“Acquired brain injury and return to work”: the feasibility of a training program for insurance physicians

Abstract

Purpose: To study the feasibility (limited efficacy, acceptability, and implementation) of a training program for insurance physicians.

Methods: Limited efficacy was evaluated over time (T0–T2) by conducting knowledge question tests using realistic case scenarios, analyzed by non-parametric Friedman and Wilcoxon signed-rank tests. Acceptability was evaluated by asking participants to agree or disagree with statements; for example, the knowledge was “relevant,” “useful,” or “appropriate.” Answers were analyzed using descriptive statistics. Open-ended questions were used to ask participants what, in their opinion, were the facilitators of and barriers to implementing the knowledge taught. Their answers were coded and categorized.

Results: Fifty-one IPs participated in the study. Concerning limited efficacy: the median values of the knowledge scores increased significantly over time and between time points from 16 (T0) to 21 (T1) and 32 (T2), p < 0.00. Concerning acceptability: 46 of 47 respondents perceived the training program to be “relevant,” “useful,” and “appropriate”; 44 respondents intended to use it in practice. Concerning implementation: participants reported “training” and “utility” as examples of facilitators and “lack of time,” for example, as a barrier.

Conclusion and implications: The feasibility (limited efficacy, acceptability, implementation) of the training program is demonstrated; the training program can be applied in practice.

Implications for rehabilitation

• The “acquired brain injury and return to work” training programme can be applied in postgraduate teaching and continuing medical education for insurance physicians.

• Interactive teaching methods including realistic case scenarios with a link to practice are recommended to provide insurance physicians the opportunity to learn to apply and discuss new knowledge and effectively improve insurance physicians’ knowledge.

• Implementation of a training programme for insurance physicians can be facilitated if a brief summary of the imparted knowledge is available.

• Barriers, such as “other occupational healthcare and paramedical professionals being unfamiliar with the imparted knowledge” need to be addressed when implementing the “acquired brain injury and return to work” training programme.

KEYWORDS:

• Acquired brain injury
• return-to-work
• RTW
• occupational health
• training program
• education program
• feasibility

Introduction

Acquired brain injury (ABI), both with a traumatic and a non-traumatic cause affects many individuals of working age every year [1]. Less than half of those who are working before suffering ABI return to work (RTW) within 2 years of the injury [2]. It has been reported that RTW after ABI has a significant positive impact on a person’s quality of life and life satisfaction [3–5]. In this study, RTW was defined as having part-time or full-time paid employment without consideration of the job demands or working hours. Given the importance of work, the RTW process of patients with ABI should be optimized.

In the multidisciplinary RTW process, medical and paramedical professionals, such as neurologists, rehabilitation physicians, general practitioners, and occupational healthcare professionals, such as occupational therapists, job coaches, occupational physicians, and insurance physicians (IPs), all collaborate to help patients with ABI to RTW [6,7]. As part of this, the specific role of occupational physicians in the Netherlands is to guide patients with ABI through the RTW process during two years of sick leave. IPs evaluate the RTW process after long-term sick leave and assess the patient’s functional abilities and prognosis of functioning. In addition, IPs provide recommendations regarding RTW. In order to support IPs’ tasks, scientific evidence on ABI, the RTW process and related effective interventions has recently been obtained [6,8–11]. In addition, researchers have investigated the RTW experiences of patients and employers, and gathered expert opinion on the coordination of multidisciplinary care in the RTW process. This knowledge is embedded in the multidisciplinary guideline “ABI and Work Participation” intended for all (para)medical and occupational healthcare professionals involved in the RTW process of patients with ABI [12].

Although adherence to guidelines allows for evidence-based best practice and has been shown to improve quality of care [13,14], implementing new guidelines is still challenging [15,16]. Numerous studies have revealed barriers at the organizational, patient or professional level, such as lack of knowledge on the part of individual healthcare physicians [13,15,17,18]. A range of approaches can be taken to address these knowledge gaps, such as educational interventions [13,19,20]. Among these, interactive multifaceted interventions have proven to be effective in changing healthcare professionals’ knowledge [21,22]. These insights formed the basis for developing the “ABI and RTW” training program for IPs [23].

