What does real-world walking mean to people with stroke? An interpretive descriptive study.

PURPOSE: Understanding personal experiences of real-world walking for stroke survivors could assist clinicians to tailor interventions to their clients' specific needs. We explored the research questions: "What does real-world walking mean to people after stroke and how do they think it can be better?" METHOD: Using an Interpretive Descriptive methodology, we purposively sampled eight stroke survivors who reported difficulty walking in the real-world. We sought diversity on key participant characteristics. Participants were interviewed using a semi-structured guide. Data were analysed with thematic analysis. RESULTS: Many found real-world walking, particularly in the outdoors, created opportunities for freedom from dependence and a visible step by step progress, which generated hope for future recovery. Conversely, when participants did not experience sufficient progress, they expressed negative emotions. Participants strove to overcome challenges to their walking goals using everyday routines, planning skills, and confidence building experiences to motivate themselves. They also drew on, and extended, social resources highlighting the relational aspects of real-world walking. CONCLUSIONS: Walking in their real-world provided a meaningful, desirable, but challenging goal for participants that required significant emotional effort. Successful progress in real-world walking builds confidence and hope and can contribute to psychological wellbeing by providing opportunities for successful mastery and social connectedness.IMPLICATIONS FOR REHABILITATIONReal-world settings can be unpredictable which makes walking in the real-world after stroke demanding.Positive experiences of walking in the real-world can provide significant psychological benefits to stroke survivors.Many survivors need to carefully concentrate on the act of walking in outdoor settings.Pre-planning routes, confidence-building experiences and developing daily routines may help patients overcome these challenges.

Support workers' experiences of work stress in long-term care settings: a qualitative study.

Background: Support-workers' performance and well-being are challenged by increasingly high workloads and poor working conditions, leading to high levels of occupational stress. Aims: To explore the experiences of work stress for support-workers in New Zealand residential facilities. Design: An Interpretive Descriptive study. Methods: Data from ten (n = 10) support-workers were collected between December 2013 and June 2014, using semi-structured in-depth face-to-face interviews. Thematic analysis was used to identify key themes that captured participant reports of their experiences. Results: Work stress was conceptualized by participants as being an everyday experience of having too much to deal with and feeling under constant pressure. It appeared to be a complex and fluid experience representing an inherent, dynamic tension between reasons to be a caregiver and the burden of caregiving. Participants highlighted a range of influencing factors (including lack of recognition, person and work context, and coping strategies), which may account for that fluidity. Conclusion: The findings extend current knowledge about support-workers' work stress by identifying the challenges relating to the lack of recognition of their role and expertize, the unintended consequences of person-centered care and the challenges faced by migrant support-workers.

Recovery and adaptation after traumatic brain injury in New Zealand: Longitudinal qualitative findings over the first two years.

Knowledge about the impacts of traumatic brain injury (TBI) and aspects that influence recovery and adaptation are key to understanding how best to provide appropriate services. Whilst injury experiences have been documented, factors that help or hinder recovery and adaptation over time and across injury severities remain unclear. We present overarching findings addressing these matters in a large longitudinal qualitative study of recovery and adaptation following TBI. People experiencing TBI (n = 52) and their significant others (n = 37) were interviewed at 6-, 12- and 24-months post-injury. Data were thematically analysed cross-sectionally and longitudinally. Two overarching themes were captured in the analysis: making room for recovery and cultivating important resources. Themes comprise circumstances and processes that changed and developed over time in different ways for different participants. Key complexities within the overarching themes included the notion of "acceptance" and the role it played in allowing for recovery and adaptation; and the concept of "self" as a resource aiding recovery, but one that is perpetually at risk due to the intersection between the functional and social effects of the injury. Developing concepts of TBI recovery and living with TBI were central processes across diverse participants, but necessarily individualised in how they could be enacted.

Development of a toolkit to enhance care processes for people with a long-term neurological condition: a qualitative descriptive study.

