Persons with brain injury and employment supports: Long-term employment outcomes and use of community-based services.

OBJECTIVES: To understand how employment services (ES) are provided to persons with brain injuries (PWBIs) in Ontario, Canada, and the impact service delivery has on competitive-employment outcomes. DESIGN AND METHODS: A mixed-method case study of one community-based agency that provides specialized services to PWBIs. Relationships between demographic, service-related variables and employment outcomes (2009-2014) were analysed using chi-squares and analyses of variance. In addition, 14 interviews were conducted and analysed using thematic analysis. RESULTS: PWBIs accessed services on average of 16 years post injury; 64% secured at least one competitive-employment job, which was how employment success was defined in this study. Average job tenure was 368 days, and average job intensity was 3.8 hours/day. Employment success was significantly associated (p < 0.05) with use of job development, job coaching, case management and job retention services. Interviews revealed that PWBIs were provided five services: job goal(s) identification, assessment of work-related abilities/skills, job development, on-the-job supports and job retention assistance. Challenges to ES delivery included lack of suitable jobs and hiring incentives, and difficulties in establishing natural supports at the workplace. CONCLUSIONS: PWBIs' employment outcomes may be supported through provision of ES to assist with: the development of realistic job goals and job-finding skills, securing work, on-the-job coaching and advocacy with employers.

Occupation-based strategy training for adults with traumatic brain injury: a pilot study.

OBJECTIVE: To evaluate, before undertaking a larger trial, feasibility of the study processes to determine the effectiveness of occupation-based strategy training for producing changes on trained real-world behaviors, and to determine whether far transfer of training effects to measures of real-world impact, including participation in everyday life, could be achieved. DESIGN: Partially randomized controlled trial with pre- and postintervention assessments done by assessors masked to the treatment arm. SETTING: Testing occurred at a research institute, interventions at participants' homes. PARTICIPANTS: People (N=13) with chronic traumatic brain injury (TBI), 7 in the experimental group (mean age, 42.6y; mean time post-TBI, 9.8y; 4 men) and 6 in the control arm (mean age, 40.5y; mean time post-TBI, 10.8y; 3 men), were assessed immediately before and after the intervention phase. INTERVENTION: Occupation-based strategy training, an adapted version of the Cognitive Orientation to daily Occupational Performance (CO-OP), was provided in two 1-hour sessions per week for 10 weeks. MAIN OUTCOME MEASURES: Canadian Occupational Performance Measure, Dysexecutive Questionnaire, Mayo-Portland Adaptability Inventory-4 Participation Index, and Assessment of Motor and Process Skills. RESULTS: The study processes (testing and intervention) were acceptable to all participants. Evidence of far transfer was found as the experimental group improved significantly more than the control group on performance and satisfaction with performance ratings on untrained goals (P<.05), and reported increased levels of participation (P<.01). CONCLUSIONS: Findings must be interpreted with caution since the sample is small and comparisons are made with a no-treatment control. Nevertheless, they suggest that the training is feasible and a larger trial warranted.

Impact of the COVID-19 pandemic on community-based brain injury associations across Canada: a cross-sectional survey study.

Background: The COVID-19 pandemic created new difficulties for people living with brain injury, their families, and caregivers while amplifying the challenges of community-based associations that support them. We aimed to understand the effects of the pandemic on clients who live with brain injury, as well as on the provision of community brain injury services/programs in Canada. Methods: Online cross-sectional survey conducted in January 2022. Representatives of brain injury associations across Canada completed the 31 open- and closed-ended questions about meeting clients' needs, addressing public health guidelines, and sustaining the association. Data were analyzed using descriptive statistics (close-ended questions) and qualitative content analysis (open-ended questions). Results: Of the 45 key representatives from associations in Pacific/Western (40%), Central (56%), and Atlantic Canada (4%), the majority were paid executive directors (67%). Participants reported that the most frequent psychosocial challenges experienced by their clients during the pandemic were social isolation (98%), loneliness (96%), and anxiety (93%). To alleviate these challenges, associations implemented wellness checks and psychosocial support. Most respondents (91%) affirmed that clients faced multiple technological barriers, such as a lack of technological knowledge and financial resources for devices and/or internet. In the open-ended questions, twenty-nine (64%) associations reported providing clients with devices, technology training, and assistance. Regarding public health measures, thirty (67%) respondents reported that clients had challenges understanding and/or following public health guidelines. Forty-two associations (93%) provided tailored information to help clients understand and comply with public health measures. Although associations (67%) received pandemic-related funding from the Canadian government they still struggled with the association's sustainability. Thirty-four (76%) lost funding or financial resources that prevented them from delivering programs or required the use of reserve funds to continue to do so. Only 56% reported receiving sufficient funding to address additional COVID-19-related expenses. Conclusion: Although the pandemic added further challenges to the sustainability of brain injury associations across Canada, they quickly adapted services/programs to respond to the increasing and varied needs of clients, while complying with protective measures. To ensure community associations' survival it is essential to aptly recognize the vital role played by these associations within the brain injury care continuum.

