Work outcomes in public safety personnel after potentially traumatic events: A systematic review.

BACKGROUND: It is well documented that public safety personnel are exposed to potentially traumatic events (PTEs) at elevated frequency and demonstrate higher prevalence of trauma-related symptoms compared to the general population. Lesser studied to date are the organizational consequences of workplace PTE exposure and associated mental health outcomes such as acute/posttraumatic stress disorder (ASD/PTSD), depression, and anxiety. METHODS: The present review synthesizes international literature on work outcomes in public safety personnel (PSP) to explore whether and how PTE and trauma-related symptoms relate to workplace outcomes. A total of N = 55 eligible articles examining PTE or trauma-related symptoms in relation to work outcomes were systematically reviewed using best-evidence narrative synthesis. RESULTS: Three primary work outcomes emerged across the literature: absenteeism, productivity/performance, and costs to organization. Across n = 21 studies of absenteeism, there was strong evidence that PTE or trauma-related symptoms are associated with increased sickness absence. N = 27 studies on productivity/performance demonstrated overall strong evidence of negative impacts in the workplace. N = 7 studies on cost to organizations demonstrated weak evidence that PTE exposure or trauma-related mental health outcomes are associated with increased cost to organization. CONCLUSIONS: Based on available evidence, the experience of workplace PTE or trauma-related symptoms is associated with negative impact on PSP occupational functioning, though important potential confounds (e.g., organizational strain and individual risk factors) remain to be more extensively investigated.

Methodological correlates of variability in the prevalence of posttraumatic stress disorder in high-risk occupational groups: A systematic review and meta-regression.

BACKGROUND: Although numerous studies have reported on PTSD prevalence in high-risk occupational samples, previous meta-analytic work has been severely limited by the extreme variability in prevalence outcomes. METHODS: The present systematic review and meta-regression examined methodological sources of variability in PTSD outcomes across the literature on high-risk personnel with a specific focus on measurement tool selection. RESULTS: The pooled global prevalence of PTSD in high-risk personnel was 12.1% [6.5%, 23.5%], and was similar to estimates obtained in other meta-analytic work. However, meta-regression revealed that PTSD prevalence differed significantly as a function of measurement tool selection, study inclusion criteria related to previous traumatic exposure, sample size, and study quality. PTSD prevalence estimates also differed significantly by occupational group and over time, as has also been reported in previous work, though exploratory examination of trends in measurement selection across these factors suggests that measurement strategy may partially explain some of these previously reported differences. CONCLUSIONS: Our results highlight a pressing need to better understand the role of measurement strategies and other methodological choices in characterizing variable prevalence outcomes. Understanding the role of methodological variance will be critical for work attempting to reliably characterize prevalence as well as risk and protective factors for PTSD.

PREVALENCE AND PREDICTORS OF POSTTRAUMATIC STRESS DISORDER, DEPRESSION, AND ANXIETY IN PERSONNEL WORKING IN EMERGENCY DEPARTMENT SETTINGS: A SYSTEMATIC REVIEW.

BACKGROUND: Professionals working in the emergency department (ED) are regularly exposed to traumatic events. Rates of posttraumatic mental health conditions vary widely in the literature and there is no agreement that rates in ED staff are elevated relative to other populations. OBJECTIVE: We conducted a systematic review of international literature reporting prevalence of posttraumatic stress disorder (PTSD), depression, and anxiety in ED personnel to determine whether prevalence is elevated compared to the general community, and to evaluate convergent evidence across the literature for predictive factors. To our knowledge, there is no comprehensive review on this topic in the literature at this time. METHODS: Seven databases were searched for studies reporting rates of PTSD, depression, and anxiety in ED personnel. Two independent researchers screened studies and assessed quality using Munn's Prevalence Critical Appraisal Instrument. Best-evidence synthesis determined whether conditions demonstrated elevated prevalence compared to the general population of Canada, a conservative benchmark. RESULTS: Twenty-four studies from 12 countries and a combined sample size of 4768 were included. PTSD rates ranged from 0% to 23.6% (mean 10.47%), depression ranged from 0.7% to 77.1% (mean 24.8%), and anxiety rates ranged from 2.4% to 14.6% (mean 9.29%). Each condition was elevated compared to the general population. Sociodemographic variables were not consistent predictors. Elevated PTSD seemed most strongly related to workplace exposure and maladaptive coping. CONCLUSIONS: ED professionals have an elevated risk of experiencing PTSD, depression, and anxiety. Identification of organizational and workplace predictors are needed to inform interventions that will reduce risk and provide optimal treatment and management of PTSD, depression, and anxiety in ED settings.

