Early Opportunities to Explore Occupational Identity Change: Qualitative Study of Return-To-Work Experiences After Stroke
Keywords:Stroke, Work, Employment, Vocational Rehabilitation, Community Participation, Social identification, Social Adjustment, Qualitative Research
Background: Rates of return-to-work after stroke are low, yet work is known to positively impact people’s wellbeing and overall health outcomes.
Objective: To understand return-to-work trajectories, barriers encountered, and resources that may be used to better support participants during early recovery and rehabilitation.
Participants: The experiences of 31 participants (aged 25–76 years) who had or had not returned to work after stroke were explored.
Methods: Interview data were analysed using reflexive thematic analysis methods within a broader realist research approach.
Results: Participants identified an early need to explore a changed and changing occupational identity within a range of affirming environments, thereby ascertaining their return-to-work options early after stroke. The results articulate resources participants identified as most important for their occupational explorations. Theme 1 provides an overview of opportunities participants found helpful when exploring work options, while theme 2 explores fundamental principles for ensuring the provided opportunities were perceived as beneficial. Finally, theme 3 provides an overview of prioritized return-to-work service characteristics.
Conclusion: The range and severity of impairments
experienced by people following stroke are broad, and therefore their return-to-work needs are diverse. However, all participants, irrespective of impairment, highlighted the need for early opportunities to explore their changed and changing occupational identity.
The aim of this study was to understand how best to support people returning to work after a stroke. A total of 31 people who had or had not been able to return to paid work after stroke were interviewed. We listened to their experiences and considered what worked best for different people with a range of needs and aspirations. People talked about wanting opportunities soon after their stroke to explore changing thoughts about themselves and their ability to return to work. Conversations with participants and their families, often starting very early after stroke, were important. People also wanted opportunities to practise skills they typically used at work, such as social skills or planning and organizational tasks. Through these ongoing conversations and opportunities to practise, people talked about gradually regaining their confidence in the skills they had retained after their stroke, rather than focusing only on the difficulties they were experiencing.
Carter K, Anderson C, Hacket M, Feigin V, Barber PA, Broad JB, et al. Trends in ethnic disparities in stroke incidence in Auckland, New Zealand, during 1981 to 2003. Stroke 2006; 37: 56-62. doi:10.1161/01.STR.0000195131.23077.85 DOI: https://doi.org/10.1161/01.STR.0000195131.23077.85
https://doi.org/10.1161/01.STR.0000195131.23077.85 DOI: https://doi.org/10.1161/01.STR.0000195131.23077.85
Feigin VL, Norrving B, Mensah GA, Fisher M, Iadecola C, Sacco R. Global Burden of Stroke. Circ Res 2017; 120: 439-448. doi:10.1016/S1474-4422(21)00252-0 DOI: https://doi.org/10.1161/CIRCRESAHA.116.308413
https://doi.org/10.1016/S1474-4422(21)00252-0 DOI: https://doi.org/10.1016/S1474-4422(21)00252-0
GBD 2016 Neurology Collaborators. Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019; 18: 439-458. doi:10.1016/S1474-4422(18)30499-X DOI: https://doi.org/10.1016/S1474-4422(18)30499-X
https://doi.org/10.1016/S1474-4422(18)30499-X DOI: https://doi.org/10.1016/S1474-4422(18)30499-X
Leng T, Xiong ZG. Treatment for ischemic stroke: from thrombolysis to thrombectomy and remaining challenges. Brain Circ 2019; 5: 8-11. doi:10.4103/bc.bc_36_18 DOI: https://doi.org/10.4103/bc.bc_36_18
https://doi.org/10.4103/bc.bc_36_18 DOI: https://doi.org/10.4103/bc.bc_36_18
Ranta A. Projected stroke volumes to provide a 10-year direction for New Zealand stroke services. New Zeal Med J 2018; 22: 15-28.
