By Michael A. Fryar, M.S., CRC, RN, CCM, CLCP, QRP and John J. Humphreys, B.S., M.S., CRC, Inquis Global
INTRODUCTION
Severe injuries such as Spinal Cord Injuries, Amputations, Burns, Traumatic Brain Injuries and/or other Polytrauma circumstances can create very challenging and life-long consequences for an individual. In addition to the immediate medical and functional consequences derived from these types of injuries/diagnoses, such persons are often moving through difficult psychological processes to adapt emotionally to the sudden cognitive and/or physical changes which have occurred. More often than not, these types of significant injuries will immediately disrupt the pursuit of work and can lead to extended vocational displacement and reliance upon disability benefit systems. Vocational rehabilitation services can be provided to directly assist with the assessment, planning and overall work adjustments necessary to support re-engagement of appropriate employment endeavors. This article will explore the overall vocational rehabilitation process necessary to appropriately support persons who have experienced severe injuries and the inherent benefits in pursuing such objectives. Also, a hypothetical case scenario will be outlined for illustrative and educational purposes.
VOCATIONAL REHABILITATION & SEVERE INJURIES
As discussed in Foundations of Forensic Vocational Rehabilitation (Robinson, 2014), the overall vocational rehabilitation process is composed of distinct phases: Evaluation, Planning, Treatment and Termination. The Evaluation Phase typically begins through an intake interview with the individual by the Vocational Rehabilitation Counselor. The interview will likely explore relevant physical, medical, educational, vocational, psychosocial, economic and other personal factors. Next, input through additional assessments, consults, and/or the detailed analysis of past treatment records will be pursued to establish the necessary medical and/or psychological foundation necessary to begin the process of developing an appropriate Individualized Vocational Rehabilitation Plan (IVRP) for the person. Such plan development may include the completion of standardized testing (i.e., intelligence, aptitudes, interests, etc.) by a Vocational Rehabilitation Counselor or other qualified healthcare professionals, a work transferability analysis, vocational research and/or career counseling. A formal individualized plan is established once the Vocational Rehabilitation Counselor has collected necessary and sufficient data/information to establish appropriate objectives to reach vocational, or potentially avocational, goals for the individual. After the Planning Phase is complete, the Treatment Phase of the overall vocational rehabilitation process begins. This phase involves the direct delivery of services to reach the educational and/or vocational goals established. Essentially, it is the unfolding of the individualized plan through the completion of designated objectives to reach educational and/or career goals. The final phase in the standard vocational rehabilitation process includes the termination of services (i.e., the Termination Phase), which is hopefully completed after the establishment of successful employment by the individual.
Past national research (Duta et al., 2008) identified the following job placement statistical outcomes for persons after the receipt of vocational rehabilitation services:
“Sixty-two percent of the clients in this study were gainfully employed after receiving vocational rehabilitation services. Individuals with sensory/communicative impairments had the highest success rate (75%) compared to 56% for the physical impairments group and 55% for those with mental impairments.”
Historically, when it comes to the vocational rehabilitation outcomes of persons with severe injuries and disabilities, the published literature describes one of the major barriers as the appraisal of earnings available through paid employment, compared to established disability-related benefits (Robinson, 2014 & Duta et al., 2008). Specifically, Dr. Robinson points out the following (Page 7):
“A major confounding issue in evaluating the effectiveness of vocational rehabilitation services, which has little to do with the quality or type of the vocational rehabilitation intervention, is systems of financial compensation that reside outside of the vocational rehabilitation delivery systems. Examples include disability-related compensation benefits offered through workers’ compensation programs, Social Security Disability Insurance (SSDI), or veteran’s compensation benefits related to service-connected impairments.”
However, as to be discussed, the overall benefits of work can extend far beyond the economic gains received by the individual.
BENEFITS OF WORK
The International Classification of Functioning, Disability and Health (ICF) of the World Health Organization (WHO) defines employment as “… engaging in all aspects of work, as an occupation, trade, profession or other form of employment, for payment or where payment is not provided, as an employee, full or part time, or self-employed”. A return to gainful employment after experiencing a severe injury can help individuals achieve economic self-sufficiency, attain personal growth, adjust to their disability, increase social interactions, and improve life satisfaction, health and well-being. (Trenaman et al., 2014).
Relative to the benefits of work, Ullah et al. (2017) completed a review of research regarding adults with Spinal Cord Injuries (SCI). Based upon their empirical findings, three common themes or benefits from returning to work after such a severe neurological injury were identified.
The first theme or benefit identified was the re-development or re-defining of self. The individuals of the study had strong motivation to establish a career following the injury. Through such motivated vocational activities, they were able to gain confidence and re-establish a sense of control over their environments and lives. Moreover, reengagement of work helped these persons recognize inherent abilities and shifted their focus away from their newly acquired functional/neurological limitations or disabilities.