As a first step, prior to implementation in IPs’ practice, we investigated the feasibility of this program for imparting knowledge and whether it needed to be adapted [13,24,25]. A feasibility study provides information on, for example, how the target population reacts to an intervention, whether an intervention is likely to be applied within an existing or a different system, and whether the intervention yields trends for positive outcomes [24]. In accordance with recommendations on the design of feasibility studies [24], the aim of this study was to address specifically: (1) whether the training program resulted in an increase in IPs’ knowledge concerning ABI and the RTW process (“limited efficacy”); (2) whether IPs perceive the knowledge taught in the “ABI and RTW” training program to be relevant, useful, and appropriate (“acceptability”); and (3) regarding “implementation” in daily practice, what, according to IPs, are potential facilitators of or barriers to the implementation of the knowledge acquired.

Methods

Feasibility was studied by undertaking a pilot of the “ABI and RTW” training program for IPs. Limited efficacy was evaluated by using an experimental “pre-post” design. Acceptability and implementation were studied by means of a qualitative design.

The research was conducted in accordance with the principles set out in the Declaration of Helsinki [26]. The research proposal was submitted to and approved by the Medical Ethical Committee of the Academic Medical Center. The latter judged that a comprehensive evaluation would not be required, on the grounds that this study is not subject to the Medical Research Involving Human Subjects Act (Reference number W17_028 # 17.040).

Participants

Participants who were registered as or training to become IPs, who were employed by the Dutch National Institute for Employee Benefit Schemes and working at one of three offices of the Dutch National Institute for Employee Benefit Schemes in the eastern part of the Netherlands, were considered eligible and invited to participate. They were informed about the study’s aim and procedure during a regular staff meeting at their workplace. They received additional detailed written information about the study and an informed consent form. Participants were given a guarantee that participation was voluntary and that all data would remain confidential and used solely for research purposes. Those IPs who agreed to participate signed the informed consent form and returned it to the first author. They were subsequently enrolled in the study and assigned to three different training groups at three different local training sites.

Training program

The research team designed the “ABI and RTW” training program for IPs.

The content of the training program was based on evidence-based recommendations embedded in a multidisciplinary guideline [12]. The research team selected recommendations relevant for IPs and defined learning objectives, based on the knowledge contained in the guideline. The learning objectives were categorized in accordance with IPs’ professional tasks: evaluating the RTW process and assessing capacity to work and prognosis of functioning of patients with ABI. The detailed learning objectives are presented in Supplementary Table S1.

The training format was based on learning theories and empirical evidence of effective teaching methods [21,22,27–30]. In addition, educational experts advised on how best to enable participants to acquire new knowledge. The learning objectives and input on teaching methods were incorporated to produce a 1-day, 4-h interactive training program, featuring case-based learning activities that provide a link to IPs’ daily practice. The second author, an experienced IP, moderated the training program. The first author contributed to the content of the program when needed. The training program plan is outlined in Table 1.

Table 1. The 1-day, 4-h training program plan “ABI and RTW” for IPs.

Topics related to IPs’ professional tasks	Teaching methods	Time
Introduction		5 min
ABI	Interactive lecture	10 min
Evaluation of the RTW process of patients with ABI	Interactive lecture Quizzes Exercises Simple case scenarios in small groups Plenary feedback More complex case scenarios in small groups, facilitated by instructor Plenary feedback Plenary discussion Reflection on own practice	1.5 h
Assessment of work capacity of patients with ABI	Interactive lecture Quizzes Exercise Case scenarios in small groups Plenary feedback Plenary discussion Reflection on own practice	1 h
Assessment of medical and functional prognosis of patients with ABI	Interactive lecture Quizzes Exercise Simple case scenarios in small groups Plenary feedback More complex case scenario derived from daily  practice in small groups, facilitated by instructor Plenary feedback Plenary discussion Reflection on own practice	1 h

Limited efficacy

In order to evaluate whether the training program resulted in increased knowledge over time, knowledge was assessed three times using test questionnaires [31]: without documentation (T0), after reading a print version of the guideline “ABI and Work Participation” (T1) and, finally, after attending the face-to-face training program (T2).