OBJECTIVE: To (A) explore perspectives of people with a long-term neurological condition, and of their family, clinicians and other stakeholders on three key processes: two-way communication, self-management and coordination of long-term care; and (B) use these data to develop a 'Living Well Toolkit', a structural support aiming to enhance the quality of these care processes. DESIGN: This qualitative descriptive study drew on the principles of participatory research. Data from interviews and focus groups with participants (n=25) recruited from five hospital, rehabilitation and community settings in New Zealand were analysed using conventional content analysis. Consultation with a knowledge-user group (n=4) and an implementation champion group (n=4) provided additional operational knowledge important to toolkit development and its integration into clinical practice. RESULTS: Four main, and one overarching, themes were constructed: (1) tailoring care:referring to getting to know the person and their individual circumstances; (2) involving others: representing the importance of negotiating the involvement of others in the person's long-term management process; (3) exchanging knowledge: referring to acknowledging patient expertise; and (4) enabling: highlighting the importance of empowering relationships and processes. The overarching theme was: assume nothing. These themes informed the development of a toolkit comprising of two parts: one to support the person with the long-term neurological condition, and one targeted at clinicians to guide interaction and support their engagement with patients. CONCLUSION: Perspectives of healthcare users, clinicians and other stakeholders were fundamental to the development of the Living Well Toolkit. The findings were used to frame toolkit specifications and highlighted potential operational issues that could prove key to its success. Further research to evaluate its use is now underway.

Engaging people experiencing communication disability in stroke rehabilitation: a qualitative study.

BACKGROUND: Engagement is commonly considered important in stroke rehabilitation, with some arguing it is essential for positive patient outcomes. An emerging body of research indicates the practitioner influences engagement through their ways of relating, communicating and working with the patient. People experiencing communication disability may face particular challenges with engagement as a practitioner's communication and interactional patterns may limit their ability to engage. AIMS: To understand how rehabilitation practitioners worked to engage people experiencing communication disability throughout the course of rehabilitation. METHODS & PROCEDURES: A qualitative study using the Voice Centred Relational Approach. Longitudinal observational and interview data were gathered from 28 practitioners and three people experiencing communication disability in inpatient and community stroke rehabilitation services. Data were analyzed using the Listening Guide. OUTCOMES & RESULTS: Engagement was a relational practice on the part of the rehabilitation practitioner. It was underpinned by a relational philosophy and characterized by three core processes: embedding relational work throughout rehabilitation; getting to know the patient and working in ways valued by the patient; and communicating using relational dialogue and supported conversation. Practitioners wove these together with their technical, disciplinary-based work and rehabilitation tasks. CONCLUSIONS & IMPLICATIONS: Patient engagement was constructed through relationships and strongly influenced by the practitioners' way of thinking about and enacting practice, challenging the idea that engagement is solely an intrinsic patient state and behaviour. The findings raise questions about which aspects of rehabilitation work and communication are most valuable when working to engage people experiencing communication disability. Viewing engagement as a relational practice and understanding the different ways this is enacted may support practitioners to reflect on their understandings of engagement, their patient's engagement, their ways of working, and the frames and philosophies that surround and influence their practice.

Strengths and Difficulties Questionnaire: internal validity and reliability for New Zealand preschoolers.

OBJECTIVES: This observational study examines the internal construct validity, internal consistency and cross-informant reliability of the Strengths and Difficulties Questionnaire (SDQ) in a New Zealand preschool population across four ethnicity strata (New Zealand European, Maori, Pasifika, Asian). DESIGN: Rasch analysis was employed to examine internal validity on a subsample of 1000 children. Internal consistency (n=29 075) and cross-informant reliability (n=17 006) were examined using correlations, intraclass correlation coefficients and Cronbach's alpha on the sample available for such analyses. SETTING AND PARTICIPANTS: Data were used from a national SDQ database provided by the funder, pertaining to New Zealand domiciled children aged 4 and 5 and scored by their parents and teachers. RESULTS: The five subscales do not fit the Rasch model (as indicated by the overall fit statistics), contain items that are biased (differential item functioning (DIF)) by key variables, suffer from a floor and ceiling effect and have unacceptable internal consistency. After dealing with DIF, the Total Difficulty scale does fit the Rasch model and has good internal consistency. Parent/teacher inter-rater reliability was unacceptably low for all subscales. CONCLUSION: The five SDQ subscales are not valid and not suitable for use in their own right in New Zealand. We have provided a conversion table for the Total Difficulty scale, which takes account of bias by ethnic group. Clinicians should use this conversion table in order to reconcile DIF by culture in final scores. It is advisable to use both parents and teachers' feedback when considering children's needs for referral of further assessment. Future work should examine whether validity is impacted by different language versions used in the same country.