The second identified benefit derived from working after a Spinal Cord Injury was it promoted re-establishment of personal roles within the community. Specifically, returning to work facilitated much needed personal opportunities for the individuals to exit their homes, interact socially, perform purposeful activities, and directly contribute to their communities in a meaningful way.
The third and final theme or benefit determined from the research concerned autonomy, and in particular, the finding that a career affords individuals with severe injuries the opportunity to regain overall self-sufficiency and personal autonomy for their lives. In summary, multiple benefits arise from the performance of work for persons with severe injuries and disabilities which extend well beyond the receipt of a paycheck.
WORKPLACE ACCOMODATIONS
Individuals who attempt employment after acquiring a severe injury often face a variety of barriers which can significantly hamper or prevent a successful return to and/or the maintenance of competitive employment. These barriers, whether perceived or actual, can often be minimized or eliminated through the implementation of effective workplace/job accommodations. The U.S. Department of Labor (USDOL) defines workplace accommodation as follows:
“A job accommodation is an adjustment to a job or work environment that makes it possible for an individual with a disability to perform their job duties. Accommodations may include specialized equipment, modifications to the work environment or adjustments to work schedules or responsibilities. Not all people with disabilities (or even all people with the same disability) need the same accommodation. For example, a job applicant who is deaf may need a sign language interpreter during the job interview; an employee who is blind or who has low vision may need someone to read information posted on a bulletin board; and an employee with diabetes may need regularly scheduled breaks during the workday to monitor blood sugar and insulin levels.”
Based upon the Americans with Disabilities Act (ADA, Title-1), an employer must provide the reasonable accommodation(s) necessary for a qualified individual with a disability to have equal opportunity to acquire and successfully perform the essential functions of their job to the same extent as their nondisabled co-workers. According to the ADA, a reasonable accommodation should not cause the employer undue hardship, relative to their business operations.
In their systematic review regarding job accommodations, return to work and job retention for persons with physical disabilities, (Wong et al., 2021) reaffirmed while job accommodations are critical to ensuring equal access of employment for persons with disabilities, a few primary issues or concerns from employers can directly hinder the process. The first major issue the employers relayed concerned their lack of understanding job accommodations and how to effectively implement such to meet the needs and requirements of their employees. To address this employer concern, the Job Accommodation Network (JAN), a service of the U.S. Department of Labor’s Office of Disability Employment Policy (ODEP), is available to provide expert and confidential guidance regarding workplace accommodations for employers and employees free of charge.
The second concern identified by the employers within the research (Wong et al., 2021) pertained to the cost of job accommodations. However, based upon a 2019 employer survey by the Job Accommodations Network (JAN), the polled employers indicated approximately 56% of the accommodations provided did not have a cost to implement, and the remaining typically had a per occurrence expense of less than $500.00. Moreover, the surveyed employers explained the benefits of providing workplace accommodations outweighed the costs and included employee retention, improved productivity, increased morale, reduced workers compensation costs, and increased workplace diversity.
In the authors’ experiences, proactively providing and/or communicating relevant information, data and resources to employers regarding reasonable accommodations could serve to increase overall labor market opportunities for persons with severe injuries and disabilities.
TELEWORK
One possible employment avenue to consider for the accommodation of persons with severe injuries would include telework career opportunities. Job placement into likely positions and with employers allowing, or actually preferring, their employees work from home could serve to remove environmental obstacles and effectively provide greater personal flexibility. Such vocational flexibility could improve the employee’s ability to attend medical appointments, accomplish medical treatments and/or manage daily matters such as bowel and bladder programs and other activities effectively from an accessible home. Due to the labor market impacts of COVID-19, an increasing prevalence and acceptance of telework has been observed within the national economy, which is a fortunate circumstance for individuals with severe injuries.
Relative to this matter, empirical research completed by Dingel and Neiman (2020) included direct evaluation and classification of occupations which could be accomplished remotely by an employee. Specifically, the researchers analyzed data from the O*NET database, as well as survey findings from the Work Context Questionnaire and the Generalized Work Activities Questionnaire, in relation to the Standard Occupational Classification (SOC) structure established by the United States Department of Labor (USDOL). The researchers concluded 37 percent of national jobs can plausibly be performed from home. Additionally, the researchers explained:
“There is significant variation across occupations managers, educators, and those working in computers, finance, and law are largely able to work from home. Farm, construction, and production workers cannot. Workers in occupations that can be performed at home typically earn more. If we assume all occupations involve the same number of hours of work, the 37 percent of US jobs that can plausibly be performed at home account for 46 percent of all wages.”
