Barriers to and enablers of return to work after stroke survivor and employer perceptions

 MV Ntsiea and H van Aswegen

Department of Physiotherapy, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Correspondence: Veronica Ntsiea, Physiotherapy Department, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, 2193. e-mail: veronica.ntsiea@wits.ac.za

ABSTRACT

Background: Stroke often affects people who are still within the working age and impacts a survivor’s ability to participate in community activities, such as returning to work. Determining potential successful return to work (RTW) requires identification of possible barriers and enablers of RTW, and the employee’s work potential.

Objectives: To establish stroke survivors’ and employers’ perceived barriers to and enablers of RTW.

Methods: Twelve employers and 24 stroke survivors were interviewed. Purposeful sampling was used to include participants in blue and white collar occupations.

Results: The most commonly perceived enablers of RTW were ability of the employer to provide reasonable accommodation (change in the work environment or the way a job is performed that enables a person to cope in the workplace), and good interpersonal working relationships between stroke survivors, employers and co-workers. The most commonly perceived barriers of RTW were cognitive and speech impairments, fatigue and the inability to work at the required pace. Employers also identified reasonable accommodation and unsafe working environments, while stroke survivors high-
lighted the inability to meet the demands of the job, challenges regarding transport, and fear of losing employment.

Conclusion: Regular and early communication between the stroke survivor, employer and therapist is necessary to make well-informed decisions about the RTW process, and to explore possibilities of reasonable accommodation at the workplace where possible.

 

Keywords: reasonable accommodation, communication, transport, accessibility, disability

INTRODUCTION

Stroke often affects people who are of working age,1,2 and impacts a survivor’s ability to participate in community activities.3 Stroke survivors of working age need complex and cognitively demanding activities during rehabilitation to prepare them for return to demanding workplace activities.4

The prevalence of stroke is increasing, with most of the burden in developing countries.5 Most people survive their stroke because of improved health services.6 Young stroke survivors are likely to live longer, and need to continue working for financial sustainability and to have a sense of purpose. However, there are limited vocational rehabilitation services available in South Africa.7

Return to work (RTW) helps to reduce the devastating consequences of unemployment which are linked to financial hardship and the inability of stroke survivors to meet their basic needs,8 and to improve their life satisfaction, wellbeing and social identity.8,9 An independent income is more financially beneficial than relying on social welfare.10 It is therefore important to focus rehabilitation programmes on the resumption of work11 as well as restoring body functionality.9,12

Stroke survivors are sometimes forced into early retirement because of the perception of employers that they are unable to perform their duties.13 The right of persons with disabilities to work on an equal basis with others is expressed in the United Nations Convention on the Rights of Persons with Disabilities.14 This is also enshrined in the Constitution of South Africa15 which provides protection against discrimination against people with disabilities.

The rate of RTW for stroke survivors in the Gauteng province, the most populous province of South Africa,16 is 34% two years after stroke.8 This is almost half of that reported in a national Danish study, viz. 62% two years after stroke.17 It is difficult to compare RTW studies due to differences in follow-up periods and worker definitions. In addition, differences in RTW between countries might reflect varying economic conditions, unemployment rates, and cultural factors, such as availability of help from family members and disability compensation structures.

The rate of RTW might differ by income level. Higher income is associated with a higher probability of RTW after stroke.17 Stroke survivors might have participation limitations because of their socioeconomic status. A study in the Western Cape established that 80.7% of the stroke survivors had an income below R1000 per month and were therefore likely to rely on public transport to participate in community activities.18 Thus, on returning to work, these stroke survivors would encounter transport challenges, e.g. having to walk to catch public transport or hire vehicles which is more costly.

