WCMT-Melissa-Kelly

hansnzst

Specialist Spinal Vocational Rehabilitation

Mel Kelly

Kaleidoscope

Research undertaken in 2014


Acknowledgements

This research was made possible thanks to the Winston Churchill Memorial Trust, for granting

me a Fellowship to travel to the U.S, UK and Switzerland. I am also grateful to the New Zealand

Spinal Trust for their kind support. I would like to thank the hospitals and spinal associations that

hosted me and whom provided insight and expertise that greatly assisted my research.

I thank a number of valued colleagues for assistance and suggestions that greatly improved the

manuscript, also Tracey Croot who reminded me to think about what I wanted to achieve and not

limiting my vision, by considering the resourcing challenges.

To the patients I have supported, celebrating your successes no matter how small, brings me such

joy; by no means is this ‘just a job’ to me. There are many of your stories to tell; be it work

related or not and you have allowed me into your lives. I thank you for being vulnerable,

courageous and trusting in the ability to be knocked down but get back up again. You inspire me.

Last, and certainly not least, to my beautiful family-thank you.

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Contents

Executive summary Page 3

Introduction – Kaleidoscope ‘Partnering people into Work Programme’ Page 5

Research Fellowship Objectives Page 7

SECTION 1 - History and Observations of the visited locations

Rusk - New York, USA Page 9

Burke - New York, USA Page 14

Paraplegic Centre, Notwill, Switzerland Page 17

Stoke Manderville, United Kingdom Page 21

Spinal Injuries Association, United Kingdom Page 23

SECTION 2 - Key areas to address

A strategic collaborative approach is needed Page 25

Community integration Page 27

SECTION 3 - Resulting Action

Great Expectations Project – Employers Page 29

Ability Awareness Learning Experience Page 31

Patient Workshops – Outreach and extension of service Page 32

Conclusion Page 33

References Page 35

Appendices

Appendix One: Model Explanation of ‘The Kaleidoscope Way’

Appendix Two: Return to work in the context of Kaleidoscope

Appendix Three: Te Whare Tapa Whā Māori Model of Health, NZ

Appendix Four: Winston Churchill Memorial Trust Fellowship schedule, May 2014

Appendix Five: Example schedule, Swiss Paraplegic Centre, Notwill

Appendix Six: Pictorial Fellowship highlights

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Executive Summary

For the 770 persons with a spinal cord injury (SCI) that Kaleidoscope has supported since 2003,

it is often impossible to imagine life without work, life without meaning, and life without

purpose. For many, work is the fabric of their daily lives – how they communicate with each

other, social network, be a role model to their children, support themselves and their family as

well as contributing to the global economy. Following SCI the top four questions a person asks

are:

1. Will I Survive?

2. Will I walk again?

3. Can I still have sex?

4. Will I work again?

With vocational rehabilitation being delivered in the acute phase following serious SCI, work is

being addressed much sooner as part of rehabilitation. For many, just knowing someone is there

to support the area of work, liaise with an employer, or to address a fear is often enough;

involving the family is also vital.

The opportunity provided to me by the Winston Churchill Memorial Trust (WCMT) allowed me

to visit four internationally respected spinal hospitals. An insight into how vocational

rehabilitation was delivered in other hospital environments and the community integration

practices, would allow further development of Kaleidoscope.

As a result of my learnings I have proposed three initiatives addressing each area; as well as

making recommendations. The three initiatives are as follows:

1. Expanding the Kaleidoscope service by piloting a group work readiness series - By

hearing how other people tackle problems and make positive changes, it is my hope that

patients will discover a whole range of strategies for facing their own concerns. The aim

is to educate and build confidence, recognise shared experiences and develop a new set of

skills and resources for community patients and where appropriate inpatients.

2. The ‘Great Expectations’ Project is redeveloping our employer education and aims to

transform attitudes – working to support employers when they question what is possible,

accessibility is embraced and they employ a person with a SCI. Complimentary to this is

formulation of a Business Advisory Committee

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3. Ability Awareness Learning Experience - Exploring the role of people with disabilities in

the community enables pupils or employees to have an appreciation of SCI, but also

awareness of what people ‘can do’ and how they do it

Preparing, resourcing and delivering a number of initiatives is a good start. But my primary

recommendation, ahead of community engagement, is collaboration. With the release of the

Spinal Cord Impairment Action Plan (SCIAP, 2014), this is a call to action! So Kaleidoscope

will work towards improving vocational support for the SCI community in the future by:

1. Better educating healthcare professionals from non-specialist settings as well as local

vocational provider knowledge of SCI. Kaleidoscope has the skills and resources in place to

deliver this nationally and a collaborative model of engagement could be investigated and put in

place.

2. Master classes for employers - education and a lived client experience (invited consumer)

3. Promoting and growing a societal expectation that a person will work following a SCI.

4. Collaboration of inpatient – outpatient vocational providers during the discharge planning

phase to enhance the patient journey and continuity.

5. Research in the acute vocational rehabilitation setting. A quantitative evaluation of data

collection and emerging themes would be valuable.

6. Supporting clinical colleagues in the implementation of the SCIAP, a collective multidisciplinary

approach

7. Working with both ACC and the MOH where we can contribute to their education and

vision, as well as add value through planning and preparation support

My primary learning was that the vocational programmes visited were better resourced, mainly

due to funding. The teams were greater in size and in dedicated singular roles. In saying this,

excellent results are being achieved for spinal patients following vocational rehabilitation in NZ

and in many cases Kaleidoscope is leading the way.

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Introduction – Kaleidoscope ‘Partnering people into Work Programme’

According to a Disability Survey conducted in 2013 by Statistics NZ, 24 percent of the New

Zealand population is identified as disabled, a total of 1.1 million people. The increase from the

2001 rate (20 percent) is partly explained by an ageing population.

