Working with a brain injury: personal experiences of returning to work following a mild or moderate brain injury.

OBJECTIVE: Most brain injuries occur in people of working age. Individuals with mild or moderate injuries may have unrecognized problems affecting return to work. Previous studies have focused on factors that predict return to work after brain injury. There is limited information about the experiences of individuals returning to work. DESIGN: Individual interviews explored the work-related expectations and experiences of workers who had sustained mild to moderate brain injury. A sampling frame ensured a spread of participants by age, injury severity and work type. METHODS: Thirty-three interviews were conducted 4-6 months post-injury. Most participants had returned to work. Interviews were transcribed verbatim for thematic analysis. RESULTS: Key emerging issues for participants were the invisibility of their injury, continuing symptoms affecting their ability to do their job and lack of advice and guidance on returning to work. Return to work support systems were considered to be poorly coordinated and managed. CONCLUSION: It is important that healthcare professionals anticipate the vocational rehabilitation needs of patients who have sustained mild to moderate brain injury. These patients may require additional coordinated interventions and specific person-centred information to ensure a successful and, most importantly, a sustained return to work.

Serious untoward incidents and their aftermath in acute inpatient psychiatry: the Tompkins Acute Ward study.

Serious untoward incidents, or sentinel events (suicide, homicide, suicide attempt, serious assault, and absconding of high-risk patients) occur from time to time in association with acute psychiatric inpatient wards. The aim of this study was to discover the impact of serious untoward incidents on inpatient wards. Doctors, nurses, and occupational therapists at three hospitals were interviewed about these events and their impact on their wards. Staff reported feelings of shock, depression, demoralization, upset, loss, and grief, followed by ruminations, guilt, and anxiety. Levels of containment increased, as did the focus on risk assessment. Processing of the emotional impact was hindered by the pace of ward life, a lack of external support, and management investigations. Patient responses were largely ignored. A few staff responded negatively, hindering service improvements. Much more attention needs to be given to the needs of the patient group following incidents. Substantial planning, organization, and investment are required to properly prepare for such events and manage their outcome. Without this planning and action, acute inpatient work has the capacity to be damaging to staff.

Keeping nurses working: development and psychometric testing of the Nurse-Work Instability Scale (Nurse-WIS).

AIM: This paper reports a study to develop and test the psychometric properties of the Nurse-Work Instability Scale (Nurse-WIS). BACKGROUND: Work Instability describes the extent of any mismatch among functional (in)capacity, work demands and its potential impact on efficiency/productivity at work. Recruitment, retention and migration of nurses are global issues influenced by many factors. It is well documented that musculoskeletal pain and subsequent disability account for a high proportion of sickness absence and premature retirement in the nursing workforce. The challenge to clinicians is to identify such problems early so that appropriate interventions can be targeted to facilitate job retention. METHOD: Analyses of 48 qualitative interview transcripts conducted with nursing staff during 2003 were used to generate potential items for the Nurse-WIS. Analysis of the psychometric properties of the scale derived from these items was undertaken by using the Rasch model and data generated in postal surveys in 2004. The scale was validated against a gold standard of expert vocational assessment by occupational health physiotherapists/ergonomists. FINDINGS: The resulting self-administered questionnaire consisting of 30 items not only measures the risk of job loss relating to musculoskeletal symptoms, but also captures relevant psychosocial issues. The scaling properties of this questionnaire meet the rigorous psychometric requirements of the Rasch model. CONCLUSIONS: The Nurse-WIS is a psychometrically sound method for the early identification of nursing staff experiencing difficulties at work. It offers the prospect of positive proactive management to prevent or minimize sickness absence and potentially prevent loss of nursing staff from the workforce through long-term sickness absence and early retirement.

Screening for job loss: development of a work instability scale for traumatic brain injury.

OBJECTIVE: The objective of this study was to explore the concept of work instability (a mis-match between an individual's functional and cognitive abilities and the demands of their job) following traumatic brain injury (TBI) and develop a work instability scale specific to this population. METHOD: Work instability (WI) following TBI was explored through qualitative interviews which were then used to generate items for a work instability scale (WIS). Rasch analysis was used to examine the scaling properties of the TBI-WIS which was then validated against a gold standard of expert vocational assessment by occupational psychologists. RESULTS AND CONCLUSION: The resulting measure is a 36 item, self-administered scale which can be scored in three bands indicating low, medium and high risk of job retention problems. The scale meets modern psychometric requirements for measurement and presents an opportunity in routine clinical practice to take positive action to prevent job loss.

Construct validity and reliability of the Rivermead Post-Concussion Symptoms Questionnaire.