Most RTW research has been conducted in developed countries and might have limited application in other settings. One of the few studies in developing countries was conducted in South Africa and explored the perceptions of physiotherapists and occupational therapists about the barriers to and enablers of RTW in stroke survivors.19 Variations in socioeconomic and labour legislation among countries might influence such perceptions because of differences in work accommodation programmes and disability compensation structures. These variations and paucity of information in developing countries provided the basis for our study which sought to establish stroke survivors’ and employers’ perceived barriers to and enablers of RTW in a South African context. The study was conducted in Gauteng province as it has the largest number of stroke rehabilitation facilities, workplaces and therapists in the country.16

 

METHODS

We defined RTW as part- or full-time work done for payment, without limitations on the number of hours worked.20 Housewives and students were not included as they are not catered for under the South African labour law; thus, factors that affect their RTW are likely to be different to those of people who work for economic provision and are protected by labour laws.

A qualitative study method was used. Stroke survivors who were employed at the time of stroke, and their employers, were recruited from 2010 to 2012. The survivors were recruited from stroke clinics at two academic hospitals and one private stroke rehabilitation unit in Gauteng province, and their employers were contacted after obtaining consent from the survivors. These clinical sites were chosen for convenience: two are attached to the University of the Witwatersrand teaching hospitals which have stroke clinics, and the private unit was selected because it has a stroke rehabilitation unit.

Purposeful sampling was used to include participants in both blue and white collar occupations. The study population comprised six employers in white and six in blue collar occupations, and 12 stroke survivors in white and 12 in blue collar occupations. White collar occupations were those that were performed in an office environment, related to customer interaction, entertainment and sales. Blue collar occupations referred to those that involved skilled or unskilled manual labour, e.g. mining, construction, mechanical, maintenance, and technical installation. The minimum of six participant interviews per category was considered sufficient as the groups were homogenous with respect to type of occupation (blue or white collar), as recommended by Kuzel.21

Stroke survivors were included if they were aged 18 to 60 years and employed at the time of the stroke. They were excluded if they had a Barthel Index score of less than 60% (to exclude those with severe functional limitations who would not be considered for RTW) or did not want the researcher to interview their employers.

Age, gender, side of stroke and functional level (measured as activities of daily living using the Barthel Index; mobility using the modified Rivermead mobility index; and basic cognitive function using the Montreal cognitive assessment) were recorded for all stroke survivors. Interview questions were developed based on schedules developed by Medin and co-workers10 with input from stroke rehabilitation therapists who reviewed the questions for clarity of language and logical flow of information. The revised interview schedule was finalised by the project development team.

Therapists at the research sites identified potential participants and the researcher confirmed if they met the inclusion criteria. Employers of stroke survivors who met the inclusion criteria were contacted telephonically by the researcher. The research assistant (an occupational therapist with experience in qualitative research) interviewed stroke survivors whose employers also agreed to participate in the study. The stroke survivors were interviewed at the clinics. The research assistant then visited the workplace where the employer was interviewed.

The interviews were semi-structured and voice recorded. Interview notes were taken for those who refused to be recorded. The questions covered the following: expectations of the stroke survivor/employer, ability to work, enablers of and barriers to RTW, and challenges encountered in RTW and how these were addressed.

The interviews were voice-recorded, transcribed and manually coded. Interviews were conducted until saturation was reached (no new information was forthcoming). Categories were developed using words, phrases and statements that reflected common phenomena. Similar items were coded and categorised separately by the researcher, and one therapist with experience in research who was impartial to the views of the study, until no new explanations and perspectives were identified. The researcher and therapist codes and categories were compared and similarity was established before formulation and interpretation of themes.

Credibility was ensured by capturing detailed descriptions of the perceived RTW barriers and enablers, and transcribing voice recordings verbatim to capture each narrative. Transferability was ensured by providing a thick description of the study methods and findings. Each process and decision trail of the study was reported in detail for dependability. The researcher’s biases and assumptions were dealt with through peer evaluation of the codes and categories to ensure confirmability.

Ethical clearance was granted by the University of the Witwatersrand Human Research Ethics Committee (Medical): clearance certificate number M081132.

 

RESULTS

The results are presented as four themes of RTW: stroke survivors’ perceived enablers, employers’ perceived enablers, stroke survivors’ perceived barriers, and employers’ perceived barriers. Within each theme are several categories which are presented separately.