At inauguration of Kaleidoscope, for the population who had a serious SCI, as a result of an

accident and who were entitled to ACC Earnings Related Compensation (ACC ERC), the

proportion of people confirmed in full or part-time work was 12%, implying an unemployment

rate of a staggering 88%.

During the course of the report I will refer to SCI, which covers serious spinal cord injury or

illness (with a neurological diagnosis). Further to this the use of the word patient pertains to

those persons engaged in vocational rehabilitation be it in the acute, rehabilitation or community

setting.

Kaleidoscope was formed in response to a clear need, and driven by a man Professor Alan

Clarke. He first formed the New Zealand Spinal Trust (NZST) in 1994 to address the unmet

needs of rehabilitation, information, research, advocacy and support for people with spinal cord

injuries throughout New Zealand. The NZST is firmly focused on supporting independent living

and improving the quality of rehabilitation through initiatives, projects and programmes that

directly benefit people with a SCI. Professor Clarke said the language of good recovery is

positive and personal, not cautious, p.c. or impersonal and institutional. He named this new

approach the ‘New Rehabilitation’ which encourages each person to steer a new course for

themselves, in the sure knowledge that fulfillment and happiness is achievable. If you think this

sounds soft and fuzzy you are right. Serious recovery is very personal and involves hope, trust

and happiness.

Kaleidoscope is an early intervention vocational rehabilitation programme set up in 2003,

dedicated to getting people who have a SCI into meaningful and sustainable employment. We

have paved the way forward in developing a model of practice (Appendix 1.) which provides

explanation of how we engage patients and gives context to what we do (Appendix 2.).

Kaleidoscope is a programme of the NZST based at both the Burwood and Auckland Spinal

Rehabilitation Units and also delivering services at Middlemore Hospital. The service delivered

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is specialist spinal vocational rehabilitation, both to acute patients and community patients.

Kaleidoscope’s guiding principles are:

• Everyone can have a great job

• It’s healthy to be working

• The sooner the better

• There are thousands of work opportunities

• Personal networks are the key

• The process for getting a job is the same as before

• You can do it yourself – whatever it takes!

• Your life experiences give you unique qualifications

The Kaleidoscope programme undertakes vocational

rehabilitation work with people much earlier in their

rehabilitation, i.e. 80% of patients are engaged within three

weeks post SCI. This, combined with the holistic approach of

the multi-disciplinary team engagement, sets these people up to

powerfully re-enter the job market. Specialist Vocational

Consultants provide on-going individual career coaching with a

strong emphasis on the patient doing as much of the work as

possible. Dependency can be a learned behaviour and we

recognise this and want our patients to own their vocational

rehabilitation, receive education and feel empowered.

The other key aspect of the Kaleidoscope programme and

crucial to its success is engaging employers early. Further to

this, the close involvement of the local business community,

tertiary training institutes and the persons family. This approach

builds the patient’s confidence, self-awareness and improves

their chances of getting jobs. The maintenance of hope and building resilience is recognised and

carefully considered by the Kaleidoscope programme.

“I haven’t fallen through the cracks

because Kaleidoscope didn’t allow

them to appear, and by being at work

even just for lunch to start with, filled

a social void and a purpose for the

effort of just getting there. Work is

more than just a job and money and

now I see what Kaleidoscope has

always seen.

As a child a favourite toy of mine was

a kaleidoscope, and now to me, a SCI

at first is like a kaleidoscope of dark

and broken pieces that won’t stop

spinning to allow you to make sense of

what has happened. BSU has put the

colour back in my ‘kaleidoscope of

life’ and now it even stops so I can

enjoy the new and wonderful things I

see and do.”

Kaleidoscope patient – 2011

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Now, in 2015, the SCI Return to Work rate for patients that had received Kaleidoscope services,

either as an inpatient or as a community patient is, 60% in paid employment. This is

represented by 348 people.

Our aim is to ensure New Zealanders with a SCI are valued, productive and participating

citizens. Kaleidoscope will enrich not only the persons’ life, but the NZ community; through

inclusion and understanding.

Research Fellowship Objectives

The primary focus of my fellowship was to examine the vocational hospital services available at

international renowned SCI centres and look at initiatives for community inclusion. Further to

this, I aimed to access any educational SCI resources provided to patients; with the intention of

enhancing overall wellness through work. This is in line with Te Whare Tapa Whā; the Māori

health model supporting physical, mental, spiritual and family wellness (see Appendix 3.).

I’d been questioning how to provide better support and education to New Zealand employers

about hiring people with SCI. How could we better promote and encourage society as a whole

that people with disabilities can participate in work and the value of it to everyone?

The invaluable knowledge gained from the ability to learn from other countries delivering

services, was to support the development and delivery of the Kaleidoscope (Partnering People

into Work) Programme nationwide. Kaleidoscope is the only acute vocational rehabilitation

programme in New Zealand dedicated to getting people who have a SCI back into full or part

time employment – one step towards a fully independent, productive and confident life. To date

we have had institutes worldwide visiting and learning from our programme, as well as

providing training internationally; the acute aspect is the most unique element. The primary

objectives I worked on are:




To meet with other organisations that provided vocational rehabilitation services.

To discover and learn about other initiatives in the vocational rehabilitation field.

To build networks with other agencies doing similar work.

To improve the Kaleidoscope programme and serve as a rehabilitation model/specialist

programme for a nationwide audience of community development practitioners.

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Four specialist centres were selected because of their approach to rehabilitation, international

respect and that vocational support was being delivered in a hospital environment; a timetable of

my travels can be found in (Appendix 4).