Specifically, based upon Dingel and Neiman’s research, the following percentage share of jobs arranged within their associated greater occupational grouping could plausibly be performed at home:
|
Computer and Mathematical Occupations
|
1.00
|
|
Education, Training, and Library Occupations
|
0.98
|
|
Legal Occupations
|
0.97
|
|
Business and Financial Operations Occupations
|
0.88
|
|
Management Occupations
|
0.87
|
|
Arts, Design, Entertainment, Sports, and Media Occupations
|
0.76
|
|
Office and Administrative Support Occupations
|
0.65
|
|
Architecture and Engineering Occupations
|
0.61
|
|
Life, Physical, and Social Science Occupations
|
0.54
|
|
Community and Social Service Occupations
|
0.37
|
|
Sales and Related Occupations
|
0.28
|
|
Personal Care and Service Occupations
|
0.26
|
|
Protective Service Occupations
|
0.06
|
|
Healthcare Practitioners and Technical Occupations
|
0.05
|
|
Transportation and Material Moving Occupations
|
0.03
|
|
Healthcare Support Occupations
|
0.02
|
|
Farming, Fishing, and Forestry Occupations
|
0.01
|
|
Production Occupations
|
0.01
|
|
Installation, Maintenance, and Repair Occupations
|
0.01
|
|
Construction and Extraction Occupations
|
0.00
|
|
Food Preparation and Serving Related Occupations
|
0.00
|
|
Building and Grounds Cleaning and Maintenance Occupations
|
0.00
|
In addition, Salon et al. (2022) empirically investigated telework prevalence and future projections after the pandemic through a national survey of adults and concluded the following:
“Analyzing a nationally representative panel survey of adults, we find that 40–50% of workers expect to telecommute at least a few times per month post-pandemic, up from 24% pre-COVID. If given the option, 90–95% of those who first telecommuted during the pandemic plan to continue the practice regularly. We also find that new telecommuters are demographically similar to pre-COVID telecommuters. Both pre- and post- COVID, higher educational attainment and income, together with certain job categories, largely determine whether workers have the option to telecommute.”
In summary, telework options appear to be a growing employer trend within our national economy, which could assist persons with severe injuries during their pursuit of an appropriately planned return to employment.
CASE SCENARIO
The following hypothetical case scenario for a person with a severe injury is offered for educational and illustrative purposes:
- o Paraplegia (Young Adult)
Larry Smith, a 21-year-old male, sustained a complete Spinal Cord Injury (i.e., Paraplegia) during a motor vehicle accident. After the accident, he required a manual wheelchair for mobility, but had full range of motion and strength within his upper extremities. He had to self-catheterize multiple times per day due to his neurogenic bladder, and he needed to follow a regular bowel program every other day.
At the time of the Spinal Cord Injury, Larry was set to enroll into his second year of college with intended pursuit of a major for Chemistry. He had planned to complete a pre-medical school academic track. Due to the necessary hospitalization period and rehabilitative process, Larry withdrew from college. Approximately one year after the accident, he reported being very depressed and anxious about his future, especially his career. The family hired a private Vocational Rehabilitation Counselor to assist Larry.
The Vocational Rehabilitation Counselor completed an initial assessment with Larry, which was followed by standardized testing to determine his aptitudes, career interests and work values. The initial assessment and testing were followed by a period of career counseling to pinpoint specific educational and vocational goals and objectives. Following his experiences after the Spinal Cord Injury and the care and rehabilitation which followed, Larry presented with both tested and verbalized interests for pursing a medical degree with specialization as a Physical Medicine and Rehabilitation Physician. A detailed academic pathway was developed by both Larry and the Vocational Rehabilitation Counselor through shared research, discussions and vocational assignments during the period of career counseling. Once Larry was re-enrolled into college, the Vocational Rehabilitation Counselor met with, and remained in contact with, the Disability Coordinator for the University to ensure Larry would have appropriate environmental access and classroom modifications necessary to accommodate his wheelchair and overall needs as a person with a Spinal Cord Injury throughout his period of academic study. Larry moved back into an accessible dormitory on campus and reconnected with his prior social group after encouragement and support from the Counselor. He began college classes and remained in contact with his Counselor, at least quarterly, throughout his period of education for advocacy, counsel and guidance, as needed. Upon completion of medical school and his necessary residency, onsite vocational rehabilitation services increased for Larry, including assistance with job seeking and placement. Also, the Counselor worked with Larry to hone his interviewing skills and overall comfort for discussing accommodation requirements for his work in the healthcare workplace. Consultation was completed with the Job Accommodations Network (JAN) to facilitate and support Larry’s performance of essential duties as a Physician. After three months of job searching and interviewing, Larry accepted an offer of employment. Following a successful six months of employment, at a regional rehabilitation hospital, Larry’s file was closed by the Vocational Rehabilitation Counselor, with the option to re-open, should additional career guidance, counsel and/or advocacy be needed in the future.