Characteristics of stroke survivors are shown in Table 1. Most of the stroke survivors (n = 15; 62.5%) were principal breadwinners. Stroke survivors’ occupations and RTW information is presented in Table 2. The number of blue and white collar stroke survivors who returned to work was similar (6 and 7 out of 12, respectively). The most common reason for white collar workers not returning to work was physical sequelae; for blue collar workers, it was that the employer would not rehire (no reasonable accommodation). The most common reason for white collar workers returning to work was boredom, while for blue collar workers it was financial necessity.

 

Stroke survivors’ perceived enablers of return to work

Eleven enablers of RTW were identified and grouped into three categories: personal enablers, employer and co-worker support, and communication (Table 3).

 

Personal enablers

Good balance and upper limb function, i.e. the ability to balance when walking, climbing stairs or even climbing a ladder at work was identified as an important factor for RTW, especially for survivors working in labour intensive occupations.

Psychological wellbeing was emphasised as being important by stroke survivors who highlighted the challenges of dealing with stroke and work:

 “I need them to help me with psychological support . . . I don’t know how I will manage with me getting stress from my disease and having to worry about work stress” (P03).

Ability to work fast and accurately was perceived as an enabler by survivors in both blue and white collar occupations:

“I will need to have good time keeping and accuracy in doing my work because they (employers) don’t allow mistakes which will mean that the company will lose money” (P13).

Stroke survivors indicated that, if good interpersonal relationships could be developed with their supervisors and colleagues, then RTW would be enabled:

“I will have to work hand in hand with my supervisor so that we can communicate and know what is going on with me. I should not have secrets. I will also not take myself to be better off than my colleagues by wanting my supervisor to always focus on me” (P13).

 

Employer and co-worker support

Some stroke survivors indicated that their employers focused a lot on production and did not give an allowance for therapy time during working hours. Ability to RTW was perceived to be highly dependent on the employers’ willingness to have stroke survivors RTW even if it meant performing only those duties with which they could cope while recovering:

“Availability of the line manager to discuss my situation and let me show them that I am able to do the job or alternative job within the company will be helpful” (P08).

Workplace accessibility was considered an enabler, and some survivors felt that, if physical modifications were made in the workplace, they would be able to RTW:

“What will help is building of ramps in areas where there are stairs on the ground floor as I still struggle with climbing of stairs even with tripod . . . But I still believe that we need ramps even if I get better because my situation has helped me to see that if we have somebody like me who wants to come to our company or one of our co-workers gets sick, it means they will struggle to walk in our company yard” (P15).

Employers’ knowledge of the medical condition was suggested to facilitate RWT:

“They (employer) have to talk about my disease . . . We (stroke survivor and therapist) have to keep talking with them (employer) and they must know how I am doing . . .” (P20).                                                                                                              

Supportive co-workers were believed to help keep the work flowing smoothly while one was on sick leave and even when back at work:

“It helps to have supportive colleagues who don’t always complain to the manager about doing things to help me while I recover. We should all help each other. I have always helped them” (P24).

The following is an example where co-worker assistance helped with RTW:

“I could not lift heavy meeting documents: this has been handled by asking others to lift and bring the documents to meetings. I still continue doing all my work except the lifting for now” (P17).

 

Communication

Stroke survivors felt that, if there was communication between the employer and the therapist, the survivors would be more inclined to want to RTW. One survivor shared:

What will help is talking to human resource and my supervisor to help them find out if I am coping about my situation and to also make them understand my situation . . .” (P17).

Being able to communicate openly and honestly with the employer was perceived as a factor that would increase the chances of RTW. One survivor stated:

“I think what will also help is openness between me and employer. They must tell me the honest truth about what they are thinking or planning to do with me. They must not surprise me at the end by telling me that my job is finished” (P14).

 

Employers’ perceived enablers of return to work

Interviews with employers allowed for the identification of 10 enablers of RTW. These were further classified into three categories: stroke survivor related enablers, work environment, and employer and co-worker support (Table 3).

 

Stroke survivor-related enablers

Willingness to work was indicated as an important enabler of RTW. The employers felt that a person who was willing to RTW would make an effort to do their best when given an opportunity to work, despite having a stroke:

“An employee who is willing to come back to work will do their best when given a chance” (E04).