With rates of 130 - 180 New Zealanders a year acquiring a SCI through accident or illness,

demand continues to grow. The injured person might be a young person yet to leave home, a

parent with a family growing up, the main breadwinner or business-owner or an older person

who had spent years planning out their retirement. Kaleidoscope’s support may last months or in

some minuet cases years, depending on the individuals’ ability to adapt, up skill or change

direction. My goal and that of the NZST is to ensure that this effective and valuable service is

available to everyone nationwide whenever they need it. Securing employment or re-launching a

business, the benefits are obvious in terms of independence and financial security; also though,

valuable skills and abilities return to the local economy and community.

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SECTION 1 - History and Observations of the visited locations

Rusk - New York, USA

History

Dr. Howard A. Rusk, widely considered “the father of rehabilitation medicine”, founded the

Institute for Rehabilitation Medicine in 1948 (In 1984, the institute was renamed in his honour.)

Drawing on his experience treating wounded soldiers during World War II, Dr. Rusk developed

the Rusk Institute around the philosophy that rehabilitation medicine provides care for the entire

person-not only their illness or disability, but also their emotional, psychological and social

needs.

I selected this institute due to the extensive vocational department, but also because the

philosophy aligned with that of Kaleidoscope and the Māori Model of Health - Te Whare Tapa

Whā (see Appendix 3). With its strong foundations and four equal sides, the symbol of the

wharenui (house) illustrates the four dimensions of Māori well-being. Should one of the four

dimensions be missing or in some way damaged, a person, or a collective may become

‘unbalanced’ and subsequently unwell. In the NZ healthcare system, we focus and treat the

physical presentation and the Māori health model otherwise known as the four cornerstones, also

recognises the spiritual wellness, family inclusion (wairua) and the balance of the mind.

Among its many innovations, the Rusk Institute pioneered vocational training for people with a

range of disabilities. This is accessible for multiple disabilities; those with a SCI are part of this

integral service.

Rusk’s approach to Rehabilitation

Rusk was also the first rehabilitation hospital to adopt a formalised multidisciplinary team

approach to rehabilitation. In this approach, the attending rehabilitation physician evaluates the

patient, and then develops an individualised treatment plan that may involve sessions with many

different specialists - including physical, occupational, speech and vocational therapists,

swallowing specialists, cognitive, music and recreational therapists, psychologists, nutritionists

and social workers.

In addition to caring for the patient’s physical condition, the rehabilitation team addresses the

challenges of developing new strategies for daily living; the psychological adjustment of coping

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with change and uncertainty; the need for new forms of support for patients and their loved ones;

and techniques for managing pain in order to improve comfort and aid healing. Patients and their

families are important members of the care team as well. Through this team approach which is

shared internationally, including NZ, patients receive coordinated care that includes a broad

array of resources and therapies, carefully designed to help with each stage of recovery.

Rusk consists of the following sites; I visited sites 2 and 3.

1. Rusk at the NYU Langone Main Campus (530 First Avenue - 9th Floor) - inpatient adult

rehabilitation

2. Rusk at 17th Street (301 East 17th Street, in the Hospital for Joint Diseases) – inpatient

adult rehabilitation and inpatient and outpatient paediatric rehabilitation

3. The Ambulatory Care Centre (240 East 38th Street) – outpatient adult rehabilitation

4. The Centre for Musculoskeletal Care (333 East 38th Street) – outpatient adult

orthopaedic/musculoskeletal rehabilitation

Vocational Services at NYU Langone’s Rusk Rehabilitation

The vocational programme has been an integral part of NYU Langone’s Rusk Rehabilitation

since its inception. The components offered are:

Vocational counselling services

Diagnostic Vocational evaluation

Work Readiness and Job Skills Training Programme

Computer Skills Training

Job Placement Services

Vocational Rehabilitation for Limb Loss

o Commencing during the pre-prosthetic Programme

Business Advisory Committee

Vocational Evaluation Service

Vocational Evaluation Services is an in-house programme which is offered to outpatients and the

manner, in which this service is setup, allows the consultants to ‘learn from the patients’. The

primary goals are self-awareness, career exploration and empowering the person; respecting their

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different disabilities and skills.

The environment is a small

classroom setting, factoring in

multiple assessment stations

such as desks, workshop tasks

and a computer laboratory area

(shown to the right). Patients

are given tasks/assessments and

consultants work with the

person, as well as observing

behaviour; indicating preferred

learning styles, vocational

strengths and any other

highlighted considerations. The

sessions that I observed

included the following tasks:

A high school level mathematics practice test

An aptitude exercise, whilst being timed

Building a model from a manual

Writing a CV on the computer

Solving a puzzle

Feedback is provided throughout the evaluation period and consideration is given to each

individual. Each person has a journal to record daily about vocational activities, support and

captures their thoughts.

Initial evaluation is for a period of 10 – 15 days, followed by a case conference which is patient

led. Following the vocational assessments the skills, interests, academic history, work tolerance

and aptitude formulate a vocational objective and tailored rehabilitation plan. The plan is likely

to include further training, work readiness support or referral to job placement services.

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Work Readiness and Job Skills Training programme

In participating with the group who consented to my presence, I was able to observe the benefits

of a group job skills method of delivery, versus 1:1 consulting. The vocational consultant

facilitating these sessions provided an encouraging environment where patients shared openly

and really engaged in discussion. They were contributing to each other’s growth and found

comfort in the similar challenges of job searching. Tools utilised, that we also use in NZ, were

both behavioural and motivational interviewing, as well as reflective listening and a work

readiness workbook.

The seminar I took part in covered:

What employers look for when hiring staff

Thought for discussion: People leave managers, not jobs

Disability and self-promotion

Using initiative in your job search

Things hiring managers wish you knew: Alison Green

How to target the right jobs

Your soft skills and specific job skills

The ups and downs of job search - peer support amongst the group

Following participation in the Rusk Rehabilitation’s Work Readiness and Job Skills Training

Programme, participants are able to develop good work behaviours, and job skills in actual

workplace settings. Participants are placed in offices, housekeeping areas, food service

operations, information technology services, patient admitting areas, employee health services,

and other worksite locations, either at NYU Langone or at external organisations. Participants

receive supervised training and gain real work experience while refining their job performance

and skills; in NZ we call this a work trial, which also tests a person’s capacity to work.