Co-constructing engagement in stroke rehabilitation: a qualitative study exploring how practitioner engagement can influence patient engagement.

OBJECTIVE: To explore how practitioner engagement and disengagement occurred, and how these may influence patient care and engagement. DESIGN: A qualitative study using the Voice Centred Relational Methodology. Data included interviews, focus groups and observations. SETTING: Inpatient and community stroke rehabilitation services. SUBJECTS: Eleven people experiencing communication disability after stroke and 42 rehabilitation practitioners. INTERVENTIONS: Not applicable. RESULTS: The practitioner's engagement was important in patient engagement and service delivery. When patients considered practitioners were engaged, this helped engagement. When they considered practitioners were not engaged, their engagement was negatively affected. Practitioners considered their engagement was important but complex. It influenced how they worked and how they perceived the patient. Disengagement was taboo. It arose when not feeling confident, when not positively impacting outcomes, or when having an emotional response to a patient or interaction. Each party's engagement influenced the other, suggesting it was co-constructed. CONCLUSIONS: Practitioner engagement influenced patient engagement in stroke rehabilitation. Practitioner disengagement was reported by most practitioners but was often a source of shame.

Interventions to improve real-world walking after stroke: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to determine the effectiveness of current interventions to improve real-world walking for people with stroke and specifically whether benefits are sustained. DATA SOURCES: EBSCO Megafile, AMED, Cochrane, Scopus, PEDRO, OTSeeker and Psychbite databases were searched to identify relevant studies. REVIEW METHODS: Proximity searching with keywords such as ambulat*, walk*, gait, mobility*, activit* was used. Randomized controlled trials that used measures of real-world walking were included. Two reviewers independently assessed methodological quality using the Cochrane Risk of Bias Tool and extracted the data. RESULTS: Nine studies fitting the inclusion criteria were identified, most of high quality. A positive effect overall was found indicating a small effect of interventions on real-world walking (SMD 0.29 (0.17, 0.41)). Five studies provided follow-up data at >3-6 months, which demonstrated sustained benefits (SMD 0.32 (0.16, 0.48)). Subgroup analysis revealed studies using exercise alone were not effective (SMD 0.19 (-0.11, 0.49)), but those incorporating behavioural change techniques (SMD 0.27 (0.12, 0.41)) were. CONCLUSIONS: A small but significant effect was found for current interventions and benefits can be sustained. Interventions that include behaviour change techniques appear more effective at improving real-world walking habits than exercise alone.

"It's just so bloody hard": recommendations for improving health interventions and maternity support services for disabled women.

PURPOSE: Little is known about the barriers and facilitators to pregnancy, birth and motherhood for disabled women within the New Zealand context. Our study explored this deficit with the aim of improving health care interventions and support for disabled mothers. METHODS: This paper reports on the third phase of a mixed-methods study. The first two phases used semi-structured individual and focus group interviews with disabled women, and health professionals, involved in maternity and postnatal care and has been reported elsewhere. Phase 3 utilised a modified Delphi technique with both groups of participants to seek consensus on the prioritisation of recommendations from the study. This article focuses on the disabled women's recommendations. RESULTS: In all, 20 disabled women took part in the Delphi phase of the study (28% of the cohort from Phase 1). In total, 11 key recommendations were identified by the disabled women, with the top seven discussed in detail here. CONCLUSIONS: Health professionals and health systems could, and arguably should, utilise a matrix of these recommendations to facilitate a review of service responsiveness to disabled women. Implications for Rehabilitation Becoming a mother is a potentially relevant and important rehabilitation issue for women of childbearing age who come into contact with rehabilitation services. Disabled women encounter a range of economic, attitudinal and knowledge barriers in relation to becoming mothers. Centralised sites/sources of information have potential to provide accessible and useful information for disabled women and health professionals.

Optimising qualitative longitudinal analysis: Insights from a study of traumatic brain injury recovery and adaptation.

