AN ENQUIRY INTO VOCATIONAL REHABILITATION SERVICES PROVIDED BY WORKSAFE BC: PERSPECTIVE OF THE INJURED WORKER by Julie M. Wessel BSc, University of Northern British Columbia, 2006 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN DISABILITY MANAGEMENT UNIVERSITY OF NORTHERN BRITISH COLUMBIA March 2011 © Julie M. Wessel, 2011 1*1 Library and Archives Canada Bibliotheque et Archives Canada Published Heritage Branch Direction du Patrimoine de I'edition 395 Wellington Street Ottawa ON K1A 0N4 Canada 395, rue Wellington Ottawa ON K1A 0N4 Canada Your file Votre riterence ISBN: 978-0-494-75177-0 Our file Notre reference ISBN: 978-0-494-75177-0 NOTICE: AVIS: The author has granted a nonexclusive license allowing Library and Archives Canada to reproduce, publish, archive, preserve, conserve, communicate to the public by telecommunication or on the Internet, loan, distribute and sell theses worldwide, for commercial or noncommercial purposes, in microform, paper, electronic and/or any other formats. L'auteur a accorde une licence non exclusive permettant a la Bibliotheque et Archives Canada de reproduire, publier, archiver, sauvegarder, conserver, transmettre au public par telecommunication ou par I'lnternet, preter, distribuer et vendre des theses partout dans le monde, a des fins commerciales ou autres, sur support microforme, papier, electronique et/ou autres formats. The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. L'auteur conserve la propriete du droit d'auteur et des droits moraux qui protege cette these. Ni la these ni des extraits substantiels de celle-ci ne doivent etre im primes ou autrement reproduits sans son autorisation. In compliance with the Canadian Privacy Act some supporting forms may have been removed from this thesis. Conformement a la loi canadienne sur la protection de la vie privee, quelques formulaires secondaires ont ete enleves de cette these. While these forms may be included in the document page count, their removal does not represent any loss of content from the thesis. Bien que ces formulaires aient inclus dans la pagination, il n'y aura aucun contenu manquant. 1+1 Canada Vocational Rehabilitation Services ii Abstract This study involved the use of descriptive phenomenological methodology in order to explore the lived experience of 26 injured workers who had participated in WorkSafeBC's Vocational Rehabilitation services. The aim of this research was to explore, from the perspective of the worker, vocational rehabilitation programs provided by WorkSafeBC. There is a gap in the vocational rehabilitation literature where evidence has yet to be provided from the perspective of the worker rather than the service provider. This study seeks to contribute understanding of this experience by providing evidence from this unique perspective. Analysis of the interview data revealed the central theme of interpersonal communication in addition to six major themes, each comprised of multiple factors. Interpersonal communication between the injured worker and WorkSafeBC staff was found to be the central factor affecting the worker's perspective of their overall experience. The remaining identified themes were: the human factor, expectations, re-employment considerations, psychological factors, injured workers identification of strengths of vocational rehabilitation services, and injured workers proposed improvements to vocational rehabilitation services. The findings of this study provide insight and useful recommendations not only for WorkSafeBC, but also other service providers of vocational rehabilitation. Vocational Rehabilitation Services iii Table of Contents Abstract ii Table of Contents iii List of Tables vi Glossary vii Acknowledgement viii Introduction 1 Literature Review 3 Research Aims 38 Research Questions 39 Research Methodology Orientation of the Study Participant Selection Ethical Considerations Study Participants Data Collection Technique Interview Protocol Transcription and Data Storage Data Analysis 39 Results Introduction Theme 1: Interpersonal Communication Communication between the vocational rehabilitation consultant and worker Communication surrounding decision making Worker understanding of policy and legislation Communicating the end of entitlement to benefits Implied negative messaging Theme 2: The Human Factor Perceived treatment by the vocational rehabilitation consultant Different consultant Feeling a part of the process Support from WorkSafeBC staff Feeling pushed off the desk Holistic individual Theme 3: Expectations 50 51 55 58 Vocational Rehabilitation Services iv Expectations of WorkSafeBC Process expectations Outcome expectations Financial expectations Theme 4: Re-employment Considerations 61 Barriers to employment Decision making and options Retraining Pre-injury employer Job search Job placements Return to work Socioeconomic status equivalence Social support Theme 5: Psychological Factors 67 Depression Misunderstanding presentation Need for counseling Psychological effects of injury Theme 6: Injured Workers Identification of Strengths of Vocational Rehabilitation Services 69 Communication Support from vocational rehabilitation program Maintaining focus on return to work Progress toward identified goals or positive outcomes Retraining and education Theme 7: Injured Workers Proposed Improvements to Vocational Rehabilitation Services 71 Communication Vocational rehabilitation consultant knowledge and approach Counseling and post traumatic stress disorder Outcome improvements Discussion 75 Recommendations for Future Study 90 Limitations of the Study 92 Implications of Practice 92 Conclusion 102 References 103 Appendix A- Recruitment Letter 106 Vocational Rehabilitation Services Appendix B-Information Letter 107 Appendix C-Informed Consent 108 Appendix D- Participant Demographics 109 Appendix E- Interview Protocol 111 Appendix F- Additional Supporting Quotes for Themes 112 v Vocational Rehabilitation Services vi List of Tables Table 1: Participant Pre-Injury Occupations 44 Table 2: Additional Supporting Quotations for Themes 112 Vocational Rehabilitation Services Glossary CBT- cognitive behavioral therapy DM- disability management IPS- Individual Placement and Support Programs PTSD- post traumatic stress disorder RTW- return to work UK- United Kingdom UNBC- University of Northern British Columbia VR- vocational rehabilitation VRC- vocational rehabilitation consultant WSBC- WorkSafeBC (British Columbia's workers' compensation board) WSIB- Workplace Safety and Insurance Board of Ontario vii Vocational Rehabilitation Services viii Acknowledgments I would like to take this opportunity to express my most sincere gratitude to everyone that directly or indirectly contributed to the production of this thesis. First and foremost, a special thank you to my supervisor Dr. Shannon Wagner, and committee members Dr. Henry Harder and Dr. Lela Zimmer for their guidance and encouragement throughout this project. As well I would like to acknowledge the assistance of Sherri Tillotson for her time in reviewing the coding breakdown for several interviews, and of course to my amazing friend Joyce Henley who is always willing to read, edit, and provide me with useful feedback on any of my projects. I would also like to thank the wonderful people in my life for always supporting me throughout my academic and personal journey. My friends and family are everything to me and they have always supported me with attaining any and all of my goals in life. Thank you so much to my mom, Brenda Latkowski, for always pushing me forward, listening to my frustrations, and encouraging me to continue. Thank you to my husband and beautiful son, Ryan and Caiden Wessel, for always believing in my abilities and giving me a reason to want a brighter future. Thank you to my wonderful friend Sarah Devison for always encouraging and being there even at a distance. I truly feel privileged to have had the opportunity to participate in attaining my goal of achieving a Masters degree. AN ENQUIRY INTO THE VOCATIONAL REHABILITATION SERVICES PROVIDED BY WORKSAFEBC: THE PERSPECTIVE OF THE INJURED WORKER Introduction Vocational rehabilitation is a service that has developed in the recent past to address the needs of workers with disabilities. It is a well developed area of professional practice as well as the focus of much research. In the year 2009 WorkSafeBC (WSBC) had reports of 141,968 workplace injuries. Of these reported injuries 94,252 were accepted claims costing a total of 804 million dollars (WorkSafeBC Statistics, 2009). These figures represent only twelve months in one Canadian province. The total yearly cost of occupational injury and illness across Canada alone is substantial. Forty-three percent of associated costs of these claims result from long term claimants that have more complex injury, illness, or disease that requires increased time away from the workplace. Often these claimants are unable to return to their pre-injury occupation and require the services of vocational rehabilitation (VR) in order to assist them to return to suitable employment. Within the context of WorkSafeBC vocational rehabilitation is a service provided to workers with an active claim, when the worker may not be able to return to their pre-injury employment situation. After an employee has experienced a workplace injury they are provided with treatment and time for recovery. Certain limitations and restrictions are identified for the worker, either in the temporary or permanent sense. When these limitations become permanent they may affect the worker's ability to complete their job demands on a long term basis, and thus a referral is made to vocational rehabilitation services. If an injured worker utilizes vocational rehabilitation services with WSBC they may be presented with a range of services including retaining the employment relationship or Vocational Rehabilitation Services 2 exploring accommodation options with the pre-injury employer, vocational assessments, retraining to increase job skills, job placements, job search and/or vocational counseling. In some cases it is not possible for the worker to return to their job and so exploration of alternative options for safe and durable employment is required. The specific aims of this research were to examine injured workers' perspectives of the vocational rehabilitation services provided by WSBC. A discernible gap has been identified in the literature of vocational rehabilitation such that the perspective of the injured worker has yet to be thoroughly examined. In order to address this gap, the graduate student researcher agreed to take part in this research project in conjunction with two of the examining committee members and the director of vocational rehabilitation at WorkSafeBC. The efforts in establishing the format of the research, such as the interview protocol, were collaborative between these parties. The graduate student researcher was an appropriate choice to conduct and analyze the data for this project as she had an extensive history working with people with various disabilities, was nearing the end of her Master of Arts degree in Disability Management, and had been exposed to coordinating a qualitative research project in the recent past. Her educational background included a Bachelor of Science degree in Psychology which presented a bias in her outlook of disabilities and the related barriers associated with acquiring a disability. The graduate student researcher took the time to acknowledge this bias and consider how it may affect the project. Another bias identified by the graduate student researcher was the fact that she had one significant WorkSafeBC claim in her past. The injury related to that claim occurred eight years prior to involvement in this project and did not result in the use of vocational rehabilitation services. Given these biases, the student researcher had relatively Vocational Rehabilitation Services 3 little knowledge about WorkSafeBC and their vocational rehabilitation services at the outset of this project. Having a researcher with limited knowledge is advantageous given the scope of this project, in that the researcher did not have preconceived notions about the service or stakeholders involved. The graduate student researcher became involved in the project due to the importance of the topic and the potential for impacting countless future workers. Providing vocational rehabilitation services is a noble occupation and imperative to the wellbeing of injured workers. Any attempt made to expand on the current knowledge base is crucial to increasing the effectiveness of that service and aiding workers to return to meaningful employment. Literature Review A pertinent area missing in vocational rehabilitation literature is the perceptions of the programs by the workers that actually utilize them. Few self report measures are used in this research area; rather, success of vocational rehabilitation services is measured by simply determining whether the employee has re-entered the workforce. Little concern has been shown for whether these employment situations are durable and successful from the viewpoint of the worker or employer. Workers have been given limited opportunities to provide reports of their experience and their thoughts for improving vocational rehabilitation services. The aim of vocational rehabilitation is to provide supports and services for persons with disabilities in order to enable them to enter the workforce in safe and durable employment situations. Return to work specialists utilize a multitude of interventions aimed at enabling individuals to work within their abilities and maintain successful employment. Researchers and health practitioners continue to work at improving interventions and Vocational Rehabilitation Services 4 techniques available as well as the most effective way to measure rates of success. Research in the area is split between studying those with severe physical limitations, those with mental health disorders, and those with other impairments effecting successful employment in the open employment market. The current literature review will discuss vocational rehabilitation services provided to disabled individuals. The content will include a review of the literature in the areas of defining vocational rehabilitation, statistics on injury rates, vocational rehabilitation services available, effectiveness of VR services, interventions for those with physical disabilities, interventions for those with mental health disabilities, the experience of injured workers as they return to work, evaluation of VR programs, outcome measures, and role of ethnicity. Defining Vocational Rehabilitation Vocational rehabilitation (VR) is a contemporary practice aimed at assisting people in obtaining and retaining meaningful employment. In general terms, the aim of vocational rehabilitation services is to promote employment opportunities for persons with disabilities in the open job market. Dean, Dolan and Schmidt (1999) state that it is a program designed to provide "a wide range of employment-related services to persons with physical, mental, or emotional impairments" (p.163). Pruett et al., (2008) have expanded on this definition, stating that VR services typically include: "diagnostic evaluation, medical restoration, personal adjustment training, independent living training, job readiness training, vocational training, and job placement" (p.57). Further, they add that VR services can be multidisciplinary in nature ranging from acute care to community based interventions and services for individuals with complex and diverse disabilities (Pruett et al., 2008). Young and Murphy (2002) describe the aim of VR as changing the individual from an unsatisfactory Vocational Rehabilitation Services 5 status to one with which all stakeholders are satisfied. As well, Hutchinson, Anthony, Massaro, and Rogers state that, "meaningful work is described as one of the functional indicators of healing and growth beyond the disability and is seen as critical in recovering a personal sense of worth and value" (2007, p. 189). Vocational rehabilitation services provide an extensive array of services to largely differing groups of people. These services should be focused on utilizing a biopsychosocial perspective to aide those with a disability or limitation with inclusion in employment. The biopsychosocial model focuses on the ways in which biological, psychological and social factors interact with each other to influence illness, disability and/or disease. The biomedical model has been the traditional model utilized since the mid-twentieth century for all patient care and focuses exclusively on the biological or cellular level when treating aliments (Borrell-Carrio, Suchman, & Epstein, 2004). George Engel offered a holistic alternative for medical practitioners who were interested in responding to all facets of patients' suffering. In order to provide patients with more complete understanding and treatment of illness and disability he proposed responding to the biological, psychological, and social dimensions of illness (Borrell-Carrio et al., 2004). These treatment perspectives have been embraced by many professionals working outside of medicine as treatment options in health care have expanded. In terms of VR, a biomedical model focuses primarily on the mechanism of injury, the effects of that injury on the mechanics of body movement and tissue, and the resulting limitations and restrictions on the worker for return to work options. Alternatively, the biopsychosocial model incorporates a more holistic outlook of the worker as an individual in order to determine the level of functioning at which the worker remains for return to work Vocational Rehabilitation Services 6 options. Using the biopsychosocial model, psychological impacts of injury and social factors such as supports, community involvement, and leisure activities are all considered in conjunction with the medical restrictions and limitations when determining suitable employment and VR services. Injury Statistics White, Beecham, and Kirkwood (2008) state that in Australia chronic pain affects approximately 20 percent of the population and that this condition costs the Australian society over 34 billion dollars annually. Similarly, Kuoppala and Lamminpaa (2008) suggest that 45 percent of the working age Finnish population have some type of chronic disease or traumatic defect and that at the time of the study "15% of men and 22% of women had a need for vocational rehabilitation" (p. 796). In the 2006 fiscal year, Finland officials reported the number of people retired and receiving old age pension was equivalent to the number on disability pension, suggesting that there is a high number of disabled workers within the Finnish population. The main disability categories reported were mental disorders (33%) and musculoskeletal diseases (32%) (Kuoppala & Lamminpaa, 2008). Oyeflaten, Hysing, and Eriksen (2008) state that in Norway, musculoskeletal and psychiatric complaints are the greatest causes of sickness absence and long term incapacity to work. Shaw, MacAhonic, Lindsay and Brake (2009) provide some Canadian statistics on injuries as reported through workers' compensation systems. These authors report that currently, 60 to 65 percent of lost time claims reported from the Workplace Safety and Insurance Board of Ontario (WSIB) are accounted for by soft tissue injuries, costing two billion dollars annually. Of these costs, back injuries comprise the largest portion of soft tissue injuries. Similarly, for the time period of 1996-2005, back injuries accounted for 25 Vocational Rehabilitation Services 7 percent of all claims made in the British Columbia workers' compensation system. Approximately 10 percent of these back injuries become chronic and thus are the group of cases that become the most costly (Shaw, MacAhonic, Lindsay & Brake, 2009). "In 2004, the WSIB reported over 270,000 workplace injuries and determined that 20% of the subsequent claims are chronic problems that account for 80% of the costs of claims" (Korzycki, Korzycki, & Shaw, 2008, p.277). The types of disabilities that are reported and treated have changed throughout recent history (Reese, 2009). "In particular, for the musculoskeletal complaints, up to 85% of cases are non-specific. For these conditions there is a high risk of co-morbidity with other subjective health complaints, and the degree of co-morbidity influences the prognosis and degree of disability" (Oyeflaten, Hysing, & Eriksen, 2008, p.548). Recent trends in disabling disorders are turning towards non-specific conditions that have little objective pathology, including soft tissue injures and chronic pain. In contrast, previous trends of disability were related to serious and traumatic injuries. The labour market has changed dramatically in the types of occupations workers participate in, moving from physically demanding work to more sedentary duties resulting in this change of categories for the majority of disabling conditions reported. Increased mental illness claims are also a part of the changing trends in disability. In the UK, Seebohm et al. (2005) describe "of all disabled groups, mental health service users in general have the lowest rates of employment, at 25%. This is despite the fact that most mental health service users have aspirations to work. The situation is even worse for people with severe mental health problems, with one study showing that just 8% were in paid work" (as cited in Robdale, 2008, p. 24). Vocational Rehabilitation Services In the United States, Migliore and Butterworth (2008) state that only 35 percent of individuals in the disabled community are employed, compared to the general population at 78 percent. In addition, Migliore and Butterworth (2008) found: according to the data reported in the annual report of the U.S. Department of Education (2007), 33% of VR closures in FY [fiscal year] 2004 were those with an employment outcome. However, some data suggest that these figures do not fully reflect the employment potential of customers. Dean et al. (2002) found that 28% of people whose cases were closed by VR without an employment outcome were later employed. Similarly, Hayward and Schmidt-Davis (2003) found that after leaving VR services without employment, 37% of people were employed 3 years later (p.36). There appears to be a greater potential to maintain paid employment for those with a given disability than previously thought. If provided with appropriate interventions, modifications, and time, a far greater percentage of the disabled community could be participating in work outside the home. Given the reported statistics it would seem that a significant proportion of the global population of working age individuals are suffering with some kind of injury or illness and relatively few of these people maintain regular employment. Vocational rehabilitation is one method to address these issues and assist people in attaining and maintaining safe employment. Vocational Rehabilitation Programs Available Robdale (2008) provides an excellent review of the vocational rehabilitation programs that are currently utilized as well as the ones that have been used previously. One of the first programs heavily utilized was supported employment, otherwise referred to as traditional industrial therapy. This program was dominant in the field twenty to thirty years ago and consisted of activities such as assembling basic appliances or the collation of booklets. Clients were rewarded for their work with minimal payment so not to affect any 8 Vocational Rehabilitation Services 9 benefits he/she may have been receiving (Robdale, 2008). This type of VR service is still available today as it is demonstrated to provide individuals with a sense of well being and belonging and the benefits of being involved in work. Another historical program is the 'train and place' model. Robdale (2008) explains: this approach became popular in the early 1990s as part of a greater government drive to tackle unemployment. It is an approach that has been used for the general unemployed population and was borrowed for various disabled groups. The approach consists of providing training places for the various groups. In mental health there has been training provision in horticulture, catering and information technology. One common criticism is that individuals tended to go from one training programme to another without really encountering the real world of work (p.25). Train and place has been found to be particularly helpful for middle aged or older people with schizophrenia or other psychotic disorders (Robdale, 2008). Rinaldi and Perkins (2007) explain that in the UK vocational rehabilitation programs have traditionally taken two forms, sheltered employment or segregated pre-vocational training and education. It has only been recently that supported employment such as the individual placement and support (IPS) programs have been brought to the UK. Sheltered employment strategies are similar to the supported employment technique, whereby the worker would complete tasks like assembly in a sheltered environment away from the open labour market. Conversely, the segregated pre-vocational training and education has also been referred to as step-wise pre-vocational training, which involved long periods of employment preparation. This preparation involved skill development, education, and personal development and training in sheltered segregated environments. The client would learn a new skill they could take to the job market in addition to training on how to be a Vocational Rehabilitation Services 10 successful employee. After such programs, a client would attempt to find employment in the open market (Rinaldi & Perkins, 2007). Individual placement and support, or sometimes called the 'place and train' approach is one of the most validated program techniques in the literature. Developed by Deborah Becker and Robert Drake in the early 1990s, it has become the dominant approach in VR. EPS is based on the premise of finding a work placement for trainees during which realistic work experience and development of skills needed for a specific work setting are gained (Robdale, 2008). Simply stated this approach is a type of 'training on the job'. Burns, White, and Catty (2008) state IPS "emphasizes a 'rapid job search' reflecting patient preferences and ongoing support to patient and employer from an employment specialist" (p.498). IPS creates organized and supported work placements and is seen as responsive to the needs of the employment market. However, this approach favours higher functioning individuals that are more capable of sustaining open employment (Robdale, 2008). In the past four to five years, job retention services have emerged. This approach was initially seen as an addition to the IPS model in which training on the job would occur and job retention services would remain a part of the employment relationship. Currently, job retention services are utilized in a greater capacity for many employment relationships. These services are essentially an open invitation for both the employee and employer to seek support in maintaining an employment position by reinitiating contact with a VR specialist, if further supports are required. Prior to the addition of job retention services, if problems were encountered in the employment relationship after a training on the job, termination of the employee was likely the result, as no supports were available for either the worker or employer (Robdale, 2008). Job retention services are intended to support the worker so that Vocational Rehabilitation Services 11 they are able to retain their secured employment. For a person with severe or enduring mental illness this support is necessary to avoid the negative impacts of continuous employment failure (Robdale, 2008). In addition to supporting IPS placements some job retention services have introduced programs that offer services to the