Less severe stroke was associated with more limitations in ability to do the work, and thus some employers indicated that they would consider taking a stroke survivor back into the workplace only if the stroke was not severe:

“We also need to consider how serious the person’s stroke is, because a debilitating stroke would make it impossible for . . . (employee name) . . . to come back to work even if the company wants to take them back” (E04).

Psychological support for both the stroke survivor and co-workers was considered an enabler as indicated by one of the employers:

“I think they will benefit a lot from making use of the psychologist to help them and colleagues deal with their psychological problems” (E03).

 

Work environment

Employers indicated the importance of an accessible work environment before having the stroke survivor back at work:

“Another thing that can help a person return to work is if the working environment is good. By this I mean if it has ramps for a weak person who cannot climb stairs” (E13).

Employers were concerned about the safety of the work environment and worried that a stroke survivor could get injured in the workplace: 

“Willingness of the employee to try the best to do the work but not to force coming back to work as we don’t want them to put their life at risk” (E14).

 

Employer and co-worker support

Employers felt that reasonable accommodation could be an enabler of RTW:

“They (stroke survivor) should be able to come back to work even if it means doing less workload or light duty. They can even work in the office because doing visits and talks requires more walking and driving. This will all depend on whether they will cope. The question is whether they are also willing to try. We can help with what needs to be done . . . ” (E05).

Some employers indicated that they would like to to help the stroke survivor without compromising the organisation, indicating that they were worried about the company image:

“Giving the employee an opportunity. . . . This should be done without denting the image of the company by letting a person who is sick sit at reception and do the work” (E17).

Moral support from co-workers was considered a RTW enabler, with employers indicating that having supportive co-workers would motivate the stroke survivor to RTW with the knowledge that they would get the help they might require while settling back into the workplace:

“She will also need to get support by other staff members and me (employer). She has to know that we want her to get better and will help with whatever we need to do . . .” (E15).

Employers indicated the need for ongoing communication between them and the stroke survivor in order to develop solutions for challenges faced on a regular basis, instead of letting the stroke survivor struggle and eventually consider giving up:

“They (stroke survivor) should try to work and if they see that they have limitations, they should try to let the supervisor know as soon as possible, to get help. . . . If a person cannot communicate, the supervisor will never know when they have a problem” (E24).

The importance of employers receiving advice from therapists with regard to the RTW process was identified as one of the factors that could enable the stroke survivor to RTW:

“This communication is good when it is also done with you people (therapists) because it helps us understand what is going on and what can be done to help. This is very difficult. I mean trying to help a person but not knowing what to do and what is safe to do” (E24).

 

Stroke survivors’ perceived barriers to return to work

Seven barriers to RTW were identified from the interviews with stroke survivors and classified into three categories: personal barriers, employer related barriers, and environmental barriers (Table 4).

 

Personal barriers

Physical sequelae of stroke survivors, such as cognitive impairments (memory and attention), fatigue and poor vision were considered to be factors that might make it difficult for a stroke survivor to do his or her usual work. The following quotes were shared:

“I need to learn techniques to use to remember things, so that I don’t miss meetings and appear incompetent in front of my manager and colleagues” (P01); “I get tired all the time. I just want to sleep or rest. It becomes impossible to do the usual job all day” (P04); and “I can only go back to work if I recover my vision as I cannot read and write . . .” (P10).

Fear of mocking was considered a barrier to RTW. Some stroke survivors indicated that there was a need to counsel the co-workers to prepare them for their RTW as they were concerned that if co-workers did not understand and accept their medical condition, they might mock them:

“If I struggle, the learners and colleagues will mock me” (P15).

 

Employer-related barriers

Some stroke survivors thought the employer might not give them time off during the day to attend their therapy sessions. They would therefore rather be on extended sick leave and know that they could go to their therapy sessions without having to continuously ask for permission:

“What will also make it difficult is if my supervisor will stand in my way when I have to go for treatment” (P13).