Predictors of compassion satisfaction and compassion fatigue in health care workers providing health and rehabilitation services in rural and remote locations: A scoping review.

INTRODUCTION: A better understanding of the predictors of compassion satisfaction and compassion fatigue in health care workers in rural and remote communities is needed to inform preventative interventions for this sector of the health workforce. OBJECTIVE: To identify predictors of compassion satisfaction and compassion fatigue in health care workers providing health and rehabilitation services in rural and remote locations. DESIGN: A scoping review informed by Arksey and O'Malley's five-stage framework and the scoping review protocol of the PRISMA-ScR statement. FINDINGS: The search yielded 946 articles, and 34 full texts were screened for eligibility, leaving 12 studies meeting the inclusion criteria. No studies on workers providing rehabilitation services were identified. Three studies assessed possible predictors of compassion satisfaction and compassion fatigue in health care workers, and all studies evaluated burnout. The most studied predictor variables were age, gender, profession and workload. DISCUSSION: This study identified potential risk and protective factors for health care workers that are likely relevant to those providing rehabilitation services in rural locations. Little is known about possible predictors of compassion satisfaction and compassion fatigue in professionals working in rural and remote areas outside of medicine and nursing or health care workers in rural community-based settings. CONCLUSION: Research examining predictors of compassion satisfaction and compassion fatigue in rehabilitation health care workers working in rural and remote locations is scant. Research that identifies risk and protective factors in this rapidly growing sector of the health care workforce is needed to inform the development of interventions that promote professional quality of life.

Exploring men's use of mental health support offered by an Australian Employee Assistance Program (EAP): perspectives from a focus-group study with males working in blue- and white-collar industries.

BACKGROUND: Men continue to be overrepresented in the Australian suicide statistics despite wide scale public health initiatives to improve men's mental health literacy and to increase their help-seeking behaviour. Employee Assistance Programs (EAP) deliver free and confidential mental health support; however, their services are underutilised by men. In the absence of contemporary literature that explores end-user experiences of EAPs, we asked men from blue- and white-collar employment settings about the barriers and enablers to using EAP services and explored differences between employment settings. METHODS: Forty-four men participated in this qualitative study: 32 from one white-collar employer and 12 from one blue-collar employer. Two qualified mental health professionals facilitated five first-round and three second-round focus groups and one interview with white-collar workers, and two focus groups and three interviews with blue-collar workers. Data were thematically analysed using a framework approach. RESULTS: Four of the six main themes were barriers: no need for EAP-alternative supports; uncertainty of EAP services; scepticism and distrust of EAP; and societal and workplace cultures. Elements of enduring barriers to EAP use were contained within sub-themes. These included lack of knowledge about EAPs, issues of trustworthiness and confidentiality, and fear of stigma and career jeopardy. Enablers comprised the need for attractive, reliable messaging and proactive connections and service delivery. Differences within sub-themes for white-collar and blue-collar groups reflected the corporate nature of work and workplace culture for white-collar participants, and workers' communication and practical problem resolution preferences for blue-collar workers. CONCLUSION: Some elements identified in the barriers to EAP use are more entrenched than were previously estimated and these need to be a priority for action to increase confidence in EAP services by end-users. EAPs that have a visible and proactive presence in the workplace, that tailor their marketing and service delivery to different workgroups, that provide a competitive advantage to its service users, and more confidently conveys independence from its client organisations may help to increase men's interest in accessing EAP support services. Further initiatives that reduce the stigma surrounding mental health and help-seeking both in society and the workplace are needed.

Evaluating the Consistency Between Conceptual Frameworks and Factors Influencing the Safe Behavior of Iranian Workers in the Petrochemical Industry: Mixed Methods Study.