CONCLUSIONS
Severe injuries can significantly disrupt individuals from their active or emerging careers. When vocational displacement occurs, these individuals can benefit from working directly with a qualified and experienced Vocational Rehabilitation Counselor. An individualized plan toward a new or related career should be developed to guide such services. The plan may require academic training or focused vocational skill development to facilitate a return to gainful employment within the competitive labor market. Appropriate selection of a career path, with or without accommodations, and the development and subsequent pursuit of objectives to accomplish the intended vocational goal(s) are critical to promote financial independence for many persons with severe injuries and disabilities. Outside of the economic value, the engagement of successful employment provides many other benefits for the individual, and can mitigate many of the emotional, psychological and social challenges that often occur after severe injuries. In closing, persons with severe injuries and disabilities should not be automatically judged disqualified from the world of work. Rather, astute vocational rehabilitation assessment, with individualized planning and counsel, can serve to establish many career paths for persons with severe injuries, including those potentially not easily discerned at first appraisal. In the end, having an appropriately selected and established career can improve personal adjustment, motivation and overall quality of life for persons with severe injuries and disabilities and by virtue, is a worthy goal of pursuit.
ABOUT THE AUTHORS
Michael Fryarearned a Bachelor of Arts in Psychology from the University of North Carolina at Chapel Hill. He subsequently graduated Summa Cum Laude with a Dual Master’s in Rehabilitation Counseling and Vocational Evaluation from East Carolina University. In 2005, he completed a 120-hour post-graduate training program in life care planning through Kaplan University with lead instructor, Dr. Paul Deutsch, the founder of the life care planning process. Finally, Mr. Fryar completed his Associate Degree in Nursing at Sampson Community College. Mr. Fryar is a Certified Rehabilitation Counselor (CRC), Registered Nurse (RN), Certified Case Manager (CCM) and Certified Life Care Planner (CLCP). He is also a registered Qualified Rehabilitation Professional (QRP) through the North Carolina Industrial Commission. Mr. Fryar has worked as a Rehabilitation Charge Nurse for the brain injury, spinal cord injury and general rehabilitation units of Wake Forest University Baptist Medical Center. He has served as the past Secretary for the International Association of Rehabilitation Professionals’ (IARP) National Forensic Board. He is currently an active IARP member and is involved with the Rehabilitation and Disability Case Management (RDCM) National Board of IARP to include past appointment to the Education Subcommittee. More recently, he became Chair for the Rehabilitation and Disability Case Management (RDCM) section of IARP. Finally, Mr. Fryar was recently invited to assist in the updating of the life care planning educational program offered by the Institute of Rehabilitation and Education Training (IRET). In total, Mr. Fryar has worked over 22 years within the vocational rehabilitation, case management and life care planning fields. He provides independent case management and rehabilitative consultant services.
John Humphreys earned a Bachelor of Science in Education from the University of Georgia. He subsequently graduated from East Carolina University with a Dual Master’s in
Rehabilitation Counseling and Vocational Evaluation. Additionally, Mr. Humphreys received certification in Substance Abuse Counseling from Central Piedmont Community College. Mr. Humphreys is a Certified Rehabilitation Counselor (CRC). Prior to obtaining his master’s degree, Mr. Humphreys taught children with intellectual and developmental disabilities, as well as those with neurodiverse needs, to prepare them for work and independent living. In the field of rehabilitation, he worked as the Director of Vocational Services for Carolinas Rehabilitation Hospital of Charlotte, NC. In this role, he provided vocational rehabilitation counseling, vocational evaluation, case management, job placement, and training to individuals with acquired disabilities, such as Traumatic Brain Injuries, Strokes and Spinal Cord Injuries. Mr. Humphreys currently works as a Vocational Rehabilitation Counselor for the North Carolina Division of Services for the Blind. He manages a caseload of individuals with low vision and blindness and provides the rehabilitative assessments, counseling, and services necessary to assist each person with identifying, obtaining, and maintaining competitive employment. Mr. Humphreys has over 23 years of experience within the field of vocational rehabilitation, providing counseling, evaluation, placement, training, and case management to individuals with catastrophic injuries to ensure their successful return to work.
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American with Disabilities Act. Retrieved from https://www.ada.gov
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Job Accommodation Network (2019). Retrieved from https:// www.askjan.org
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Salon, D. et al. (2022). “The COVID-19 Pandemic and the Future of Telecommuting in the United States.” Transportation Research, 112 (1-24). https://doi.org/10.1016/j.trd.2022.103473
Trenaman, L. et al. (2014). “Review Interventions for Improving Employment Outcomes
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general/topic/disability/jobaccommodations.
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