Best Practices in Return to Work Services for Stroke Survivors: Perspectives From Experienced Clinicians

PURPOSE: The purpose of this paper is to describe the experiences of expert occupational therapy practitioners and their perceptions of best practices in delivering RTW services for persons with stroke.

BACKGROUND: The incidence of stroke among adults of working age (21–65 yr) is rising (George et al, 2011; Roth & Lovell, 2014); however, the rates of RTW are low (O’Brien & Wolf, 2010). Key documents of the profession such as the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2014) and the 2011 ACOTE Standards identify that work is an important domain of the profession. However, little is known about how practitioners address work among stroke survivors. In a national survey, occupational therapy practitioners recognize their role in promoting RTW for clients with stroke, yet, practitioners identified gaps in their knowledge and service delivery. By targeting expert practitioners with experience in RTW for stroke survivors, we may better understand consensus-based best practices and areas for further development.

METHOD: Based on the participants of a national survey on RTW, a subset of occupational therapy practitioners with varying levels of expertise in providing RTW services for stroke survivors were invited to participate in a semi-structured 1:1 phenomenological interview to describe their experiences and their perception of what constitutes best practices. In addition, further explanations were explored to the barriers and facilitators in providing RTW services. A total of 9 participants were interviewed by phone with each interview lasting 60–90 min. All participants were employed in outpatient practice settings and had at least 5 yr experience. Interviews were digitally recorded, transcribed, and analyzed using “a priori” coding based on outcomes of the survey study and the Occupational Therapy Practice Framework: Domain and Process. Subcategories were generated to maximize mutual exclusivity and exhaustiveness of data. To ensure credibility of the data, member checking was applied and the second author acted as a peer reviewer.

RESULTS: Best practices were identified as (1) addressing RTW early after stroke and emphasizing RTW as an end; (2) conducting comprehensive, ecologically valid, and occupation-centered evaluations; (3) integrating psychosocial coping and metacognitive strategies in interventions; (4) addressing the readiness of the employer and work environment to receive the employer/stroke survivor; (5) and advocating for support services as needed.

An emergent theme to best practice implementation is the need for occupational therapy practitioners to develop competencies and build their professional capacity to address RTW with younger stroke survivors. Subcategories of needed competencies include (1) understanding work laws and regulations; (2) developing knowledge of, and ability to analyze job demands and work environment; and (3) communication skills with employers and other professionals/service providers. Factors that facilitate provision of RTW services include having prior training/experience, mentorship, and organizational support. Barriers to service provision include lack of time, physical resources, lack of RTW-specific knowledge and skills.

IMPACT STATEMENT: Occupational therapy practitioners have a unique role and make significant contributions in providing RTW services for stroke survivors. Our study findings present key implications on practice, education and research. In practice, the study reinforces the unique concept of “occupation as an end” as a critical guide to facilitate return to the worker role and successful engagement in work occupations. However, our study also points to the importance of OT practitioners having RTW-specific competencies to successfully deliver RTW services, which implies the need to examine entry-level preparation and continuing competency of OT practitioners. Finally, research implications include studying the effectiveness of RTW services that incorporates OT, and demonstrating the efficacy of occupation-centered approaches to promoting RTW for stroke survivors.

REFERENCES

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. http://dx.doi.org/10.5014/ajot.2014.682006

George, M. G., Tong, X., Kuklina, E. V., & Labarthe, D. R. (2011). Trends in stroke hospitalizations and associated risk factors among children and young adults, 1995–2008. Annals of Neurology, 70, 713–721. http://dx.doi.org/10.1002/ana.22539

O’Brien, A. N., & Wolf, T. J. (2010). Determining work outcomes in mild to moderate stroke survivors. Work, 36, 441–447. http://dx.doi.org/10.3233/WOR-2010-1047

Roth, E. J., & Lovell, L. (2014). Employment after stroke: Report of a State of the Science symposium. Topics in Stroke Rehabilitation, 21(Suppl. 1), S75–S86. http://dx.doi.org/10.1310/tsr21S1-S75