The vocational consultant monitors the participant’s progress and provides job coaching as

needed. Patients who complete the programme may either get placed in a job or be referred to an

occupational skills training school or an academic programme.

As a result of my learnings in this area, Kaleidoscope will be launching group patient

workshops, followed by assessment, development and forward-panning from what is learnt

in the initial phase.

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Vocational Consultants open session

A primary objective of my journey was to understand how early in vocational rehabilitation

employers are engaged, how and what supports are offered to businesses and the resourcing that

accompanies it. A Business Advisory Committee (BAC) was formed by the Rusk vocational

department, and to date consists of 40 employers; monthly meetings are held where typically six

to seven members participate. The vocational team present patients that are job ready at the

meeting (no more than three) and the employers provide industry advice regarding the three

patients and may also invite any of them for an interview; recruiting on skills rather than created

roles. This is a strong network and typically comes from the employers of patients that the

services encounter, or in some cases specific industry networks are targeted. Also as part of the

BAC, vocational consultants are able to seek work trials following completion of the

occupational work skills Programme. I see merit, in developing a committee like this for

Kaleidoscope to engage with, on a regular basis and with a formalised structure. Subsequently, I

will make steps toward developing a BAC, that will primarily include employers in the

Canterbury and Auckland regions where Kaleidoscope is based; not to say that other regional

organisations will be excluded.

In New York, employers are concerned that if someone with a disability is hired and it isn’t

successful, then performance management can’t be put in place. This is due to the government

possibly becoming involved. In place however, is a 90 day trial period similar to NZ.

When asked what works about vocational services in NYC for the SCI population, the response

was, it is about independence for the candidate, but where required they act as brokerage –

partnership. The long-term partnerships with companies are key to their success and engaging

employers around their needs, “all about connections”. When a vocational consultant says to an

employer “we’re from Rusk” it discloses the patient group. The skills of the consultants

delivering services are essential – vocational rehabilitation counsellors with the right education

and skills for the patient group are recruited.

The team respect patient privacy, have key performance indicators respecting patient needs and

are productive with their time.

Transport to work, has the ability to impact on return to work in New Zealand. In New York,

responding to the same challenge, Access-A-Ride was formulated and provides accessibility

services. Access-A-Ride is for people with a disability who are unable to use public transport

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such as buses and trains. The service is available 24 hours a day, seven days a week, including

holidays, and the one-way fare for each registered passenger is the same as the full fare on a

bus/subway train; personal carers travel at no cost.

Primary barriers faced, are societal perceptions of SCI and that it is a competitive workforce

where unemployment is low. Vocational rehabilitation is funded highly by the Government and

it is further supplemented with grants. Rusk Vocational Rehabilitation Services is the largest in

the tri-state area, and one of the largest in America. As with New Zealand, not many vocational

services are embedded in hospitals and this is a unique and sought after skill-set.

Burke - New York, USA

History

Burke Rehabilitation Hospital opened its doors in April of 1915, through the generosity of John

Masterson Burke, a New York City philanthropist.

World War II transformed the field of medical rehabilitation, as the vast number and variety of

injuries suffered, led to an increased emphasis on physical and occupational therapies,

improvements to prosthetic limbs and wheelchairs, and the development of community services.

In 1951, with its strong focus on multi-disciplinary medical rehabilitation, the Foundation

formally became The Burke Rehabilitation Hospital. Today, Burke is a not-for-profit, private

rehabilitation hospital and a leader in the field of medical rehabilitation and research.

Burke’s Approach to Rehabilitation

There is never a ‘one size fits all’ approach at Burke; it’s one of the reasons I chose to visit their

institute. Mapping the patient journey, desired goals to achieve and tailoring the pathway is best

practice and promotes independence and best outcomes for the person, which is what all multidisciplinary

teams work towards.

Group discussions and individual counseling sessions help patients and family members adjust to

circumstances resulting from physical disability, and prepare for a new way of life.

Vocational Services

At Burke Hospital, I observed the acute – rehabilitation setting, there was not a dedicated

vocational service delivered at this centre. I took the opportunity to observe multiple settings

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catering to those with an acquired SCI. Vocational rehabilitation is available post-discharge and

is offered through ACCESS Services across New York State.

The Social Worker assumes a leadership role in planning and preparing for the individual’s

discharge and, as with any rehabilitation facility, the planning and preparation begins when the

individual is admitted to the inpatient Programme, continues during the inpatient stay and

culminates when the team determines that the individual is ready to move to the next step in the

rehabilitation process.

The social worker is also responsible for arranging individuals tutoring for adolescents when

necessary to address the patient’s educational needs. Occupational therapists help patients to

become as independent as possible in their daily activities. This includes getting around in the

home and community, and pursuing work-related and leisure activities.

With this knowledge, I spent time with the social workers and occupational therapists to discuss

patient rehabilitation, as well as vocational support.

The Social workers, whom I met with, had a crucial role to play in the patient journey and

demonstrated a high passion and commitment, to address any patient concerns in the area of

work. They were engaging the injured person on admission and then facilitated a patient and

family meeting within 10 days to provide information and reassurance. If the patient was

working, then they might receive financial aid from the company and possibly a period of sick

leave, however at the time of discharge a person uses personal insurance and/or workers

compensation and can be assessed for eligibility for Medicaid.

A daily patient education programme is run and provides unit solidarity as well as an evolving

community feeling; this, coupled with disciplinary input and essential peer support, fosters a

sense of hope for the future.

Helen Hayes facility provides a transition programme with those patients who are discharging. It

is a 10 bed unit, supporting not only SCI but also traumatic brain injury and increased

independence is an expected outcome and the patient participates 100% in achieving this.

