VRA 2014 Article Jain Holmes

Implementing evidence-based vocational rehabilitation (VR)

Evidence-based practice (EBP) involves integrating the best available
research evidence to make the best clinical decisions (Graham et al,
2013). Unfortunately this is a complex process and the routes by which
evidence gets into practice are non-linear. Given the importance of EBP
and use of professional guidelines that are developed from evidence, it
would seem important to understand how best to ensure that evidence is
taken up and used by clinicians. Part of understanding the ability to
implement a complex intervention such as VR involves analysing the
training and support used to transfer knowledge and put evidence into
practice. This article will explore some of the barriers to implementing
research in relation to vocational rehabilitation practitioners delivering
services to people with brain injuries.
What is the scale of TBI in the UK?
Headway, the UK brain injury charity tells us that one million people in the
UK are living with the long term effects of brain injury (Headway, 2014). It
is not just severe head injuries that affect peoples lives, but mild to
moderate head injuries can result in cognitive and psychological problems
affecting everyday life, which includes working.
What is VR?
Vocational Rehabilitation (VR) defined as whatever helps someone with a
health problem return to or remain in work (Waddell et al., 2008) involves
helping people find work, helping those who are in work but having
difficulty and supporting career progression in spite of illness or disability
(Frank and Thurgood, 2006).
How is VR used to help people with TBI RTW?
Returning to work or education is a major goal for many people who
sustain a TBI but only about 41% of those working at onset are in work at
one and two years later (van Velzen et al 2009) and the advice given to
patients is often very varied ranging from simple signposting to detailed
vocational interventions (Playford et al, 2011). It is well understood that
the right work is good for health and wellbeing and being out of work has
negative consequences, starting within six weeks of unemployment.
What policies support VR for people with a brain injury?
Focussing on job retention is consistent with the VR role of health care
professionals and especially occupational therapists as outlined in the
Black report (2008) and with the National Health Services (NHS) remit to
ensure people with long term conditions (LTNC) remain in work (Outcomes
Framework , 2010/11). VR is quality requirement 6 of the National Service
Framework (NSF) for Long Term Neurological Conditions (2005) and clinical
guidelines and professional recommendations stipulate that it should be
provided (BSRM, 2003). Despite these guidelines and outcome demands,
health-based services supporting people with a TBI in returning to work
are rare in the UK. Keeping people with TBI in work is also problematic as

VRA 2014 Article Jain Holmes

it is known that premature return is unsustainable for some who then drop
out of the workforce. This then has implications on personal and family
finances , the workplace in terms of lost productivity and replacement
recruitment and eventually the local community in terms of costs such as
welfare claims.
The Governments agenda to reduce the welfare bill and support those
who can return to work after injuries is financially driven and increasingly
appropriate in the current climate of economic austerity in the UK.
Targeted VR interventions have the potential impact of preventing people
from dropping out of the workforce and becoming welfare claimants by
supporting them to return to and remain sustainably in employment.
How do we know if these interventions work?
As VR practitioners , we may try out different ways of working with
people to see if they are successful , but unless we do rigorous research,
we cannot be certain whether these methods will work only for that
person or whether they may be more widely applicable to groups of
similar people. One such VR intervention is ESTVR, (Early Specialised
Traumatic brain injury Vocational Rehabilitation), which was developed
and adapted from an NHS service model provided by the Nottingham
Brain Injury Service(NTBIS) for more than 20 years. ESTVR is a model of
early specialist health based VR for people admitted to hospital with TBI,
which has been formally evaluated (Radford et al, 2013) and the content
described (Phillips et al, 2010). The findings of the research suggest
ESTVR may be more effective and cost effective than usual care at
returning people with TBI to work and ensuring job retention. The
evidence-based ESTVR is specifically targeted at job retention (return to
work with an existing employer) by intervening early to prevent job loss
and providing ongoing support to maintain work but it also includes retraining and or finding new work for those unable to return to an existing
job.
Formal guidance in VR?
VR practitioners often look for guidance in delivering return to work
interventions and this can come from Policy as mentioned above and from
research evidence. Evidence-based practice (EBP) involves integrating
the best available research evidence with clinical expertise and service
users values and circumstance to make the best decisions regarding
interventions (Graham et al, 2013). Evidence-based medicine and
practice has been recognised by many, including commissioners of
services, as the best way to ensure that the most appropriate
treatments/interventions are provided to service users of the NHS. Eccles
et al (2009) describes how in October 2006, the Chief Medical Officer of
England responded to the chapter 'Waste not, want not' in the CMOs 2005
annual report 'On the State of the Public Health' by appointing a group to,
address possible ways forward to improve clinical effectiveness in the UK
NHS and promote clinical engagement to deliver this. This group became
known as the Clinical Effectiveness Research Agenda Group (CERAG)
headed by Professor Martin Eccles who said, The findings from clinical