general population of employees. Job retention services can be utilized as a prevention program in the general population because it is expected that mental health issues will impact a large percentage of workers at some point in their lives (Robdale, 2008). The intent of general job retention services is to support people with mental health issues to stay in their current employment position, as a relationship has already been developed with their employer. "Advocates of this approach point to the general benefits for individuals of retaining their employment and to the benefits for the economy in general, as individuals remain as gross economic contributors through taxation rather than benefit claimants" (Robdale, 2008, p.26). Within this context this type of service deals more with people afflicted with stress related problems such as anxiety and depression. Anxiety and/or depression would affect the average group of workers more often than serious and enduring mental health issues because these workers have sustained employment situations. For those unable to maintain employment relationships it is likely that serious mental health disorders have already been identified, and so with the average group of workers, shorter duration episodes of mental health disabilities are more likely to occur (Robdale, 2008). Self employment is another alternative, although not a typical vocational rehabilitation approach. Entrepreneurial endeavors provide the ability to create employment without the difficulty of going through the application and interview process. In addition, it Vocational Rehabilitation Services 12 can reduce the prejudice in working relationships associated with certain disorders. However, if pursuing this route the disabled worker requires the ability to compete openly in the business community, as well as the energy and commitment to keep the business propelling forward (Robdale, 2008). Education or formal training is another vocational rehabilitation approach. Offering education to an individual with a disability or providing them with some type of transferable skill increases their ability to compete in the open labour market. Flannery et al. (2008) state "for young adults with and without disabilities, completion of postsecondary education, including postsecondary occupational training, significantly improves employment rates and financial well-being" (p.26). However, these authors report in the United States "only 19% of students with disabilities are participating in postsecondary education compared with 40% of students in the general population" (Wagner et al., 2005 as cited in Flannery et al., 2008, p. 27). Hutchinson, Anthony, Massaro, and Rogers (2007) also discuss supported education as an important component of the recovery process for those with a mental illness; this approach allows an individual's identity to be refrained from patient or consumer to that of student and hopefully worker. Effectiveness of VR Services Dutta et al. (2008) report the employment rates of people with disabilities after receiving VR services as around sixty percent. As well, those with greater education levels at the time of application had higher success rates in later employment (Dutta, et al., 2008). For individuals with mental illness, Bond (2004) reports that quality studies have shown a twenty to forty percent increase in the competitive employment rate when using supported Vocational Rehabilitation Services 13 employment services rather than other vocational programs, with similar results being found for those with traumatic brain injury (Pruett et al., 2008). Several comparative studies have recently taken place regarding the models of VR services. Robdale (2008) refers to a few studies in which the IPS model is compared with sheltered work or train and place models. The highest rates of competitive employment were found utilizing the IPS model, although train and place was especially beneficial for older people with schizophrenia related disorders. These findings have also now been replicated in Europe, where participants in the IPS program received twice the benefit compared to the train and place model (Robdale, 2008). Bolton, Bellini, and Brookings (2000) also presented favorable results for job placement services (similar to an IPS model) stating that it was the most important service provided for successful case closures, but not for amount of earnings. As well, Moore, Feist-Price and Alston (2002) report similar findings indicating job placement services predicted positive employment outcomes (as cited in Beach, 2009). Hutchinson et al. (2007) report supported employment models were more effective than usual vocational services, and the IPS program was able to assist 55 percent of participants to obtain competitive employment compared with 34 percent of controls (Hutchinson, et al., 2007). Cimera (1998) concluded that supported employment programs are positive for society as a whole and Wehman, West, and Kregel (1999) agreed that IPS programs provide a higher level of benefit than sheltered work environments for those with severe disabilities (as cited in Pruett et al., 2008). According to Rinaldi and Perkins (2007) until the introduction of the IPS model, the United Kingdom (UK) traditionally had a dismal history of rehabilitation programs for people with disabilities. These researchers compared a newly introduced IPS program with a Vocational Rehabilitation Services 14 well established segregated pre-vocational service, which operated as a train and place approach for mental health clients. Within the 12 months that the programs were compared, the IPS program assisted 37 percent of the clients into open employment positions, while the prevocational service assisted 17 percent. IPS also assisted 17 percent into mainstream education or training and nine percent into voluntary work, while the pre-vocational service assisted five percent and three percent respectively (Rinaldi & Perkins, 2007). When comparing cost, the pre-vocational program averaged 6.7 times more per participant than the IPS program (Rinaldi & Perkins, 2007). Fraser et al. (2008) compared an IPS program with a Diversified Placement Approach (DPA) for psychiatric patients. DPA was the existing program model, using a stepwise employment approach that was focused on work readiness. The main principles of the program included: 1) obtaining paid employment, 2) gradually moving through the vocational continuum, 3) flexibility in moving between placements, 4) utilizing peer support, 5) having an array of job options, and 6) partnerships with the business community. They found that the DPA program relied heavily on ready-made job positions within their business, whereas the IPS program had ninety-eight percent of jobs in the open market. Consequently, these authors concluded, "evidence-based supported employment provides superior competitive employment outcomes to those of traditional vendors of vocational rehabilitation services" (Fraser, Jones, Frounfelker, Harding, Hardin, & Bond, 2008, p.338). The North American literature of IPS success has been replicated in the UK (Burns, White, & Catty, 2008). Essentially, Burns, White, & Catty (2008) found a greater portion of participants were able to obtain open employment with IPS, and these positions generally lasted a longer duration. This research also contributed to the literature demonstrating that Vocational Rehabilitation Services 15 local unemployment rates influence the effectiveness of IPS, which is contrary to many researchers' opinions. The general consensus has been that IPS operates independently of unemployment rates, however this is changing with trials recently completed showing that IPS outcomes are dependent on local unemployment rates (Burns, White, & Catty, 2008). This is because these placement programs depend on there being available employment in the open market. When there are large numbers of unemployed workers there is more competition for all positions in the open labour market thus contributing to the effectiveness of the IPS programs. Flannery et al. (2008) conducted a study considering the effect of a short term community college skills training program on employment outcomes. They found the completion of such a program improved the employment outcomes in the areas of wages, hours worked and also quarters worked. The findings of Flannery et al. (2008) support the notion that a short term training program can provide youth the option of going to college and, when combined with vocational rehabilitation services, increase subsequent employment outcomes (Flannery et al., 2008). Hutchinson et al. (2007) support this finding stating that both meaningful work and supported education have been shown to provide effective interventions for people suffering with mental illness. These authors evaluated a program in Boston aimed at a ten month supported education situation, followed by a two month supported internship for people with psychiatric disability. The participants ended up with modest employment status and earnings gains as well as increased self-esteem and feelings of empowerment. Participants also reduced their usage of mental health services over time (Hutchinson et al., 2007). Hutchinson et al., 2007 state: Vocational Rehabilitation Services 16 Perhaps the added value of a program such as this is that it provides supported computer education as a primary intervention and then integrates in a supported employment experience. Engaging people as students first as a transition role immediately provides a valued role which can then positively impact the recovery domains of self-esteem and empowerment. Working with students preparing for a vocational role, TFTF [the program] had the opportunity to focus on not just employment, but recovery education that may contribute to a person's functional ability to work and achieve long-term career success, (p. 196) Interventions for Those with Physical Disabilities White, Beecham, and Kirkwood (2008) completed a study on cognitive behavioral therapy (CBT) for people with chronic pain in Australia. CBT is often chosen as a treatment route for patients, to reduce pain related distress or disability by allowing the patient selfmanagement of chronic pain. Most of the participants reported pain as a barrier to their return to work efforts prior to CBT. After the program half of the participants saw improvements and had increased efforts towards full-time employment, with pain being reported less as a barrier (White, Beecham, & Kirkwood, 2008). Unfortunately, CBT does not significantly reduce pain distress for every patient. Post-program some of the participants continued to report pain as a barrier to their return to work efforts thus reiterating the fact this therapy does not alter the impairment itself. Despite these limitations, White et al. (2008) suggest that CBT helps to reduce disability cognitions and therefore allows many individuals increased participation in functional activities. While CBT is not a VR intervention it has been utilized in combination with other techniques to improve vocational status. Chronic pain patients have been studied extensively in the literature as well as those with serious injuries such as problems with the spinal cord. Meade et al. (2006) completed a survey study in Virginia with a large group of individuals with spinal cord injury. These Vocational Rehabilitation Services 17 authors were interested in discovering the relationship between those with severe physical disabilities and the utilization of vocational rehabilitation services. One third of the participants received at least one VR service and the most frequently utilized service was vocational counseling regarding job opportunities or how to get a job; the next most utilized service was vocational assessment. Vocational assessment services are most applicable to individuals dissatisfied with their current employment situation. Assessments provide insight into personal preferences and abilities and aid in exploring suitable employment possibilities, so would be for those looking to change jobs. Often times a disability changes a person's functional capacity so they are no longer able to complete the bona fide occupational requirements of their job and thus need to consider more physically or emotionally suitable employment. For a multitude of reasons a person may no longer be satisfied with their occupation and wish to change directions, this is when vocational assessments may be appropriately utilized. "Individuals who are satisfied with their current situation may be more appropriately served by the provision of additional resources (such as assistive technology, education, etc)" (Meade et al., 2006, p.8) rather than formal vocational assessments. The participants in Meade et al's. (2006) study were also asked about their satisfaction with the services received. Of the people that received a VR service about 40 percent felt these services were not helpful in transitioning to work. However, 24 percent reported these services helped them significantly, and 26 percent said they helped a little. In addition, employed participants rated their VR services higher than those who were not employed, indicating a potential bias in satisfaction with services only if they result in successful employment. Lastly, the researchers identified the extent that participants wanted Vocational Rehabilitation Services 18 and received additional services. These include "GED programs, English as a second language classes, enrollment in 2 or 4 year college, assistance with developing a new job skill, assistance with finding a job, assistance with workplace modifications/accessibility, assistance with keeping a job, budgeting and money management, and retirement planning" (Meade et al., 2006, p.8). The service most requested by participants was developing a new job skill; enrollment in college was rated as the most frequently received service (Meade et al., 2006). The participants in this study had spinal cord injury and were interested in obtaining a skill that would be easily adapted to the working environment, which would enable them to better themselves by increasing their transferable skills and giving them qualifications to search for different jobs. They did not necessarily want to be enrolled into a college program but rather were seeking increased job skills that could be applied to their daily work. Meade, et al. (2006) report job placement services are a critical component of employment success. The authors identified a significant number of people interested in receiving job placement services, although 75 percent of the participants in the study did not request this specific support. It is presumed the reason for the lack in requesting job search support is complex and multifaceted including variables such as whether the individuals were currently employed, although the authors do not expand beyond this (Meade et al., 2006). A disheartening finding is that a large number of participants were interested in certain VR services but were not able to obtain them for a variety of reasons such as, not being able to afford the service, not having access to it, or not knowing how to obtain it (Meade et al., 2006). Vocational Rehabilitation Services 19 Interventions for those with Mental Health Disabilities There are a variety of benefits to being gainfully employed. "Employment provides a means of financially supporting one's self and family, facilitates access to health care services, and serves as a basis for relationships and personal identity" (Meade et al., 2006, p.3). Robdale (2008) discusses the many potential benefits of employment for those with mental health difficulties. Not only does employment lead directly to increased income which translates to better housing and standard of living, but it is also seen as the key to social inclusion and an increased quality of life. Employment has been found to improve mental health outcomes by reducing reliance on mental health services and improving everyday functioning (Robdale, 2008). Hutchinson et al. (2007) states "individuals who achieved competitive employment showed greater improvements in symptoms, greater self-esteem, and more satisfaction with the leisure and financial aspects of their lives than a group of individuals who were equivalent at baseline and who did not achieve competitive employment" (p. 196). Other benefits, specifically for those with schizophrenia, included increased socialization, selfesteem, activity levels, and an improvement in symptoms and overall health (Robdale, 2008). Cimera (2008) completed work regarding cost of supported employment services for psychiatric disordered patients in comparison to groups of people with different types of impairments. This author found that non-psychotic mental illness consumers were the least expensive group to receive this type of rehabilitation, at an average annual cost of $2579. This was followed by 'other' health impairments ($3637), people with psychotic mental illnesses ($3846), communication difficulties ($4286), other learning disabilities ($4337), autism spectrum disorders ($4716), traumatic brain injury ($4848), mental handicap ($4969), Vocational Rehabilitation Services 20 physical and mobility limitations ($5098), and lastly sensory impairments ($6257). These findings show that both psychotic and non-psychotic mental illnesses are among the three least expensive groups to be provided with supported employment services. These findings provide support for the goal of Cimera's research, as it aimed to address reasons for the lack of participation in supported employment opportunities by psychiatric patients. It is possible that referral sources perceive these services to require extensive time and monetary commitments, although these results provide clear evidence to the contrary (Cimera, 2008). Further research would be required to determine exact reasons for the lack of participation, although the findings of Cimera's work provide evidence that speaks to the average financial commitment required. Michon, Weeghel, Kroon, and Schene (2005) attempted to address some of the conflicting results in the literature surrounding predictors of vocational outcomes for those with psychiatric disabilities. These authors found strong predictors of successful psychiatric vocational rehabilitation (PVR) to include "a higher work-related self-efficacy (i.e., positive outcome expectancy or career-related self-efficacy), social functioning during PVR, and a longer period of education" (Michon et al., 2005, p.413). Common in the literature is the finding that better employment outcomes are related to better past social functioning and a favorable work history. Poorer outcomes were related to an extensive history of hospitalizations, diagnoses of schizophrenia, and severe negative symptoms (Michon et al., 2005). The results of Michon et al's. study (2005) were found to be opposing the literature with regards to the severity of symptoms, diagnosis, and psychiatric history, in that these factors were not found to be related to outcomes. In addition, Michon et al. (2005) state: Vocational Rehabilitation Services 21 one major finding of this review is that work performance and social functioning, when measured during participation in PVR, are more predictive of vocational outcomes than work history and social functioning measured prior to programme commencement. This is contrary to the results of previous reviews. Past functioning might be a valid predictor of future vocational functioning within the broad population of individuals with mental illness, but it seems to be a less powerful predictor within the restricted population of participants in vocational rehabilitation programmes, (p.414) Given the discrepancies reported here no clear conclusions have been reached with regards to predictors of PVR outcomes. However, the fact that many domains of an injured worker's life are affected when an injury occurs seems to escape many researchers. For instance, physical, psychological, occupational, and social areas are often intertwined and thus an injury is likely to accentuate the workers vulnerability to psychological distress (Wall, Ogloff & Morrissey, 2006). Humans are extremely complex beings and therefore, recovery cannot be viewed solely by the medical model. Wall et al. (2006) indicate that working from a biopsychosocial model of recovery is essential given that psychological factors have the capacity to significantly delay recovery times. "Mood and anxiety disorders are the most common co-occuring mental illnesses and have been associated with delayed healing of natural wounds, multiple chronic pain symptoms, diabetes, and functional somatic syndromes" (Wall et al., 2006, p.514). Wall et al. (2006) postulate that the five factor model of personality may be of use in the assessment and planning stages of vocational rehabilitation. They studied the personalities of a group of workers within the compensation system in Australia, which were typical of long term claimants. These authors found that one third of the participants could satisfy the DSM-IV TR criteria for at least one personality disorder (PD). Obsessive compulsive personality disorder was the most common PD found in the group. It is Vocational Rehabilitation Services 22 important to note that this PD may be the least functionally impairing of the PDs. The study also suggests that injured workers with extreme personality traits are inclined toward poorer health outcomes and higher VR costs. Wall et al. (2006) state: This study found the trait perspective has much to offer vocational rehabilitation. Long term claimants exhibiting an overall five-factor profile of high N (neuroticism), low E (extraversion), and a trend toward low A (agreeableness) and C (conscientiousness) were found to experience greater social dysfunction, greater psychological distress and are more likely to suffer symptoms of depression, anxiety and high personality dysfunction than those who do not display this profile (p. 526). A "large percentage of injured workers with compensable injuries demonstrate poorer health outcomes than individuals with similar injuries who do not become involved in the compensation process" (Wall et al., 2006, p.514). Given this fact in combination with the relationship of high rehabilitation costs and personality dysfunctions, it becomes clear that utilizing a biopsychosocial model is beneficial for those involved in recovery within the compensation system. When a workplace injury takes place it impacts the worker not only physically and medically but also psychologically and socially depending on the person and the level of disability. Given that health outcomes for those in the compensation system are poorer than others with similar injuries, and that these poor outcomes have been related to high rehabilitation costs; in order to reduce these costs within a compensation system, beginning to treat individuals within a biopsychosocial model may be preventative medicine. By viewing an individual as a whole rather than only by their occupation and injury allows for preventative measures such as group counseling and social interventions before these components begin to complicate medical recovery and result in poorer outcomes. In application to providing VR services identifying those with extreme personality traits close to the beginning of VR services may be beneficial in providing the appropriate interventions Vocational Rehabilitation Services 23 in a timely manner resulting in better health outcomes and lower VR costs. Unfortunately though, the association of PDs and workplace injuries has resulted in disputes regarding whether the PD or the injury is responsible for enduring disability (Wall et al., 2006). However, it is not important for these purposes that a PD be diagnosed, rather that extreme personality traits be identified so that VR services can be provided in an appropriate and preventative manner. The Experience of Injured Workers as They Return to Work Interactions with injured workers. Interactions between service providers and injured workers have recently been explored by several researchers. Klanghed, Svensson, and Alexanderson (2004) explored these interactions in a group of workers during the return to work process. These authors suggest that respectful and supportive treatment defined as including: active listening, consideration, respecting the opinions and concerns of the injured worker, social and emotional support, personal involvement, accessibility, and being an advocate are qualities of the return to work professional that facilitate successful return to work. Svensson et al. (2003) also undertook a study to determine experiences of injured workers. These authors report negative experiences of workers to be related to service providers demonstrating a detached attitude in regards to worker treatment and well being. "Interactions were characterized by providers expressing doubt of client's capacities, indifference, rejection of client goals, and discrediting client symptoms. Consumers felt belittled and that their needs were managed in a routine rather than client-focused manner" (Svensson et al., 2003, as cited in Korzycki, Korzycki, & Shaw, 2008, p.278). An injured worker's experience with their service provider, be it a return to work coordinator, nurse, or physician, is directly related to Vocational Rehabilitation Services 24 the worker's satisfaction. Satisfaction is often an outcome measure that is utilized to determine quality of care in workers compensation systems (Pourat, Kominski, Roby, & Cameron, 2007). Active participation in the return to work process by the injured worker is a strategy utilized by return to work coordinators to increase satisfaction with the program and empower the worker. Active participation has been found to facilitate finding work in the VR process (Thomas & Whitney-Thomas, 1996, as cited in Korzycki et al., 2008). "Facilitators to active engagement in RTW processes included access to external social supports, utilization of previous skills, provider acceptance of consumer goals, setting clear expectations for consumer involvement, collaborating with other service providers, and respecting consumer autonomy" (Korzycki et al., 2008, p. 279). Korzycki et al. (2008) suggest barriers to active participation in the return to work process include the negative relationship and interactions between the worker and service provider. In order to maintain involvement and satisfaction of injured workers the relationship between the service provider and worker needs to remain positive incorporating all of these strategies. Opportunities need to be determined where workers are able to fully participate as partners in return to work planning. Participation in creating employment goals and in the decision making process is empowering for injured workers thus increasing the worker's cooperation (Korzycki et al., 2008). Interaction with workers' compensation. Lippel (2007) completed a study in Quebec regarding workers' experience of the worker's compensation process. Three primary causes of distress were identified: 1) stigma, 2) power imbalance, and 3) lack of social support. 1) Stigma was described as being Vocational Rehabilitation Services 25 attached to the injured worker status indicating a stereotype that injured workers are fraudulent and abusing the system. In addition, it was reported that workers felt disbelieved with regard to their level of pain, thus feeling they were accused of malingering. 2) Power imbalance was identified as the workers feeling their availability of resources were less than that of all the other players in the compensation system including the employer and the system itself. Lippel (2007) reports that workers feel a loss of control in that the compensation system seeks to control the worker, costs, medical recovery, appeals, the return to work process, as well as the worker's behavior, making the experience more difficult than necessary. 