Section 5 Returning to work after a brain injury

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Returning to

work after a

brain injury

The combined effects of the physical,

cognitive and behavioural changes described so far mean that many people with a brain injury will be unable to return to work, at least to their former occupation. People will need to consider a range of options according to the extent of their difficulties. These could include returning to work with reduced hours, retraining for alternative work, or undertaking supported or voluntary work. The most significantly disabled are unlikely to be able to manage a return to work and might consider other options such as attending a day services centre. (See Section 7, p105 for useful contacts.)

Research that has been carried out in recent years has consistently found that a lack of vocational rehabilitation is a major cause of people with severe brain injuries not being able to obtain or maintain employment. They may attempt to return to a job that is no longer suitable, because they have not received

advice on planning their return to work and the required supports are not in place.

It is important to get support in preparing to return to work. A vocational assessment is recommended. In some areas, the injured person can get help from the NHS in

accessing vocational rehabilitation through the community brain injury rehabilitation teams, particularly in relation to occupational therapy. Alternatively, contact the local Jobcentre Plus and ask to see a Disability Employment Advisor. The world of work places enormous pressure on people and it is important to consider how this will affect the individual.

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Work performance problems

Poor concentration and attention leading to distraction

How many times do we have to focus or shift our attention in everyday life, let alone a busy workplace? People with a brain injury, who had formerly to maintain and respond to more than one set of instructions or ideas, may find themselves now unable to tolerate distraction. Long shifts where sustained concentration is required could also prove problematic.

Poor memory

Poor memory can lead to difficulties in mastering new types of work. Even mild memory loss for managers, teachers, lawyers or secretaries can prove too high a burden to sustain employment in their fields.

Slowed information-processing/thinking

Slowed information-processing can lead to difficulty understanding complex information and subsequently acting upon that

information, e.g. following instructions given quickly, carrying them out or relaying them to others.

The above problems, either individually or in combination, can cause a permanent inability to perform as required in a job.

Inflexible thinking

Seeing things in black and white can lead to difficulty following procedural rules and appreciating options or another’s point of view. The person may seem to be showing traits of an anti-authority nature, whilst rigid thinking will often lead to argumentative behaviour that can prove irritating to workmates and supervisors.

Difficulty in planning

Difficulty in organising, problem-solving, making decisions, using judgement and initiative can all lead to an inability to work independently or in any work that requires multiple and complex activities. However, people lacking these skills may be able to find employment in jobs that have a routine structure.

Loss of initiative, drive and spontaneity

Loss of initiative can lead to an inability to carry out work-related tasks without being prompted.

Anxiety

Anxiety can lead to a loss of confidence and, possibly, to erratic behaviour.

Low tolerance of frustration/noise/stress

Low tolerance can lead to a quick temper, becoming easily upset and difficulty with working to deadlines.

Fatigue or tiredness

Tiredness can often make other problems seem worse and poor concentration will contribute to mistakes. Fatigue may result in days off work to recover.

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Reduced activities of daily living

Activities of daily living relate to a person’s ability to manage their everyday life, such as getting up on time in the morning, cooking, shopping, self-care, time management, organising money and transport, and so on. A reduction in these abilities can result in late or unreliable attendance. (See section 7, p105 for information on Momentum’s vocational rehabilitation programmes.)

Lack of insight and awareness

Lack of insight and awareness can lead to unrealistic expectations of work capability and a possible insensitivity to others. Poor interpersonal skills at work, such as impulsiveness, mood swings, etc., can all be problematic.

A number of factors impact on a successful return to work, including:

• The nature and severity of residual difficulties, particularly the degree of self-awareness and how well the person has adjusted to their disability

• The nature of the pre-injury occupation • The timing and management of the

return to work

• The employer and co-worker support Success in obtaining or sustaining employment depends on the person being able to do the job – they must have the cognitive and social skills that the job demands. When considering a return to work, it is very important to be realistic about this and to take advice from the rehabilitation team. Unrealistic expectations caused by reduced insight can present a formidable barrier to a successful return to work. There is no doubt that the degree of self-awareness and adjustment to difficulties is a critical factor in recovery.

People who have accepted their difficulties practise strategies to compensate and adapt. They open their minds to alternative suggestions for employment if a return to their pre-injury occupation is not feasible. In short, a person must accept their new circumstances before they can learn to use alternative strategies and realise “success” again.

It is extremely important to learn social skills to initiate a good working relationship with colleagues. Research has consistently shown that poor interpersonal skills are the biggest barrier to a successful return to work.