Feigin VL, Krishnamurthi RV, Barker-Collo S, McPherson KM, Barber PA, Parag V, et al. 30-year trends in stroke rates and outcome in Auckland, New Zealand (1981-2012): a multi-ethnic population-based series of studies. PLoS One 2015; 10: 1-28. doi:10.1371/journal.pone.0134609 DOI: https://doi.org/10.1371/journal.pone.0134609
https://doi.org/10.1371/journal.pone.0134609 DOI: https://doi.org/10.1371/journal.pone.0134609
Thompson SG, Barber PA, Gommans JH, Cadilhac DA, Davis A, Fink JN, et al. Geographic disparities in stroke outcomes and service access: a prospective observational study. Neurology 2022; 99: e414-e426. doi:10.1212/WNL.0000000000200526 DOI: https://doi.org/10.1212/WNL.0000000000200526
https://doi.org/10.1212/WNL.0000000000200526 DOI: https://doi.org/10.1212/WNL.0000000000200526
Wyeth EH, Wilson S, Nelson V, Harcombe H, Davie G, Maclennan B, et al. Participation in paid and unpaid work one year after injury and the impact of subsequent injuries for Māori: results from a longitudinal cohort study in New Zealand. Injury 2022; 53: 1927-1934. doi:10.1016/j.injury.2022.03.006 DOI: https://doi.org/10.1016/j.injury.2022.03.006
https://doi.org/10.1016/j.injury.2022.03.006 DOI: https://doi.org/10.1016/j.injury.2022.03.006
Fadyl JK, Anstiss D, Reed K, Levack WMM. Living with a long-term health condition and seeking paid work: qualitative systematic review and thematic synthesis. Disabil Rehabil 2022; 44: 2186-2196. doi:10.1080/09638288.2020.1826585 DOI: https://doi.org/10.1080/09638288.2020.1826585
https://doi.org/10.1080/09638288.2020.1826585 DOI: https://doi.org/10.1080/09638288.2020.1826585
Royal Australasian College of Physicians, Australasian Faculty of Occupational and Environmental Medicine. Australian and New Zealand Consensus Statement on the Health Benefits of Work. Sydney, 2011. [cited 2022 Oct 2]. Available from: www.racp.edu.au
Sen A, Bisquera A, Wang Y, McKevitt CJ, Rudd AG, Wolfe CD, et al. Factors, trends, and long-term outcomes for stroke patients returning to work: The South London Stroke Register. Int J Stroke. 2019; 14: 696-705. doi:10.1177/1747493019832997 DOI: https://doi.org/10.1177/1747493019832997
https://doi.org/10.1177/1747493019832997 DOI: https://doi.org/10.1177/1747493019832997
Schwarz B, Claros-Salinas D, Streibelt M. Meta-synthesis of qualitative research on facilitators and barriers of return to work after stroke. J Occup Rehabil 2018; 28: 28-44. doi: 10.1007/s10926-017-9713-2 DOI: https://doi.org/10.1007/s10926-017-9713-2
https://doi.org/10.1007/s10926-017-9713-2 DOI: https://doi.org/10.1007/s10926-017-9713-2
Murray A, Watter K, McLennan V, Vogler J, Nielsen M, Jeffery S, et al. Identifying models, processes, and components of vocational rehabilitation following acquired brain injury: a systematic scoping review. Disabil Rehabil 2022; 44: 7641-7654. doi:10.1080/09638288.2021.1980622 DOI: https://doi.org/10.1080/09638288.2021.1980622
https://doi.org/10.1080/09638288.2021.1980622 DOI: https://doi.org/10.1080/09638288.2021.1980622
Waddell Gordon, Burton AKim, Kendall Nicholas. Vocational rehabilitation: what works, for whom, and when? TSO London 2008. [cited 2022 Oct 2]. Available from: http://eprints.hud.ac.uk/id/eprint/5575/
Fadyl JK, McPherson KM. Understanding decisions about work after spinal cord injury. J Occup Rehabil 2010; 20: 69-80. doi:10.1007/s10926-009-9204-1 DOI: https://doi.org/10.1007/s10926-009-9204-1
https://doi.org/10.1007/s10926-009-9204-1 DOI: https://doi.org/10.1007/s10926-009-9204-1
Krause JS, Terza J v, Saunders LL, Dismuke CE. Delayed entry into employment after spinal cord injury: factors related to time to first job. Spinal Cord 2010; 48: 487-491. doi:10.1038/sc.2009.157 DOI: https://doi.org/10.1038/sc.2009.157
https://doi.org/10.1038/sc.2009.157 DOI: https://doi.org/10.1038/sc.2009.157
Middleton JW, Johnston D, Murphy G, Ramakrishnan K, Savage N, Harper R, et al. Early access to vocational rehabilitation for spinal cord injury inpatients. J Rehabil Med 2015; 47: 626-31. doi:10.2340/16501977-1980 DOI: https://doi.org/10.2340/16501977-1980
https://doi.org/10.2340/16501977-1980 DOI: https://doi.org/10.2340/16501977-1980
Dunn JA, Martin RA, Hackney JJ, Nunnerley JL, Snell DL, Bourke JA, et al. Developing A Conceptual Framework for Early Intervention Vocational Rehabilitation for People Following Spinal Cord Injury. J Occup Rehabil 2022; doi:10.1007/s10926-022-10060-9. DOI: https://doi.org/10.1007/s10926-022-10060-9
https://doi.org/10.1007/s10926-022-10060-9 DOI: https://doi.org/10.1007/s10926-022-10060-9