3) Lack of social support was identified as when the worker did not have available a person knowledgeable about the compensation system process with whom the worker had confidence. "When workers felt supported by a doctor, a lawyer, an injured workers' association, a well informed union representative, a CSST caseworker, a sympathetic employer, a colleague, a spouse or other injured workers, the frustrations caused by the process had a less negative effect on their health. The therapeutic effect of the support was maximized when it came from a person in a position of power" (Lippel, 2007, p.435). Depression and Return to Work Depression has been identified as an issue associated with pain and injury in workers known to complicate return to work efforts. Stice and Dik (2009) report, among injured workers with chronic pain, those with higher levels of depression and affective pain were less likely to return to work. Consistent with the literature, Better and Shaw (2009) found "individuals that reported higher levels of perceived pain interference while completing daily activities demonstrated higher levels of depression" (p. 149). The findings of these authors indicate pain and depression are comorbid yet independent conditions. "This study Vocational Rehabilitation Services 26 documents that this comorbid relationship also exists for individuals within a disability compensatory system" (Better & Shaw, 2009, p. 149). Potential explanations for this relationship between pain and depression in injured workers within the worker's compensation system may include worker inability to participate in pleasurable activities. Rather than the presence of physical pain, the explanation may be worker inability to fully participate in activities of daily living (Better & Shaw, 2009). The findings of Better and Shaw (2009) suggest rehabilitation professionals may be warranted in screening for the presence of depression when an injured worker self reports high levels of pain interference with activities of daily living. These authors argue that Workers' Compensation systems would benefit from any interventions available that might help identify workers for whom an early focus on psychological issues may result in more successful VR outcomes. Most often service providers focus only on physical rehabilitation and return to work without considering the impact of psychological issues on return to work outcomes. This method of doing business may initially seem to be more economical however in the long run it will be more costly if the employee fails to successfully return to work (Better & Shaw, 2009). Depression among injured workers has frequently been associated with stress. A study completed by Asmundson et al. (1998) found 34.7% of participants experienced symptoms consistent with Post Traumatic Stress Disorder (as cited in Stice & Dik, 2009). Further, injured workers have reported high levels of stress at home and also stress related to the compensation system process (Kirsh & McKee, 2003, as cited in Stice & Dik, 2009). Authors have suggested that the diathesis-stress model provides an explanation of depression among injured workers (Stice & Dik, 2009). The diathesis-stress model proposes that a person is at risk for developing depression when biological, cognitive, and social Vocational Rehabilitation Services 27 predispositions are triggered by environmental stressors. "To extend the diathesis-stress model specifically to those with work-related injuries, depression would ensue when an individual has vulnerability factors for depression and is exposed to a sufficiently detrimental work-related injury" (Stice & Dik, 2009, p.355). Depression has been significantly associated with both pain and psychosocial stress, in fact, the relationship was found to be moderated by psychosocial stress (Stice & Dik, 2009). "This supports the diathesis-stress model interpretation that under sufficient pain and stress, people's vulnerability factors become activated, contributing to higher rates of depression" (Stice & Dik, 2009, p.360). Return to work outcomes may become complicated by chronic pain and depression regardless of the etiology. However, it is important that service providers are aware of the potential for occurrence of depression in injured workers and the effect it may have on VR interventions and return to work success. Evaluation of Vocational Rehabilitation Programs Vocational rehabilitation programs evaluation efforts have been exhaustive and generally unsuccessful. This lack of success may be related to the broad activities found within the vocational rehabilitation field and difficulty defining and measuring success. White, Beecham, and Kirkwood (2008) point out the difficulties related to dichotomizing treatment outcomes where not working is related to failure and working is related to success. The return to work process is dynamic in nature and consequently, reducing outcomes to a simple question of working or not negates the process involved in return to work efforts (White et al., 2008). In addition, what is considered work is dependent on the author and purpose of the study, as several definitions are used within the literature. To date a 'gold standard' of outcome measurement has not been reached within this field. Vocational Rehabilitation Services 28 Despite the fact that there is no single standard of outcome measurement, researchers in the health sciences field have recently agreed that factors beyond physiology impact VR outcomes. Young and Murphy (2002) describe that there are many influences beyond that of physical health that impact individual vocational rehabilitation gains. Namely, these authors categorize these influences as related to "(i) individuals' psychosocial characteristics, (ii) their wider social environment, (iii) their physical environment, and (iv) their economic environment. To date, identified factors include age, sex, pre-injury employment, level of education, socioeconomic background, marital status, and social networks" (Young & Murphy, 2002, p. 176). A longitudinal study conducted by Hayward and Schmidt-Davis (2003) identified several variables related to VR success including: higher gross motor skills; higher cognitive ability; work history; career knowledge of different jobs; and motivation for nonmonetary benefits of employment. These authors report negative predictors or successful VR case closure to include: "visual disabilities, mental illness, cognitive disabilities, significance of disability, receiving Social Security Insurance, and age" (Hayward & Schmidt-Davis, 2003 as cited in Beach, 2009, p. 148). Studies have attempted to predict return to work outcomes based on the variables described. However, "while a number of variables have been identified as significantly related to return to work, efforts to date have struggled to account for more than about 33% of the variance in employment status" (Young & Murphy, 2002, p. 176). Michon et al. (2005) believe that for a predictive model to be comprehensive for psychiatric vocational rehabilitation specifically, it should include five domains. These are: 1) demographic variables such as gender and age; 2) personal history such as work experience; 3) current functioning in psychiatric VR programs (including social and work Vocational Rehabilitation Services 29 skills influenced by VR); 4) psychiatric VR characteristics (as in the content of the provided vocational rehabilitation services); and 5) contextual variables such as local and national legislation or aspects of the environment that may impact the VR process (Michon et al., 2005). It has been shown that many variables have the potential to influence whether or not a person will return to work, even though these variables may be beyond the control of the individual, as well as the vocational rehabilitation counselor. Measurement of outcome variables for vocational rehabilitation interventions has proven to be as difficult as predictive variables within the literature. Young and Murphy (2002) suggest an evaluation approach of process variables, aimed at moving the individual towards increasing efforts of improving their vocational status, an outcome based in cognitive behavioral therapy. Research has shown that those actively seeking to gain employment are more likely to become employed. Therefore, those seeking to improve their employment status will be more likely to do so. The basis of the proposed measure of vocational outcomes is that any intervention that results in a person increasing their efforts to improve their employment status could be argued to be successful. "The measure of success would be the efforts people make to change aspects of their vocational status with which they are dissatisfied. This may include active job seeking behavior, returning to vocationallyorientated study, participating in voluntary work in order to gain confidence and work experience, or seeking to improve current employment circumstances" (Young & Murphy, 2002, p. 177). Seventy-four percent of the unemployed participants were unhappy with their employment status, and many people that were employed were not completely satisfied with their employment situation (Young & Murphy, 2002). The measure was therefore useful in developing VR initiatives for individuals through guiding and evaluating the process. "The Vocational Rehabilitation Services 30 measure is effective in identifying those with the potential to benefit from services, as well as providing a way of determining an individual's desired outcome, and a way of collecting baseline information about relevant behaviors upon which the effectiveness of VR services can be evaluated" (Young & Murphy, 2002, p. 187). However, this measure should not be expected to stand alone in program evaluation and should be used with achievementorientated outcome measures. This evaluation process can be "viewed as a timely, intermediary measure of VR success" (Young & Murphy, 2002, p. 188). "Although the proposed approach requires further testing and development, the current study has demonstrated that focusing on process variables holds promise as an approach to evaluating VR intervention effectiveness" (Young & Murphy, 2002, p. 189). White et al. (2008) have developed what they call the 'vocational continuum' which is used to report vocational outcomes. It considers the "cognitive dimensions of RTW (return to work) intention alongside behavioural dimensions of attaining or increasing participation in work" (White et al., 2008, p.308). The spectrum ranges from not working, with no intention of working, to full-time employment. The vocational continuum was developed and tested out of the START program, a multidisciplinary cognitive behavioural therapy program for people affected by chronic pain (White et al., 2008). This continuum provides vocational rehabilitation counselors a tool to baseline clients in regards to their participation in employment in addition to their related intentions. This approach holds promise in adding to the arsenal of the VR counselor's toolkits of outcome assessment. Spijkers and Arling (2006) developed a documentation system to streamline vocational training. The system tracks the progress of vocational rehabilitation clients through what they call the 'Profile-Module' which "contains estimates on a six point scale of Vocational Rehabilitation Services 31 each feature: social competence, personal competence, methodical competence, culture skills, disciplinary problems, momentary mental state, health-consciousness, momentary physical state, and social situation" (Spijkers & Arling, 2006, p.369). The standardized measurement tool allows an individual's progress to be tracked. While monitoring the client's progress the counselor can create a visual graph providing information about the client at different time points in their rehabilitation. The authors claim this instrument provides an objective and reliable monitoring system of the quality of the vocational training process (Spijkers & Arling, 2006). Outcome Measures Used in Evaluating Vocational Rehabilitation Programs As stated previously, when determining how to measure outcomes of vocational rehabilitation programs often it is the case that a dichotomous variable such as working or not working is utilized. Aakvik, Heckman, and Vytlacil (2005) discovered that a phenomenon called cream-skimming is occurring in the selection of VR program participants. Cream skimming means counselors selecting participants for entrance into a VR program are choosing those that display more of the characteristics positively associated with employment. Whether these decisions are made consciously or otherwise, such decisions result in the program appearing more effective than it potentially would be if it had served lower functioning individuals. Consequently, having dichotomous outcome measures may bias case managers into selecting participants that are likely to be successful rather than based on need. Aakvik, Heckman, and Vytlacil (2005) suggest changing the VR program participant selection to select workers most in need of training to improve the overall employment promoting effect of vocational rehabilitation services. Vocational Rehabilitation Services 32 i Outcomes by disability type. Dutta et al., (2008) completed a study comparing vocational outcomes for three groups of individuals with different disabilities. Those with sensory or communicative disabilities had the highest successful employment rate (75%), followed by people with physical disabilities (56%), and people with mental impairments (55%). "Jpb placement assistance, on-the-job support, maintenance, and other services were found to be related to employment success for all three disability groups" (Dutta et al., 2008, p.332). Perceptions and beliefs affecting RTWoutcomes. Martz and Xu (2008) discovered that having a positive perspective about the quality of services received, for example, job placement, vocational training services, or education, or having a positive perspective about obtaining the services that were needed, predicted later employment. Dutta et al. (2008) found vocational training and general educational development were significant predictors of employment success for people with mental illness, but not for the other two groups. This may be because those with a mental disability on average were lacking in training and education in comparison to those with physical or sensory disabilities. However, to improve the employment outcomes for the other two groups improvements were made in the level of functioning and health status of individuals by providing services such as surgery, prosthetics, nursing services, dentistry, physical, occupational, or speech therapy, prescription medications, and supplies (Dutta et al., 2008). These authors suggest that providing such services would 'even the playing field' with those without disability by reducing individual impairments. Interventions such as these provided by a multidisciplinary team (for example, including a physician, physical therapist, i Vocational Rehabilitation Services 33 occupational therapist, nurse, pharmacist, disability manager, dietician, or psychologist) in VR provide a broader range of services from which to choose. Oyeflaten et al (2008) conducted a study in which the main objective was to "examine whether fear-avoidance beliefs, illness perceptions, subjective health complaints, and coping are prognostic factors for return to work after multidisciplinary vocational rehabilitation, and to assess the relative importance and inter-relationship of these factors" (p.548). It was determined positive expectations and good health may be enhanced through multidisciplinary vocational interventions which may influence the client's return to work (RTW), as expectations surrounding RTW is an important prognostic factor (Oyeflaten et al., 2008). Illness perceptions can be described as involving such things as personal beliefs about health and disease, illness duration, expected outcomes and recovery. Fear avoidance beliefs have been associated with prolonged disability and work absence. "Expectancies of outcome, coping, illness perceptions and fear avoidance have been shown to be important predictors for RTW for patient groups with specific diagnoses" (Oyeflaten, et al., 2008, p.549). The variance in fear avoidance beliefs for work was explained mainly by the variables education, subjective health complaints and illness perceptions, suggesting these three variables are the main links to fear avoidance beliefs. Oyeflaten et al., (2008) found that fear avoidance beliefs for work were a main prognostic factor in returning to work at both three and twelve months after the VR intervention. "It is likely that, to be successful, interventions for long-term sick-listed individuals with complex health conditions should be directed at fear-avoidance beliefs, since this was the main prognostic factor for not RTW. Our findings also indicate that interventions should target illness perceptions about Vocational Rehabilitation Services 34 subjective health complaints" (Oyeflaten, et al., 2008, p.553). It may be important to determine early in recovery people with fear avoidance beliefs as this directly relates to return to work outcomes in certain cases. Working alliance with the counselor. Pruett et al. (2008) conducted a review of the literature in the context of evidencebased practice. These authors propose the relationship between the counselor and client, most often referred to as the working alliance, is a primary influence on VR and counseling outcomes. "Working alliance can be defined as (a) the client's affective relationship with the therapist; (b) the client's motivation and ability to accomplish work collaboratively with the therapist; (c) the therapist's empathic response to and involvement with the client; and (d) client and therapist agreement about the goals and tasks of therapy" (Pruett et al., 2008, p.58). It was determined by Wampold (2001) that working alliance predicted positive client perception of future employment opportunities and client satisfaction with current employment (as cited in Pruett et al., 2008); furthermore, there is some evidence to support the notion of VR services as effective in returning people with disabilities to competitive employment. "Central to the delivery of VR services is the rehabilitation counselor, with moderate support found for counselors with graduate training in rehabilitation counseling being more effective than those without such degrees. Strong empirical evidence exists to support the efficacy of certain components of the counseling process including working alliance and skills training" (Pruett et al., 2008, p.61). Vocational Rehabilitation Services 35 Barriers related to outcomes. Dutta et al. (2008) found transportation issues (especially for those with sensory or communicative impairments) were a risk factor that reduced successful employment rates; in addition, people with co-occurring physical and mental illness had reduced odds of successful rehabilitation outcomes (Dutta et al., 2008). This study also points out the potentially adverse effect of obtaining gainful employment on disability related benefits - the individual must weigh the financial and personal benefits of paid employment against that of losing their assistance (Dutta et al., 2008). An interesting finding by White et al. (2008) when completing the vocational continuum study was that more participants in the group that did not advance along the continuum were married or in common-law relationships. Conversely, more participants in the group that moved toward working full-time were divorced or separated. This finding suggests that those with a spouse may be at risk of not moving along the vocational continuum, thus influencing return to work (White, et al., 2008). Another barrier to employment outcomes found by Migliore and Butterworth (2008) was that socioeconomic factors play an important role in shaping VR program outcomes. "During the period of 1995 to 2005, about 48% of the variance in trend of employment closures was explained by the variance in trend of unemployment rates in the general population. Moreover, about 62% of the variance of earnings of people placed in integrated employment was explained by the variance of per capita income of the general population" (Migliore & Butterworth, 2008, p.42). Vocational Rehabilitation Services 36 Cost effectiveness. Pruett et al. (2008) state "research reporting the cost-effectiveness ratios of public and private sector rehabilitation programs varies considerably, ranging from approximately a 3to-1 ratio to an 18- to-1 ratio" (p.61). In a US study, Dean, Dolan, and Schmidt (1999), reported vocational rehabilitation interventions made a return in the economy of approximately $2.50 for each dollar spent. Dean et al. (1999) also quote the Rehabilitation Service Administration of the state-federal VR program as reporting that every dollar spent in VR programming generates $18.00 in tax payment to the government (Dean, Dolan, & Schmidt, 1999). Therefore, depending upon how cost effectiveness is framed, the dollars reported vary considerably from study to study. Regardless, the bottom line is that an overall cost savings for society is normally reported when people with disabilities are offered vocational rehabilitation services. The Role of Ethnicity Several of the studies reviewed considered differences between ethnic groups in addition to their main hypotheses, along with the few studies that sought to focus on these differences. Dutta et al. (2008) stated that African Americans and Native Americans had lower odds of obtaining open employment in comparison to European Americans. Martz and Xu (2008) also reported discrepancies; males were more likely to be employed than females among those with visual and 'other' disabilities, and those with hearing or 'other' disability types were more likely to be employed if they belong to a minority ethnicity group rather than the majority Caucasian group. These findings could suggest that discrimination may be apparent within certain impairment categories with males and minority groups employed more, although further studies would be required even for preliminary results. Vocational Rehabilitation Services 37 Robinson and Klein (2008) found non-minorities received more college training than their minority counterparts leading to greater earning power. "Minority clients who are dually diagnosed with mental illness and substance abuse earned $8.82 per hour; while nonminority consumers earned almost $1.00 more or $9.79 per hour"(Robinson & Klein, 2008, p.22). The reason for this finding can only be speculative as minority clients had lower educational attainment which may have affected wages. Furthermore, several other possibilities such as discrimination, the VR counselor's ability, or things of this nature are possible. This study also found that duration of time for successful case closures were shorter for non-minority clients than their minority client counterparts. However, both groups worked an average of thirty-seven hours per week (Robinson & Klein, 2008). Meade et al. (2006) discovered differences in clients accepted to receive services; this study found non-Caucasian clients more likely to receive services than Caucasian clients, with no differences found with the quality of services received. As well, Meade et al. (2006) found non-white and unemployed individuals were most likely to report they were interested in additional VR services and training. This may be due to availability of services within existing social and community support networks (Meade, et al., 2006). Many of these studies did not speculate or explore the potential reasons for these findings. Results were mixed and likely quite dependent on context. For instance, in some communities minorities may have a more difficult time obtaining continuing education independently and therefore they would be assisted to obtain this goal at higher frequencies than non-minorities within local VR because the number of people obtaining services through this avenue would be higher. There are many other speculative explanations that require further scientific investigation. Vocational Rehabilitation Services 38 Conclusion Vocational rehabilitation services are provided to persons with disabilities with the aim of aiding in returning workers to safe and durable employment. A broad range of services can be provided to assist people with all kinds of disabilities. The evaluation of VR programs is an area of research that continues to evolve. The current consensus is that IPS is the most researched and highly favored model available to date. The outcome measures used depend on the individual study, although multidisciplinary research continues within the area of predicting positive outcome variables. It is clear that a biopsychosocial model needs to be adopted when considering any outcomes within the return to work area as health status is dependent upon most other factors of an individual's life. The relationship between the psychological, social, and biological factors of an injury or disability are beginning to be acknowledged in the literature as more studies support the theory that other factors impact healing time and the resulting functional abilities of an injured worker. When considering the methods of evaluating VR programs it becomes clear that the perspective of the worker has been limited in the research. Particularly self report measures are lacking from the perspective of the individuals involved in VR services. Future research should attempt to address this area in order to obtain a holistic view of VR program operations, evaluation methods, and outcomes. Research Aims This research project aimed to gain a deeper understanding of injured workers experiences with WorkSafeBC (WSBC), in particular with regard to vocational rehabilitation (VR). This study was conducted in an exploratory manner providing the injured workers an opportunity to discuss their thoughts and feelings of their experiences. The aim of the Vocational Rehabilitation Services 39 research was to provide a voice for this group of workers and to provide detailed information to the vocational rehabilitation professionals that will allow them to focus on the positive aspects of VR practice. Improving the services provided by vocational rehabilitation consultants (VRC) with WSBC was the ultimate goal, in turn having a positive impact on society by aiding injured workers in the process of return to work. Research Questions 1) What factors impact an injured worker's lived experience of vocational rehabilitation provided by WorkSafeBC? 2) What aspects of the provided services are done well and perceived positively by the injured workers through their lived experience? 