The test questionnaires were aligned with the learning objectives [31] and comprised three sets of 16 questions, with equivalent content for three measures at T0, T1, and T2, respectively. The knowledge test items were a combination of “true or false,” “multiple choice,” and open-ended questions. The open-ended questions required participants to construct their own answers built around a written realistic case scenario concerning the RTW process of patients with ABI.

The topics of the test questions provided were as follows:

• Consequences/causes of ABI, disorders of which ABI is a result

• Aspects that are positively or negatively associated with RTW of patients with ABI

• Patient, work and environment-related aspects that might hinder RTW

• Professionals involved in the RTW process of a patient with ABI

• Aspects that can facilitate/hinder RTW

• Solutions for barriers to RTW

• Effective RTW interventions

• Prognosis of functioning of a patient with ABI

The following is an example of an open-ended question:

Patients with ABI often lack insight into the consequences of ABI. Mention two interventions that can be applied accordingly.

The following is an example of a multiple choice question:

Indicate which of these aspects are associated with RTW: long stay in rehabilitation, high level of education, low level of education, unemployment prior to injury, independence in activities of daily living.

The following is an example of a “true or false” question:

A majority of patients with ABI do not experience changes in functioning after two years. True or false.

The test questionnaires were constructed by the research team, and subsequently reviewed and approved by an educational expert. The first author formulated answers based on the content of the guideline, and developed a detailed scoring document on how to evaluate participants’ performance. This document was then verified by the research team. The questionnaires and scoring documents are available from the corresponding author on request. The score for each correct response ranged from 0 to 5 points. The performance of all participating IPs was assessed based on the sum score of all of the responses they provided. This resulted in a minimum total score of 0 and a maximum total score of 40 points. The participants’ performance was measured at each time point (T0, T1, and T2).

Acceptability

In order to evaluate acceptability, participants were requested to complete a survey after attending the training program (T2). The survey comprised eight statements about the “ABI and Work Participation” guideline that was taught during the training session.

These statements were:

• The guideline is easy to read

• The guideline is clear

• The guideline is relevant for daily practice

• The guideline is useful for daily practice

• The guideline is appropriate for use with patients with ABI in daily practice

• The guideline is appropriate for assessing the functional capacity of patients with ABI

• The guideline is appropriate for assessing the prognosis of patients with ABI

• I intend to continue using the guideline

Participants were asked to indicate whether or not they agreed with the statements, using a 4-point scale: “strongly agree,” “agree,” “disagree,” and “strongly disagree.”

Implementation

In order to evaluate whether the training program “ABI and RTW” could be implemented in practice, participants were requested to answer three open-ended questions after the training program (T2).

These questions were:

• In my opinion, facilitators of implementation of the guideline in daily practice are…

• In my opinion, barriers to the implementation of the guideline in daily practice are…

• In my opinion, if implementation was hindered, … would be needed/necessary.

Analysis

Limited efficacy

The participants’ performance, that is, the sum scores of the knowledge tests taken by all participating IPs, was evaluated over time (from T0 to T2). The values of the participants’ sum scores were analyzed for normality using the Kolmogorov-Smirnov and the Shapiro-Wilk tests, at each time point (T0, T1, and T2). If the participants’ sum scores were normally distributed, analysis of sum scores over time was performed using the Repeated Measures ANOVA. If the distribution of the scores was not normal, the nonparametric Friedman test was used. If significant differences were found, this was followed by a post hoc analysis, that is, the Wilcoxon signed rank test. If the p values were below 0.05, differences were considered to be significant.