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Meet Erick

Forty-eight-year-old Erick Mason

from Northumberland suffered

horrific head injuries in a motorbike

accident in 2005, which left him

fighting for his life. Now he is back

working and is raising money to help

fund the services that got his life back

on track.

In 2005 I was out for a motorbike ride with a group of friends. We were travelling along fine when one of my friends, who was driving in front of me, crashed his motorbike. I threw myself off my own bike in the hope of avoiding a serious collision. But my leg became caught and I was catapulted along the road with the bike. I was rushed to the local hospital’s intensive care unit with a punctured lung, a broken arm and other severe internal injuries. My family was told to expect the worst but I survived. However, as a result of the accident, I also suffered brain damage to the frontal lobe leaving me with memory difficulties, loss of control over my

inhibitions, mood swings and changes to my personality.

After the accident I returned to work and tried to carry on as if everything was the same. Unfortunately, due to my brain injury

it was not, and after a while struggling on it got to the point where I gave up my job. Since my accident I am a totally different person and those who know me really well will all tell you that. It is extremely frustrating that I can’t do the same things that I could before the accident. I can’t multi-task at all and find it very difficult to retain new information. I suffered massive trauma to my head and I had to re-learn how to walk and eat. I also suffer from bad mood swings.

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But, thanks to Momentum Skills’ brain injury centre in Newcastle and its staff, I’m now able to get on with my life with my wife and three children. Before attending the centre I was in complete denial that I had brain damage. This led to me almost having a nervous breakdown as I tried to continue as if nothing had happened. I found it difficult to accept that I had changed as a person.

But the staff there helped me to realise that I will never be the same person again, and with their support I have been able to accept that and get on with my life. The support that I’ve had from Momentum Skills has been invaluable. I can’t thank them enough.

Momentum has helped to show me new ways of being able to carry out the tasks I had lost the ability to do, by learning new strategies such as using a calendar and daily diary to remember appointments and tasks. I have learned what triggers my anger issues and have put in place strategies to deal with these in a more controlled manor, and more importantly learned how to deal and control with my higher fatigue levels.

I started Momentum in September 2010, and while on the programme I secured a work placement in the motor industry. Once I completed the programme,

with the help of Momentum Skills, the placement turned into a permanent position and I now work 15 hours a week. Keeping the hours to this limit has allowed me to continue attending Momentum Skills, meaning I have support at hand if I need it.

It has also allowed me to take on the role of service user representative. I didn’t need to think very long before accepting this role, as I felt a sense of achievement being able to help service users and sharing what I have learned in the 9 years since my injury happened.

I also help to raise funds for the centre and recently organised a quiz night with disco and auction. Not only did the evening raise £3700, but it also helps me to improve my cognitive functioning and confidence. It’s just my way of saying thanks to Momentum Skills for saving me.

Momentum Skills provides a range of innovative vocational rehabilitation services for people with an acquired brain injury. Its brain injury rehabilitation programmes are offered in Aberdeen, Glasgow, South Lanarkshire, Ayrshire, the Scottish Borders, Newcastle and Birmingham. They offer comprehensive assessment, specialist training, job coaching, work placement and job

retention support. For further information, visit www.momentumskills.org.

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Management and

professional positions

Even a mild injury can have a serious impact on the executive skills required in the

workplace. Professional and senior executives will have particular problems and face great difficulty in returning to their pre-injury occupation because, as previously outlined, the executive skills are the ones most likely to have been impaired.

Having to consider routine work can be devastating for an executive used to performing a variety of complex and responsible tasks. However, it need not be boring. A variety of jobs are possible if the opportunity is available to impose structure and diversification.

Self-employed

In the case of people who were previously self-employed, it is important to be realistic and if a return to work does not seem viable, advice should be sought on whether it might be sensible to sell the business or perhaps employ someone else to run it.

Students

Students may also experience particular problems returning to study. Even a mild

injury can have a significant impact on students because of the demands on attention, memory and speed of thinking. Allowances might not be made because teachers may not be aware of the difficulties. Often, though, there is a student disability resource centre that can offer support. Severe injury may prevent continued study in higher education and affect career aspirations, which can be very difficult to deal with.

Returning to your

pre-injury occupation

When thinking of returning

to a previous job or position,

there are many options

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It is quite natural to want to go back to work as soon as possible. However, people often make the mistake of thinking because they are feeling physically able to return to work, that they will be able to cope with the wider demands of the job. Many jobs are lost because the person returns to work too soon. Typically, they will overestimate their abilities and underestimate the effects of fatigue on performance.