3) What do injured workers identify through their lived experience as areas for improvement for vocational rehabilitation services from WorkSafeBC? Research Methodology The research methodology used in this study was based on qualitative research methods. Qualitative research has been defined as an inquiry process of a human or social problem involving a naturalistic approach. The researcher is the "instrument of data collection who gathers words or pictures, analyzes them inductively, focuses on the meaning of participants, and describes a process that is expressive and persuasive in language" (Creswell, 1998, p. 14). The research conducted in this study was exploratory in nature and as such was best suited to this qualitative research design. Specifically, this study employed a qualitative research design using a phenomenological perspective to explore and understand the experiences of injured workers having participated in vocational rehabilitation provided by WSBC. Qualitative research interviewing took place in order to obtain Vocational Rehabilitation Services 40 descriptions of the lived world of the participants with respect to their experience with vocational rehabilitation (Kvale & Brinkmann, 2009). Orientation of the Study Phenomenology is a philosophy as well as a specific approach to research in qualitative methodology. Creswell (1998) defines phenomenology as studying "the meaning of the lived experiences for several individuals about a concept or the phenomenon" (p. 51). Specific techniques are utilized in phenomenology to achieve its goals. Central to the process is the requirement of the researcher 'to bracket' or to put aside all preconceived notions and allow concepts in front of the researcher to appear as they are (Moustakas, 1994; Creswell, 1998; Patton, 1990). Moustakas (1994) discusses this concept of epoche in terms of "this way of perceiving life calls for looking, noticing, becoming aware, without imposing our prejudgment on what we see, think, imagine, or feel" (p. 86). The search in phenomenology is for the essence or the central meaning underlying each individual's experience, thus providing the researcher with a view of each participant's lived experience (Creswell, 1998). This study focused on determining the essence of the lived experience for a group of injured workers having participated in WSBC's vocational rehabilitation services. To date and to our knowledge an investigation of WSBC's vocational rehabilitation program has not been explored from the unique perspective of the injured worker. Many studies have been completed by WorkSafeBC themselves, however, it was considered important to have independent researchers investigate the lived experience of the injured worker in order to reduce bias. WorkSafeBC frequently evaluates their services through such avenues as 'voice of the customer' program which is a survey based evaluation requesting customers of WSBC to rate the level of service provided by their customer service representative, nurse advisor, Vocational Rehabilitation Services 41 entitlement officer, or case manager. Additionally, they complete quarterly surveys of the injured workers involved in vocational rehabilitation. These service ratings are used to provide WSBC with an office by office evaluation (H. Legg of WorkSafeBC, personal communication, February 24, 2010). It must be noted that these self evaluations are completed internally to WSBC. The corporation was interested in having an outside researcher complete an evaluation of the WSBC VR services provided across the province of British Columbia. This has enabled a situation from which an outsider to WSBC has explored the VR services from the perspective of the injured workers themselves. Participant Selection This research was conducted to gain a better understanding of the experiences of injured workers who participated in vocational rehabilitation services with WSBC. In order to obtain richer data, purposeful sampling was used. In other words, to better understand the experiences of workers who were injured on the job and participated in vocational rehabilitation services it was necessary to select individuals based on the following criteria: 1) having a compensable workplace injury or illness based on WorkSafeBC standards 2) having been referred for vocational rehabilitation services with WorkSafeBC 3) had a claim expenditure that excludes short duration claims 4) no evidence of threat codes on WorkSafeBC's case file (to maximize the safety of the researcher) 5) case closed from vocational rehabilitation services in the time frame of minimally six months, maximally two years. Vocational Rehabilitation Services 42 WorkSafeBC determined the pool of potential participants from the inclusion criteria, and in compliance with the Freedom of Information and Protection of Privacy Act, sent out recruitment letters to the potential participants naming both WSBC and the University of Northern British Columbia (UNBC) as the sender. Attached in Appendix A is a copy of the recruitment letter used for this study. The injured workers were instructed in the letter to contact the graduate student researcher to indicate their willingness to participate in the study. Ethical Considerations In June of 2008 ethics approval was obtained from the research ethics board at UNBC. In March of 2009 the initial ethics approval was extended, as the research project was ongoing. Confidentiality was paramount in this study since participants were discussing past claims with WSBC and the potential for future claims often existed. To alleviate any privacy concerns during the pre-interview conversation, the researcher discussed confidentiality with each participant, had them sign the informed consent, and answered any and all questions with regards to the study or the participant's right to privacy. Confidentiality was maintained beyond the interview itself as the transcripts were labeled with a numerical code for each participant on the transcript itself and on any stored audio or text files. There were no known risks associated with participation in this study with several potential benefits including having the opportunity to tell one's story and make an impact on future service delivery of vocational rehabilitation from WSBC. Study Participants As a result of the recruitment letter, 32 potential participants contacted the disability management (DM) graduate researcher, either by phone or email. From this group, 27 Vocational Rehabilitation Services 43 consenting participants were interviewed by the graduate student researcher and 26 participants were included in the data analysis. Seven of the participants were female and nineteen male. The participants reported age (in years) included two participants in their 30s, six in their 40s, twelve in their 50s, four in their 60s and two in their 70s. Seven participants reported having English as their second language. Eight reported being single, thirteen married, four divorced, and one widowed. There was a range in the highest level of completed education with one person having elementary school education, one having some high school, three graduating high school, seven obtaining vocational training or apprenticeships, five participating in either some college or university, four graduating college, and four graduating with a university degree. For reported ethnicity, 19 people stated they were Caucasian, two Portuguese, two Indo-Canadian, and one each of Spanish, First Nations, and European roots. Four participants reported having poor health status, while five reported below average, ten average, three above average, and four very good health status. Eight of the participants could not remember exactly when their vocational rehabilitation benefits ended. Of those that reported a date, six completed in the year 2006, nine completed in 2007, and three ended in 2008. Years working for employer prior to injury included nine participants having been with the employer five years or less, two had six to ten years employment, two had eleven to fifteen years, three had been with the employer sixteen to twenty years, and ten had been employed by the pre-injury employer for twenty one years or more. The occupations each of the participants held prior to injury were generally middle class, see table 1 for a complete list of occupational titles. A range in the compensable injury was also reported between participants with eight stating they had a Vocational Rehabilitation Services 44 shoulder injury, six a knee injury, five varied back problems, two each for finger injury, foot, and post traumatic stress disorder, and lastly one with a wrist injury. Table 1 Participant Pre-injury Occupations Truck driver (2) Journeyman Carpenter (2) Teacher Labourer Auto Mechanic Certified Dental Assistant Shipper/reciever Crane Operator Manager Courier Lineman Paramedic Dryer technician Pipe fitter/welder (2) Medical Lab Technician Hospital housekeeper Printing Pressman Health Care Worker Construction Worker Rollform Operator Animal Control Officer Iron Worker Search and Rescue Diver After completing VR services and at the time of the interview, eleven participants reported they were working, twelve reported they were not employed, four had retired, and two worked in a volunteer capacity. Of those that reported being employed, four work fulltime jobs, five part-time, two casual, and the two volunteers. The participants involved with paid employment after VR services included eight participants employed by a new employer with a new job description, one participant with the same employer and same job description, one participant with the same employer and a new job description, and one participant became self employed. Data Collection Technique In order to collect the data, interviews were scheduled with each participant preferably in their home town. Some participants traveled a short distance to a neighboring Vocational Rehabilitation Services 45 community in order to meet with the graduate student researcher. Interviews were held around British Columbia, mainly in the lower mainland and Vancouver Island in order to meet face to face with each participant. Twenty-four of the interviews took place in this manner, in a public place such as a conference room in a hotel or local library where the environment could be kept as similar as possible across all of the interviews. Face to face interviews were not possible for three of the participants and so a phone interview was scheduled ahead of time for each of them. All of the participant interviews took place in the time frame of March 30 to July 17, 2009 during working daytime hours. At the commencement of each face to face interview, the participant was greeted by the graduate student researcher and offered a comfortable place to sit. The discussion began with an explanation of the graduate student researcher's role in the study, being the primary researcher to collect and analyze data for this research as a partial fulfillment of a Masters of Arts degree from the University of Northern British Columbia. It was emphasized at this time that this researcher was in no way affiliated with WSBC and that every participant's data would be kept confidential. An explanation was provided for the necessity to audio record the interview and exactly what would happen with the data afterward, again any questions were addressed prior to beginning the interview. The participant was presented with the following: an information sheet about the study, informed consent to be signed, and a demographic questionnaire to complete, attached as Appendix B, C, and D. Any questions the participant had were answered while they were filling out the paperwork, or assistance was provided with the process as required. Discussion followed with an elaboration on the type of information hoped to be elicited by describing the format of the interview, that it would take an informal approach Vocational Rehabilitation Services 46 with very few structured questions. The official interview began by asking the participant to explain what their injury or illness was and how it occurred on the job. Most participants openly explained what their job entailed and how they were injured without any further prompting. Participants tended to go through their experience and describe it in a story like manner in chronological order. They started with the beginning and described their initial injury, their case manager, health care interventions they participated in, and eventually whether or not they could return to work. From that point the discussion of vocational rehabilitation began. The participants continued with their story although now with the VRC involvement. The stories ended with describing their current situation in terms of their vocational outcome, health and social status. At that point the participant had been given an opportunity to describe their story, their frustrations, and their success. The conversation was directed to evaluate both their experience with the initial health care recovery and their experience with vocational rehabilitation. They were asked to describe separately what they felt made the experience good during each of those times, what could have been better, and what they would change. The participant was given an opportunity to discuss any topics in further detail or introduce any new thoughts they may have had. Most of the participants took this as an opportunity to provide a brief summary of the conversation, highlighting the most important points to them, or introducing a thought they may have forgotten about. Following the interview, each participant was then provided with a fifty dollar honorarium in addition to fifty dollars to cover the expenses of the face to face interviews. The process of transcription was described and permission granted for further contact with the participant. They all agreed to read and discuss the content of the interviews with the graduate student researcher upon receiving them in the mail. Each participant's mailing Vocational Rehabilitation Services 47 address and contact information was then confirmed. Every participant was given a sincere expression of gratitude and was walked out of the meeting space. Interview Protocol The interviews were conducted with phenomenological methods within qualitative research interviewing as described by Kvale and Brinkmann (2009). The goal of this type of interviewing is described with the following; "this kind of interview seeks to obtain descriptions of the interviewees' lived world with respect to interpretation of the meaning of the described phenomena" (Kvale & Brinkmann, 2009, p. 27). The interviews were participant directed with very little structure in order to enable the injured workers to describe their experience using a phenomenological approach. The content of the interviews was guided by the conversation provided by the participants. If they introduced certain topic areas as being important to them, then probing for more details occurred, for example topics such as, psychological health, expectations, or barriers to employment. However, if the next participant did not discuss such topics then they were not introduced to that particular interview. One of the main goals of completing these interviews was to elicit the important information from each injured worker regarding their experience and what they felt was most significant to them. Attached in Appendix E is the interview protocol followed for each participant interview. Transcription and Data Storage Following the completion of each participant interview, the digital recording was uploaded to a laptop computer, assigned a participant number and saved in a secured format. A numerical identifier was allocated to each interview to establish and maintain anonymity of the participants. The digital file was then uploaded to the secure website for transcription Vocational Rehabilitation Services 48 to a text format. Once this was completed, each of the transcripts were retrieved by saving a file on a removable data storage device in addition to a copy on the laptop. The data was always secured by password protection on any digital media, or stored in a locked file cabinet, in a locked lab at UNBC which only the senior research supervisor and research assistants had access to. Data Analysis After all of the interviews were completed, uploaded and transcribed they were extensively reviewed for accuracy by initially reading each interview and correcting any typos. Once each transcript had been independently read, it was read again concurrently while listening to the audio recording of the interview to correct any further errors. Once each transcript was satisfactory, it was printed and a copy mailed through Canada Post to the participant for verification. Approximately two weeks elapsed before contacting the participant by telephone to ensure they agreed with the content of the transcribed interview, and to ensure they had no further amendments or additions to contribute to the study. Some participants requested additional time to review the transcript, and thus an appointment was made to contact that participant again. Few amendments were required to the transcripts and none that had any impact on the details of this study, although changes were promptly completed when necessary. One participant was unable to be contacted for verification as the telephone number was no longer in service and no new number or relative could be located in the local listings. The interview was included for analysis as it was relatively short and the graduate student researcher was confident in the accuracy of the transcript. Another participant's data was removed as after several interactions with the participant the result was a refusal to cooperate Vocational Rehabilitation Services 49 with the process of verification, thus ending of the participant-researcher relationship was required as the interactions were becoming non-productive. Once all of the transcripts had been verified, NVivo 8, was introduced to assist in maintaining organization during the data analysis period. Due to the sheer volume of data involved with 26 interviews lasting well over an hour, the software was found to be beneficial in keeping the codes organized and easily accessible. All of the transcripts were uploaded into the program and content coding began. Data driven coding was utilized for the analysis since this study was exploratory in nature and focused entirely on the responses of these particular participants (Kvale & Brinkmann, 2009). There were no concept codes created ahead of time in order to allow the themes to emerge from the data collected. Qualitative research methods involve a cyclical pattern of analysis rather than a linear step by step procedure to determine the results of a study. Therefore, ample amounts of time was spent 'living with' the data, reading and reviewing the transcripts, listening to the interviews, and moving through the development of a coding scheme to emerging themes. It was important that the student researcher gained an understanding of the essence of each participant's experience. Everyone had a story to tell that was equally important although often had different underlying meaning. To begin in the development of coding, each of the interviews was read again and separated into two content areas, everything related to vocational rehabilitation and everything else. From there, a small list of codes appeared important after reviewing each of the interviews in their entirety. The data designated as being related to the experience of vocational rehabilitation was reviewed extensively. These quotes were repeatedly read to further develop the coding scheme. When a more exhaustive list of codes was identified Vocational Rehabilitation Services 50 representing the experiences in VR, coding of the individual quotes began. Once that was complete, work continued with the codes separately to determine the underlying meaning and identify overlap in thoughts with the other codes. This process was moved through countless times, refining each of the codes until certainty was achieved. From these codes and the prolonged involvement with the transcripts, the themes emerged. To satisfy the rigor of the coding scheme, three of the interviews plus an additional section of the VR quotes were provided with the related content coding to each of two members the research team. These members independently reviewed the coding scheme and themes providing feedback to the graduate student researcher, thus triggering further ideas from an outside perspective to organize some of the data into detailed themes. Once these two members of the research team were satisfied with the coding scheme, an outside naive reviewer was utilized for the purpose of further confirming accurate phenomenon descriptions of two of the participant's experiences. She reviewed two transcripts and provided comments to the student researcher; additionally, she indicated that she would have coded the transcripts in a similar manner. Results Introduction This section presents the findings from analysis and synthesis of the data collected in this study. The process as described in the methods section involved transcription of the oral interviews and review of the text, followed by a cyclical process of evaluating and 'living with' the data. This process allowed the themes and subthemes of this study to emerge with clarity after a period of being immersed in the data. The central theme presented is that of interpersonal communication, with an additional six major themes following, each comprised Vocational Rehabilitation Services 51 of several factors. The remaining themes were namely, the human factor, expectations, reemployment considerations, psychological factors, injured workers identification of the strengths of vocational rehabilitation services, and lastly injured workers proposed improvements to vocational rehabilitation services. The themes are identified in this section as subtitles. Each is introduced with a few brief statements followed by one or multiple citations of the participant's quotes verbatim from the transcripts. This allows for the reader to better understand the lived experience as described in the interviews of the injured workers perspective of vocational rehabilitation provided by WSBC. The following section provides detailed discussions of each theme and subtheme indicating any deeper meanings and interpretations of the raw data. See table 3 for additional supporting quotations of minor themes not included in the results section. Theme 1: Interpersonal Communication Communication between the vocational rehabilitation consultant and worker. One of the main areas discussed during the participant interviews was communication with the VRC. It was a dichotomous subject area with the participants either being very pleased or dissatisfied with the level and quality of communication. Positive communication was discussed at length where the VRC was able to explain the situation and help the worker understand, or simply give an honest answer to a question. Many people described being listened to and having open communication with their VRC such as these quotes describe: I was being listened to... they listened to every single thing I had to say They sat down when they were making the plan it was, they looked at my ideas and they were honest if it wasn't feasible financially or whatever, they told me right, and I let people know to be honest with me, just be honest and they were. If it meant they said no, it was no. When they look into it, they Vocational Rehabilitation Services 52 looked into it. If it was yes, it was yes. They were straightforward. They were professional, very professional. The greatest areas of complaint involved not being listened to and not being informed throughout the process. Some participants said: Also disappointment where they won't listen to me Nobody was telling me I got a certain budget Everybody's very polite and professional and all, per se, but you know, really kept me in the dark 'til I finally found out... nobody exactly came out and said... no, it's like 'oh, you're gonna go over here' and on and on and, you know. Nobody's telling me why I'm going to go see this person... Several participants described the approach of their VRC as ineffective in assisting them, where they felt the communication was negative or simply insincere: I couldn't believe how many times I was yelled at by her It was the verbal, uh, part where, 'yes, we want to help you. Sure we'll we'll get you fixed up.' All the things that, you know, never did come to pass, but you know, that's, that's just rhetoric Communication surrounding decision making. During the planning stage when an injured worker enters VR entitlement the primary task is deciding what the worker's one rehabilitation plan will entail. During this time the worker and VRC brainstorm and decide options for each a recommended and alternate plan. Communication during these negotiations is of utmost importance so that both parties understand what the other is saying and can agree on the details of a plan. Many participants identified great communication during these negotiations, especially if they had an idea of what they were interested in: I came with a plan, though. I already had a plan in place, and I had everything we needed... she didn't really have to do too much, and she even said so herself that she didn't have to find me, like I guess it could come down to her forcing me into something else if I didn't make a decision Vocational Rehabilitation Services 53 Other participants identified communication during these tasks as difficult at times, feeling they did not have enough input into the process of deciding, for example, what retraining options to pursue: It would've been nice if I had had a little more input into whether I actually wanted to go into this program rather than they, uh, uh, consultant more or less tell me I had to go into it Communication is number one really and working together, not being pushed into things that you don't really want to do, you know Also, participants identified feeling coerced into a plan rather than having the freedom to suggest changes they may like: They're trying to force you into something, and there's no, I don't want to say recourse, but there's no information or guidance... their way or the highway kind of thing Worker understanding of policy and legislation. The injured workers expressed disappointment when they discussed WSBC law and policy. Many identified that they were unable to understand what their rights were during the process of VR, giving the impression that several of the participants felt helpless. Essentially the workers identified that they were unable to comprehend the policies quoted to them, and did not feel they could turn to anyone for help: I would go and fight for myself, but I could not figure it out, I gave up. Honest, English is not my first language and if was in Spanish then okay maybe... I don't have a university degree, but I am not stupid. To me it was too confusing and there is nothing much you can do. They have lawyers, they have doctors, they have this and they have that and you are just wasting your time and your money and all that so I gave up And I wasn't informed about my rights or anything what I can do or what I can say or how long it could last, or nothing. They never told me nothing You can go online and see, read all the million compensation laws, rules, and regulations.. .but, you know, you just get lost in the shuffle Vocational Rehabilitation Services 54 Communicating the end of entitlement to benefits. Participants had several different types of experiences regarding the end of their entitlement to benefits and the communication received stating this. A group of the participants recognized their entitlement was over at the end of their job search period and had clear communication indicating this: When my three months was over that was the end of that Another group of participants claim to have had their entitlement end immediately following a conversation with their VRC, multiple times throughout their VR services: That was in the morning when I had a WCB meeting in the afternoon, and uh, I phoned her and said I'm having to deal with my dad having cancer and I cancelled the meeting, and she said that my priorities were wrong, that my job came before my family, and cut me off all my money. I think two or three times she stopped all my money... because she didn't think I was working hard enough to find another job... because I phoned to cancel the meeting because of my dad I had one [initial meeting] and they cut me off. I remember like it was today. I said, basically, I want to get fit and go back to work then, and a couple of weeks later I got the last payment from them Another participant could not comment on the communication around the ending of her benefits, she said: It just sort of fizzled out and it kind of went away Implied negative messaging. Many participants indicated