Dunn JA, Hackney JJ, Martin RA, Tietjens D, Young T, Bourke JA, et al. Development of a programme theory for early intervention vocational rehabilitation: a realist literature review. J Occup Rehabil 2021; 3: 730-743. doi:10.1007/s10926-021-10000-z DOI: https://doi.org/10.1007/s10926-021-10000-z
https://doi.org/10.1007/s10926-021-10000-z DOI: https://doi.org/10.1007/s10926-021-10000-z
Accident Compensation Corporation. Getting back to work after an injury [cited 2022 Aug 12]. Available from: https://www.acc.co.nz/im-injured/financial-support/return-to-work/
Paul C, Derrett S, Mcallister S, Herbison P, Beaver C, Sullivan M. Socioeconomic outcomes following spinal cord injury and the role of no-fault compensation: longitudinal study. Spinal Cord 2013; 51: 919-925. doi:10.1038/sc.2013.110. DOI: https://doi.org/10.1038/sc.2013.110
https://doi.org/10.1038/sc.2013.110 DOI: https://doi.org/10.1038/sc.2013.110
Dunn J, Martin RA, Hackney JJ, Nunnerley JL, Snell D, Bourke JA, et al. Early vocational rehabilitation for people with spinal cord injury: a research protocol using realist synthesis and interviews to understand how and why it works. BMJ Open 2021; 11: 1-8. doi:10.1136/bmjopen-2021-048753 DOI: https://doi.org/10.1136/bmjopen-2021-048753
https://doi.org/10.1136/bmjopen-2021-048753 DOI: https://doi.org/10.1136/bmjopen-2021-048753
Snell DL, Hackney JJ, Maggo J, Martin RA, Nunnerley JL, Bourke JA, et al. Early vocational rehabilitation after spinal cord injury: a survey of service users. J Vocat Rehabil 2021; 55: 323-333. doi:10.3233/JVR-211166 DOI: https://doi.org/10.3233/JVR-211166
https://doi.org/10.3233/JVR-211166 DOI: https://doi.org/10.3233/JVR-211166
Martin RA, Nunnerley JL, Young T, Hall A, Snell DL, Hackney JJ, et al. Vocational wayfinding following spinal cord injury: in what contexts, how and why does early intervention vocational rehabilitation work? J Vocat Rehabil 2022; 56: 243-254. doi: 10.3233/JVR-221189 DOI: https://doi.org/10.3233/JVR-221189
https://doi.org/10.3233/JVR-221189 DOI: https://doi.org/10.3233/JVR-221189
Braun V, Clarke V. Conceptual and design thinking for thematic analysis. Qual Psychol 2022; 9: 3-26. doi.org/10.1037/qup0000196 DOI: https://doi.org/10.1037/qup0000196
https://doi.org/10.1037/qup0000196 DOI: https://doi.org/10.1037/qup0000196
Shaw J, Gray CS, Baker GR, Denis JL, Breton M, Gutberg J, et al. Mechanisms, contexts and points of contention: operationalizing realist-informed research for complex health interventions. BMC Med Res Methodol 2018; 18: 1-12. doi:10.1186/s12874-018-0641-4 DOI: https://doi.org/10.1186/s12874-018-0641-4
https://doi.org/10.1186/s12874-018-0641-4 DOI: https://doi.org/10.1186/s12874-018-0641-4
Emmel N, Greenhalgh J, Manzano A, Monaghan M, Dallin S. Doing realist research. London: SAGE; 2018. DOI: https://doi.org/10.4135/9781526451729
https://doi.org/10.4135/9781526451729 DOI: https://doi.org/10.4135/9781526451729
Ellis-Hill C, Payne S, Ward C. Using stroke to explore the Life Thread Model: An alternative approach to understanding rehabilitation following an acquired disability. Disabil Rehabil 2008; 30: 150-159. doi:10.1080/09638280701195462 DOI: https://doi.org/10.1080/09638280701195462
https://doi.org/10.1080/09638280701195462 DOI: https://doi.org/10.1080/09638280701195462
Carragher M, Steel G, O'Halloran R, Torabi T, Johnson H, Taylor NF, et al. Aphasia disrupts usual care: the stroke team's perceptions of delivering healthcare to patients with aphasia. Disabil Rehabil 2021; 43: 3003-3014. doi:10.1080/09638288.2020.1722264 DOI: https://doi.org/10.1080/09638288.2020.1722264
https://doi.org/10.1080/09638288.2020.1722264 DOI: https://doi.org/10.1080/09638288.2020.1722264
Kohler M, Mayer H, Kesselring J, Saxer S. (Can) not talk about it - urinary incontinence from the point of view of stroke survivors: a qualitative study. Scand J Caring Sci 2017; 32: 371-379. doi:10.1111/scs.12471 DOI: https://doi.org/10.1111/scs.12471
https://doi.org/10.1111/scs.12471 DOI: https://doi.org/10.1111/scs.12471
Hackett ML, Anderson CS. Frequency, management, and predictors of abnormal mood after stroke: the Auckland Regional Community Stroke (ARCOS) Study, 2002 to 2003. Stroke 2006; 37: 2123-2128. doi:10.1161/01.STR.0000231387.58943.1f DOI: https://doi.org/10.1161/01.STR.0000231387.58943.1f
https://doi.org/10.1161/01.STR.0000231387.58943.1f DOI: https://doi.org/10.1161/01.STR.0000231387.58943.1f
Harwood M, Ranta A, Thompson S, Ranta S, Brewer K, Gommans J, et al. Barriers to optimal stroke service care and solutions: a qualitative study engaging people with stroke and their whānau. New Zeal Med J 2022; 135: 81-93.