BACKGROUND: Unsafe worker behavior is often identified as a major cause of dangerous incidents in the petrochemical industry. Behavioral safety models provide frameworks that may help to prevent such incidents by identifying factors promoting safe or unsafe behavior. We recently conducted a qualitative study to identify factors affecting workers' unsafe behaviors in an Iranian petrochemical company. OBJECTIVE: The aims of this study were to (1) conduct a review of the relevant research literature between the years 2000 and 2019 to identify theoretical models proposed to explain and predict safe behavior in the workplace and (2) to select the model that best reflects our qualitative findings and other evidence about the factors influencing safe behaviors among petrochemical workers. METHODS: This research used mixed methods. Initially, we conducted a qualitative study of factors that Iranian petrochemical workers believed affected their safety behavior. Four themes emerged from the semistructured interviews: (1) poor direct safety management and supervision; (2) unsafe workplace conditions; (3) workers' perceptions, skills, and training; and (4) broader organizational factors. Electronic databases, including PubMed, Embase, Scopus, Google Scholar, EBSCOhost, and Science Direct, were then searched for eligible studies on models to explain and predict safe behaviors, which were published between the years 2000 and 2019. Medical subject headings were used as the primary analytical element. Medical subject headings and subheadings were then extracted from the literature. One researcher conducted the search and 3 researchers performed screening and data extraction. Then, constructs described in each study were assessed to determine which were the most consistent with themes derived from our qualitative analysis. RESULTS: A total of 2032 publications were found using the search strategy. Of these, 142 studies were assessed and 28 studies met the inclusion criteria and were included in the review. The themes identified in the qualitative study most closely matched 3 scales included in Wu et al's model that measured safety behavior and performance, safety leadership, and safety climate in petrochemical industries. Poor direct safety management and supervision matched with safety leadership and its subscales; unsafe workplace conditions matched with safety climate and its subscales; workers' perceptions, skills, and training matched with safety performance and its subscales; and broader organizational factors matched with some subscales of the model. CONCLUSIONS: This is the first literature review to identify models intended to explain and predict safe behavior and select the model most consistent with themes elicited from a qualitative study. Our results showed that effective safety leadership and management and safety climate and culture systems are the most frequently identified factors affecting safe behaviors in the petrochemical industry. These results can further help safety researchers and professionals design effective behavior-based safety interventions, which can have a more sustainable and persistent impact on workers' safety behaviors. TRIAL REGISTRATION: Iranian Registry of Clinical Trials IRCT20170515033981N2; https://www.irct.ir/trial/26107. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1186/s12889-019-7126-1.

The prevalence of PTSD, major depression and anxiety symptoms among high-risk public transportation workers.

OBJECTIVE: Public transportation workers are exposed to higher levels of stress related to accidents, injuries, and person-under-train events when compared to other workers. This systematic review integrates the existing literature on mental health among high-risk public transportation workers to estimate the prevalence of post-traumatic stress disorder (PTSD), major depressive and anxiety symptoms following critical incidents while on duty. METHODS: This systematic review is part of a larger systematic review which examines mental health and work outcomes of individuals working in professions at high risk of critical incident exposure, i.e., high-risk professions. Articles were included if they measured the prevalence of PTSD, Major Depressive Disorder (MDD) and Anxiety Disorder (AD) in a transportation population following exposure to a major incident, for example, a person-under-a-train. RESULTS: Among the ten articles, all reported prevalence of PTSD which ranged from 0.73 to 29.9%. Four articles reported prevalence of depression among transportation workers exposed to a critical incident and prevalence outcomes ranged from 0.05 to 16.3%. Only two reported prevalence of anxiety from 1.3 to 13.9%. CONCLUSIONS: This literature reports that transportation workers are prone to involvement in traumatic accidents leading to higher rates of PTSD compared to the general population. Strategies to reduce transportation accidents and to provide transportation workers follow-up mental health support is needed for this vulnerable population.

Mental Disorders in Firefighters Following Large-Scale Disaster.