throughout their interview that they felt they were indirectly being accused of 'cheating the system'. Through both written and verbal communication participants stated they felt a negative attitude from the VRC regarding their return to work efforts. Some participants commented: I know there's a lot of people who abuse the system... but I wasn't Vocational Rehabilitation Services 55 But then they sent you a letter, and again you get, there's a tone in the letter that you're trying to get something that you're not entitled to Then they try to twist things around to make it look like a person is looking for an excuse not to work. Like a person has gotten too comfortable getting paid to do nothing. It's, it's it takes the meaning out of life Theme 2: The Human Factor Perceived treatment by the vocational rehabilitation consultant. Many of the injured workers that participated in the interview described instances of how their VRC treated them. Several workers described a situation of monitoring where they felt supported through their retraining but not hassled: Even when I was in school they would phone every once in a while and see how it was going, which I never heard of before, so it was good Many also described that they felt their VRC was invested in them personally and were working towards a positive outcome: He cared about me individually... I wasn't just another case to him He was great, he was at every meeting Others described an opposite experience of feeling disbelieved and without care: Could you imagine when a woman tells you that, a doctor could lie, he could say anything. Because I told her that I am not ready for work It just got worse, and finally she wouldn't even return my phone calls They were not interested in me at all Some more participants provided descriptions of when they felt disrespected with regard to their personal time: I showed up for my appointment, and that went for twenty minutes while I watched the case worker out in the hall having coffee with everybody Vocational Rehabilitation Services 56 I had to wait and sit on my rear end for four months while they got their crap together in vocational rehab, and then made a plan Different consultant. Some of the injured workers stated that they requested a different VRC to work on their return to work planning as they felt there was a personality conflict or difficulty communicating: I actually phoned and asked if they could switch me to a different counselor, somebody who has got some kind of vision [for my future] Others speculated on whether they felt they may have had a different experience with another worker. Many agreed their outcome or experience may have been quite different, although others felt the policy was firm and thus a different staff member would only have been a different personality: I'm sure if I had somebody else that had a bit of compassion, it would' ve been dealt with differently [My] experience would probably be different, ya. You know, could have tried more things or not been so biased and judgmental and all that. I know I couldn't have worked, I still can't work Feeling apart of the process. Responses to the query of 'did you feel a part of the process' were also dichotomous. Participants felt their vocational rehabilitation consultant acted as a partner with them providing support and guidance through VR, or they did not. Typical responses were such as these: Yes. Oh, very much. I kind of led the process I wasn't a part of it at all. Um, I, I, actually, I had no clue what I was supposed to do I wasn't a part of the process, no. Not, not, I didn't feel like it. Maybe I was, but I didn't feel like it Vocational Rehabilitation Services 57 Support from WorkSafeBC staff. When the issue of feeling supported was raised by the participants, most identified their VRC as being supportive of their efforts. They describe being provided with a large amount of support for all of their issues related to returning to work. Some of these comments include: They were more than just a little bit... a little bit supportive. They were hugely supportive in my efforts Once we had a plan, she was so supportive However, there were also few reports of an opposite nature: Basically I was left on my own It kind of irked me because they weren't... 'we are here to support you... we are here to help.' How are you helping me, making me do it. I appreciate that you see my need for that independence, but that doesn't mean I don't need support. That irked me, it really did Feeling pushed off the desk. A sentiment that was replicated continuously throughout the interviews was an overwhelming feeling of being pushed off the desk. The participants often felt the VRCs did not have enough time and wanted to get their claim 'off the desk' so they could move onto other work. Many described feeling the VRC wanted to move them through the program as quickly as possible and thus did not care about them as individuals: I think she just wanted it off her desk personally They don't give a damn what happens to your life, or your family, or any aspect of you once they can throw you off the desk She just wanted to write me off as soon as she could, I think, you know what I mean, like get this one over and done with as fast as she could kind of thing Vocational Rehabilitation Services 58 Holistic individual. Discrepancies were noted between the way in which injured workers and VRCs considered the participant's disability. VRCs were noted to contemplate only working time and job demands in relation to the disability, where the injured workers were often focused on the impact the disability made on their entire life. The participants discussed the loss they suffered in their personal life in addition to their occupational goals. Many described situations where they were seeking the VRC to view them as a person in their entirety, rather than simply an employee that does certain tasks. Comments made regarding these issues were: They're looking just at, what, what you can do at your work, but, you know what? Basically, I found it hard to get another job because my whole life was impacted. It wasn't just... losing my job, it was losing everything All because the person that was there to try to fit, fit me in a job that I could do, was not really seeing the whole picture. And, feeling that they were not responsible for the other aspect... Like a learning disability, and the other difficulties.. .They can't be thrust aside because it's something that a person, I couldn't thrust aside... I have to deal with it Theme 3: Expectations Expectations of WorkSafeBC. Participants that were unsatisfied with their experience with vocational rehabilitation expressed that the experience did not meet their expectations of what they thought WSBC would provide: Very unsatisfied I was with them, very. I was expecting something more, you know, from an outfit like that Alternatively, there were situations where the participants were expecting to have difficult interactions because of what others in their life had told them. Although, often they did not share these types of experiences and were pleasantly surprised: Vocational Rehabilitation Services To me none of that happened. I didn't have to prove myself, anything to them. They did their job well. That's all I can say.. .right from the get go it was good. I enjoyed the whole experience. It was refreshing actually Process expectations. Expectations about what will happen within the VR program shapes a person's experience of that program as either their expectations will be met or they will not. The participants in this study held many expectations of their vocational rehabilitation experience, including ideas surrounding the level of involvement they would have with regards to decision making, and the amount of personal attention necessary: I should be part of this plan. I should be able to say this doesn't work for me They should have paid more attention to me, and maybe get some work that I... and I was expecting more from them Several of the participants expected the VRC to provide them with detailed directions and advice on what job options they may be suitable for: .. .then she couldn't advise me which training course to take I said, 'it's your job to evaluate me and tell me what you feel I'm suited to do for the rest of my life... that is your job' Many other participants held strong expectations that the VRC would provide assistance through the job search period: I think if they're really serious about people going out and getting a job, that there should be some help I expected them to give me the occasional job lead, direct me in some way, shape, or form. Was it an unrealistic expectation? No, I don't think so 59 Vocational Rehabilitation Services 60 Outcome expectations. Participants felt they may have had different expectations of their outcome situation than the VRC, including exactly what job options would be possible at the completion of retraining: And that was probably the most disappointing part. I felt, well especially when they kept saying, well now, you know, now we've done this you'll be able to get back your earning power. And it was like, uh, what world are you living in? Um, I mean, theoretically it would be possible. They were able to find jobs that were posted that, uh, paid almost as much as I was making. But, um, not ones that anybody was willing to hire me with a business certificate... and without any... [experience] The participants often simply had different ideas about what would be at the end of the vocational rehabilitation experience. Their expectations were often not aligned with reality of what the program could offer: Train people to go to university, or get a decent job at the end of the, you know. Like I say, for me, I would've went on to BCIT, took my apprenticeship and all that.. .but at the end of the day, when you, when you see, and they're trying to slide you off as, as a security guard, you know... to me, it's just a total insult Financial expectations. Of the participants that were retrained many were surprised about the amount of money provided towards the retraining in addition to wage loss payments. Statements were made regarding the ability of WSBC to approve large sums of money in addition to outside resources such as tutors and supplies: .. .tuition, that is an awful lot of money. And for them to just kind of sign off on that and say, 'fine,' ... and then there's also, I mean, they're still paying me at that point, like wages.. .as well, and things like that, right through it all Other participants felt additional training money was not made available to them when they expected it should have been: Vocational Rehabilitation Services 61 I asked if there was any money for training. She said I'd paid for my education all along and I need to keep on paying for it, that there was no money to train me for a job Theme 4: Re-employment Considerations Barriers to employment. The participants identified many different areas that they considered to be barriers to obtaining successful employment. One of the most commonly cited barriers was age: I'm fifty-six years of age now, and I'm not, I don't have that much time left to, to, to get into an entry level job and work my way up If I am retrained where I am going to go at 65? Nobody is going to hire me no matter what kind of health you're in Another commonly referenced barrier was restrictions in physical ability: How can I start a new job when I only can work one or two hours. If I worked eight hours one day because I can try, what happened if I had to be off two days, are you going to hire me in your company like that? I don't think so Other identified barriers included living in remote locations or small communities as there are less potential employers, having an extended gap in work history, and the injured work stigma: I had a full resume, and then all of the sudden it was -nothing... Oh, I was on stress leave. 'Well, okay and you want to be a manger, oh'... And I could understand their point of view Well, soon as I said I was on, uh, WCB, they didn't want nothing to do with me... and they said, uh, 'we don't hire people that are injured... or recovering, because, in case something else happens to them on our premises' Decision making and options. Many of the participants had difficulty making decisions about future career options. Some participants felt they were given an opportunity to explore their options and make decisions following: Vocational Rehabilitation Services 62 We kind of talked about it and ultimately they agreed to continue to pay me for two or three months while I was down there to check these things out and hopefully ultimately get work in doing those sort of things Some participants requested vocational assessments, and others had ideas that they wanted help exploring: I couldn't understand why I couldn't even get, you know, one of those assessment jobs that helps you identify your strengths, or what kind of job you could get into? They wouldn't look into what I was interested in before I got hurt. Um, it just, I don't know, really, it's just the whole thing has been frustrating... but they wouldn't even look into it for me or help me out A portion of the participants felt they were pushed in a direction they did not want: No it wasn't going to happen, they had me already signed up and this is the program, you are going to follow it... hold on, this is supposed to be my choice, but no, it was never my choice Retraining. The majority of the participants that went through course work spoke fondly of their retraining period: I got my certificate and got an award for top mark in the program... Um, really the most positive of it was the actual me being at school If there were difficulties the WSBC staff addressed them in a timely manner in order to set the participants up for a successful experience: I phoned [my VRC] in Compensation who was in charge of this, and I said 'this is, this is a joke. You get me outta here.' So, then I was sent to SprottShaw Several of the participants reported struggling through their retraining because of their physical disability. Some also reported struggling cognitively as they perceived retraining to be difficult due to the amount of time they had been away from school. Even though these Vocational Rehabilitation Services 63 types of experiences were reported, these participants still referred to their training as a positive experience: So I went onto the computer and the bookkeeping drove me nuts but I finally just barely passed on the second time once I kind of understood the concept... I enjoyed the interaction in college. I enjoyed hanging out being a student again that was kind of cool, I enjoyed meeting people. I enjoyed the computer training, it was really cool Pre-injury employer. When discussing the relationship with the participants' previous employer the sentiment was often frustration. These injured workers had a strong desire to return to their job site where things were familiar, although many employers were unable to accommodate the workers in an appropriate manner. The VRC's were noted to have made a great effort in attempting to work with the pre-injury employers as well as the efforts to help the worker understand their options: He [the employer] wasn't willing to entertain any idea of me doing anything, even office work... He [the VRC] was great. He was at every meeting. In fact, my employer disallowed him to come to meetings that we had And so basically, it was [the VRC] that came out and said, you know, like you'll never go back there. They've already made that decision. So at least she was helpful to make me understand that, you know, because I thought I still had a chance to go back to my employer Job search. A job search period was provided to many of the participants where they were required to apply for approximately five jobs each day for a period lasting about three months. During this time the injured workers were continually provided with their wage loss benefits in order to allow them the necessary time to secure a job. Many of the participants commented that they felt having to apply with five employers a day was too much. Some participants felt limited either by the small community they live in as there was not a large Vocational Rehabilitation Services number of employers, or the fact that there are only so many jobs available in certain occupations: .. .then I have to go to five companies a day and said I was here, here, and they have to sign. I felt a little stupid, I told him go five places, there are [only] so many places I can work, I am not going to just go and do this and that... I believe that it is a little bit too much, five places you have to go every day, plus that costs money too, driving here and there Yeah, she would know that there isn't that many contractors in Qualicum that I could contact for four months, twenty a week, Ah, ridiculous, ridiculous, twenty a week for four months It was noted that a number of the participants referenced their job search period in terms of having to complete the task of dropping off resumes or face the consequence of not being paid. This attitude was framed negatively towards the process rather than viewing it as an opportunity: I gave a list of places that I had put applications in and stuff. Until I did that she wouldn't send me my cheque kind of thing, yeah I did that for the whole three months I had to have five interviews a day, it was crazy, 35 a week so that I could get paid, that is stupid Other participants discussed the difficulty they had finding employment during their job search period due to physical limitations: I found doing all these interviews, people are quite interested in you, basically because of the way I spoke, I suppose, before they ever met me. And, then you get to the interview, and you can almost see the change in their face... And, they're mostly pretty good at saying, 'well, yes, we're an equal opportunity employer,' but I do have some physical issues for any job now, unfortunately. And, I always got the same thing, 'well, when we finish the interviews, we'll, we'll call you again.' Job placements. Several of the participants entered into job placements or 'training on the job' with local businesses. This program is one in which WSBC and the potential employer split the 64 Vocational Rehabilitation Services 65 injured workers wages for a time in order for the worker to learn a new job. Unfortunately, only one of the participants in this study had a successful outcome in their job placement(s). Some of the participants believe there were businesses that took advantage of injured workers by only obtaining them for a short time at a low wage: The guy was just using me. They were behind in their, their inventory, so they brought me in there and, you know, I, I could just see that place was just a, you know, like they were just using me again, right, for cheap labor. So at the end of that, like, once again I got laid off. In other situations the participants were simply unable to complete the demands of the job: In one month I worked maybe two weeks out of the month because I couldn't hack it Return to work. The participants described the return to work experiences as that of trial and error working and making adjustments in order to identify a successful situation. Some of the return to work attempts resulted in safe and durable positions whereas others were not able to make accommodations successful, mainly because of physical limitations or pain. One injured worker described his experience: So, then later on, I wasn't turning any switches. So, I was just doing the job that I was able to do within my, within my physical reach. And, they had somebody else doing the other stuff... In the end, all the kinks did get ironed out Socioeconomic status equivalence. During the planning stage of VR participants expressed concern about being required to search for and accept jobs that were not equivalent in pay as their previous employment: So I said 'you want me to go out there and try and get jobs... you want me to go take a job for fourteen bucks an hour when normally I, I make thirty-five with benefits' I, I said, 'how does that compute?' Vocational Rehabilitation Services 66 There were equal concerns regarding the financial implications of having to accept jobs that were a distance away from the participant's home and either having to run two households or having the increased cost of commuting: They wanted me to, uh, move to Victoria and come on the weekends... not even commute because the job was too far for me, so they thought I could get an apartment and just go home on the weekend. Wasn't going to happen. And I'm thinking, for a $12 an hour job, and it's going to cost me $2000 a month to live in Victoria... what's the point? .. .when it cost me thirty a day just to drive to Crofton and back Social support. Lack of social support was identified quickly in the interviews by those participants that had little outside supports to rely on: I didn't have anybody in the background saying hey this is wrong, this not how it should be dealt with you know, by myself, alone and dealing with the system is hard Many recommended implementing some type of support system to aid workers through the WSBC recovery process. These participants did not seem aware of the existing Workers Advocate groups or their functions: .. .if they have a group that can support them, like advocacy, like you said, things would be different. You are dealing with a person one on one and she is more educated as to what the laws were for how to deal with cases and you don't know... Those that stated they had social supports most often discussed the role of their partner, occupational rehabilitation program, or union: I feel that I only had a good experience because I had a team of people that helped me, and that was from occupational rehab. So you don't just go in there and do exercises I have a good understanding wife And my union was there, and they're trying to help too Vocational Rehabilitation Services 67 Theme 5: Psychological Factors Depression. When a person suffers a serious injury resulting in a physical change of function the potential impacts of that experience are almost limitless. One impact identified across the participants was the effects of injury on mental health. Depression was acknowledged as one of the key changes that occurred psychologically going through recovery and vocational rehabilitation. Participants commented: Then I went into a huge depression, like terrible depression, to the point where I wanted to kill myself. I was so depressed, because I wasn't working. And I loved my job, and I loved all the people I worked with There is a bit of depression there obviously because it changes your whole lifestyle right I was very depressed, that was a disheartening experience being involved Misunderstanding presentation. Traumatic and serious injuries result in people utilizing many different coping mechanisms to deal with reality. Often people display a range of emotional states, for example anger, pain, resentment, regret, or hopeful optimism during the course of their recovery. When workers enter the VR stage of the process, the physical healing has reached plateau yet workers are not necessarily in the same place emotionally. Injured workers may utilize different coping mechanisms they found useful during their experience, which may be misunderstood by others. One gentleman described his experience: Sorry, I try to use humor to deal with it... with a lot of the stuff I've gone through and still going through. I try to use humor and my workers, they think oh I'm all better because I can joke about it or make a joke or whatever. But they can't understand, I don't know why... they can't understand why, that's the way a lot of people deal with it Vocational Rehabilitation Services 68 Another worker expressed his frustrations regarding appearing healthy and upbeat, although feeling tormented inside and frustrated with his inability to work: They seen me I am too full of energy in my face and they think the face doesn't work... it is me that works... it is my brain. If the brain doesn't work properly, it is sad, mad, all that stuff, like I said, everything is coming against me, but they didn't want to help me out Needfor counseling. Participants broached the topic of counseling either because a psychological component was involved with their injury or because they were having difficulty coping. It became clear that these workers were interested in participating in some form of counseling to help them through this difficult time in their life. Many workers that go through VR have permanent disabilities along with permanent limitations and restrictions affecting their functional capacity and changing their ability to complete certain job demands. The participants in this study found this to be difficult to address without the help of a professional. Some participants associated the need for counseling with being depressed because of their circumstances: my life changed and that is depressing. Your friendships are changed because I can't go with you when you want to go on a bike or you want to go hiking, I can't go with you Others discussed the emotional healing process and the need to help people address it: Mental health, it needed way more as far as I was concerned. The soft tissue, like all of the people said at the rehabilitation program, would heal. And you know what? They're right, it healed. But it's your brain that you.. .yeah. It messed me up for awhile. And it took a long time before I could really talk about it. And then I started to blame myself Others yet requested counseling and were denied: I did call and ask for a counselor and was told that there wasn't anything, anything... any type of counseling that I could get. I would have to pay for it myself... And I think if your permanently disabled, you need it actually Vocational Rehabilitation Services 69 before you go look for a job.. .because you have to deal with the fact that you're not going back to your old job... and your whole life has changed Psychological effects of injury. Several of the participants in this study were diagnosed with post traumatic stress disorder (PTSD) either as a component of their injury or as the main accepted illness and reason for the claim. Those with a main diagnosis of PTSD worked on therapy provided by WSBC to help minimize the impact of the symptoms on their potential job opportunities as well as daily life. Other workers that experienced a serious or traumatic injury identified psychological effects and may or may not have been offered any psychological assistance. One gentleman describes the clear impact of his injury on his ability to return to work: another circumstance is psychological, I cannot come back to my job... they did not look at that, like I said, my job, I don't want to come back... there is no way I could do it. Even if they gave me a million dollars a month I would not do it Another participant describes how desensitization therapy was never completed as the preinjury employer refused to have the worker back on the job site: did I get the therapy that I needed, no I never completed it and it bothers me because now I can't do it... because I couldn't complete the treatment, why, because they stopped me in the middle of it Theme 6: Injured Workers Identification of Strengths of Vocational Rehabilitation Services Communication. The focus of much of the conversation relating to strengths of the VR program was communication. Specifically, the participants described situations where the VRC was able to explain and help them understand aspects of their claim and the direction they needed to look: she was able to, you know, say like you can't do this, you can't do that. This is your slice of the pie. She was able to demographically break it down to, you Vocational Rehabilitation Services 70 know, what I would be looking for and, you know, and it sort of