OBJECTIVES: To provide further evidence of reliability and internal and external construct validity of the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), which measures severity of postconcussion symptoms following head injury. DESIGN AND SETTING: A cross-sectional study of consecutive patients presenting with a head injury in two urban teaching hospitals and a community trust. PATIENTS: Three hundred and sixty-nine patients returned a questionnaire from 1689 consecutive adult patients (18 years and above) referred to radiology for a skull X-ray following a head injury, and those who were currently under the care of a community-based multidisciplinary head injury team. METHOD: Internal construct validity tested by fit to the Rasch Measurement model; external construct validity tested by correlations with Rivermead Head Injury Follow-up Questionnaire (RHFUQ); test-retest reliability tested by correlations at two-week intervals. OUTCOME MEASURES: Rivermead Post-Concussion Symptoms Questionnaire and Rivermead Head Injury Follow-up Questionnaire. MAIN RESULTS: RPQ scores ranged from 0 to 64 (17.3% floor, 0.3% ceiling). Overall fit to the Rasch model was poor (item fit mean -0.416, SD = 1.989, chi-squared= 172.486, p<0.01) suggesting a lack of unidimensionality. The items headaches, dizziness and forgetful displayed misfitting residuals and the first two items also displayed significant item trait fit statistics (p < 0.0006). After removing the items headaches, dizziness and subsequently nausea the RPQ demonstrated good fit at overall and individual item levels, both for the remaining 13 items (RPQ-13) and the three items (RPQ-3) which now formed a subsidiary scale. All items functioned consistently across age and gender. The RPQ-13 and RPQ-3 scales showed test-retest reliability coefficients of 0.89 and 0.72 (both p-values < 0.01) and positive correlations with RHFUQ scores (0.83 for RPQ-13, 0.62 for RPQ-3, both p-values < 0.01). CONCLUSIONS: As currently used, the RPQ does not meet modern psychometric standards. Its 16 items do not tap into the same underlying construct and should not be summated in a single score. When the RPQ is split into two separate scales, the RPQ-13 and the RPQ-3, each set of items forms a unidimensional construct for people with head injury at three months post injury. These scales show good test-retest reliability and adequate external construct validity.

A low back-specific version of the SF-36 Physical Functioning scale.

STUDY DESIGN: A prospective repeated measures design was used to produce a back-specific version of the Short Form-36 Physical Functioning scale (SF-36 PF) by Rasch analysis of a pool of items from the SF-36 PF, Oswestry Disability Questionnaire, and the Quebec Back Pain Disability Scale. OBJECTIVES: To identify items for a back-specific version of the SF-36 PF scale and to compare the psychometric properties of the new version with the original 10-item scale. SUMMARY OF BACKGROUND DATA: Adequate assessment of patient function requires the administration of a generic and a condition-specific questionnaire. A back-specific version of the SF-36 PF would facilitate comprehensive patient assessment in the clinical setting. METHODS: Consecutive patients with low back pain presenting for physiotherapy treatment were recruited at three public hospitals, three community health services, and four private practices. Patients completed questionnaires on two occasions 6 weeks apart. RESULTS: A scale of 18 items showed a better fit to the Rasch model than the original SF-36 PF scale. Items in the original scale that had a poor fit (INFIT/OUTFIT statistics outside the range 0.7-1.3) showed an acceptable fit in the new scale. The augmented scale had comparable reliability and improved responsiveness to the original 10-item SF-36 PF scale. The minimum detectable change (90% confidence) and the minimum clinically important difference were 12 points. Floor and ceiling effects were practically eliminated. The psychometric properties of the new scale were comparable to those of the Oswestry Disability Questionnaire. CONCLUSIONS: The Low-Back SF-36 PF18 comprises the 10-item SF-36 PF scale and four items each from the Oswestry and Quebec back pain questionnaires. The possible total score ranges from 0 to 100, with a higher score indicating better function. The new scale appears to offer advantages over the use of the original scale for the assessment of functioning in patients with low back pain.

Measuring disability in ankylosing spondylitis: comparison of bath ankylosing spondylitis functional index with revised Leeds Disability Questionnaire.

OBJECTIVE: Disability has been identified as a core outcome measure in ankylosing spondylitis (AS). The Dougados Functional Index (DFI) and the Bath Ankylosing Spondylitis Functional Index (BASFI) have been selected as core measures of function in this disease. However, neither of these instruments has undergone rigorous psychometric testing. METHODS: The psychometric properties of 2 measures of disability, the BASFI and the revised Leeds Disability Questionnaire (RLDQ), were compared in a cohort of 208 outpatients with AS. Rasch analysis was used to examine the properties of each measure and to compare them on a common scale. Test-retest was assessed in a cohort of 149 subjects who completed each instrument twice over an interval of 2 weeks. RESULTS: Both instruments gave an even spread of scores across the study group, but BASFI responses were positively skewed and RLDQ responses negatively skewed. There was a highly significant difference between perceived severity groups for both instruments (Kruskal-Wallis chi-squared: RLDQ, 75.1; BASFI, 80.4; both p < 0.0001). Both instruments gave acceptable test-retest scores (RLDQ ICC = 0.95, 95% CI 0.93-0.97; BASFI ICC = 0.94, 95% CI 0.92-0.96). Both instruments were found to be unidimensional according to the Rasch model, but the BASFI had more items displaying differential item functioning. Category disordering was apparent with the BASFI but not the RLDQ. However, both instruments displayed disordered item thresholds. Neither instrument can be used as an interval measure. Both measures had "towers" of thresholds whereby several thresholds were marking the same point on the underlying disability construct. This was particularly notable in the case of the BASFI. CONCLUSION: Both the BASFI and RLDQ provide a unidimensional measure of function in AS that is in accord with patient perception of disease severity. Neither instrument can be used as an interval measure. Changing the way that the instruments are scored, for example by collapsing categories, may improve their performance.