Many people expect to be able to work a full day straightaway, and finding out that this is not possible for various reasons can really damage confidence and self-belief. It

is therefore an essential part of the task of any rehabilitation team to help the person identify the most suitable type of future job and the optimum build-up of hours over a period of time, once all factors are taken into account.

Is it possible to go back to work too soon?

specialised neurological care “Thank you so very much for it all. You should be so proud of PJ Care I think it’s an outstanding operation.”

Liz, family member of one of our residents

PJ Care is a leading provider of specialist neurological care and neuro rehabilitation for people with progressive or acquired neurological conditions.

Our residents’ care is at the heart of everything we do. We strive to nurture dignity, independence and privacy through our purpose-built facilities, our highly trained multi-disciplinary teams, the care models we offer and the therapies and activities we provide.

We have three specialist neurological care centres in Milton Keynes and Peterborough. We’d love to show you around our

award-winning facilities.

To book a visit, please contact us on:

0330 20 20 305

or email:

[email protected]

Compassion. Commitment. Care.

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Meet Mandy

Thirty-nine-year-old Mandy

Donaldson sustained a brain injury

as a toddler when she fell from an

upstairs bedroom window. After

struggling through most of her life

without any support, in 2008 Mandy

finally asked for help. Now she is in a

job she enjoys and is undertaking a

national qualification.

When I was 3 years old, I fell from an upstairs bedroom window. My skull was fractured – I’ve been told my head was the size of ten footballs – and I also had a brain injury. From the age of 3 to 15 I also had epilepsy because of this.

I struggled through school mainly because I couldn’t remember much. The teachers would say, “Mandy must concentrate and ask more in class.” I went through life pretending I didn’t have a brain injury and to everyone around me I was quiet but “normal”.

Throughout my adult life, I had moved from job to job and tried going to college – I couldn’t settle or make a success of

anything. I never let on to people that I had a brain injury.

I had never asked anyone for help until I moved away from home in 2008. I eventually spoke to my GP who referred me to an occupational therapist. It was the first time I had ever asked anyone for help. It was through the occupational therapist that I found out about Momentum. I first tried the

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service in 2011, but I wasn’t ready then. But in May 2012, I decided to give it another go. Going to Momentum was a big deal for me but it’s turned out to be my saviour. The staff helped me to accept my brain injury and to start moving forward with my life.

While attending Momentum, I learned more about brain injury and strategies to deal with my memory problems and how to manage stress. I also learned skills in planning and time management. I was introduced to Rachel – my Momentum job coach – who helped me with my CV and with searching for suitable companies to apply for jobs with. I managed to get two work placements alongside each other. I started my first placement at a surgery, sorting out all the mail. I had a second placement at a housing organisation where I was assisting the PA to the Chief Executive with her duties.

The placements were great in helping me build up my confidence and learn skills I needed for work.

Now, I’m happy to say I am in paid employment as a mobile carer, which I’ve been doing for more than a year and am also undertaking a National Vocational Qualification.

With Momentum’s help I have come to terms with my brain injury and am doing a job that I enjoy. I have more confidence and nothing will knock me back now. I am not hiding my disability anymore – it’s a part of me and who I am. And the strategies that I have learned I now use daily. I’m really happy with my life now.

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Managing a return to work

A gradual return to work is important, as are easier working conditions and tasks. This will allow the person to build up their stamina and capabilities; a situation that may need to continue for quite an extended time. Ideally, people returning to work should start with just a few hours per day, building up hours over time as stamina improves. However, before a gradual return to work is considered, there should be evidence that the injured person can maintain concentration and have sufficient stamina to work safely and effectively for a specified period in the working day.

Easier working conditions may include a quieter working environment that is free from unnecessary distractions. Consideration will also have to be shown for any physical disabilities – wheelchair access, adapted computers, etc. Such special aids can be

obtained from a disability employment advisor, based at the local Jobcentre Plus, under the Access to Work scheme.

Having someone to act in a mentoring capacity may be useful. While an employer or line manager might not be able to find the time to devote to this, having somebody take on this role can be mutually beneficial. None of us are the best judges of how we are managing with new tasks in our work. This is of particular relevance to somebody with brain injury, so the employer just has to use common sense in dealing with the situation.

The advice to a person looking to

re-enter the employment market following brain injury is that it is often better to start off with some voluntary work or maybe a short college course, where strengths and

weaknesses can be identified early. If the person is still based within a hospital or

neurological centre, the occupational therapist will be able to refer them to the local disability employment advisor who, in turn (depending on locality), can outline available options as appropriate.