Knowledge about aspects that influence recovery and adaptation in the postacute phase of disabling health events is key to understanding how best to provide appropriate rehabilitation and health services. Qualitative longitudinal research makes it possible to look for patterns, key time points and critical moments that could be vital for interventions and supports. However, strategies that support robust data management and analysis for longitudinal qualitative research in health-care are not well documented in the literature. This article reviews three challenges encountered in a large longitudinal qualitative descriptive study about experiences of recovery and adaptation after traumatic brain injury in New Zealand, and the strategies and technologies used to address them. These were (i) tracking coding and analysis decisions during an extended analysis period; (ii) navigating interpretations over time and in response to new data; and (iii) exploiting data volume and complexity. Concept mapping during coding review, a considered combination of information technologies, employing both cross-sectional and narrative analysis, and an expectation that subanalyses would be required for key topics helped us manage the study in a way that facilitated useful and novel insights. These strategies could be applied in other qualitative longitudinal studies in healthcare inquiry to optimise data analysis and stimulate important insights.

Cross-cultural acceptability and utility of the strengths and difficulties questionnaire: views of families.

BACKGROUND: Screening children for behavioural difficulties requires the use of a tool that is culturally valid. We explored the cross-cultural acceptability and utility of the Strengths and Difficulties Questionnaire for pre-school children (aged 3-5) as perceived by families in New Zealand. METHODS: A qualitative interpretive descriptive study (focus groups and interviews) in which 65 participants from five key ethnic groups (New Zealand European, Maori, Pacific, Asian and other immigrant parents) took part. Thematic analysis using an inductive approach, in which the themes identified are strongly linked to the data, was employed. RESULTS: Many parents reported they were unclear about the purpose of the tool, affecting its perceived value. Participants reported not understanding the context in which they should consider the questions and had difficulty understanding some questions and response options. Maori parents generally did not support the questionnaire based approach, preferring face to face interaction. Parents from Maori, Pacific Island, Asian, and new immigrant groups reported the tool lacked explicit consideration of children in their cultural context. Parents discussed the importance of timing and multiple perspectives when interpreting scores from the tool. CONCLUSIONS: In summary, this study posed a number of challenges to the use of the Strengths and Difficulties Questionnaire in New Zealand. Further work is required to develop a tool that is culturally appropriate with good content validity.

Measuring Neurobehavioral Functioning in People With Traumatic Brain Injury: Rasch Analysis of Neurobehavioral Functioning Inventory.

OBJECTIVE: To examine internal construct validity of the Neurobehavioral Functioning Inventory (NFI) by applying Rasch analysis. SETTING: An outpatient rehabilitation program trial in New Zealand employing a goal-setting intervention in people with traumatic brain injury (TBI). PARTICIPANTS: One hundred eight people (mean age = 46 years; 73% male) between 6 months and 5 years post-TBI. DESIGN: Rasch analysis of the NFI (Partial Credit Model). RESULTS: Three NFI subscales were not unidimensional and at least 4 items in each subscale had disordered response categories. Two items showed differential item functioning by age, 1 item by educational attainment, and 2 items were found to misfit the overall construct. These items were excluded from the total score calculation. The revised scale fit the Rasch model and supported the internal construct validity of the NFI. CONCLUSIONS: Current scoring of the NFI subscales for people with TBI in New Zealand does not meet the requirements of the Rasch model. The revised version of NFI can improve the interpretation of scores but should be further tested with people with TBI in other settings.

Choral singing therapy following stroke or Parkinson's disease: an exploration of participants' experiences.

PURPOSE: People with stroke or Parkinson's disease (PD) live with reduced mood, social participation and quality of life (QOL). Communication difficulties affect 90% of people with PD (dysarthria) and over 33% of people with stroke (aphasia). These consequences are disabling in many ways. However, as singing is typically still possible, its therapeutic use is of increasing interest. This article explores the experiences of and factors influencing participation in choral singing therapy (CST) by people with stroke or PD and their significant others. METHOD: Participants (eight people with stroke, six with PD) were recruited from a community music therapy choir running CST. Significant others (seven for stroke, two for PD) were also recruited. Supported communication methods were used as needed to undertake semi-structured interviews (total N = 23). RESULTS: Thematic analysis indicated participants had many unmet needs associated with their condition, which motivated them to explore self-management options. CST participation was described as an enjoyable social activity, and participation was perceived as improving mood, language, breathing and voice. CONCLUSIONS: Choral singing was perceived by people with stroke and PD to help them self-manage some of the consequences of their condition, including social isolation, low mood and communication difficulties. IMPLICATIONS FOR REHABILITATION: Choral singing therapy (CST) is sought out by people with stroke and PD to help self-manage symptoms of their condition. Participation is perceived as an enjoyable activity which improves mood, voice and language symptoms. CST may enable access to specialist music therapy and speech language therapy protocols within community frameworks.