Employers’ unrealistic expectations or increased physical job demands were considered as RTW barriers. The concern raised was that an employer who was not willing to reasonably accommodate the stroke survivor back at work might demand that they continue to perform at the same rate that they did before stroke, without giving them an opportunity to ease slowly into the job:

“The employer might demand that I work at the speed that I used to have. This will not be possible” (P13).

 

Environmental barriers

The high unemployment rate was considered a barrier to RTW. Some stroke survivors thought that employers would rather hire an unemployed person than let them continue working, and that it would be difficult for them to find another job due to the high unemployment rate. A survivor shared:

“My fear is that I may not be able to find a new . . . job as there are no jobs . . . in South Africa. It will be worse for me because I can’t . . . talk properly” (P07).

Some stroke survivors who used public transport indicated that RTW would be difficult because of poor transport accessibility. Some indicated that they had to walk up and down several flights of stairs at the train station and would therefore be tired by the time they reached their workplaces. Some indicated that walking long distances to catch a taxi was also a challenge:

“It was difficult to get public transport because of long distance from home to taxi” (P03).

Inaccessible work environments were considered a barrier to RTW while mobility in the workplace was considered the main deterrent for RTW:

“There are lots of steps around the school and the school is an upstairs (double storey) building. Toilets do not have rails for me to hold onto for balance when I need to use them” (P14).

 

Employers’ perceived barriers of return to work

Six barriers of RTW were identified from the interviews with employers, and classified into three categories: stroke survivor-related barriers, employer-related barriers, and environmental barriers (Table 4).

 

Stroke survivor-related barriers

Physical sequelae, such as working slowly, cognitive impairments (memory and attention), speech problems, and poor upper limb use were identified as factors that might make it difficult for a stroke survivor to do his or her usual work. Being able to remember job specifications and instructions, and being able to pay attention to avoid making mistakes when doing the work, were considered important aspects in the workplace that would help to prevent mistakes which, in some instances, could be fatal. Some employers indicated that these cognitive abilities would be required before they could consider accepting the stroke survivor back at work. Employers of stroke survivors whose job required that they spoke to customers, e.g. sales people, educators and receptionists, emphasised the need for the stoke survivor to regain speech before RTW.

Some of the employers indicated that, if the stroke survivor could not use both hands at work, it would not be possible for him or her to cope with the work demands. The following quotes were shared to indicate how they felt about the physical sequelae:

“ . . . (employee name) . . . was working slower than other employees” (E03)

“If . . . (employee name) . . . can recover her memory and be able to pay attention to detail, she can come back to work” (E06)

“She has to talk properly again so that she can come back to work and be able to speak to customers” (E07)

“What will make it difficult for her to cope here at work is if she is not able to use both hands as she is supposed to scan documents and she can’t do this with one hand” (E13).

Stroke survivors’ lack of communication was considered a barrier to RTW. Some employers felt that a stroke survivor who did not contact the employer to update them of their progress and discuss their plans, would make it difficult for the employer to help them RTW:

“It is difficult to deal with an employee who does not communicate and expects the employer to help them. We can only help if we discuss these things . . . (employee name) . . . took a very long time away from work without contacting us to let us know what was happening since she had a stroke and it was difficult for us to get hold of her” (E14).

 

Employer-related barriers

Costs of reasonable accommodation which must be incurred by employers were highlighted as a barrier to RTW. Some employers indicated that they were sympathetic to the issues of RTW for stroke survivors; however, financial constraints did not enable them to facilitate stroke survivor RTW, as they would have to hire another person to cover some of the duties which the stroke survivor was no longer able to do because of his or her disability:

“Our company does not have the financial ability to get an additional staff member” (E07).

Being on prolonged sick leave was considered a barrier for RTW by some employers who indicated that it would be better to have a person go on physical incapacity pension which would take care of his or her salary. They indicated that having a person who did not cope with his or her work was also difficult as reduced production was costly for the company:

“It was difficult for the company as we can’t afford to have a staff member who does not complete a shift and who cannot finish their allocated duties. We had to let her go on incapacity pension and get a person who can do the job” (E14).

 

Environmental barriers

Some employers indicated that, if the environment was not accessible, it would be difficult for the stroke survivor to RTW:

“the work environment is not conducive to accommodate her. We don’t have ramps and have lots of stairs around the school
. . . This can make it difficult for her to walk around the school and to various classes”
(E25).