Acceptability

Participants’ agreements or disagreements with the statements were analyzed, applying descriptive statistics.

Implementation

The first author and a research assistant read and coded the participants’ answers individually. Subsequently, the first author and the research assistant independently categorized the codes into “facilitators” of and “barriers” to implementation and “what is needed/necessary when implementation is hindered,” using qualitative data analysis software. The first author and the research assistant created subcategories based on similar answers concerning the main categories, and then reached consensus on the subcategories. The results of the categorization were presented to and checked by the second and third author.

Results

Participants

Eighty-two IPs were invited to the staff meeting at their workplace. Fifty-seven IPs were willing to participate, six IPs were unable to attend the training program due to holidays (N = 1), sick leave (N = 2), other training (N = 1), and for unknown reasons (N = 2). As a consequence, 51 IPs participated in the study, of whom 27 were male. The mean age of the participants was 49 years (SD =11, range 27–64 years). The participants’ mean practice experience was 14 years (SD =11, range 1–34 years). All participants were employed by the Dutch National Institute for Employee Benefit Schemes.

Training program

The face-to-face “ABI and RTW” training program was provided on three occasions in April and May 2017, at three different locations in the east of the Netherlands.

All 51 participants completed the limited efficacy questionnaires at baseline (T0), just before the training program (T1), and directly after the training program (T2). Up to seven participants did not indicate their level of agreement with each specific statement of the survey on acceptability. Five participants did not answer any questions concerning facilitators of and barriers to implementation and what, in their opinion, would be needed or necessary if implementation is hindered. One participant gave a reason for this, namely, not having read the guideline.

Limited efficacy

The knowledge tests at T0, T1, and T2 each took 15–20 min to complete. The first and the second author scored the questionnaires of all participants independently, based on the scoring document, and resolved any disagreements. The values of the sum scores of the knowledge tests of all participants were found to be non-normally distributed. The non-parametric Friedman test demonstrated that the median values of knowledge scores increased significantly over time from 16 (range 8–23, T0) to 21 (range 12–32, T1) and 32 (range 20–36, T2), χ2(2) = 95.95, p < 0.00. Post hoc analysis showed a significant knowledge increase from T0 to T1 (p < 0.00) and from T1 to T2 (p < 0.00), respectively.

Acceptability

A majority of participants reported that the “ABI and Work Participation” guideline [12] taught in the “ABI and RTW” training program was easy to read, clear, relevant, useful and appropriate, and that they intended to continue using it.

The results are outlined in detail in Table 2.

Table 2. Acceptability of the “ABI and RTW” training program for IPs (N = 51).

	Statements (number of respondents)	Strongly disagree (N)	Disagree (N)	Agree (N)	Strongly agree (N)
1	The guideline is easy to read (N = 44)	0	1	37	6
2	The guideline is clear (N = 44)	0	1	37	6
3	The guideline is relevant for daily practice (N = 47)	0	1	34	12
4	The guideline is useful for daily practice (N = 47)	0	1	34	12
5	The guideline is appropriate for use with patients with ABI in daily practice (N = 47)	0	1	36	10
6	The guideline is appropriate for assessing the functional capacity of patients with ABI (N = 45)	0	5	31	9
7	The guideline is appropriate for assessing the prognosis of patients with ABI (N = 45)	0	1	36	8
8	I intend to continue using the guideline (N = 44)	0	0	28	16

Implementation

The participants reported various facilitators and barriers concerning implementation, as well as what, in their opinion, would be needed/necessary if implementation is hindered. These facilitators, barriers and necessary measures have been categorized and outlined in detail in Supplementary Table S2. A few are presented below; quotations have been included as examples.