Firefighting service is known to involve high rates of exposure to potentially traumatic situations, and research on mental health in firefighting populations is of critical importance in understanding the impact of occupational exposure. To date, the literature concerning prevalence of trauma-related mental disorders such as posttraumatic stress disorder (PTSD) has not distinguished between symptomology associated routine duty-related exposure and exposure to large-scale disaster. The present systematic review synthesizes a heterogeneous cross-national literature on large-scale disaster exposure in firefighters and provides support for the hypothesis that the prevalence of PTSD, major depressive disorder, and anxiety disorders are elevated in firefighters compared with rates observed in the general population. In addition, we conducted narrative synthesis concerning several commonly assessed predictive factors for disorder and found that sociodemographic factors appear to bear a weak relationship to mental disorder, while incident-related factors, such as severity and duration of disaster exposure, bear a stronger and more consistent relationship to the development of PTSD and depression in cross-national samples. Future work should expand on these preliminary findings to better understand the impact of disaster exposure in firefighting personnel.

Bereaved Family Members' Views of the Value of Coronial Inquests Into Fatal Work Incidents.

Fatal work incidents result in an array of government responses, and in countries such as the United Kingdom and Australia, this may include the holding of coronial inquests. A common theme from the scant literature is that family members have a strong need to know how and why their loved one died. The inquisitorial nature of inquests suggests potential in uncovering this information, although little is known about families' experiences with these proceedings. Interviews with 40 bereaved relatives explored their views and experiences of inquests. Findings suggest that families, often frustrated with other investigative processes, want inquests to provide a better understanding of how and why the death occurred, uncover any failings/responsibilities, and thereby move closer to a sense of justice being obtained for the deceased. Families identified problems perceived to impair the process and where improvements could be made to secure a more effective and meaningful institutional response to the fatality.

Factors associated with unsafe work behaviours in an Iranian petrochemical company: perspectives of workers, supervisors, and safety managers.

BACKGROUND: The petrochemical industry is hazardous, in part because of the inherently dangerous nature of the work conducted, and incidents frequently result in significant financial and social losses. The most common immediate cause of incidents and injuries in this industry is unsafe worker behaviour. Identifying the factors encouraging unsafe work behaviours is the first step in taking action to discourage them. The aim of this study was to (a) explore workers', supervisors' and safety managers' attitudes and perceptions of safety in a petrochemical company in Iran, and (b) identify the factors that discourage safe work behaviours. METHODS: A qualitative study was conducted by applying the steps described by Graneheim and Lundman (2004). Twenty participants were recruited from an Iranian petrochemical company using a multi-stage approach, with initial purposive sampling followed by snowball sampling to enhance recruitment. Individual face-to-face and semi-structured interviews were conducted to gain an in-depth understanding of factors acting as barriers to safe behaviour. The interviews were recorded and transcribed in Persian and then translated into English. Conventional content analysis was performed. RESULTS: The main themes emerging from the interviews were: (i) poor direct safety management and supervision; (ii) unsafe workplace conditions; (iii) workers' perceptions, skills and training; and (iv) broader organisational factors. CONCLUSIONS: The findings give insights into practical organisational measures that can be implemented by management to promote workers' commitment to safety and engage in safe behaviours in their workplace. TRIAL REGISTRATION: Iranian Registry of Clinical Trials: IRCT20170515033981N2 . Retrospectively registered 19 June 2018.

Systematic review of posttraumatic stress disorder in police officers following routine work-related critical incident exposure.

BACKGROUND: The prevalence of PTSD in police officers has been the subject of a large and highly variable empirical literature. The present systematic review evaluates the extant literature on PTSD in police officers using an international dataset. METHODS: We employed best-evidence narrative synthesis to evaluate whether PTSD prevalence in police is elevated in comparison to the general population of Canada (8%), which itself has a higher lifetime PTSD prevalence than many other regions and thus serves as a conservative standard of comparison. RESULTS: PTSD prevalence in police varied considerably across studies from 0% - 44% (M = 14.87%, Median = 9.2%). Despite this variability, strong evidence exists to suggest PTSD prevalence is elevated in police officers. Examination of possible sources of variability in prevalence outcomes highlighted substantial variability in outcomes due to the selection of measurement tool for assessing PTSD (e.g., DSM vs. IES). Examination of commonly-assessed predictive factors for PTSD risk across the literature showed that individual-difference factors (e.g., age, years of service) bear weak-to-nonexistent relationships with PTSD risk, while incident-specific factors (e.g., severity of exposure) are more strongly and consistently associated with PTSD prevalence. Organizational factors (e.g., low support from supervisor) are at present understudied but important possible contributors to PTSD risk. CONCLUSIONS: PTSD prevalence is elevated in police officers and appears most strongly related to workplace exposure. Measurement variability remains a critical source of inconsistencies across the literature with drastic implications for accurate detection of officers in need of mental health intervention.