Not having a safe working environment was considered a hazard which could have cost implications in the long term, should the stroke survivor get injured while trying to work:

“If the work environment is not safe, like if a person has to lift heavy things which can hurt them, if they are still weak, this can cost the company a lot of money on insurance” (E22).

 

Comparison of perceived barriers and enablers of RTW between groups

The employers and stroke survivors generally identified similar enablers of, and barriers to, RTW. Stroke survivors, however, raised more workplace-related barriers to RTW which were within the control of the employer, such as lack of opportunities to be reasonably accommodated. Issues raised by the employers, which the stroke survivors did not mention, were safety in the workplace, willingness of the stroke survivor to RTW, unaffordable costs for reasonable accommodation, and maintaining production while the stroke survivor was on prolonged sick leave.

Stroke survivors in blue collar occupations identified the lack of light duty while regaining physical strength as the main barrier, and having an opportunity to practice job skills within the workplace as the main enabler, of RTW:

“Hard labour, like lifting and moving heavy boxes, standing for too long and walking around a lot. Working long hours. This will make it difficult for me to go back to work unless my employer allows me to do other things (light duty)” (P14).

Those in white collar occupations identified lack of support in the form of motivation and communication from their employers as the main barrier to RTW, and considered good cognitive function and good interpersonal working relationship to be the main enablers:

“I think I would only be able to go back to work if I can remember things, especially to count money as they will never allow me back at work if I can’t count money because the company would lose a lot of money if I make mistakes” (P09).

 

DISCUSSION

Enablers of RTW after stroke

Having an opportunity to be reasonably accommodated after stroke was considered the main RTW enabler by stroke survivors and their employers. Examples of accommodations mentioned by stroke survivors in this study included the need to work reduced hours and do less work per day at the beginning of RTW. This need is not unique as about 66% of stroke survivors in Treger et al.’s Israeli study reduced their working hours on RTW.3 Stroke survivors also identified the need for flexibility in the scheduling of work as some people might require extra time to prepare for work, and to travel to and from work. This enabler was also identified in various studies that established that employer flexibility and allowance for job modifications is one of the factors that enable successful RTW.9,13,22 In situations where a stroke survivor cannot RTW, arrangements can be made for transitional work (temporary modified work) which has been shown to facilitate early and sustained RTW.23,24

Some employers in this study indicated that they would not let a stroke survivor RTW if he/she had severe stroke with poor upper limb function. This was reported to have a strong correlation with decreased RTW rates in other studies.1,25-27 Fatigue was mentioned as a possible RTW barrier in this study, supporting findings from a previous study.28 Stroke survivors might have the ability to walk and use their upper limbs but might still suffer from poor endurance, resulting in limited ability to cope in the workplace.

Some stroke survivors and their employers mentioned the importance of having good working relationships which included those with co-workers. This illustrates that, even if the employer is willing to accommodate a person back to work, there is a need to have co-worker support.29 In some cases, advocacy is required to help build an understanding of disability among co-workers30 in order for them to be able to assist where necessary. Good communication between stakeholders helps to enhance understanding of the stroke survivor’s capabilities.23,31

Having an accessible work environment was mentioned as a factor that could contribute positively to stroke survivors RTW. Rhoda et al. highlighted the fact that environmental barriers such as lack of ramps could be more limiting for the stroke survivor than the neurological deficits.18

 

Barriers of return to work after stroke

Cognitive impairment (memory and attention) which was expressed, by stroke survivors, as the inability to remember job specifications and instructions, and the inability to pay attention and so avoid making mistakes when doing the work, were considered barriers to RTW. Lock et al. identified some stroke survivors who could not RTW due to poor memory and attention span, despite them not suffering from any physical impairment.32 Similar findings were reported by Balasooniya-Smeekens et al.33 who found that invisible impairments such as memory, personality changes and fatigue might make it difficult for a stroke survivor to stay at work. It is therefore important to identify stroke survivors with cognitive problems, especially attention and memory deficits. Knowledge of stroke survivors’ cognitive levels will increase their chances of receiving memory training during the rehabilitation process.34

