Employment outcomes for people following traumatic spinal cord injury

Background: Traumatic spinal cord injury (SCI) has devastating consequences, affecting the physical, psychological, social and vocational areas of a person’s life. Employment potential in people with traumatic SCI appears unrealised, with rates of labour force participation lower than the general population and substantially lower than pre-injury employment levels. Research on this issue has been limited to date, but it suggests that the process of returning to work after SCI is complex and that vocational interventions should be tailored and flexible to respond to individual needs. Overview: Chapter One of this thesis presents the background rationale for the research program. Chapter Two reviews and critiques the literature concerning vocational rehabilitation and the issues surrounding employment after SCI. The aims of the research are identified here. The third chapter provides a systematic review, appraisal and thematic synthesis of the qualitative literature that focuses on the experience of returning to work following SCI. Chapter Four describes an audit of patient medical records with the aim of identifying employment outcomes for people admitted to Austin Health with SCI over a four year period. Chapter Five presents the findings of a longitudinal cohort study that followed a group of people who participated in a newly implemented program of early intervention vocational rehabilitation. It examines the nature and extent of relationships between contextual factors and employment outcomes over time for these people. The sixth chapter presents an interpretative phenomenological analysis, undertaken to develop an in-depth understanding of the experiences and pathways of persons seeking and gaining ii employment after SCI. Chapter Seven reflects on the work presented throughout the thesis, discusses overall findings, identifies implications for practice, acknowledges the limitations of the thesis, and makes recommendations for future research. Chapter Eight presents conclusions from the research program. Findings: Results from the program of research led to six main findings. First, early intervention vocational rehabilitation shows promise in enhancing employment outcomes for people following traumatic SCI. Second, the concept of worker identity includes the process of becoming a worker after SCI, and the meaning and value of being a worker post-injury. Third, secure relationships, social supports, and the presence of a positive employment culture in institutional and social environments appear facilitatory of labour force participation. The fourth finding is that people with access to loss of earning benefits or equivalent are less likely to return to the labour force, while the fifth finding showed that having a higher level of pre-injury education was positively related with participation in the labour force. Finally, higher levels of subjective wellbeing are predictive of labour force participation and are positively associated with higher levels of social participation. Conclusions: This thesis establishes the importance of paid employment in people’s lives after traumatic SCI, while recognising the uniqueness of the employment journey for each individual. The experience of seeking, gaining and maintaining employment is complex. For people with SCI, the pathway to employment can be supported by involvement in an early intervention vocational rehabilitation program, gaining further education, and the existence of strong social supports. Seeking to re-establish worker identity, financial stability and subjective wellbeing are essential factors that facilitate an employment outcome.