Ultimately, a successful return to work depends on:

• A good match between the job and current abilities/skills

• Sufficient stamina to get through the working day or hours agreed

• Attention and concentration adequate to carry out work tasks

• Acceptable interpersonal/social skills • Mentoring/job coaching

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Support from employers

and co-workers

The need for support from both a person’s employer and co-workers cannot be

overstated. It is very important that, at the very least, the employer or line manager or equivalent knows a little about the long-term effects of brain injury. With this knowledge, they will be able to provide support when and where necessary.

Like many people, employers tend to view disability as a physical condition. When they see no obvious outward signs, such as a wheelchair, they might assume the person is fine. Brain injury is often referred to as a “hidden disability”, and as such can easily lead to misinterpretation.

For example, loss of initiative or fatigue can be interpreted as laziness. Additionally, the person may be asked to stay late at work. Their commitment may lead them rarely to refuse such a request, but the required tasks may not be completed to a satisfactory standard. Because of these examples of potential misunderstanding, organisations such as Momentum Skills have job coaches whose role is to educate and support the employer as well as the employee with a brain injury.

Finding work is difficult enough for anyone, but there is no doubt that it is harder for people who have had a brain injury. The person may be unable to complete an application form

pre-interview or may have difficulty sufficiently impressing an interviewer; they may suffer from a reduced speed of thinking or not have regained sufficient social/interpersonal skills to be able to undertake a successful interview. Make contact with the disability employment advisor at the local Jobcentre Plus when the time is right. They can be of invaluable help.

Of course, starting work may be even more difficult for a young person who has not yet chosen a career or who has not had a job pre-injury. Choosing a suitable career or occupation without prior experience of the employment market is an incredibly daunting task. Support is available from the local Connexions or Careers Scotland Service or from the Jobcentre Plus disability employment advisor. Alternatively, get in touch with Momentum. (See Section 7, p105 for contact details.)

What about those who are

unemployed pre-injury?

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Meet Wayne

Forty-three-year-old Wayne Forbes

sustained two brain injuries within a

few years of each other while serving

in the army. Having spent his entire

adult life protecting his own country

and peacekeeping in others, he

felt without purpose when he was

medically discharged and unable to

find other employment. Now Wayne

is back working full-time and enjoying

life with his wife and three children.

I joined the army at just 16 years old. I saw my first action in Northern Ireland, before being transferred to Iraq in 1991 where I fought in the first Gulf War. I also saw action in Bosnia and Kosovo before returning to Iraq for a second time in 2001 to take part in further military action.

After completing my time in Iraq, I went on to be a sky diving specialist – demonstrating the sky diving skills used by the army at public events across Scotland.

However, in 2007 I was drafted into back action in Afghanistan. I spent 6 months in the desert

with my platoon fighting the Taliban. It was during one of these battles that I sustained my first brain injury after I was blown up by an improvised explosive device (IED). I was taken into hospital to recover for a period of only 6 weeks before returning to action as platoon sergeant. I remained in Afghanistan for the full 6-month tour before leaving for Germany. It was while in Germany in April 2010 that I sustained a second head injury, when I was the

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victim of assault and was hit across the back of the head with an iron pole – an injury that left me in an induced coma for about 5months. When I gained consciousness, I was transferred to Birmingham for rehabilitation – but at this point I couldn’t even remember my name and was still unaware of what had happened to me. After being medically discharged from the army, I was referred to Momentum Skills’ vocational rehabilitation programme – Pathways – in Aberdeen in July 2012.

As a consequence of my injuries, I was

experiencing cognitive difficulties, particularly with memory and attention. However I also had problems with the concept of being a “civvy” (a civilian). Having spent all of my adult life in the army, I had no experience of living as a civilian and was having difficulty adjusting to my new life with the added complication of having acquired brain injury and difficulties with post-traumatic stress disorder.

During my time at Momentum Skills, I worked hard to develop a whole new set of coping strategies and made a lot of changes to my way of thinking in order to adapt to my new set of circumstances. This journey of self discovery – with high and low points along the way – means that I now live independently and am employed full-time as a refuse collector. Momentum Skills in Aberdeen has been an excellent support. It

has helped me to learn more about my acquired brain injury and given assistance with helping me get back to work.

My hope for the future is that people like me, who have a brain injury, are given the information they need and are able to access the support of services – like Momentum Skills – when it’s needed.

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