Burke Gym “There are no barriers”

Whilst visiting the Burke Gym, I was introduced to a young man who was excited about his

future, and through his accident had found his passion. He sustained a SCI at the level of C5 as

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the result of a water incident and at the time was a University student. He had returned for three

months of intensive therapy. He instantly struck me as a man with a purpose and joy for life.

Following his SCI, he had returned to university and was

accommodated in the dorms. I asked him if there were any

‘Attitude equals altitude’

barriers moving forward with his career plans, at which time he smiled and responded, “There

are no barriers and you know what, in a few years I’m going to travel to NZ”. He intends to work

in the area of brain injury and is studying Neurological Science.

An old colleague of mine used to say, ‘Attitude equals altitude’, and this young man was a great

example of it in action!

Therapeutic Recreation

In spending time conversing with the Therapeutic Recreational team, I was enthused by the

range of therapy interventions available for patients. The patient has to be referred for the

intervention (medically approved) and the therapists then works with the patient to incorporate

specific interests into the therapy, to achieve optimal outcomes that transfer to real life situations.

Research supports the concept that people with active satisfying lifestyles will be happier and

healthier, ‘Active Body, Active Mind’. The therapy interventions included (but were not limited

to):

1. Relaxation Therapy

a. In relaxation therapy sessions, patients learn stress management techniques that

help to prevent or alleviate a variety of symptoms that may occur with illness or

injury.

2. Group Humour Therapy (Humour is Good for Health)

a. HIGH (Humour Is Good for Health) therapy uses the power of laughter, humour,

and positive attitude to bring about physical and emotional benefits.

3. Complementary Therapy

a. Modalities offered include acupressure, biosonic repatterning, polarity,

reflexology, visualization, massage therapy and body work.

4. Adaptive Yoga

a. Adaptive Yoga follows the same principles as traditional yoga, but also provides

the participant specific instruction in the use of props and modifications for poses.

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5. General Recreation

a. Burke offers general recreation Programmes which may be therapeutic, such as

entertainment, social Programmes, horticulture activities, music, games, crafts

and a variety of other activities.

Paraplegic Centre, Notwill, Switzerland

History

From the moment I stepped onto the train platform in Notwill, I knew there was something

special about this place. Instantly, accessibility was apparent and I learned how the community is

built to support those with a SCI. The Swiss Paraplegic Centre (SPC) in Notwill provides its

patients with an extensive range of world-class treatments, services and medical care in a setting

that supports all areas of wellness. The centre provides individually-tailored, comprehensive

treatment in three phases (acute, reactivation and integration) through the use of very highly

skilled staff and state-of-the-art equipment.

The (SPC) was opened by Dr Guido A. Zäch in 1990; he began his journey in the 1960s and

went on to establish the Swiss Paraplegic Foundation (SPF) in 1975. During my visit, I was

fortunate enough to meet Dr Zäch as he was attending the Paraplegia Athletics which was held

on-site. The SPC is a privately owned clinic, which is acclaimed nationwide, specialising in

primary care, acute treatment, comprehensive rehabilitation and lifelong care of people with SCI

and similar syndromes. The SPC has 140 beds, including an intensive care unit. The annual bed

occupancy is over 99%.

Interesting to note is that 1100 people are employed from 80 vocational backgrounds, speaking

more than 35 different languages.

The specialist clinic is part of the Swiss Paraplegic Group (SPG), which forms an integrated

network for the comprehensive rehabilitation of people with SCI. The network is supported by

the SPF, established in 2000 and has a strong research arm employing over 50 staff.

Notwill’s Approach to Rehabilitation

The aim that the comprehensive team work towards, is to re-establish a patient’s personality and

lifestyle to the fullest possible extent, with a holistic approach to treatment that includes mental,

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physical and social aspects such as career, family and leisure activities; which like Burke aligns

with the Māori model of Health; Te Whare Tapa Whā.

As a unique centre, they offer the patients, services which are geared towards their specific

needs, meeting high ethical standards, scientific and practical demands. The range of services on

offer is significant and ranges from Paraplegiology specialists, vocational rehabilitation through

to Equine therapy; the Centre in my view is truly holistic, resourced and inspiring.

The vocational services include the Vocational Teaching Department, Vocational Workshop &

Technological Learnings and a team of Vocational Consultants. My schedule at SPC, can be

found in Appendix 5 and demonstrates SPC providing exposure to a range of departments; not

only vocational.

Vocational Teachers

The Vocational Teaching department offers in-house educational support to both school and

university students one to two times weekly. Only the main school subjects are taught, however

it does include the range of languages spoken by teachers. The

teaching is available once a patient has mobilised. Factors

considered when entering patients into the vocational teaching

unit are, that they are able and willing, possess capacity to learn

and fatigue and tolerance are making positive progress.

What I found encouraging was that whether it is a school or

university student who is injured, the whole class is invited to

the centre. Students try out wheelchairs, have lunch with staff

and other patients and develop a sensibility around SCI.

Teachers gain the material to educate the class about SCI.

People that are injured whilst in the process of an apprenticeship are also included and are able to

take exams as the teacher will come to the centre, or if possible transport is provided for students

to have a break from the rehabilitation schedule and can attend off-site.

“Whether it is a school or

university student injured,

the whole class is invited to

the centre. Students try out

wheelchairs, have lunch

with staff and other

patients and develop a

sensibility around SCI”.

For adult patients, the vocational teachers aim to get each individual to a skill level higher than

they possessed on admission. For example, a receptionist gaining skills to support moving into

administrative work, or in a case I observed, a lawyer learning a new language. The teachers are

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able to provide formal examinations and reported that this goes a very long way to remove the

fear, if higher learning or complete retraining is required.