Implementation of an assistive technology for meal preparation within a supported residence for adults with acquired brain injury: a mixed-methods single case study.

OBJECTIVES: This study aimed to investigate the feasibility of implementing an assistive technology for meal preparation called COOK within a supported community residence for a person with an acquired brain injury. METHODS: Using a mixed-methods approach, a multiple baseline single-case experimental design and a descriptive qualitative study were conducted. The participant was a 47-year-old woman with cognitive impairments following a severe stroke. She received 21 sessions of training on using COOK within a shared kitchen space. During meal preparation, independence and safety were evaluated using three target behaviours: required assistance, task performance errors, and appropriate responses to safety issues, which were compared with an untrained control task, making a budget. Benefits, barriers, and facilitators were assessed via three individual interviews with the client and three focus groups with the care team. RESULTS: Both quantitative and qualitative analyses showed that COOK significantly increased independence and safety during meal preparation but not in the control task. Stakeholders suggested that the availability of a training toolkit to a greater number of therapists at the residence and installation of COOK within the client's apartment would help with successful adoption of this technology. CONCLUSION: COOK is a promising assistive technology for individuals with cognitive deficits who live in supported community residences.Implication For RehabilitationCOOK is a promising assistive technology for cognition to increase independence and safety in meal preparation for clients with ABI within their supported living contexts.Receiving training from an expert and the availability of technical support are imperative to the successful adoption of COOK.

Using the cognitive orientation to occupational performance (CO-OP) with adults with executive dysfunction following traumatic brain injury.

BACKGROUND: Meta-cognitive strategies have a positive effect on the rehabilitation of executive dysfunction. However, achieving generalization to daily life remains a challenge. We believe that providing rehabilitation in the person's own physical environment and using self-identified tasks will enhance the benefits of meta-cognitive training and promote generalization. PURPOSE: This pilot study tested the applicability of the Cognitive Orientation to Occupational Performance (CO-OP) approach for use with adults with executive dysfunction arising from traumatic brain injury (TBI). METHODS: A single-case design was used with 3 adults, 5 to 20 years post-TBI and their self-identified significant others. Assessments included neuropsychological tests and the Canadian Occupational Performance Measure. The intervention entailed guiding participants to use a meta-cognitive problem-solving strategy to perform self-identified daily tasks that they needed and wanted to do and with which they were having difficulties. The intervention occurred over 20 one-hour sessions in participants' environments. FINDINGS: Performance improved to criterion (2-point positive change) on 7 of 9 trained goals and on 4 of 7 untrained goals (self-report). Improvement was maintained at a 3-month follow-up assessment. IMPLICATIONS: The CO-OP approach has the potential to improve performance in daily functioning for adults with executive dysfunction following TBI.

The big sell: Managing stigma and workplace discrimination following moderate to severe brain injury.

BACKGROUND: Misperceptions regarding persons with brain injuries (PWBI) can lead to stigmatization, workplace discrimination and, in turn, influence PWBIs full vocational integration. OBJECTIVE: In this study we explored how stigma may influence return-to-work processes, experiences of stigma and discrimination at the workplace for persons with (moderate to severe) brain injuries, and strategies that can be employed to manage disclosure. METHODS: Exploratory qualitative study; used in-depth interviews and an inductive thematic analytical approach in data analysis. Ten PWBI and five employment service providers participated. PWBI discussed their work experiences, relationships with supervisors and co-workers and experiences of stigma and/or discrimination at work. Employment service providers discussed their perceptions regarding PWBI's rights and abilities to work, reported incidents of workplace discrimination, and how issues related to stigma, discrimination and disclosure are managed. RESULTS: Three themes were identified: i) public, employer and provider knowledge about brain injury and beliefs about PWBI; ii) incidents of workplace discrimination; iii) disclosure. Misperceptions regarding PWBI persist amongst the public and employers. Incidents of workplace discrimination included social exclusion at the workplace, hiring discrimination, denial of promotion/demotion, harassment, and failure to provide reasonable accommodations. Disclosure decisions required careful consideration of PWBI needs, the type of information that should be shared, and the context in which that information is shared. CONCLUSIONS: Public understanding about PWBI remains limited. PWBI require further assistance to manage disclosure and incidents of workplace discrimination.

'Participate to learn': a promising practice for community ABI rehabilitation.

OBJECTIVE: To identify best practices and promising practices to enhance participation in meaningful and productive activities. METHOD: An electronic search of the ABI rehabilitation research literature since 1990 yielded 974 articles of which 30 focused on interventions that targeted participation and evaluated effectiveness using direct measures of participation. Three reviewers rated these articles according to the standards set out by the Centre for Reviews and Dissemination. Following the systematic review, an interpretive review of the same articles was completed. RESULTS: Only three studies were rated as strong. No best practices were identified. Three promising practices found some support. The interpretive review suggested 'Participate to learn' as a useful rehabilitation model. The model rests on roles as goals, learning by experience in real-life contexts and the use of personal and environmental support to enable participation. CONCLUSIONS: 'Participate to learn' is both a credible rehabilitation model and deserving of more study.