worked and that's how I found the security company. [The VRC] came out and said, you know, like you'll never go back there. They've already made that decision. So at least she was helpful to make me understand that... you know, because I thought I still had a chance to go back to my employer Support from the vocational rehabilitation program. Being provided with the necessary support to aid the workers through the difficult transition of occupations was another common strength reported for VR services. Support was described in a few ways such as directly from the VRC, having a smooth experience, indirectly from the VRC simply by being kind, and having the opportunity to be retrained. Some of the participants stated: They were hugely supportive in my efforts It's a pretty good ... It's set up pretty well. It really is. Um, the way it is right now. I mean, j u s t . . . just the ... just being able to, to uh, to go to college and, and do retraining and have an organization pay for it, pay your living expenses and things like that is great. They were just kind to me Maintaining focus on return to work. Another aspect that contributed to participants positive experiences was maintaining a solution focused outlook on the process. The participants wanted to obtain the end result of returning to work and were pleased at the attempts made to progress in that direction. Some comments included: Excellent, and we made it happen fast. he also said we are going to do this, and the next step you are going to do this, so I can do that, so we can together in the hospital. So many times like this kind of a situation right it was good because number one they got me to where I was going Vocational Rehabilitation Services 71 Progress towards identified goals or positive outcomes . Many of the participants were pleased with the VRC's ability to get things moving along in vocational rehabilitation. The VRC has maintained relationships with certain service providers and thus is able to make requests of them. In addition the VRC has the skills and knowledge to push forward when there appear to be roadblocks in the workers progress towards return to work. This identified strength was related to power by the participants in that the VRC had the power to persuade service providers where the average person does not. This was similar to the ability to have health care treatments expedited by WSBC. The statements provided by the participant interviews around this topic were: And so then [the VRC] phoned me and said, why aren't you at work? And I said because I can't work because I don't have my certificate from the Justice Institute. So she phoned them and asked them why and then called me back and said, you call them again and tell them you want it. So I phoned them back and said I wanted it and because she had already called, within three days it was in the mail.... So she, you know, she was able to get things moving along, right. ... He figured it out. Like, he's been ... obviously been around a long time, and, uh, he came in. And, like I say, "We'll start dealing with the Union." And, that was very positive with him. It was very, very positive Retraining and education. Lastly, some of the participants described the most positive of their experience was having been retrained and their time at the educational institutions: really the most positive of it was the actual me being at school I enjoyed the interaction in college. I enjoyed hanging out being a student again that was kind of cool. Theme 7: Injured Workers Proposed Improvements to Vocational Rehabilitation Services Vocational Rehabilitation Services 72 Communication. Many comments were made directly and indirectly regarding improving the communication between WSBC staff and injured workers. Specifically, the injured workers want to be listened to, they stated: Have workers that would actually listen to you Listen to me, just take me to one side and say, 'okay, you know, we want to get you back to work. How can we do it?' Other workers also requested they have more input during communication about what vocational rehabilitation services the worker will be involved with: It would have been a lot more positive experience if I had some input into it More input from the, from the injured worker... about the direction that, that they're, that rehabilitation takes Lastly, workers made suggestions regarding the explanation of information. They want to have a clear understanding of what is coming next and what all the options are in their case: I would just say that, that the options of letting a person know what their options are in regards to retraining. Um, you know, be more explanatory But, there was no brochures given out. That's the big thing. Why didn't they give a brochure out. 'There are our policies. This is, this is what we can do, you know. These are the options you have in vocational rehab.' There's no literature on that, nothing... There's lots of literature, I mean, if you, say, you go out on a ferry, there's tons of literature to go to some resort. When you go to WCB, there's no literature, there's nothing. So, you don't even know what your options are. There should be a package put together, some kind of package, or, you know. And then, then you go see the counselor, right? Vocational rehabilitation consultant knowledge and approach. An improvement that was mentioned by the workers was the approach of the vocational rehabilitation consultants. The word compassion appeared often within the transcripts of the interviews. Some workers stated: Vocational Rehabilitation Services 73 Just having compassion, like real compassion.. .if you really felt like somebody really honestly wanted to know how you were doing... but somebody who is actually listening to what you are saying and can understand your frustration and you stress... it would be so nice Have somebody that actually cares about the client instead of treating them like a number It would have made a difference if WCB had said, we're really sorry this happened to you Another improvement suggested to enhance the injured worker's experience was to increase the VRC's knowledge of the jobs the injured workers are participating in. Comments such as these were made: I think a lot of these people that work for WCB should be taken out to these different job sites and do a bit of job training to see exactly what people go through. Because, they don't really know. They're, they're listening to what you say with, unless they've been there and experienced things for a few weeks, they, they don't really have a clue... They'd have more knowledge. They'd know how to deal with it, and they'd realize exactly what they're going through .. .they have not enough experience from the working process that they offer to people. When they, let's say they offer a job as a security or in the insurance business, they have not enough experience with what's going on there. They can't transmit it to the people.. .this here, these people are just simple people when we show up, and we have to transmit a job to these people Counseling and post traumatic stress disorder. To expand upon the comments made regarding the need for counseling, participants directly stated that an improvement to the vocational rehabilitation services would be the offer of counseling to injured workers that require it. Much energy is put into healing the physical aspects of an injury where the psychological components are largely ignored: Psychologically there should be certain psychological counseling Mentally and physically, you know because it damages you mentally quite a bit. I mean it just upsets you, everything does.. .yeah and if you don't have Vocational Rehabilitation Services 74 anybody to communicate with on that, then you have to deal with it on you own really. Nobody wants to listen to you being negative about everything all the time anyway They could do more for depression because it is very, very, very bad Outcome improvements. What the participants stated for improvements to the outcome of cases was quite varied. Essentially, they all simply wanted to have a job at the end of their journey with WorkSafeBC, and provided thoughts for improvements that would have helped them attain that goal. Some of the comments made centered around providing more time and with that time it should be spent exploring job options to gain a better understanding of what different vocations do: The program is only so long. You only have so much time... to find something and move on. And it could be longer So that there was a little more time to, to really try and figure out, maybe even go out and check out maybe some, you know, on the job type of... 'oh, all right. That is what a newspaper person does... oh, I don't want to do that.' I think that would be a huge, uh, actually, an improvement. Something that could be improved is that somebody that, that is going to go into some sort of retraining of any kind should know what they're being, what, what, what's at the end of it. What they are going to be doing, you know... Go out and have a look at, at worksites, and things like that Other suggestions included providing more vocational assessments, and providing more help to job search: I think that if they gave assessments to people, because I came in, I was so traumatized by not going back to work that I needed somebody to sit down and go, okay, these are the things you can do But the biggest thing that I would have wanted to see differently, actually, was when they say, okay, well here we give you this training. Now you need to get a job. And then just let me go and leave it at that. Personally, I think if they're really serious about people going out and getting a job, that there should be some help, maybe an incentive to the employer to get things started Vocational Rehabilitation Services 75 or at least them, you know, doing some, uh, doing something to help you [get] working Discussion Interpersonal Communication In total seven major themes emerged from the data, each comprised of many factors. The first major theme that related to several of the other themes was interpersonal communication. Communication between the VRC and injured worker impacted almost all aspects of the working relationship. The factors comprising this section included communication between the VRC and worker, communication surrounding decision making, worker understanding of policy and legislation, communicating the end of entitlement to benefits, and implied negative messaging. The ability to communicate between the VRC and worker was central to the perception the injured worker held of their experience. This was a dichotomous theme in which the perception of communication during the interactions was open and clear or it was elusive and vague. This communication pattern ultimately affected the worker's understanding of potential options and therefore, their return to work outcomes. If the worker perceived there to be a problem communicating with their VRC then an element of distrust formed; they questioned the process and the decisions being made. Many of the participants noted that they would like to be informed throughout the entire process. Workers simply wanted to know the steps they were required to progress through in the claim. They also indicated they wanted information on such things as budgetary considerations and all the options that were available to them. The workers wanted to feel like they had a voice and they wanted to feel as though they were being heard. They wanted to be able to share their thoughts and concerns to a welcoming ear that would Vocational Rehabilitation Services 76 assist them to understand the process. Finally, the participants wanted to see promises of action followed through. Participants also spoke about having 'input' when making decisions and they wanted their values and opinions to be heard and taken into consideration. No one wants to be forced into an occupation they do not feel passionately about or, at a minimum, have positive feelings toward. These concerns were largely tied to the injured worker's understanding of WSBC policy and legislation. Many did not know their rights and so were unsure as to their role in the decision making process. Often the participants discussed their feelings of uncertainty and disappointment with regard to understanding the policies. They stated that quoting policy to them in letters was useless information as it provided no understanding or context to the meaning of the quotes. Some also talked about trying to create an understanding by learning through the literature on the WSBC website or deciphering the letters, although most said their efforts were fruitless. Communication was also discussed with regard to certain events such as the end of entitlement to benefits. When the workers discussed being 'cut off there was quite often a negative connotation attached to that event, as the communication surrounding it was not perceived to be clear by the worker. At times they simply did not understand why their benefits were ended or clearly disagreed with that decision. Some participants attributed the end of their benefits to something they said during a conversation with the VRC, but then did not understand the impact of their comments. Communication is complicated by the context of whether the person was provided all the benefits they were entitled to, or whether they were 'cut off in the midst of their program and felt they were entitled to receive more from WSBC. Vocational Rehabilitation Services 77 Additionally, the participants indicated a deep impact from implied negative messaging where the participants felt accused of cheating the system or malingering by the VRC. These were perceptions rather than outright accusations and thus again are part of the greater level of communication between the VRC and worker. The better the communication patterns, the less likely the worker was to experience these types of messages. The Human Factor The human factor is the theme that involved elements of injured workers' perceptions regarding interactions with a VRC. It encompasses all aspects of human interactions between the VRC and worker, beyond communication. The subthemes that emerged were perceived treatment by the VRC, different consultant, feeling a part of the process, support from WSBC, being pushed off the desk, and holistic individual. Treatment by the VRC occurred along a spectrum in that the participants seemed to have a tremendous variation in experiences from wonderful, caring VRCs to descriptions of the opposite. Personal preferences for interactions would have an effect on how the worker responds to a certain approach by a given VRC. For example, certain participants preferred to be given more space and thus required less contact with some caring overtures by the VRC. Others preferred more frequent contact and caring overtures from the VRC. These individual preferences would have an impact on the development of the working relationship between the two parties. Those participants that had developed a poor relationship with their VRC frequently requested a new worker. Most felt if they could connect with another VRC, communication and collaboration would increase thus resulting in a more favorable outcome for them and thus a different experience. These participants recognized that there is a level of subjectivity Vocational Rehabilitation Services 78 to the events in VR and thus believed that if they had a better relationship with their VRC their experience would have been dissimilar. The workers seemed to think if a good working relationship can be developed with the VRC, they potentially may become more invested in the worker and then 'push harder' in the worker's favor. This potentially would result in increased expenditures, better arguments for retraining, or a more involved job search with a greater level of assistance. However, to mediate all of these concerns and reduce worker's requests to change VRCs, WSBC could provide workers with detailed information about legislation and policy with respect to its impact on decision making. If workers understand what is possible in their case, in other words what they are entitled to in VR, it may reduce the desire to 'VRC shop' to obtain the best personal outcomes. This may also provide the impression of standardization of entitlements. When a worker reported feeling a part of the process, they generally also felt supported by WSBC staff and the VRC in particular. Participants also identified the difference between talking about being supportive and showing support to the injured workers. The VRCs that did not follow through on their statements made the injured workers feel as though they were simply being paid lip service, which further eroded the working relationship. However, reports of sincere support were plentiful and appreciated by the participants. Another area of contention in the human factor was workers feeling "pushed off the desk". The reports of workers having felt this were numerous and heartfelt in that the workers were then given the impression that their life did not matter as much as the case load of the VRC. Participants in this study, and arguably most workers, organize their life around their occupation and working hours. When the VRC was not focused on providing them Vocational Rehabilitation Services 79 with a favorable outcome of RTW, by engaging in such behaviors as rushing through the process or not providing as much attention as required, then workers felt they were not cared for and did not matter. They wanted to feel that getting back to work was as important to the VRC as it was to them, and when workers felt pushed off the desk, they were not experiencing this level of service. Lastly, being viewed as a holistic individual was another area the participants demonstrated they would prefer. Few reports were made of being treated as an individual with a unique life and circumstances. Additionally, most of the participants felt they were being forced into a mold that did not fit them. The workers did not want to be treated the same as the next injured worker, as they felt their circumstance differed and was unique with each person. Introducing the concept of the biopsychosocial model to VRCs may aide with this area of difficulty for the injured workers. As well, the workers described that the VRC only focused on the participant's eight hours at work each day. The injured workers felt the remaining sixteen hours of the day were just as important, as their workplace injury impacted all aspects of the worker's life. All of the subthemes in the human factor theme were somewhat related, because if the worker felt they were treated well by the VRC then they felt a part of the process, were provided a high level of support, and were treated as a unique individual with unique circumstances and desires. The opposite was true if they felt they were treated poorly by the VRC, then they felt pushed off the desk, and that a different VRC would have resulted in better outcomes for them. Vocational Rehabilitation Services 80 Expectations Participants held many expectations of WSBC prior to entering VR services and prior to ever filing a claim. Generally, people tend to create constructs of reality, and therefore these participants created constructs in their mind about what WSBC is and what it would do for them in the event of an injury at work. One of the issues with having certain expectations of an organization and then participating first hand is that often reality does not match the preconceived expectations. If this experience is deemed negative, then the result is disappointment. The participants in this study held certain expectations of WSBC in general, and most often their experience did not match their expectation. The participants that were expecting more from their experience were disappointed, and those that were expecting difficulties and did not come across them were satisfied. WSBC has an image in the general population that is deep rooted from decades of settling workplace injury claims. This image could be described as causing workers difficulties when filing a claim, and generally not providing the extent of services that may be required. However, there is also another image with workers that have been through the WSBC experience and were completely satisfied with the level of service. As the history in any customer service based business proves, there will always be a certain number of satisfied customers, as well a certain number of customers that are unsatisfied. Also true, is that both of these types of customers are vocal to their friends and family about their experience. The focus on customer service within WSBC may not have been as prominent in the past as it is today. This sentiment has followed WSBC, with many workers today hesitant on the type of treatment to expect when filing a claim. This hesitancy is a cause for concern as many workers enter the WSBC experience uncertain of what to expect. Vocational Rehabilitation Services 81 A common misconception found in this study was that workers entering VR services expect to be provided with extensive retraining in order to return to work. Many workers did not understand the differing levels of entitlement to vocational rehabilitation services. If the worker was provided only with a period of time for job searching, their expectations often were not met, as most people tended to expect a college education. These expectations were also directly linked to the level and quality of communication between the worker and VRC. If at the commencement of VR services, the VRC took the time to explain what the worker should expect from their experience, the worker may not agree, but they would have outcome expectations aligned with the VRC. For example, if a minimum wage earner was sent to VR services with a minor injury that precluded them from completing the demands of their job, they likely would be able to restore their earnings with an accommodation with the current employer, or a job search focused on other abilities the worker has. Typically, there are many different types of jobs offering minimum wage compensation. However, if this same worker came to VR with the expectation of being sent to college for retraining, they would be disappointed when they are given three months to find a new appropriate job. If the VRC takes the time at the beginning of the referral to explain what the workers entitlement is, the worker may not like what they hear, but will then be provided with an accurate representation of the services they are likely to receive, bringing their expectations closer to the reality of the situation and potentially boosting satisfaction with the experience once complete. Worker's expectations were an important factor to how their perceived experience ended. Taking the time to manage the workers' expectations may result in increased numbers of workers being satisfied with their experience, as well as providing an opportunity for goal focused communication. Vocational Rehabilitation Services 82 Re-employment Considerations The re-employment considerations theme is dense with information provided by the workers, starting with barriers to employment. Decision making and options was a factor that developed from participants' struggle with determining the direction their VR program would take. Many felt that they were provided enough time and support to explore the options and make a decision in conjunction with the VRC, and others wanted more tools to help develop some ideas. This is another area where approach of the VRC made a difference in the experience of the participant, whether they felt supported or pushed. Those participants that were sponsored for retraining had very positive experiences attributable to the support provided by the VRC and the program. Most participants felt fortunate to be provided with a high level of financial assistance. Additionally, participants were pleased when the VRC ensured potential downfalls were addressed early, by providing additional courses as necessary, or such things as tutors and supplies. The job search period was a time of much contention for many of the workers and their vocational rehabilitation consultant. Having the requirement of contacting five employers a day for the goal of locating suitable employment was found to be excessive by some workers for various reasons. This may be partially due to misunderstanding by the workers. Some were not able to articulate how they were required to make contact with potential employers, and others portrayed that they were required to have five 'interviews' a day. Having interviews and dropping off resumes with mangers are very different vocational activities. Language barriers and communication with the VRC is pertinent in this discussion as miscommunication most likely resulted in confusion for the workers, followed by resentment of the VRC for requiring an unattainable goal. Vocational Rehabilitation Services 83 Most of the participants simply completed the task of contacting employers in order to receive payment throughout the job search period. It was often discussed in terms of a requirement in order to be paid. This is unfortunate, as these workers were provided an opportunity to be paid while looking for a new job. It afforded them the opportunity to be selective and methodical in their approach to finding a new job, rather than desperate and rushed. Time is a necessity for injured workers, as locating a match in the employment situation can be difficult depending on the injury, limitations, and restrictions that a worker must accommodate in a working situation. Perhaps the workers were simply displaying their emotions of frustration toward the job search, as many times their efforts were not rewarded and a suitable employment situation was not found in the time allotted. As a vocational tool, job placements offer the worker another alternative to formal training, in that they enable workers to spend time on the job learning and improving their skills. A job placement also allows the employment relationship to develop over time so that both the worker and employer feel comfortable with the worker's performance on the job. In order for training on the job to be successful, the right employers must be located, and this is where the experiences of the participants were generally not positive. Certain participants felt they were being used rather than developing an employment relationship, as they were laid off several times by different employers after a certain amount of work was completed. Avoiding this outcome is preferable, although difficult to predict. The VRC can never truly be sure of the intentions of any employer until they have had some experience with them in this capacity. Return to work situations were successful for many of the participants in this study. They were not always successful on the first attempt; however, if the stakeholders involved Vocational Rehabilitation Services 84 remained flexible then adjustments could be made to improve the chances of success for the worker. It is also important that best practices of disability management (DM) are followed during any return to work attempt in order to maximize the potential for success. Many of the unsuccessful situations that were described during the interviews involved actions that are contrary to DM best practices, such as putting the worker in a menial position in the workplace that does not utilize their skills and abilities (Dyck, 2006). Additionally, situations were described where the worker was placed into positions that would require physical or emotional abilities where the worker had limitations, another example of not following DM best practices. The effects of social support can mediate the difficulties of an injury by providing assistance when needed, someone to listen, and an advocate for the rights of an injured worker. Through the process of data collection, it became clear