Of absolute importance, was connecting everyone involved both in the multi-disciplinary group,

inter-vocational support and external in supporting the person to either return to school, return to

work or to return to an entirely new environment. Job coaching begins early, as does employer

engagement. The teachers expressed the need to look at the practical versus theory post-injury,

commenting that the higher level of injury tetraplegia group provided a greater challenge, as

often more time was required.

Vocational Consulting

Patient X

“In the first moment you came to my bed I could have murdered you because I was thinking

about relationships, life, toilets and my injury. But when I left the hospital I understood why you

came so early; it was necessary and I thank you forever. Initially I couldn’t deal with work issues

if they arose, it would be too much.”

The return to work rate for the Swiss population is 55-60% (in 2012 it was reported at 58%). The

following statements from the vocational consultants attribute to the success of the patients

outcomes and strongly echo our experience at Kaleidoscope:

o We make communication with the employer very early on.

o The patients are consulted about the vocational team contacting their employers.

o Having a vocational consultant early and prioritised, the patients report “It is one problem

less, no need to worry about work.”

o An appointment is made with the employer, initially to visit the hospital and then the

consultants visit the workplace and conduct a worksite assessment, if geographically

possible.

o An objective is to remove the fear of workplace modification costs from the employer.

o A message delivered to the patients is, “we will try and find a solution together; it may be

different now, but there is a future.”

o We link patients with peers in the community working in the same job, if the patient

wishes for this to occur.

WCMT Research Fellowship 19


o It is so important to reintegrate the person into their community and provide vocational

services. In saying this, it is equally important is to build self-image, confidence and selfefficacy.

o SCI is normalised and an example of this is school children using the SPC swimming

pool, community groups visiting and tours of the institute and allowing the community to

access the large cafeteria and dine with inpatients.

The funding model in Switzerland is not dissimilar to New Zealand, whereby if it is an accident

the person receives accident insurance, and an injury at work will entitle them to insurance of

incapacitation (90% of salary). For spinal illnesses, the person will receive the pension and an

invalidity benefit.

There is further insurance, whereby if the person is injured by another person i.e. hit by a car or

stabbed, and then they will receive 100% lifetime compensation; however this is a lengthy

process, with lawyers involved, and can be very hard on the patient.

The general unemployment rate in Switzerland is 3%; the government expects and also supports

employers to return disabled persons to work. At the time of discharge, and when a patient is

returning to work, they conduct a work-capacity assessment for a period of three months; in NZ

this is referred to as a ‘work trial’ or ‘graduated return to work’. The vocational consultants

conduct a three month post-discharge reassessment interview, examining how the patient has

adapted to their vocational setting, life adjustment and medical wellness; this is conducted again

at six months post-discharge.

I was encouraged by the conversations and the time I spent with the vocational counsellors to

learn that we essentially operate in parallel, despite being over the other side of the world.

Also, what they value as integral in the ‘early intervention’ work with patients is identical to

Kaleidoscope.

Vocational Workshop and Computer laboratory

I have to be honest and say that upon walking into the workshop and computing area my

immediate comments were “Is that a 3D printer, hold on do you have a CAD machine?” For a

vocational rehabilitation department to have these two pieces of machinery is quite astonishing.

My immediate thought was how fantastic for the patients to leave their rehabilitation trained or,

WCMT Research Fellowship 20


on their way to being trained in two highly sought after skill areas; particularly 3D printing. The

computer laboratory area contains a large

array of software and computer training, for

example Dragon Naturally Speaking

software support provided by the Assistive

Technology Department. Patients can learn

Computer Numerical Control training; obtain

CAD software design qualifications and 3D

printing skills. The vocational workshop

offers the opportunity for patients to try

making a vast range of things and it seemed

to me that any and everything was being

achieved, an example is the picture

articulation on the right. The machines are not modified and test the limitations of the person;

particularly hand function.

Stoke Manderville, United Kingdom

History

The National Spinal Injuries Centre (NSIC) is the oldest, and one of the largest spinal injuries

centres in the world. As with the other spinal units I visited, Stoke Mandeville was established to

treat servicemen who had sustained spinal cord injuries as a result of WW2 in 1944; founded by

neurologist Professor Sir Ludwig Guttmann. An ambitious fundraising campaign to create a

purpose built spinal cord injuries centre was launched, following severe flood damage to NSIC

in 1980. Within three years, with the generosity of the public, £10m was raised and the new

facilities opened in 1983.

NSIC offers diagnosis, treatment and rehabilitation for patients with acute spinal cord injuries

and non-traumatic spinal cord lesions of acute onset. Patients are referred from all over the UK,

and from many countries around the world. I was also fortunate to visit the paediatric spinal

ward, where I observed a different setting. The unit was the first accredited paediatric unit in

Europe.

WCMT Research Fellowship 21


Stoke Mandeville’s Approach to Rehabilitation

With highly specialised and experienced staff, appropriate facilities and equipment, proven

research based methods and a positive attitude, Stoke Mandeville offers a powerful community

full of possibilities. Possibilities are what it is all about following SCI and what a person can do

as opposed to what they cannot. The ultimate aim of Stoke Mandeville is for the patient to be

safely discharged from the centre, and reintegrated back into family and community life; in a

way that meets their own wishes and needs.

One step closer to achieving discharge and heightened self-awareness and independence is the

pre-discharge rehabilitation ward (St Joseph). Patients transition to St Joseph Ward prior to going

home and have the support and security provided by experienced nursing staff. The ward is more

like a unit and enables patients to be more active in their rehabilitation, as well as having time in

the community. Patients had a full timetable of rehabilitation activities and were encouraged to

try different things; much like the Transitional Rehabilitation Unit based at Burwood Spinal Unit

in Christchurch, NZ.

Vocational Services

There is not a dedicated vocational rehabilitation team at Stoke Mandeville, however all

therapists are encouraged to promote ‘work’ with patients; a cohesive disciplinary team message.