Table

1. Facilitators of implementation

Familiarity with guideline

“That attention is paid to this” (participant 12)

Training

“Practise/discuss with colleagues” (participant 51)

Summaries

“Clear and well-organized; the summary card is particularly useful as a guide for practice” (participant 44)

Utility

“Easy to apply” (participant 5)

“Being given enough time by the Dutch National Institute for Employee Benefit Schemes to do high-quality assessment” (participant 24)

“Attractive design” (participant 1)

2. Barriers to implementation

Training

“Lots of tests” (participant 22)

Utility

“If one of the 3–4 physicians (rehabilitation physician, general practitioner, occupational physician, insurance physician) doesn’t use the guideline” (participant 42)

“A guideline can be difficult to apply at the case level” (participant 50)

“Time constraints in daily practice, also in view of timeliness” (participant 25)

“Lots of information to go through every time” (participant 36)

3. Needed/necessary when implementation is hindered

Familiarity with guideline

“Should pay attention to this” (participant 35)

Training

“Compulsory refresher courses” (participant 23)

“Regularly discuss in case histories” (participant 32)

“Brush up on an occasional basis” (participant 30)

Utility

“Effective consultation with the other disciplines” (participant 39)

Design

“Brief and succinct execution” (participant 29)

Time

“Allow the time to apply this well” (participant 2)

Discussion

The aim of this study was to evaluate the feasibility of the “ABI and RTW” training program for IPs, specifically in relation to limited efficacy, acceptability and implementation. The results of this study demonstrate the limited efficacy of the training program, leading to a significant increase in knowledge over time. The participants considered the knowledge embedded in the guideline to be acceptable for daily practice and intend to continue using it. The participants reported aspects that could facilitate or form barriers to the implementation of this knowledge, such as “training” and “lack of time,” respectively.

Context of the training program

When designing the face-to-face training program, the target audience was taken into account. The trainees were experienced physicians who underwent this training alongside their professional activities and were actively taking part in a training course linked to practice. The “ABI and RTW” training program was therefore based on the principles of adult learning theory, constructivism and cognitive load theory [27–30]. In this sense, the IPs learned to apply new knowledge actively in exercises and realistic case scenarios, and encountered practical problems; an approach that, according to adult learning theory, creates motivation to learn [30,32]. The face-to-face mode was chosen, as it provided participants the opportunity to discuss with peers and to reflect on their practice. The participants linked new knowledge to existing knowledge and assimilated it; according to constructivism, which is associated with deeper understanding and retention in the longer term [27,28,33]. Finally, by working up from simple exercises to more complex case scenarios, the cognitive load of the training program was limited [29].

Limited efficacy

One aim of this study was to investigate the limited efficacy of the “ABI and RTW” training program in a small population of IPs and, specifically, to establish whether it resulted in a significant knowledge increase on the part of participants and demonstrated the potential for broad implementation [24]. The “ABI and RTW” training program consisted of reading the guideline, followed by a 1-day, 4-h face-to-face training program, including serial assessments of knowledge.

In order to optimize knowledge transfer, the training program made use of active teaching approaches that have been shown to improve physician performance and guideline implementation [21,22]. Training programs designed in this way have been shown to result in knowledge increase in the context of guideline implementation for IPs [34] and occupational physicians [35]. Specifically, when guidelines need to be implemented in IPs’ practice, the use of interactive lectures and subgroup exercises with a trainer providing feedback has been demonstrated to increase IPs’ knowledge significantly [34]. Therefore, in this “ABI and RTW” training program, knowledge was imparted in a similar way, by means of interactive plenary lectures, exercises, simple case scenarios providing participants with opportunities to have short discussions with peers, and more complex, realistic case scenarios whereby participants learned to apply the knowledge in small groups of two or three participants. This case-based learning method allowed participants to reflect on their own practice when evaluating the RTW process, and when performing assessments of functional abilities and prognosis.

