Q1= current employment status (yes/no), Q2 = number of hours missed due to health problem, Q3 = number of hours missed due to other reasons, Q4= hours actually worked, (Q2–Q4: number of hours (count data)), Q5=degree to which health affected productivity while working(global rating scale, 0–10 (0 _ health problems had no effect on my work, 10 _ health problems completely prevented me from working)), Q6 = degree to which health affected regular (non-work) activities (global rating scale, 0–10 (0: health problems had no effect on my daily activities, 10: health problems completely prevented me from doing my daily activities)). Items are not intended to be summative http://www.reillyassociates.net/WPAI_GH.html

Table 3 Selected structure, process and outcome indicators for the employment domain.

Indicator	Denominator	Indicator Type	Time of Measurement
Proportion of SCI/D rehabilitation programs with available employment resource center	Total number of tertiary SCI/D rehabilitation programs in Canada	Structure	Annual
Proportion of SCI/D rehabilitation inpatients who receive employment assessment/consultation	Total number of SCI/D patients	Process	Rehabilitation Discharge
Readiness for Return-to-Work Scale (RRTW)	Total number of SCI/D patients	Outcome – Intermediary	Prior to rehabilitation discharge
Readiness for Return-to-Work Scale (RRTW)	Total number of SCI/D patients	Outcome – Final	18 months post rehabilitation admission
Work Productivity and Activity Impairment (WPAI) *for those who are employed*	Total number of employed SCI/D patients	Outcome – Final	18 months post rehabilitation admission

Figure 2 SCI-High employment domain indicator decision tree. Appropriate indicator data collection is based on the patient’s employment status at the time of assessment.

Table

The following section is about your feelings about getting ready to return to work. Keep in mind that “back to work” could mean back to part-time or modified work.
Are you currently back at work?	Yes (complete items14 to 22 only) No (complete items 1 to 13 only)
The letters in parentheses correspond to the stage to which each item belongs to based on a factor analysis (see Franche et al.^Citation39 for details). The acronyms are: Precontemplation (PC), Contemplation (C), Prepared for Action—Self-evaluative (PA-S), Prepared for Action—Behavioural (PA-B), Uncertain Maintenance (UM), and Proactive Maintenance (PM).
FOR THOSE NOT BACK AT WORK	Strongly Disagree	Disagree	Neither Disagree nor Agree	Agree	Strongly Agree
(1) You don’t think you will ever be able to go back to work. (PC)	1	2	3	4	5
(2) As far as you’re concerned, there is no point in thinking about returning to work. (PC)	1	2	3	4	5
(3) You are actively doing things now to get back to work. (PA-B)	1	2	3	4	5
(4) Physically, you are starting to feel ready to go back to work. (PA-S)	1	2	3	4	5
(5) You have been increasing your activities at home in order to build up your strength to go back to work. (PA-B)	1	2	3	4	5
(6) You are getting help from others to return to work. (PA-B)	1	2	3	4	5
(7) You are not ready to go back to work. (PA-S)	1	2	3	4	5
(8) You have found strategies to make your work manageable so you can return to work. (PA-S)	1	2	3	4	5
(9) You have been wondering if there is something you could do to return to work. (C)	1	2	3	4	5
(10) You have a date for your first day back at work. (PA-S)	1	2	3	4	5
(11) You wish you had more ideas about how to get back to work. (C)	1	2	3	4	5
(12) You would like to have some advice about how to go back to work. (C)	1	2	3	4	5
(13) As far as you are concerned, you don’t need to go back to work ever. (PC)	1	2	3	4	5
(14) You are doing everything you can to stay at work. (PM)	1	2	3	4	5
(15) You have learned different ways to cope with your pain so that you can stay at work. (PM)	1	2	3	4	5
(16) You are taking steps to prevent having to go off work again due to your injury. (PM)	1	2	3	4	5
(17) You have found strategies to make your work manageable so you can stay at work. (PM)	1	2	3	4	5
(18) You are back at work but not sure you can keep up the effort. (UM).	1	2	3	4	5
(19) You worry about having to stop working again due to your injury. (UM).	1	2	3	4	5
(20) You still find yourself struggling to stay at work due to the effects of your injury. (UM).	1	2	3	4	5
(21) You are back at work and it is going well. (UM).	1	2	3	4	5
(22) You feel you may need help in order to stay at work. (UM).	1	2	3	4	5

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