There is a passionate and committed occupational therapist that leads vocational support external

to her primary role and refers patients to an employment programme consisting of:

1. Occupational Therapist

2. Disability Support Services

3. Peer Support Officer (Spinal injuries Association, UK)

4. Vocational Consultant (Spinal injuries Association, UK)

5. Job Plus Careers Advisor

The employment programme runs monthly and includes both inpatients and outpatients

accessing the support. The theme of the programme is ‘Not working, but working on it’. The

vocational support provided at Stoke Mandeville Spinal Unit collaborates with the Spinal

Injuries Association (SIA) UK. I visited the association and spoke to Jamie who at the time was

their vocational outreach co-ordinator; further content is provided below.

WCMT Research Fellowship 22


Spinal Injuries Association UK

Jamie (Vocational Outreach Coordinator) at Spinal Injuries Association (SIA) UK commented

that they are about changing employers attitudes to employing people with a SCI; this fits with

my community focus on social expectations that people following SCI can work. Further to this,

that employers can through access to accurate information, see the value of employing someone

with a disability. In the UK however, there is a growing disability confidence from the

community as well as a government initiative supporting this area of work. It is called ‘Access to

Work: Return to Work scheme’ and includes funded transport, a support worker (if required),

assistive technology and work adaptations (which can be very costly). For every £1 spent the

employer can claim back £1.60 for workplace modifications. There are also diversity targets for

companies and these are monitored.

A masterclass is provided to the company regarding employing a person with a disability and

more specific support can be obtained on request. With government pledges available, in some

cases it is still possible in the UK that if a person with a disability applies and meets the

minimum criteria, then it can be a guaranteed interview for the position being recruited.

Vocational Support Clinics

SIA holds regular vocational clinics at a number of Spinal Cord Injuries Centres, including Stoke

Mandeville; each clinic is staffed by the aforementioned team. The purpose of the clinics is to

give the SCI person the best possible advice, for future opportunities for work, education or

volunteering. The clinics are open to inpatients and outpatients.

An interesting resource that was being used in conjunction with other tools was ‘New Leaf’,

which is a job matching tool specifically for SCI. Coincidently in Switzerland, there was a PhD

student developing a similar job matching tool that caught my interest. My interest stems from

my experience of transactional job matching tools that career advisors use, sometimes in

isolation. Without context this is just ‘a tool’ and whilst it can deliver some indicative advice,

further counseling is needed particularly for the SCI group Kaleidoscope supports, as injury is

not taken into consideration. The Swiss resource being developed is by far more complex, and

will look at spinal injury level and neurology, as well as work and interests. This resource set to

be released in approximately 2017.

WCMT Research Fellowship 23


Following targeted support, the attendees of the vocational clinics receive an action plan

detailing the short and long term goals that have been established with the support team; patients

centric. There are three, six and 12 month follow ups which generally speaking are milestones to

explore achievements, health and wellness and sustainability of any work outcomes.

Of interest, was discussion regarding embedding a vocational service in the medical model of a

hospital setting; in the UK acute intervention is still reasonably new. Much like in New Zealand,

Jamie identified a growing engagement from spinal trauma centres and the importance of

everyone in the multi-disciplinary team delivering the same message. I was encouraged to hear

that such an astute spinal service at Stoke Mandeville was consistently providing the ‘importance

of work’ message on the wards. With the commitment from the clinical team, the drive of the

occupational therapist leading it and SIA UK input, they are providing regular monthly

vocational clinics.

Both Jamie and I recognised that it takes time to embed a service, provide substantial evidence

based practice, and build skilled vocational counselors that have acute inpatient experience; in

turn developing the programme.

WCMT Research Fellowship 24


SECTION TWO - Key Areas to Address

A strategic collaborative approach is needed

In 2014, New Zealand released the ‘Spinal Cord Impairment Action Plan (SCIAP)’ which

promotes “The best possible health and wellbeing outcomes for people with spinal cord

impairment being achieved, which enhances their quality of life and ability to participate in

society”.

The Action Plan, outlines a vision, purpose, priorities and eight overarching objectives to help

ensure the best possible health and wellbeing outcomes for people with spinal cord impairment

(SCI), enhancing their quality of life and ability to participate in society.

In March 2012, ACC and the Ministry of Health jointly led a project to review New Zealand’s

SCI services and develop a national implementation plan for improving them.

The action plan states the following actions to address pertaining to vocational supports:

1. Develop a plan to address gaps in vocational supports using a cost-effective model.

2. Spinal rehabilitation services develop a process to include vocational support in discharge

planning.

3. ACC and the Ministry of Social Development to work together to develop a coordinated

national vocational plan that prevents duplication and addresses gaps in vocational

support for people with SCI.

4. Explore the ACC weekly compensation model and Ministry of Social Development

benefit model to ensure the right incentives are in place, so people can try work options

without fear of loss of compensation or benefit that may prevent them attempting

employment options.

5. Provide specific SCI training for ACC case managers and Needs Assessment Service

coordinators who work with people with SCI to ensure realistic back- to-work planning.

6. Specify minimum skill-set requirements of vocational support services to ensure SCI

expertise.

There is always room to improve, and a collaborative model of service for SCI vocational

rehabilitation is the way forward. This can be facilitated through the knowledge gained during

my Winston Churchill Research Fellowship. Better quality and access to information is needed

WCMT Research Fellowship 25


for patients, including those not receiving specialist vocational services, and the people involved

in their rehabilitation. This includes local vocational services (without the serious SCI expertise),

employers, family, case managers and therapists.

Pathway for patients into Kaleidoscope services

For those with a new SCI or illness (with a neurological diagnosis) depending on geographical

location, may be admitted to one of three rehabilitation facilities:

1. Burwood Spinal Unit

2. Middlemore ICU/Acute

3. Auckland Spinal Rehabilitation Unit

Currently, 80% of those admitted are engaged in vocational rehabilitation within three weeks of

admission. The remaining 20% are not engaged, most commonly due to a dual diagnosis of

medium - high brain injury, medical complexities, isolation or other circumstances which require

a period of time before engaging with the service.