Information needs of bereaved families following fatal work incidents.

The sudden and unexpected nature of fatal work incidents can leave family members with a strong need to know how and why the worker died. Forty Australian family members were interviewed to identify the information sought following fatal work incidents and explore the factors enhancing or impairing satisfaction with the account of the death. Findings demonstrated that employers tended to divert responsibility to the worker, to mask underlying systemic failures. Satisfaction was enhanced if family members believed a sense of justice was attained and formal investigations were able to expose the truth and those responsible for the death were identified.

A limb to stand on? A scoping review of employability assessment in Australian total and permanent disability insurance claims.

Purpose: Employability assessment helps in deciding to pay or decline Australian total and permanent disability insurance claims, yet it has not been critically examined. This paper reviews employability assessment from forensic vocational assessment, life insurance/superannuation, and legal perspectives.Methods: In a scoping review, we searched six multidisciplinary databases and various industry-specific resources. Items pertinent to forensic employability/vocational assessment and life insurance total and permanent disability claims were included. Return-to-work assessment, the vocational assessor, medical or functional evaluation, and case law items were excluded. Quality appraisal measures were used for research studies and other items. From 104 full-text reviews, 39 items were included for thematic synthesis from the three perspectives of interest.Results: Our review found that employability assessment is derived from forensic vocational assessment, but methodology differs in claimant contact and psychosocial aspects. Employability assessment practice is informed by policy, market changes, and legal interpretation. Assessors may work for opposing sides in forensic or indirect settings therefore high standards and credentials must prevail.Conclusions: Foundational research into the effectiveness of employability assessment and the experience of claimants is warranted. Future research into methodology, assessor credentials, and legal aspects will broaden understanding of this relatively new topic.Implications for rehabilitationEmployability assessment is an emergent and hitherto unexamined model that operates in the multi-billion-dollar Australian total and permanent disability insurance market.Total and permanent disability insurance policies and their legal interpretation are ever-changing and substantially inform employability assessment practice.Employability assessment lacks methodology and variables that are common elements in proven forensic vocational assessment models in the United States.Training and credentialing of rehabilitation professionals who conduct employability assessments are required to withstand legal scrutiny and meet international forensic standards.

Issues facing employability assessment in total and permanent disability insurance claims: A rehabilitation perspective.

BACKGROUND: Expert employment information helps life insurers to decide total and permanent disability claims. The employability assessment model was developed a decade ago by rehabilitation counselors and has not been critically examined. OBJECTIVE: This exploratory descriptive study aims to elicit key issues of employability assessment within Australian life insurance. METHODS: Ten rehabilitation advisors with knowledge of employability assessment in the total and permanent disability sector participated in a single focus group. They each nominated issues of concern about employability assessment. These issues were collated then discussed within the group. Qualitative thematic analysis was used to identify key issues. RESULTS: The predominant theme was the forensic nature of employment evidence. There were three categories of key issues. First, assessment providers- their training, qualifications, experience, and role. Second, methodology- approaches that provide most realistic information about a claimant's likelihood of work. Third, policy definitions that illustrate reliance on legal interpretation of employability. CONCLUSIONS: To withstand legal scrutiny, the credentials of providers, assessment methodology, and quality of forensic reports are key issues which need to be addressed. This foundational study will contribute to broader research on this topic, with implications particularly for rehabilitation, life insurance, and claimants.

Posttraumatic Stress Disorder, Depression, and Prolonged Grief Disorder in Families Bereaved by a Traumatic Workplace Death: The Need for Satisfactory Information and Support.