The knowledge tests over time revealed an increase in knowledge not only after completing the entire training program, but also after the IPs had read the printed version of the guideline. This is remarkable, as previous studies have demonstrated that printed education materials as a single intervention are not an effective means of influencing physicians’ knowledge or behavior [21,36], or have only a limited effect on professional practice outcomes as demonstrated in a systematic review [37]. The increase in IPs’ knowledge after reading the guideline “ABI and Work Participation” could have resulted from their awareness that their knowledge would be tested. On the one hand, the participants were motivated to achieve a good result, but on the other hand, they reported that the number of tests formed a barrier to the implementation of the training program. Moreover, this increase in knowledge could be a so-called “testing effect”; in other words, testing itself can create a learning effect and has been proven to increase the transfer and recall of information [38–40]. One systematic review, for example, reported that test-enhanced learning interventions such as short-answer questions resulted in better learning outcomes for trainees in health professions education when compared to repeated studying [39]. Teachers could therefore consider including assessments in training programs in order to improve learning outcomes in health professions education [39,40].

Acceptability

The IPs considered the “ABI and RTW” training program to be acceptable: clear, relevant, useful and appropriate. These positive comments could potentially be attributed to the content of the training program, which is congruent with IPs’ main professional tasks; namely, assessment of functional capacity, prognosis of functioning, and evaluation of the RTW process of patients with ABI. This close link between the content of the training and daily practice was highly appreciated by the participants in this study, as well as in other studies [22,32]. This, in turn, could potentially have a positive impact on IPs’ adherence to the guideline in practice, since participants indicated their intention to continue using the guideline [41]. This is important additional information with respect to broad implementation in the future, as it was derived directly from the stakeholders themselves. These positive results concerning acceptability indicate the “ABI and RTW” training program’s potential for broad implementation in IPs’ practice [24,42]. It is recommended to evaluate IPs’ long-term adherence to the guideline.

Implementation

Based on the abovementioned results, the “ABI and RTW” program is ready to be implemented in practice. This is important, as the potential of the training program stimulates participants to adopt evidence-based knowledge for their practice [35]. The IPs mentioned several aspects that they considered to be potential facilitators of the implementation of the knowledge taught, such as “training” and “the summary card for use in practice”; by contrast, potential barriers included “lack of time.” Barriers were also reported in other studies [13,15,17,18] and should be addressed when implementing the program more broadly. With regard to “lack of time,” for example, the short duration of the training program makes it feasible; a relatively limited amount of time is required to attend the training program. Furthermore, the program is accredited, meaning that IPs earn the credit points they need for their medical registration.

Implications for practice

Based on the findings of this study, the “ABI and RTW” training program will be provided to all IPs. The authors recommend the training program to be mandatory for all IPs in training, and to be integrated into continuing medical education for specialized IPs, as IPs see patients with ABI frequently [1,2]. Being regularly confronted with patients with ABI provides IPs the opportunity to practise the knowledge that has been acquired during the training program. Future studies should focus on the development of skills and methods to sustain knowledge. This 1-day training program did increase knowledge in the short term, but educational meetings should be repeated to facilitate the practising of the knowledge that has been acquired, a requirement that was also mentioned by participants in this study.

The RTW process in patients with ABI is a multidisciplinary process [12] that requires the involvement of all relevant (para)medical and occupational healthcare professionals. The adequate dissemination of the guideline content and training among these professionals could therefore improve the RTW process. “The “ABI and RTW” training program could be used to achieve this aim, as it is also suitable for all other (para)medical and occupational healthcare professionals involved in the RTW process of patients with ABI. It is recommended to evaluate the effect of the training program on actual RTW.

Conclusion

The feasibility of the “ABI and RTW” training program has been demonstrated: the training program resulted in an increase in the participants’ knowledge of ABI and the RTW process over time (limited efficacy). The training program was perceived to be for example relevant, useful and appropriate by participants who attended the training program (acceptability). The participants indicated aspects that could facilitate or form barriers to the implementation of imparted knowledge, such as “training” and “lack of time,” respectively (implementation). The “ABI and RTW” training program can be applied in practice.

Acknowledgments

The authors would like to acknowledge Wikeshkoemar Ramnarain Singh, who assisted with the data analysis.

Disclosure statement

The authors report no conflicts of interest.