VRA 2014 Article Jain Holmes

and health services research can not change population health outcomes
unless health care systems, organizations, and professionals adopt them
in practice(2009).
Many VR practitioners will be able to conjecture upon the varied barriers
to implementing evidence-based interventions and implementing
guidelines that are based on research findings. Some of these are known
to involve aspects within the organisation such as management
opposition, lack of resources (money and time), lack of in-house skill
whilst other barriers may lie outside the organisation such as a lack of
policy support, lack of networks with other organisations to support a new
initiative. Yet more barriers lie with individual health care professionals
themselves. These include lack of confidence, a lack of knowledge, a lack
of desire for yet more change and their own personal beliefs and the
beliefs of significant others e.g. line managers, professionals leads, within
the organisation about the value and importance of an intervention in a
health context. There is a developing scientific body of knowledge known
as implementation science that is,
The study of methods to promote the uptake of research findings into
routine practice, Battacharyya, 2009. One current NIHR funded study
involved in understanding the nature of implementing an evidence-based
VR intervention is the FRESH (Facilitating Return to work through Early
Specialist Health-based interventions) study at the University of
Nottingham (http://www.nets.nihr.ac.uk/projects/hta/116602). FRESH is
designed to investigate the feasibility of implementing ESTVR in three
different NHS Trusts and the proposed project seeks to understand
whether the therapists who are trained to deliver the ESTVR intervention
in these three sites are able to do so and if not, to explore what the
reasons for this may be, so that future studies attempting to explore the
effectiveness of the intervention can take account of such barriers in their
design. If ESTVR is successfully implemented it is hoped that it may have
the potential to prevent people with TBI from losing jobs, preventing
secondary ill health such as common mental health problems (including
anxiety and depression), improve health related quality of life and reduce
the number of people living solely off welfare benefits. These negative
consequences of worklessness have personal costs as well as financial
ones. Positive outcomes include the return of a valued employee to
productivity, which ultimately assists the UK economy and supports local
communities.
Translating VR evidence into day to day practice
Greater understanding about how to implement complex interventions
such as ESTVR is required to add to the body of knowledge in
implementation science but arguably more important is to have a
practical output for practitioners and commissioners of VR. That is, a
greater understanding of how best to practically support health care
practitioners in putting relevant research into day to day VR.
Using the example of the ESTVR, understanding whether it can be taught
to other NHS therapists (in this example occupational therapists (OTs)) will

VRA 2014 Article Jain Holmes

reveal not only if OTs can be trained to deliver the ESTVR intervention,
but also how OTs learn about and then put this complex evidence-based
intervention into practice. Exploring the barriers and enablers to the
implementation of the ESTVR intervention in the NHS is the focus of a
current PhD by Jain Holmes funded by a Fellowship from the UK
Occupational Therapy Research Foundation and the University of
Nottingham.
Jain will apply concepts of knowledge translation (Wilson et al 2011, VoigtRadloff et al 2011) to investigate the barriers and enablers to
implementing a complex intervention in an NHS context and to analyse
the training and support used to transfer the necessary knowledge and
evidence into practice. It is hoped that this research will generate a new
understanding of the VR implementation process, which will support OT
educators and implementation researchers to design and develop
appropriate training materials and training methods and programmes that
are also evidenced to influence clinical outcomes. In order to achieve this,
further questions need to be answered such as:
Can academic and clinical knowledge be transferred into different
NHS Trusts?
Is it possible to manualise (develop standard processes and training
materials for) a complex occupational therapy VR intervention and
train NHS OTs to deliver it in clinical practice?
Do the therapists deliver ESTVR in the way they have been taught?
Can we measure how well the OTs implement ESTVR (using an
implementation fidelity measure and patient outcomes).
In addition to objective evidence regarding what to teach and how to
teach practitioners complex VR interventions, it is also important to
address the subjective evidence; understanding whether the OTs perceive
they have the skills and confidence to implement in practice what they
learn in training (their self-efficacy). This is because implementation
science models tell us that the beliefs of the individual putting the
intervention into practice are as vital as having a supportive environment
in which to situate the service (Damschroder, 2009).
Potentially ESTVR could be rolled out to all appropriate NHS centres that
admit people with a TBI but before this can happen a greater
understanding of the contextual and multi-faceted cultural and
organisational factors that practitioners face is required. Cultural aspects
will cover rehabilitation culture, NHS culture, NHS Trust culture, employer
culture all of which may help commissioners and service providers to
better understand how best to put evidence-based complex VR
interventions into practice.
In summary, now is the time for VR researchers to investigate not only
whether an intervention is effective and cost effective and acceptable to
service users but also whether the complex intervention can be put into
daily practice by other VR practitioners, working in a different location and

VRA 2014 Article Jain Holmes

in a different organisation. To do this, researchers need to align

themselves with implementation science models in order to design their
research effectively to answer the questions we all ask, So what? How
can I deliver this VR intervention where I work? Researchers need to
consider knowledge transfer and determine how best to deliver training
and provide support to practitioners, that the training materials are
appropriate and describe components in sufficient detail that they can be
put into practice. Additionally, the individual, cultural and organisational
supports and barriers need to be investigated to establish an
understanding of how to provide initial and then ongoing support to
practitioners out in the field in real time. If this can become part of
research into the complex nature of VR interventions, then arguably we
will develop world class VR services that can be disseminated.
Words 2020
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VRA 2014 Article Jain Holmes

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