Pene BJ, Aspinall C, Wilson D, Parr J, Slark J. Indigenous Māori experiences of fundamental care delivery in an acute inpatient setting: a qualitative analysis of feedback survey data. J Clin Nurs 2021; 31: 3200-3212. doi:10.1111/jocn.16158 DOI: https://doi.org/10.1111/jocn.16158
https://doi.org/10.1111/jocn.16158 DOI: https://doi.org/10.1111/jocn.16158
McAllister S, Derrett S, Audas R, Herbison P, Paul C. Do different types of financial support after illness or injury affect socio-economic outcomes? A natural experiment in New Zealand. Soc Sci Med 2013; 85: 93-102. doi:10.1016/j.socscimed.2013.02.041 DOI: https://doi.org/10.1016/j.socscimed.2013.02.041
https://doi.org/10.1016/j.socscimed.2013.02.041 DOI: https://doi.org/10.1016/j.socscimed.2013.02.041
Cameron JI, Naglie G, Silver FL, Gignac MAM. Stroke family caregivers' support needs change across the care continuum: a qualitative study using the timing it right framework. Disabil Rehabil 2013; 35: 315-324. doi:10.3109/09638288.2012.691937 DOI: https://doi.org/10.3109/09638288.2012.691937
https://doi.org/10.3109/09638288.2012.691937 DOI: https://doi.org/10.3109/09638288.2012.691937
Rigby H, Gubitz G, Phillips S. A systematic review of caregiver burden following stroke. Int J Stroke 2009; 4: 285-292. doi:10.1111/j.1747-4949.2009.00289.x DOI: https://doi.org/10.1111/j.1747-4949.2009.00289.x
https://doi.org/10.1111/j.1747-4949.2009.00289.x DOI: https://doi.org/10.1111/j.1747-4949.2009.00289.x
Karanika-Murray M, Biron C. The health-performance framework of presenteeism: towards understanding an adaptive behaviour. Hum Relat 2020; 73: 242-261. doi:10.1177/0018726719827 DOI: https://doi.org/10.1177/0018726719827081
https://doi.org/10.1177/0018726719827081 DOI: https://doi.org/10.1177/0018726719827081
Jones F, Kulnik ST. Self-Management. In: Lennon S, Verheyden G, Ramdharry G, editors. Physical management for neurological conditions e-book. Amsterdam: Elsevier; 2018, p. 379-396. ISBN: 9780702077234.
Fu V, Weatherall M, McPherson K, Taylor W, McRae A, Thomson T, et al. Taking Charge after Stroke: a randomized controlled trial of a person-centered, self-directed rehabilitation intervention. Int J Stroke 2020; 15: 954-964. doi:10.1177/1747493020915144. DOI: https://doi.org/10.1177/1747493020915144
https://doi.org/10.1177/1747493020915144 DOI: https://doi.org/10.1177/1747493020915144
Harwood M, Weatherall M, Talemaitoga A, Barber PA, Gommans J, Taylor W, et al. Taking charge after stroke: promoting self-directed rehabilitation to improve quality of life - a randomized controlled trial. Clin Rehabil 2012; 26: 493-501. doi:10.1177/0269215511426017 DOI: https://doi.org/10.1177/0269215511426017
https://doi.org/10.1177/0269215511426017 DOI: https://doi.org/10.1177/0269215511426017
How to Cite
Copyright (c) 2023 Rachelle A. Martin, Julianne K. Johns, Jonathan J. Hackney, John A. Bourke, Timothy J. Young, Joanne L. Nunnerley, Deborah L. Snell, Sarah Derrett, Jennifer A. Dunn
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All digitalized JRM contents is available freely online. The Foundation for Rehabilitation Medicine owns the copyright for all material published until volume 40 (2008), as from volume 41 (2009) authors retain copyright to their work and as from volume 49 (2017) the journal has been published Open Access, under CC-BY-NC licences (unless otherwise specified). The CC-BY-NC licenses allow third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.