which participants did not have a support system in place, or did not have enough supports. These workers clearly identified that they needed help in the areas of additional supports. Lack of knowledge regarding the Workers' Advocate group is concerning. The advocacy groups run out of necessity to provide support to workers in need; although, if the workers are unaware of such programs, they are not being utilized to their full capacity. The injured workers want someone that is knowledgeable of WSBC law and policy to listen to them and provide advice. Psychological Factors Depression was the key psychological impact of injury identified by participants. The onset of depression can be rapid when a person's life is impacted by a workplace injury. Given the extent of injury for most of the participants it is not surprising that many struggled Vocational Rehabilitation Services 85 with depression. While the experience of depression might be common for many workers the treatment of this sometimes debilitating mental illness was not common. Most of the participants stated that they struggled alone in dealing with all impacts of their injury, including depression. One of the symptoms of depression is that a person may experience a lack of motivation which may lead to the individual being unable to fully participate in many of the activities designed to get them back to work. If the injured worker is not able to fully participate in these activities they are far less likely to reach a positive outcome. Once the individual begins to experience negative outcomes, due to the onset of depression, they may begin to spiral and end up with a permanent disability. The need for counseling was discussed at length with the participants that introduced the idea. Again, because of the selection criteria, the group that participated in this study typically had serious injuries and were involved with WSBC for a longer period of time respectively than the average claimant. Some participants insisted that if a person obtains a permanent disability, some form of counseling is required to accept that fact and move on with their life. Disabilities not only affected the participant's occupation but also affected many aspects of their lives, such as personal relationships and friendships, leisure activities, and emotional stability. Learning how to cope and deal with the changes brought on by disability was taxing emotionally, and some of the participants felt as though they would benefit from having access to a counselor or therapist. Injured Workers Identification of Strengths of Vocational Rehabilitation Services When identifying the strengths of vocational rehabilitation services provided by WorkSafeBC, the following factors emerged: communication, support from the vocational rehabilitation program, maintaining focus on return to work, progress towards identified Vocational Rehabilitation Services 86 goals or positive outcomes, and retraining and education. These factors answer the second research question which asked specifically where the strengths of vocational rehabilitation services are as identified by the workers themselves. The injured workers very much appreciated the aspects of their VR experience that they identified as being well done. Communication when done well was an important factor in the return to work experience for the workers. In some cases the VRC was able to help the worker to understand their options, and communicate effectively to a positive outcome. The relationship in these situations seemed to be more open and honest, with the worker trusting their VRC to guide them in the 'right' direction. As well, the workers in these situations listened to the advice of the VRC rather than questioning their motives. Those workers that described positive communication also discussed the impact of support from the VRC and the larger program. Support and encouragement was something that many of the workers identified needing after experiencing workplace injuries. Feeling supported through the process made the experience more positive for the workers as they were able to address problems quickly and with the help of their VRC. Maintaining a focus on return to work was a solution focused approach that the participants enjoyed. The injured workers were involved with VR services for that purpose, to return to work, and were pleased when the VRC made efforts toward that goal. Being able to address situations in a timely manner to ensure the worker was progressing toward return to work was identified as being helpful and positive by the workers, whether or not they were successful in returning to work. The VRCs also have the experience necessary to know what is effective in many common situations and can guide the workers to a more positive position. Lastly, the injured workers found the opportunity to obtain some education or Vocational Rehabilitation Services 87 retraining as very positive, as were the experiences they had during the time of course work and practicum. Injured Workers Proposed Improvements to Vocational Rehabilitation Services The last theme that emerged from the study was the answer to the third research question. The proposed improvements to VR which included communication, vocational rehabilitation consultant knowledge and approach, counseling and post traumatic stress disorder, and outcome improvements. These improvements were provided by the workers themselves as they felt changes such as these would have improved their personal experience. Again, communication was central in this theme as well. It has been reported as being done well and done poorly, and thus has been proposed as a potential improvement by the injured workers. To make improvements to the communication between the VRC and injured worker the suggestions were to listen to the worker, to allow for more input, and provide more explanations of the process and the workers options. Injured workers simply wanted to have open, honest, and positive communication with their VRC so they were able to understand what all their options were and could then make appropriate decisions based on that. Doing these things will involve the worker more and allow for increased worker participation in the last of their recovery and their return to work. The more involved the worker is in planning and making decisions, the greater their buy-in will be with the return to work plan. If the worker is invested in their plan, they are likely going to work that much harder to achieve it and thus increase chances of a positive outcome. To improve the approach of the VRC, injured workers suggested having them deal with increased compassion. People do not want to be treated as a number; they want to be treated with care and respect, understanding that their case is just as important as every other Vocational Rehabilitation Services 88 case. In addition, the workers made suggestions to improve the knowledge base of the VRCs. They stated that they thought it would be helpful if the VRCs really understood not only the job the worker did previously, but also the jobs that were being considered for the future. The workers may not necessarily have had a complete understanding of the potential jobs and if the VRC does not either, uncertainty surrounds the worker's ability to complete the potential job. The workers would like a situation where the VRC has in-depth firsthand knowledge of job duties and job sites rather than reported information of those jobs from the internet or National Occupational Classification (NOC). For improvements, as indicated in several other themes, the participants suggested there be an offer of counseling services provided in order to work through some of the difficulties that may arise when facing the future with a permanent disability. Most of the workers simply want to be as healthy as they can, including mental health. Lastly, the workers indicated they wanted improved outcomes, specifically more investigation of potential jobs, more vocational assessments, and help with job searching. To be successful and happy in a different occupation than a person had planned requires there to be exposure and knowledge of new job options. The participants in this study thought that requiring the workers to explore different occupations by going to job sites and talking to people that do the job they are interested in would provide the necessary insight and avoid being 'stuck' in an occupation that the worker does not like. Often our knowledge regarding a job with which we are unfamiliar is far from reality. Without being intimately knowledgeable about possible job opportunities and completing basic employment research, there is potential to make an unfortunate mistake of committing to a new occupation without Vocational Rehabilitation Services 89 really understanding what is done in the daily job. Workers could then be faced with an unfortunate dilemma when they begin a job and do not have the aptitude for it. Vocational assessments provide similar insight but on a deeper level to aid the worker in identifying things they like doing, which can then be matched to a job the worker should enjoy. This would be utilized when the worker needs detailed direction and assistance to explore the abilities they have and can offer to an employment situation. Often the workers felt defeated and inadequate at not being able to participate in their old occupations. While the workers understood that they could not participate in their old occupations they needed help to identify the activities they could participate in. Several participants felt an assessment would have helped them in their VR journey. As well, many felt that more help should be provided to injured workers in the job search period. The workers identified that this would help them to feel the VRC is committed to helping the worker return to work. The majority of the participants had a job search period as it is common in VR, but few identified any techniques of assistance beyond being provided with a few job postings and wage loss payments allowing them with the time to job search. Additional support during this period would be viewed as a positive improvement to vocational rehabilitation services. One of the participants commented that he might have had a better outcome if he had gone out and 'pounded the pavement'. It turns out that he spent his entire job search period at home on the computer and never personally dropped off resumes to potential employers. In this situation if the VRC was aware, they would likely have encouraged this worker to follow up with employers and make personal contact. This is a service deficit that could have been avoided with a small amount of job search coaching. Vocational Rehabilitation Services 90 Altogether, this research project has provided an additional viewpoint to be considered in vocational rehabilitation. The injured worker has been given an opportunity to provide their perspective and views on the experience of vocational rehabilitation provided by WSBC. They provided much valuable information that will hopefully be translated into improvements in practice. Recommendations for Future Study This study was exploratory in nature focusing on eliciting the 'lived experience' of injured workers that had recently gone through vocational rehabilitation provided by WSBC. Being that the study was preliminary in nature a phenomenological methodology was utilized with a comparatively large sample size for qualitative works. It is felt that after completing twenty-six interviews the data was saturated and any further interviews from this participant group would not expand the knowledge gained from this study. Creswell (2007) describes this concept of saturation as being the process of analysis and development of categories the researcher wants to find as many incidents as possible to support each category (code). During this process a point is reached at which the categories are 'saturated' meaning that there is no more ability to find further information that will add to the understanding of that category (Creswell, 2007). The data analyzed in this study was abundant due to the number of interviews completed. Several different viewpoints were presented by the participants; however, there became much overlap in these presentations allowing the researcher to feel that the codes had reached a point of saturation. Having completed further interviews would only have resulted in more data rather than new knowledge. Future research is recommended to verify the findings presented from this project. If only verifying the results reported here a quantitative study could be completed with a focus Vocational Rehabilitation Services 91 on using a larger sample size with quantitative research methodology. For example a survey based study would be appropriate in order to poll a large quantity of VR participants regarding their satisfaction with certain service delivery areas, such as communication or input in decision making. Qualitative work is a great starting point for exploratory research and this work has provided a solid base for future work to build. It has presented several clear ideas as to where workers are and are not happy with VR services provided by WSBC during this timeframe. When considering future research to build upon the knowledge gained here there are many potential options that would be appropriate depending upon the research questions. A valuable study could be developed also with qualitative methodology in order to pursue the concept of improved communication patterns between VRC's and injured workers now that we understand this to be a central area of importance. Specifically it would be beneficial to explore this concept in terms of developing methods that would improve overall communication patterns, thus increasing worker buy-in and rapport with the VRC, ultimately with the goal of improving outcomes and reducing claim costs. Quantitative methods may also want to be utilized in order to quantify the level of satisfaction or dissatisfaction with many service delivery areas from the perspective of the worker to provide further evidence of exact areas of strength or improvement. Future research in this area is recommended in order to test the efficacy of the recommendations reported in this study and to gain a further understanding of the injured workers perspective of vocational rehabilitation services, future research is recommended. Vocational Rehabilitation Services 92 Limitations of the study Several limitations have been identified for this research study. First, participants were able to self select into the study and thus may not have been typical of the larger group of injured workers completing vocational rehabilitation at that time. The participants that chose to enter the study were motivated by the desire to tell their story and additionally to help improve what they viewed as deficiencies in the system. However, an appropriate sampling of participants was obtained representing perceptions of having a positive, average, and negative experience. Interviewer bias and the unstructured interview questions may have contributed to the participant's responses. Interviewer bias is introduced into the study unknowingly by the interviewer when exhibiting certain behaviors that may influence the participant's responses. Having a large portion of the interviews unstructured required the graduate student researcher to respond quickly to the participant's introduction of certain topics, and so these questions were not standardized and may have varied slightly from participant to participant. The educational background of the graduate student researcher is in psychology and practical work in mental health, this may have influenced the way questions were asked in the interviews. However, it is believed this lead to positive impacts by enriching the data in this study. Implications for Practice It is the hope of this graduate student researcher that some of the information gathered through the extensive process of this study will be translated into improvements to the practice of vocational rehabilitation for injured workers. These implications are most appropriate for WorkSafeBC; however, many organizations operate in a similar manner, Vocational Rehabilitation Services 93 such as the other workers' compensation systems and many insurance companies. In addition, some of the information gathered may be helpful to assist community based vocational rehabilitation services by informing practice such as the treatment of injured workers. Implication #1- Verbal Communication The first implication of this study on the practice of vocational rehabilitation services surrounds communication with injured workers. It is important to provide clear, positive communication whenever possible to avoid many of the difficulties described earlier in this study. Communication is the simplest fix that everyone can engage in by becoming conscious of the words that are used, tone of voice, the overall message that is being relayed, and ensuring clarity of the message. In face to face interactions, body language is also a large component of communication. Recommendation #1- Communicate clearly, and openly with injured workers. Allow communication to flow both ways between the VRC and worker by answering all questions the worker has and providing opportunities to contribute to the discussion. To implement this recommendation, workshops could be provided to WSBC staff addressing communication needs of injured workers andfocusing on positive communication and perceptions. Implication #2- Written Communication Workers often have language and education barriers leading to inability to understand written documentation provided by WorkSafeBC. Quotation of WSBC law and policy in written documentation is not described and given context from the worker's perspective, leading to confusion and uncertainty. Vocational Rehabilitation Services 94 Recommendation #2a- Ensure that the worker will be able to understand written communication mailed to them by using simple language and clear explanations. Recommendation #2b- When providing quotes ofWSBC law and policy, include a statement addressing the meaning of the quote for the worker or impact on the worker's claim. Implication #5- Treatment of Injured Workers It is important to provide sincere, compassionate and respectful treatment to all injured workers so to protect and develop the working relationship in return to work planning. Following the 'golden rule' will allow workers to feel they are part of a team that is dedicated to getting the worker back on the job. Recommendation #3a- Ttreat the worker with respect by showing compassion, listening, and addressing all of their concerns with return to work. To implement this recommendation, workshops could be provided to WSBC staff regarding demonstration of compassion, empathy, active listening, and ways to hear and address injured workers concerns. Recommendation #3b- Provide the worker with clear opportunities to give input during the planning stage meetings regarding the direction of their return to work plan. Providing opportunities for input will help to satisfy the need workers have to direct their own affairs by providing time for their ideas to be considered by all and in turn will increase collaboration. Communication strategies and treatment of the worker has a direct impact on many of the other aspects in vocational rehabilitation as demonstrated through the discussion of the major themes found in this study. Vocational Rehabilitation Services 95 Implication #4 - Providing Information At the onset of a referral to vocational rehabilitation services, information could be provided to the injured worker to increase understanding of the process and resources available. Recommendation #4a- Provide Workers' Advisor services information to injured workers at the time of referral to VR services in addition to at the beginning of the claim. Currently, it is believed that this information is sent to workers near the beginning of their claim, although, many workers are not referred to VR services until a year or later into the claim. It is at this time that many of the workers indicated they would be interested in utilizing the Workers' Advisors service and so it only makes sense to provide this information again to remind people of the services available to them. Recommendation # 4 b- Explore the worker's expectations of VR near the beginning of the working relationship with VR services, and continue to monitor as the experience progresses. Addressing the injured worker's expectations will reduce the amount of confusion and dissatisfaction many workers feel when they are not provided with the amount of services they were expecting. Setting expectations early will also allow ample time for workers to begin to explore their options for return to work and any new jobs they may be interested in. It is also important to return to the conversation at a later time point to ensure that workers expectations continue to be realistic. Recommendation #4c- Encourage workers to complete research to explore potential jobs prior to making any decisions on retraining or job placements. Vocational Rehabilitation Services 96 Encouraging workers to make appointments with individuals in positions the injured worker may be interested in allows them to learn details about the position the worker might otherwise not know. Injured workers may also request to speak with managers or individuals in charge of hiring to gain a deeper understanding of what the company is looking for in potential employees. This provides insight into the job and company for the injured worker to make more informed decisions about future employment. This exploration can be completed prior to making any commitments, and will increase the worker's understanding of their potential job options. Having this additional insight will hopefully increase workers' satisfaction with outcomes. As well, this will provide workers with contacts to return to after retraining or upgrading has been completed and the job search commences. Implication #5- Understanding WSBC law and policy An area that was most frustrating for the participants in this study was understanding WorkSafeBC's guiding law and policy. Several recommendations resulted from these conversations. Recommendation # 5a- Compile an information package to inform workers about WorkSafeBC's legislation, policy, worker's rights and responsibilities, and VR services available with corresponding information pertaining to entitlement. Having an information package would address the most pertinent areas of knowledge currently lacking for the workers, understanding their rights and options in VR. Additionally, there are a few possibilities related to providing information, namely providing an information session or links on the WSBC website. The information session could inform new referrals to VR services of all the above information, important in guiding the decisions made by VRCs. Having an information session would remove barriers for certain workers Vocational Rehabilitation Services 97 that are unable to read or have difficulty with the English language. It would also allow for a live two way conversation to take place which would aid in answering the worker's questions. An alternative or addition to these suggestions is to create an electronic version of this information discussed by a person (i.e., video footage) accessible from the WorkSafeBC website. These interventions are aimed at increasing the worker's knowledge of WSBC operations and therefore, increasing understanding and acceptance of the guiding policy. These interventions would also enable better communication between the workers and VRCs as the workers would have a knowledge base from which to start discussion. Workers would then have a general understanding of why the VRCs are required to make certain decisions. Ultimately, this would reduce the amount of time required by each individual VRC in explaining and discussing entitlements to services with every worker. Implication # 6- Vocational Assessments Many of the injured workers discussed the concept of vocational assessments and their place in the return to work process for injured workers. Specifically, some of the participants expected to be provided with some form of assessment to help guide the worker into a new career path. Recommendation # 6- When appropriate, provide the worker with an opportunity to take part in vocational assessments. In some cases the workers need to look to work that is quite unfamiliar for them, as their previous employment situation is not at all appropriate given their restrictions and limitations. Assessments may help trigger some ideas for the worker regarding a future job they may enjoy. Vocational assessments can be provided formally or informally with Vocational Rehabilitation Services 98 various standardized tools. Many of these tools provide insight into what tasks the writer prefers completing, and then provides a list of related jobs and activities. Implication #7- Counseling Counseling services was a topic that was broached frequently by the injured workers in this study. Counseling can take many forms and can be provided either in an individual format one on one with a certified counselor, or it can be provided in a group format. In the situation of many injured workers, both formats may be applicable. Counseling may be necessary to help those workers to get through their new challenges resulting from disability in addition to recognizing that there are many other people out there in a similar situation. This need for workers with serious injuries is astonishing. The need is also important to workers that may not have had really serious injuries, yet are unable to complete their job demands. Any time a worker is forced to change their career path, there are certain psychological consequences. Work provides numerous things to people beyond a pay cheque such as social support, an identity, a purpose, a challenge, self esteem, daily structure, access to extended health care etcetera and when this is removed many people have difficulty coping and may become depressed. Counseling is one method to counteract the negative consequences of job loss and disability that many of the injured workers in this study would have benefitted from. Recommendation #7- Provide an opportunity to participate in counseling services when appropriate. Implication # 8- Job Search The job search period is an opportunity to provide specific and detailed information to the worker that may ultimately affect their level of success with return to work. Vocational Rehabilitation Services 99 Recommendation # 8a- Provide detailed information to workers prior to commencing a job search regarding the required activities and how to best approach them. Also, monitor the workers 'progress and offer suggestions to improve their success. One approach to implement this recommendation would be to conduct workshops for groups of injured workers to relay detailed job search information and best practices. We are unable to make assumptions that workers know how to search for a new job, as many of the participants in this study did not understand some of the basic concepts involved. By providing detailed information, the worker is likely to be reminded of techniques they may have forgotten or learn new strategies resulting in greater success. Monitoring during the job search period would allow additional education to be provided when it is necessary, rather than when it is too late. Recommendation #8b- Provide applicable job postings or leads to injured workers as they come available throughout the job search period. Many of the workers in this study were expecting a higher level of assistance than they received with their job search. The workers are interested in a higher level of support during this time in order to achieve their goals. Implication #9- Job Placements Several