In the current study, tiredness and the inability to work fast were identified as barriers to RTW. Companies that thrive on production require their employees to work fast to meet production demands. Besides speed, some stroke survivors indicated the need to rest frequently and this affects production. For stroke survivors to cope back in the workplace, employers need to make adaptations, in the form of working hours, work pace or the work environment. However, some employers indicated that some of these adaptations were unaffordable. In South Africa, the costs of workability assessments and making work adaptations are expected to be carried by the employer as stated in the Code of Good Practice on employment of people with disabilities.35 This can be costly for the employers, especially those with small companies.36

Safety in the workplace for stroke survivors was raised as a concern by most of the employers. This is not a unique finding as employers in a study by Kaye et al. were also concerned about the increased possibility of a workplace accident and injury to the stroke survivor, and the resultant increased insurance costs.37 It is therefore important to ensure that stroke survivors and employers receive education related to safe job performance and injury prevention.38 It is essential to visit the stroke survivors’ workplace to conduct a workability assessment as well as to educate employers and stroke survivors (employees) about safety issues.39

A few participants considered the high unemployment rate to be a barrier to RTW. The unemployment rate in South Africa was 26.5% in 2016.40 The stroke survivors were worried that, if they lost their current job, it would be difficult to find another. This fear is supported by the World Health Organization Report on Disability6 which states that laws that govern employment of people with disabilities seem to be successful in preventing discrimination among people who are already employed, and thus should be relatively easy to enforce when assisting a person with a disability to RTW rather than them finding a new job. However, it must be noted that, in South Africa, employees are protected by the employer Code of Good Practice within the Employment Equity Act No. 5535 which states that an employee should get an objective assessment to establish the extent to which he/she is able to perform work; the extent to which work conditions may be adapted; and the availability of a suitable alternative job before dismissal.

The difficulty in using public transport was identified as a barrier to RTW; similar findings have been reported in other studies.3,19 Accessing transport is not only about getting to the taxi rank, bus or train station. It also involves transport costs which can be a barrier to RTW, especially if a person must hire a car to move from one point to another due to challenges in accessing transport. This concurs with the 2002-2004 World Health Survey report that showed that transport costs ranked high as a barrier to community participation for people with disabilities, including RTW.41 This would make it difficult for a person to RTW, especially if he/she had to use public transport to get to the workplace. It is therefore important to address issues related to accessibility to the workplace as well as impairments and activity limitations.

Recommendations based on the findings of this study are as follows: there is a need for therapists to be involved in the RTW rehabilitation of stroke survivors, to do work ability assessments and to explore possibilities of reasonable job accommodation. Therapists can assist in communicating with employers and advise them about possible job accommodation, including strategies for rethinking job duties and engaging with stroke survivors to understand accommodation needs and ways of achieving job tasks. It is important to identify people with cognitive impairments early after stroke so that efforts can be made to increase awareness of the potential role that cognitive impairments might play in RTW interventions.

Limitations of this study are that a descriptive profile of employers, and the type and size of the companies, were not established; and that stroke survivors who did not want their employers to be contacted were excluded.

 

CONCLUSION

Employers and stroke survivors identified similar enablers of and barriers to RTW. Barriers that were unique to employers related to reasonable accommodation costs and safety in the workplace. Regular and early communication between the stroke survivor, employer and therapist, regarding RTW, can facilitate the process and increase the possibilities of reasonable accommodation at the workplace.

 

DECLARATION

The authors declare that they have no conflicts of interest.

 

ACKNOWLEDGEMENTS

The authors would like to thank the African Doctoral Dissertation Research Fellowship offered by the African Population Health Research Center in partnership with the International Development Research Centre for funding this study.

 

LESSONS LEARNED

1. The ability of employers to provide reasonable accommodation is dependent on their willingness to do so and not just on sympathising with the stroke survivors

2. Communication between employer, therapist and stroke survivor is necessary to discuss possible work accommodation, including strategies for rethinking job descriptions and creating a platform for informed decision making

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