30-Year Trends in Stroke Rates and Outcome in Auckland, New Zealand (1981-2012): A Multi-Ethnic Population-Based Series of Studies.

BACKGROUND: Insufficient data exist on population-based trends in morbidity and mortality to determine the success of prevention strategies and improvements in health care delivery in stroke. The aim of this study was to determine trends in incidence and outcome (1-year mortality, 28-day case-fatality) in relation to management and risk factors for stroke in the multi-ethnic population of Auckland, New Zealand (NZ) over 30-years. METHODS: Four stroke incidence population-based register studies were undertaken in adult residents (aged ≥15 years) of Auckland NZ in 1981-1982, 1991-1992, 2002-2003 and 2011-2012. All used standard World Health Organization (WHO) diagnostic criteria and multiple overlapping sources of case-ascertainment for hospitalised and non-hospitalised, fatal and non-fatal, new stroke events. Ethnicity was consistently self-identified into four major groups. Crude and age-adjusted (WHO world population standard) annual incidence and mortality with corresponding 95% confidence intervals (CI) were calculated per 100,000 people, assuming a Poisson distribution. RESULTS: 5400 new stroke patients were registered in four 12 month recruitment phases over the 30-year study period; 79% were NZ/European, 6% Maori, 8% Pacific people, and 7% were of Asian or other origin. Overall stroke incidence and 1-year mortality decreased by 23% (95% CI 5%-31%) and 62% (95% CI 36%-86%), respectively, from 1981 to 2012. Whilst stroke incidence and mortality declined across all groups in NZ from 1991, Maori and Pacific groups had the slowest rate of decline and continue to experience stroke at a significantly younger age (mean ages 60 and 62 years, respectively) compared with NZ/Europeans (mean age 75 years). There was also a decline in 28-day stroke case fatality (overall by 14%, 95% CI 11%-17%) across all ethnic groups from 1981 to 2012. However, there were significant increases in the frequencies of pre-morbid hypertension, myocardial infarction, and diabetes mellitus, but a reduction in frequency of current smoking among stroke patients. CONCLUSIONS: In this unique temporal series of studies spanning 30 years, stroke incidence, early case-fatality and 1-year mortality have declined, but ethnic disparities in risk and outcome for stroke persisted suggesting that primary stroke prevention remains crucial to reducing the burden of this disease.

Traumatic brain injury within Pacific people of New Zealand.

AIMS: Previous research has suggested there are ethnic disparities in the incidence of traumatic brain injury (TBI). This study aimed to: identify the incidence of TBI for Pacific people; describe the injury profile in this population; and determine if there were disparities in healthcare service use. METHODS: All TBI cases that occurred within a 1-year period in the Hamilton and Waikato regions of New Zealand were identified using multiple case ascertainment methods as part of a population-based incidence study. Demographic and injury data from people who self-identified as a Pacific person (N=76) were extracted and compared to New Zealand (NZ) Europeans (N=794). Differences in injury severity, mechanism of injury and acute healthcare service use were explored between the two ethnic groups. RESULTS: The total crude incidence of TBI in Pacific people was 1242 cases per 100,000 person-years, significantly higher than NZ Europeans (842 per 100,000). Peaks in incidence for Pacific people and NZ Europeans were observed between 0-4 and 15-24 years of age, with males at greater risk of injury than females. There were no statistically significant differences in TBI severity, mechanism of injury and acute healthcare use between the two groups. CONCLUSION: Pacific people are at a significantly higher risk of experiencing a TBI than NZ Europeans and targeted prevention efforts are needed.

Exploring researchers' experiences of working with people with acquired brain injury.

PURPOSE: This study aimed to investigate the challenges and positive experiences of researchers who work with people who have experienced an acquired brain injury and their families. METHODS: People who were currently or had previously worked as a researcher in the field of acquired brain injury (using either quantitative or qualitative methods) were invited to participate in a focus group or individual interview about their experiences. An expert reference group meeting was held to discuss strategies that could be implemented to enhance the researcher experience based on the interview data. RESULTS: A total of 19 researchers who worked across four different research teams took part in the study. Six inter-connected themes were identified: researcher motivation, meaning and fulfillment; human connection; knowing and understanding the role; complexity of brain injury in the research context; the research process; and state of the researcher. A number of recommendations for supporting researchers more effectively were identified. DISCUSSION: Researchers described a number of positive aspects as well as tensions they encountered in their role. The findings highlight the need to ensure researchers are supported effectively to ensure the quality of research studies in the field of brain injury.