workers were concerned with some job placement employer's motives for engaging in the employment relationship. It is important to ensure there is potential for a safe and durable employment situation for the workers, as providing short term relief is not the main goal. Vocational Rehabilitation Services 100 Recommendation #9- Research potential employers thoroughly before commencing a job placement, to ensure they are interested in providing a permanent placement for the injured worker. Implication #10- Opportunities for Continued Development of VRCs Lastly, implications of this research affect the training of the vocational rehabilitation consultants. Increased opportunities can be provided to VRCs to further develop their firsthand knowledge and exposure to the occupations that workers were doing prior to injury as well as what they are interested in for future jobs. It is not possible for every VRC to have a working knowledge and firsthand experience with all potential job opportunities; however, some of the participants in this study felt that increasing the knowledge of the VRCs would only improve the services provided. The more exposure a person has with different situations, the more comfortable they will become with it. Recommendation #10a- Provide increased opportunities for VRCs to be exposed to diverse occupations, learning about different jobs and job demands. Recommendation #10b- Provide additional training to VRCs regarding customer service techniques. For example, training could provide information to VRCs regarding customer service behaviors such as being on time for appointments, returning calls in a timely fashion, and being friendly and approachable in face to face interactions. Many situations were described during the participant interviews that could be deemed inappropriate behavior for professionals to be engaging in. The focus of this professional development should be related to how behaviors may be interpreted by an irritable injured worker. Certain behaviors are unacceptable while others are simply preferred, for example Vocational Rehabilitation Services 101 prompt service. Making an irritable injured worker wait for a prolonged period of time after the start of an appointment time will only irritate them further, thus reducing overall cooperation with the services. As indicated in the literature review, the most successful outcomes for injured workers involved being in respectful and supportive relationships with the return to work specialist. Positive behaviors such as active listening, social and emotional support, consideration, and respecting the opinions and concerns of the worker, and advocating for the worker were described as impacting the outcomes of the injured workers. It is important to keep in mind that an injured worker is often not in the same frame of mind as they would typically be in their everyday life. They can be grouchy, emotional, irrational and things of this nature, but often it is because of the many new sources of anxiety experienced in their lives, such as pain, financial difficulties, or uncertainty about the future. Recommendation #10c- Provide additional training to VRCs regarding conveying important information along with a rationale to injured workers. It seems that important information is reported to injured workers with little consistency between VRCs. Such important information could include situations such as relaying entitlement decisions, or rehabilitation plan approvals. Perhaps some guidelines could be drafted to provide an element of consistency between VRCs in verbal interactions. Recommendation #10d- Introduce the concept of the biopsychosocial treatment model to VRCs and WorkSafeBC staff. This could be accomplished through educational opportunities such as workshops, or training videoclips offered on the WSBC network. Increasing utilization of the biopsychosocial treatment model may increase understanding of the impact of workplace injuries on workers and how it may affect an injured worker. This Vocational Rehabilitation Services 102 may help the injured workers to feel that they are being treated in an individualized rather than standardized manner, by including recognition of social and psychological factors unique to each worker. Conclusion This study focused on identifying and understanding the experiences of workers having proceeded through WorkSafeBC's vocational rehabilitation programs. The results of this study will add to the current literature in that very few self report assessments have been conducted within this topic area especially from the workers' perspective. When answering the first research question, what factors impact injured workers' experience of vocational rehabilitation provided by WorkSafeBC, the answer has emerged as communication. Interpersonal communication is the main theme resulting from this research study. Communication was the one factor that had deep and lasting impacts within most of the remaining experiences had by participants. If the communication between WSBC and the worker was not clear, supportive, and transparent the relationship between the parties began to erode resulting in less than favorable reported experiences and outcomes. The one key finding that has clearly emerged from this project is the simple fact that communication with workers must be improved in order to improve service delivery and satisfaction from the workers perspective. If communication can be improved there is potential for return to work outcomes to be improved, thus ultimately improving our society by enabling a greater number of disabled workers to maintain independence. Vocational Rehabilitation Services 103 References Aakvik, A., Heckman, J.J., & Vytlacil, E.J. (2005). Estimating treatment effects for discrete outcomes when responses to treatment vary: An application to Norwegian vocational rehabilitation programs. Journal of Econometrics, 125, 15-51. Beach, D.T. 2009. 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UNIVERSITY OF-. • • NORTHED BRITISH COW WORKING TO MAKE A DIFFERENCE February 24,2009 Dear Mr. In order to better serve injured workers in this province, WorkSafeBC (WSBC) and the University of Northern British Columbia (UNBC) are conducting a study of workers' experiences with WSBC's Vocational Rehabilitation Services (VRS). Our records indicate that you received vocational rehabilitation (VR) assistance from WSBC in the last two years Because we value your feedback, we sincerely hope that you will be willing to participate in this study so that we can leam from your experience in order to improve VR services to our current and future clients. What can you expect if you participate in this study? You will be interviewed for up to two hours by one or two UNBC researchers Interviews will be conducted in or near your community, or by telephone Interview records and data gathered will not become part of your WSBC file Interview records will be held by UNBC for research purposes only UNBC will provide participants with a $50.00 honorarium and up to an additional $50.00 for other required expenses related to study participation Study results may be published when this research is completed Your name and all other personal identifiers will not be included in the study reports Why is this so Important? We desire to provide VR assistance that is the best and most valued service possible Your feedback about your experience with VRS will strengthen our understanding of what is most important to you and other clients. Your participation in this study will help us to further develop our programs to better meet the needs of all injured workers in BC. How can you get involved? The UNBC has not been given any information about you and will not be able to involve you in the study unless you contact them to express your interest in participating If you would like to be part of this study, please contact by telephone or E-mail. Julie Wessel, BSc, MA Candidate Disability Management Program University of Northern British Columbia 3333 University Way Prince George B.C. V2N 5W6 Phone- 250-960-5137 E-mail1 wessel@unbc.ca Thank you very much for considering this request to help us continue to improve the Vocational Rehabilitation services delivered by WorkSafeBC. Sincerely, Chris Hartmann, M Ed, CCRC Director, Vocational Rehabilitation Services WorkSafeBC 106 Vocational Rehabilitation Services Appendix B UfiBC UNIVERSITY OF NORTHERN BRITISH COLUMBIA Dear Sir or Madame: The purpose of this research is to gain an understanding of the experiences of people involved in vocational rehabilitation programs. Because you are a previous participant in a vocational rehabilitation program, we would like you to consider participating in a study about your experiences. All information will be collected and processed by the researchers and no identifying information will be provided to WorkSafeBC at any time. There are no known risks to participating in this project, and the potential benefit is to provide information that may help vocational rehabilitation specialists improve their practice. This project has been approved by the research Ethics Board of the University of Northern British Columbia. Participation in this project will include the completion of an interview which will be transcribed and coded for content. All information will be held in strict confidence and no names (only participant numbers) will appear on any completed data. Your interview responses will be used for research purposes only and will be kept only for the duration of this particular project (approximately 7 years, after which time the data will be shredded). Please be assured that participation in the project is on a volunteer basis. Also, once you volunteer to participate, you may withdraw from the study at any time with no consequence, and any information collected from you will be withdrawn and shredded. Only the primary researcher and appropriate research assistants will have access to the data, and they will be kept in a locked and secure place at UNBC. We will provide a $50.00 honorarium as a token of our appreciation for you spending the time to help us with this project. Additionally, we will reimburse travel or other costs related to participation (e.g., childcare), up to $50.00. If you have any questions about this project, please feel free to contact either of us at the numbers provided below. You can also contact us if you wish to receive a copy of the results of this study; however, the results will not be available for at least one year and will be in summary format. Any concerns that you may have about this project should be directed to the Office of Research at UNBC (960-5650; researchoffice@unbc.ca). Thank you very much for your time and interest in this project. Sincerely, Dr. Shannon Wagner Health Sciences Program (250) 960-6320 waaners@unbc.ca Dr. Henry Harder Health Science Program (250) 960-6506 harderh@unbc.ca 107 Vocational Rehabilitation Services Appendix C An Enquiry into the Vocational Rehabilitation Services provided by WorksafeBC: The perspective of the worker. CONSENT TO USE INFORMATION I have read the information provided in the Information Sheet and consent to participate in this research. I understand my signature is required to allow the researchers to use the information I provide. I understand I am provided with a numerical code in order that my name or any information I provide cannot be used to identify me. Signature of Research Participant Date:. 108 Vocational Rehabilitation Services Appendix D Participant Demographics Please complete the following information to the best of your knowledge: Name: Birthdate: Gender: • M • F Ethnicity: n Caucasian D First Nations a African-Canadian • Indo-Canadian • Asian a Other (please specify) Is English your Second Language? • Yes o No First Language: Highest Level of Education: • Elementary School • High School • Vocational Training/Apprenticeships n Some College/University • Graduated College • Graduated University D Post-graduate (e.g., Master's or PhD) Marital Status: • Married or common-law a Separated D Divorced D Widowed D Single Number of Children: Current Health Status: • Very good Their Age(s): 109 Vocational Rehabilitation Services D Above average • Average • Below Average • Poor Years Working for Employer Before Accident: n 0 - 5 years D 6 - 10 years • 11 - 15 years a 1 6 - 2 0 years • 21 + years Primary Occupation Before Accident:, Reason for Accessing Vocational Rehabilitation (what was the injury/illness/disease): When did you complete Vocational Rehabilitation Services with WorkSafeBC? Month: Year: Are you currently working? D Yes n No • Retired D Full-Time D Part-Time Current Primary Occupation (if different:) Are you working for: n Same employer/ Same job n Same employer/ New job • New employer/ Same type of job • New employer/ New job • Self-employed Family Income: D less than 20 000 • 20 000 to 30 000 D 30 000 to 40 000 D 40 000 to 50 000 • 50 000 to 60 000 n greater than 60 000 • Casual • Volunteer 110 Vocational Rehabilitation Services 111 Appendix E An Enquiry into the Vocational Rehabilitation Services provided by WorksafeBC: The perspective of the worker. Interview Protocol: Five questions will be used to explore the experience of Vocational Rehabilitation from the perspective of the injured worker. 1. Tell me about your experience with WorksafeBC Prompt for specifics about experience of injury/illness Time elapsed since benefit ended What are they doing now? Changes in functioning 2. Do you recall receiving services from Vocational Rehabilitation? Prompt with probes for VR consultant's name. 3. Now that you recall VR, please tell me about your experience receiving vocational rehabilitation? Prompts: You spoke a little about (or you didn't mention) the planning stage ofVR. What was your experience like? You spoke a little about (or you didn't mention) your experience working through what was planned. What was your experience like? Were there others involved in your VR process? Who were they and what did they do? Did you have support during the process? What kind of support? What was the return-to-work experience like for you? Did you feel a part of the process? Did anyone else help you? 4. Looking back over your whole voc rehab experience, is there anything about it that you would change? Prompts: anything VR could change? Anything Worksafe could change? Split into Positive and Negative 5. Thinking back over the whole experience, is there anything else you would like to tell me? Vocational Rehabilitation Services 112 Appendix F Table 2 Additional Supporting Quotations for Themes MAJOR THEME: INTERPERSONAL COMMUNICATION Factor: Communication between the vocational rehabilitation consultant and worker. Supporting Quotes: At least, you know, she was able to, you know, say like you can't do this, you can't do that. This is your slice of the pie. She was able to demographically break it down to, you know, what I would be looking for and, you know, and it sort of worked and that's how I found the security company. They should talk with people, not talk to them or at them but with them Because, she even told my wife that I was just making trouble. I was just putting too many roadblocks. In other words, I was not willing to cooperate. had they been up front and explained to me the job description to begin with, maybe I wouldn't have been kind've perhaps unknowingly, then really putting an obstacle in front that wasn't there. no one would listen to, like, the way I'm thinking how I can do a job. And nobody listened to me. She was yelling at me and calling me a liar Factor: Communication surrounding decision making. This is my life and this is what I want to be rehabilitated for, not for your vision of my frigging life. Yeah. There was some, some asking for my input. Like, they asked if I had... Maybe if I had really.. .And, like, really pushed for it, maybe it would have been different. I was asking to be retrained, because I couldn't go back into what I was doing. I just don't feel like I had a whole lot of input as to what that retraining was going to be. The way she put it is this is what we can do, this is what we will do and we have to do it this way or bite me. Vocational Rehabilitation Services 113 Factor: Worker understanding of policy and legislation. but I needed that information.. .1 needed to know the rules and I didn't know the rules. You get things thrown at you and they tell you so and so, Worker's Comp Bylaw so and so on the page... .gives me no information whatsoever. I mean, you got to be a flippin' lawyer. Everything's law and policy... And that's a lot for a labourer to start reading and actually comprehend. Factor: Implied negative messaging. Rather than trying to say that, "I'm not willing to help you, but I'm going to make it like you're the culprit." I wasn't cheating here. You know, I didn't do nothing. You know, they could see that. I, I sent two or three full sheets in for two or three weeks, and I never, ever got paid for them, and she never responded, and then she started saying I was lying about it, MAJOR THEME: THE HUMAN FACTOR Factor: Perceived treatment by the vocational rehabilitation consultant. She sent me to school, and she watched week by week, or let's say, each 14 days, she was watching me what the focus was in this school. She gave me certain advice here and there, and all of that. She checked in on me, but she didn't hassle me all the time: "How are you doing, how are you doing?" Factor: Different consultant. As a matter of fact, I honestly, I asked if I could get a new case manager because she was so horrible to me when I talked to her. Yeah. And they kept saying, no. But she was... awful. And if I'd have gotten a different case worker, I would have had a completely different experience. Vocational Rehabilitation Services 114 Unfortunately, everything I have heard, and, by their own admission, you know, they're subject to certain rules, and so-on and so-forth. I don't think there would be much change, except maybe just a different personality. Yeah, I probably would feel differently about it, if at that time, I had seen any support in that regard Factor: Feeling a part of the process. I wasn't a part at all. I was not really, I just felt like totally alienated from all the processes. No and I even spoke to my case manager about it. Yes. Factor: Support from WSBC staff. Uh, but, if I want... If I had a concern about anything, and it didn't have to be about school. It didn't have to be about my injury. It could be how I was feeling about something, [the VRC] and I talked lots of times about football, or Vancouver Canucks, or something like that, you know. He was really pushing. He was helping me out. You know, he told me he'd let me know everything about how he could help me along the way. I wasn't given any, at all. and WCB was not willing to address it, so you are all alone on your own with a problem, a legitimate problem that's not being addressed, and nobody seems to understand. Factor: Feeling pushed off the desk. she wasn't really interested. She just wanted me out of her space. Move you along They were directing me out of the program... get off of WCB and I understand that you can't.. .1 couldn't expect them to carry you indefinitely and I do understand that. I look at how many people I know that scam WCB and they get away with it and then there is somebody like me .. .think you would be more willing to look at other avenues maybe because you wouldn't feel like these people are just trying to get you off of their desk basically. Vocational Rehabilitation Services 115 Then WCB is there and they are not much better really because they just want to close your file and get you back. It's all about getting you off the books. I mean, we're nobody's fool here, right? MAJOR THEME: EXPECTATIONS Factor: Financial expectations. even you know the funding they paid for my wages and all that, my books and tuition and I was quite shocked at the amount they gave me for incidental and because I phoned them, they paid for the tuition, they paid for all my books and when I got into the classroom to find out what we needed and they said we needed like computer discs and stuff like that for the school, to use at the school, so I phoned Ash to see if I could get discs or whatever and he asked me how much, what I needed it for, I told there were pencils, binders, stuff like that, I'm a frugal shopper I told them, he says well let me see what I can do and about an hour later he phoned me and they gave me a thousand bucks for incidentals Yeah and they didn't spend any time with me and then what they spent money wise was peanuts with me on rehab really you know. MAJOR THEME: RE-EMPLOYMENT CONSIDERATIONS Factor: Barriers to employment. Nobody wanted to hire somebody that was 46 and uh, um, to.. .with a business certificate and hire them as a manager. because, I didn't have ... When you ... when you are fifty-three and three-quarters, you're fifty-three, almost fifty-four, and no grade 12.. ..And not physically fit, who's going to hire you? She was supposed make me take training for a living, security and that. I said I can't because I can't be on my feet for too long. I'm trying to explain physically how do I do that? How do I find someone who is going to say that's okay... if you can only work five hours a day or every time you step on a frigging rock and twist your ankle a little bit you got to go home. I'm just not hiring you on that basis. Vocational Rehabilitation Services 116 Factor: Decision making and options. And they told me to research the education which field I wanted to go into so I did that within a day and a half cause I had a goal already and went ahead and did interviewed three colleagues that I would like so I went to three and I got accepted to three They wanted to upgrade my skills. If I have a level four Word, yeah in 2001.. .then you damn well better give me Word four in 2003 to call it an upgrade. I got Word One in 2005, 2006, 2007 whatever particular year it was. It was not an upgrade. They did not up skill me, okay, we will give you bookkeeper, you are giving me something I don't want, I didn't want that.... Obviously I am not having any success in finding work in that area.. .gee why not find something else.. .why not try Web Design so it is another thing I can put on that resume that might make the different for me. Sure everybody has Word and everybody has Microsoft Office, but not everybody has Web Design. No, I don't have a choice of what I was doing in school. I should have the option to rehabilitate the way I want to, Factor: Job search. I agree maybe one a day or something like or three or four a week or something like that, but not 25 a week places you have to go for an interview...how do you manage that....it is impossible. But again, in that time, other than me having to send them a list of everybody that I got interviews with or sent letters to and that sort of thing.. .to show that I was actually searching, um, there was never anything done to help in the job search. they told me there was some kind of rule for so long that I should go apply for a job at five different places, every day, every day, so I have to have signed on the paper from different employers that I went to different places... Looking for a job. I told them what my story was because WCB said I had to and otherwise they would not sign on the paper. Nobody called me. I even told them that they could pay me minimum wages and on top of that my WCB would have covered that. They said we don't have anything, we always have some lifting, reaching, you know... you want to believe how many employees I have applied at more than 500-600... They just want me every week with the sheet...you go to different places and a different employer and it has to have their sign on it. Every week, Friday, I was to fax them. You know, uh, I didn't go out... I didn't go out, you know, hoof it around and start knocking on doors. Maybe that could've been something better I could've done, you know, as far as the job search went. Vocational Rehabilitation Services 117 Factor: Socioeconomic status equivalence. Where are you going to put me to work.. .if I can't work in pepsi.. ..I make $33.50/hour.. .she said they would find me a job for $9/hour.. .yeah.... I can't go back to work in my own field. Like, I'm not gonna take some low-paying job. It is just, just not on. And, I got a ... I got another fifteen, twenty years of working here. And, I wanna make sure I got half-decent wages, right? Because if you sold your home here and had to move to, uh, Vancouver, then you're back in a big mortgage again... You know? Versus if you're already mortgage-free, but you know, for me, that's a step backwards. Factor: Social support. Wife, that's all... No support at all. I was kind of lucky, in my life, you know, I had some savings, you know, and everything paid up, you know. If you were a little bit younger, and had some financial difficulties, you would have some financial difficulties. It would help. Definitely [having an advocacy group] Luckily I have a good union so, they fought for me MAJOR THEME: INJURED WORKERS IDENTIFICATION OF STRENGTHS OF VOCATIONAL REHABILITATION SERVICES There's a lot of positives. There are a lot of positives, and maybe not so many negatives. Factor: Communication. we had two sit-downs together, right? Where she took the time, like the first one, I guess, you know, they says, you know, if you don't get it right away, they don't really have the time. But she took an extra step because my brother came with me... And so then she took an extra, you know, time to sit down to make sure that I really understood it. I was being listened to. Vocational Rehabilitation Services 118 They are very good listeners and they didn't, I don't know how to explain it. It was just good. You know? Everything was smooth. Everybody was real supportive. They did their job well. Every person I dealt with their position and their expectations in their job was followed through. I mean they did their job and it was good. He explained everything Factor: Progress towards identified goals or positive outcomes. I had a great experience. well number one I was comfortable. They didn't, you didn't try to force what they thought was good for me, they didn't try to force that on me. Their process was, it wasn't scattered it was organized. Factor: Retraining and education. They let me pick t the best program, which was wonderful. MAJOR THEME: INJURED WORKERS PROPOSED IMPROVEMENTS TO VOCATIONAL REHABILIATION SERVICES Factor: Communication. the bottom line, you know, explain to him what his injuries are, or what... what the problems are ... I don't know save you time. Communication is number one really and working together, not being pushed into things that you don't really want to do you know. Factor: Vocational rehabilitation consultant knowledge and approach. She wasn't prepared at all for me... Definitely, she wasn't.. .she didn't know my case. So what could be improved is putting two people that can actually work together and that kind of thing. Somebody should oversee what the outcome is.. .not at the end, but in between. Vocational Rehabilitation Services 119 I personally feel that you would heal quicker if you could just get into something, or someone would help or listen or be on your side. Factor: Counseling and post traumatic stress disorder. I did call and ask for a counselor and was told that there wasn't anything, anything... Any type of counseling that I could get. Oh it might have [counseling].. .yeah, it might have, but I have kind of dealt with it on my own. Like I said, I went through a bit of depression there. It was pretty severe actually, the things I was thinking about that I never did in my life. And that was a shame because, um, I became more aware of how other provinces deal with this. And in Alberta, they have a team. They have a group of people who just deal with PTSD. And they're very successful at getting people back to work.