The impact of traumatic workplace death on bereaved families, including their mental health and well-being, has rarely been systematically examined. This study aimed to document the rates and key correlates of probable posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and prolonged grief disorder (PGD) in family members following a workplace injury fatality. The hidden nature of the target population necessitated outreach recruitment techniques, including the use of social media, newspaper articles, radio interviews, and contact with major family support organizations. Data were collected using a cross-sectional design and international online survey. The PCL-C (PTSD), the PHQ-8 (MDD), and PG-13 (PGD) were used to measure mental health disorders. All are well-established self-report measures with strong psychometric qualities. Participants were from Australia (62%), Canada (17%), the USA (16%), and the UK (5%). The majority were females (89.9%), reflecting the gender distribution of traumatic workplace deaths (over 90% of fatalities are male). Most were partners/spouses (38.5%) or parents (35%) and over half (64%) were next of kin to the deceased worker. Most deaths occurred in the industries that regularly account for more than 70 percent of all industrial deaths-construction, manufacturing, transport, and agriculture forestry and fishing. At a mean of 6.40 years (SD = 5.78) post-death, 61 percent of participants had probable PTSD, 44 percent had probable MDD, and 43 percent had probable PGD. Logistic regressions indicated that a longer time since the death reduced the risk of having each disorder. Being next of kin and having a self-reported mental health history increased the risk of having MDD. Of the related information and support variables, having satisfactory support from family, support from a person to help navigate the post-death formalities, and satisfactory information about the death were associated with a decreased risk of probable PTSD, MDD, and PGD, respectively. The findings highlight the potential magnitude of the problem and the need for satisfactory information and support for bereaved families.

Using an adapted Delphi process to develop a survey evaluating employability assessment in total and permanent disability insurance claims.

BACKGROUND: No research has been undertaken about employability assessment of total and permanent disability (TPD) insurance claims. Employability assessment provides vocational information to life insurers to help decide claims. To determine how helpful employability assessment is, a new measure was needed to survey insurers. OBJECTIVE: To generate survey items by harnessing the knowledge and agreement of rehabilitation advisors with expertise in employability assessment. METHODS: A panel of 10 (89% of eligible Australian rehabilitation advisors) participated in an adapted three-round Delphi process. Rounds 2 and 3 were incorporated into a novel real-time card sort format. RESULTS: From 94 potential items submitted for first round qualitative analysis, 36 items in four domains-quality, content, utility, and claims-were generated. Two quantitative ranking rounds in one face-to-face session produced a 21-item prototype. The final electronic survey instrument contained 11 sections seeking insurer demographics and feedback on: external providers; employability assessment concepts, components, quality, and usefulness; functional, occupational, labor market items; and finally, cost and type. Our Delphi process was anonymous, completed in four weeks with 100% response rate and 75% agreement. More time between Rounds 2 and 3 would enhance statistical analysis. CONCLUSIONS: Our adapted Delphi methodology for survey item generation is generalizable for any panel able to meet in person.

Bereaved families and the coronial response to traumatic workplace fatalities: Organizational perspectives.

Work remains a significant source of illness, injury, and death in developed countries. In Australia, for example, over 2,000 people die from work-related causes each year, with heavy social, economic, and personal costs (Safe Work Australia, 2013a ). Most die as a result of work-related disease. However, many die from trauma. In 2012, 223 workers were fatally injured in Australia and in the United States the figure was 4,383 (Bureau of Labor Statistics, 2014 ; Safe Work Australia, 2013b ). Apart from the immediate tragedy of each worker's death, these deaths affect the victim's immediate family, wider family, friends, and co-workers. It has been estimated that, on average, every death has an impact on at least 20 other people (Dyregrov, Nordanger, & Dyregrov, 2003 ), especially when the deceased had several families, which is an increasingly common phenomenon (OECD, 2014 ). Little is known, however, about how regulatory responses following a traumatic workplace fatality meet the needs of surviving families. With a focus on the coronial investigation, this article provides information about the regulatory responses to a traumatic workplace fatality and examines how various organizations involved in the coronial process following the death viewed its ability to accommodate the needs and wishes of surviving families.

Administering the cost of death: organisational perspectives on workers' compensation and common law claims following traumatic death at work in Australia.