Bridging the goal intention-action gap in rehabilitation: a study of if-then implementation intentions in neurorehabilitation.

PURPOSE: To test the feasibility and acceptability of an implementation intention strategy (if-then plans) increasingly used in health psychology to bridge the goal intention-action gap in rehabilitation with people with neurological conditions who are experiencing difficulties with mobility. METHODS: Twenty people with multiple sclerosis (MS) and stroke, randomised to an experimental and control group, set up to three mobility related goals with a physiotherapist. The experimental group also formulated if-then plans for every goal. DATA COLLECTION: Focus groups and interviews with participants and therapists; Patient Activation Measure (PAM), 10-m walk test, Rivermead Mobility Index, self-efficacy, subjective health status, quality of life. RESULTS: Qualitative data highlighted one main theme: Rehabilitation in context, encapsulating the usefulness of the if-then strategy in thinking about the patient in the context of complexity, the usefulness of home-based rehabilitation, and the perceived need for a few more sessions. Changes in walking speed were in the expected direction for both groups; PAM scores improved over 3 months in both groups. CONCLUSION: If-then plans were feasible and acceptable in bridging the goal intention-action gap in rehabilitation with people with MS and stroke, who are experiencing difficulties with mobility. This approach can now be adapted and trialled further in a definitive study. IMPLICATIONS FOR REHABILITATION: Goal planning in rehabilitation necessitates specific strategies that help people engage in goal-related tasks. If-then plans aim to support people to deal more effectively with self-regulatory problems that might undermine goal striving and have been found to be effective in health promotion and health behaviour change. This feasibility study with people with a stroke and multiple sclerosis has demonstrated that if-then plans are feasible and acceptable to patients and physiotherapists in supporting goal-directed behaviour.

Frequency and impact of recurrent traumatic brain injury in a population-based sample.

The aim of this study was to determine the frequency, mechanism(s), and impact of recurrent traumatic brain injury (TBI) over a 1-year period. Population-based TBI incidence and 1-year outcomes study with embedded case-control analysis. All participants (adults and children) who experienced a recurrent TBI (more than one) in the 12 months after an index injury and matched controls who sustained one TBI within the same period were enrolled in a population-based TBI incidence and outcomes study. Details of all recurrent TBIs sustained within 12 months of the initial index injury were recorded. Each recurrent TBI case was matched to a case sustaining one TBI based on age (±2 years), gender, and index TBI severity. Cognitive ability, disability, and postconcussion symptoms (PCS) were assessed 1 year after the index injury. Overall, 9.9% (n=72) of TBI cases experienced at least one recurrent TBI within the year after initial index injury. Males, people <35 years of age, and those who had experienced a TBI before their index injury were at highest risk of recurrent TBI. Recurrent TBI cases reported significantly increased PCS at 1 year, compared to the matched controls (n=72) sustaining one TBI. There was no difference in overall cognitive ability and disability between the two groups. People experiencing recurrent TBIs are more likely to experience increased frequency and severity of PCS. Greater public awareness of the potential effects of recurrent brain injury is needed.

Development of a new tool to evaluate work support needs and guide vocational rehabilitation: the work-ability support scale (WSS).

PURPOSE: This article outlines our overall approach, qualitative work, and pilot testing to develop a tool to facilitate identification of level of support needs and assist in planning for vocational rehabilitation interventions. METHODS: A set of foundation principles drawn from literature and previous critiques of work-ability assessment tools were used to guide a set of studies to develop a new tool. A review of the literature regarding factors that influence work-ability, qualitative interviews and focus groups with a range of stakeholders in the return-to-work process, and pilot testing in different settings were used to develop the Work-ability Support Scale (WSS) to a stage where it had face validity, usability and acceptability for a range of key stakeholders and was ready for further testing. RESULTS: Qualitative work and pilot testing enhanced the proposed tool with a series of changes and refinements to the content, structure and scoring framework. The current version of the tool is presented. Inter-rater reliability is presented elsewhere. CONCLUSION: Core principles and stakeholders' views (injured or sick workers, employers, case managers and health professionals) support current tool design. Although further testing is required, the WSS appears to hold potential for use in the assessment of vocational rehabilitation needs.