Quite apart from its devastating human and psychological effects, the death of a worker can have significant, life-changing effects on their families. For many affected families, workers' compensation entitlements represent the primary financial safeguard. Where the worker was self-employed, the family will generally be excluded from this remedy and have to take the more problematic option of claiming damages at common law. Despite the centrality of workers' compensation, little attention has been given to how effectively workers' compensation agencies address the needs of bereaved families or the views of other organisations involved, such as safety inspectors, unions, employers and victim advocates. Based on interviews with forty eight organisational representatives in five Australian states, this study examines how workers' compensation regimes deal with work-related death from the perspective of those organisations involved directly or indirectly in the process. The study highlighted a number of problems, including the exclusion of self-employed workers and dealing with 'mixed families'.

Rehabilitation of compensable workplace injuries: effective payment models for quality vocational rehabilitation outcomes in a changing social landscape.

PURPOSE: With social and economic costs of workplace injury on the increase, efficient payment models that deliver quality rehabilitation outcomes are of increasing interest. This paper provides a perspective on the issue informed by both refereed literature and published research material not available commercially (gray literature). METHODS: A review of payment models, workers' compensation and compensable injury identified relevant peer-reviewed and gray literature that informed our discussion. RESULTS: Fee-for-service and performance-based payment models dominate the health and rehabilitation literature, each described as having benefits and challenges to achieving quality outcomes for consumers. There appears to be a movement toward performance-based payments in compensable workplace injury settings as they are perceived to promote time-efficient services and support innovation in rehabilitation practice. However, it appears that the challenges that arise for workplace-based rehabilitation providers and professionals when working under the various payment models, such as staff retention and quality of client-practitioner relationship, are absent from the literature and this could lead to flawed policy decisions. CONCLUSIONS: Robust evidence of the benefits and costs associated with different payment models - from the perspectives of clients/consumers, funders and service providers - is needed to inform best practice in rehabilitation of compensable workplace injuries. IMPLICATIONS FOR REHABILITATION: Available but limited evidence suggests that payment models providing financial incentives for stakeholder-agreed vocational rehabilitation outcomes tend to improve service effectiveness in workers' compensation settings, although there is little evidence of service quality or client satisfaction. Working in a system that identifies payments for stakeholder-agreed outcomes may be more satisfying for rehabilitation practitioners in workers' compensation settings by allowing more clinical autonomy and innovative practice. Researchers need to work closely with the compensation and rehabilitation sector as well as governments to establish robust evidence of the benefits and costs of payment models, from the perspectives of clients/consumers, funders, service providers and rehabilitation professionals.

Contemporary vocational rehabilitation in Australia.

PURPOSE: There is a strong connection between disability and decreased participation rates in the Australian labour market. Australian government policy recognises vocational rehabilitation as a key strategy to increase employment rates of people with disabilities. METHODS: This paper examines current Australian disability employment policies and practices. It also reviews vocational rehabilitation competency research to identify knowledge and skill domains central to quality service provision, and explores the delivery of tertiary level vocational rehabilitation education. RESULTS: Policy changes in Australia over the last decade have been aimed at addressing the unsustainable increase in disability benefits. In this context vocational rehabilitation services continue to be viewed as crucial in assisting people with disabilities to maintain employment and reduce disengagement. Competencies research has consistently identified vocational counselling, personal counselling, professional practice and case management as central to quality vocational rehabilitation service provision. Two competencies identified in recent research, workplace disability case management and workplace interventions and program management, reflect the centrality of vocational rehabilitation to disability management. CONCLUSIONS: Changes in the policy environment to reduce the number of disability pension recipients will inevitably lead to an increased demand for trained vocational rehabilitation personnel. Given the development of strong accreditation standards for vocational rehabilitation education and practice that underpin the provision of tertiary level rehabilitation counselling training programs, professionally qualified rehabilitation counsellors are ideally placed to address the complex employment needs of people with a disability. IMPLICATIONS FOR REHABILITATION: It is important to understand changes that may occur in policy environments in terms of their impact on vocational rehabilitation service delivery for people with disabilities. Variable levels of training in the vocational rehabilitation sector result in people with complex needs not consistently receiving the services they need to access and maintain employment. Practitioners need to focus increasingly on individualized service delivery where the client has significant control over decisions about their rehabilitation program.