Vocational support is currently delivered in the community, complimentary to the acute services

and Kaleidoscope refers to this as restorative work; one patient had been 17 years post-injury not

working. There are a number of ways that people can access vocational support in the

community, but primarily it is through funders ACC and Work and Income NZ (WINZ).

I will never forget the people I met and went onto support, working through Kaleidoscope in

more isolated areas of NZ, especially in their comments when we first met. One patient said, as

the tears flowed, “where have you been all my life? I have wanted help with work and had no

idea of the support or that there are things I could do”. C5/6 Complete Tetraplegic, now a very

successful businessman.

Our philosophy at Kaleidoscope is a holistic approach, but also one of education. Ultimately we

are engaging a person in the area of work; however it is also about educating them on the

readiness and preparation for work and job searching. This, so that in the future they will be able

to use their own internal resource should they wish to change jobs or if they are made redundant

or seek new employment.

WCMT Research Fellowship 26


Through my Winston Churchill Fellowship Trust research, I’ve identified a number of areas of

vocational rehabilitation services, to work towards improving. They are:

1. Developing healthcare professionals from non-specialist settings (where required) as well

as local vocational provider knowledge of SCI – Kaleidoscope has the skills and

resources in place to deliver this nationally

2. Master classes for employers – education and a lived client experience (invited

consumer)

3. Promoting a societal expectation that following a SCI, the person will be able to work

4. Collaboration of inpatient – outpatient providers during the discharge planning phase to

enhance the patient journey and provide continuity, specifically in this case vocational

support.

5. Carry out research in the acute vocational rehabilitation setting, a quantitative evaluation

of data collection and emerging themes

6. Supporting clinical colleagues in the implementation of the SCIAP

7. Working with both ACC and the MOH where we can contribute to their education and

vision, as well as add value through planning and preparation support

8. The place of HOPE in vocational services and the maintenance of hope. When engaging

in vocational support in the acute setting, this not only helps to enhance people’s

recovery from illnesses, but also provides opportunities for a positive focus and enhanced

quality of life.

Delivering acute vocational support requires hope and, in many cases, a leap of faith by the

patients. It is embracing the unknown as well as possibilities, building resilience and building a

pathway forward to an altered future.

Community integration

Whilst vocational rehabilitation was my primary objective, it was very closely followed by an

overarching objective to promote and encourage the communities in NZ to expect that people

with disabilities return to/participate in work and the value of it to everyone. My observations in

Notwill were how the Paraplegia Institute is infact the hub of the community. This began with

WCMT Research Fellowship 27


the open cafeteria area, in which patients, family, clinicians, schools, sports groups and anyone

from the surrounding community can dine and socialise.

With the exception of ICU, throughout the hospital departments there are posters (in the corridor

areas) with easily understood content, as well as pictorial examples of patients carrying out their

rehabilitation. These serve as references, as well as the 10 stop points on a tour to newly injured

people, family, employers and community groups visiting for education. This enables a

normalisation of sorts in seeing people rehabilitating, and allows people visiting the hospital to

gain an insight into SCI. An example of the community groups which visited the week I was onsite,

were a bowling club, corporate team and a school class. They begin with an introduction to

the institute, followed by the tour, some wheelchair skills and time in a chair, which is then

followed with a final question and answer session. This is a great example of an opportunity to

reach out to the community and give them a little bit of knowledge and raise awareness. The

potential opportunities, such as industry advice and possible employment for patients, as well as

the networks established as a result of this exposure, would serve a great many purposes, but the

primary purpose being ‘community’.

Another example of the community awareness commitment included children’s swimming

lessons being held in the hydrotherapy pool, local people attending the paraplegic athletics

competition and sports activities on-site utilising the extensive facilities available.

As a result of these observations, and in reviewing a programme that Dr. Bernadette Cassidy

developed, aimed at providing school children SCI and disability awareness, we will collaborate

to develop a learning experience. The community SCI Ability Awareness Learning Experience;

will target schools in Canterbury as well as including identified employers. At the time of

submitting this research report the Ability Awareness Learning Experiences are due to

commence in 2016.

WCMT Research Fellowship 28


SECTION 3 - Resulting Action

Great Expectations Project – Employers

The evidence is visible – work is good for health and wellbeing. Returning to work or

commencing new employment should be a societal expectation post-injury.

Great Expectations is a new initiative from Kaleidoscope to engage employers. The project aims

to transform attitudes by working with organisations that recognise the opportunity hiring a

person with a disability presents. We will work to support them, when they ask what is possible

when minds are open, accessibility is embraced and they hire a person with a SCI.

The Great Expectations Project encompasses the following:

1. Educational seminars for employers

2. Formulating a business advisory committee

3. Customised organisational information on-site

4. Consumer availability

5. Monthly profiling of patients/quarterly newsletter

One in five New Zealanders has a disability, making up 20% of our population, many of whom

offer a unique set of skills and perspectives that bring value to our organisations, communities

and economy; when the opportunity presents.

Two things that we know for sure at Kaleidoscope are that disabled people make great

employees and that an accessible workplace is safer for everyone. Of the spinal population we

work with, most people require little or no extra support of investment to fulfil their role.

Kaleidoscope has increased the employment rate in SCI from 12.3% of spinal cord injured

patients being employed to 60%, our message to employers is ‘Why not enhance your profile,

increase the statistics and be part of this!’

Education and awareness will be made available to employers either within their organisation or,

as part of a wider community group, in a non-judgmental environment. A benefit being that,

employers will have access, to an untapped labour market which is willing, keen and able; skills

utilisation. Furthermore, employers will gain confidence to employ someone with a SCI, having

the opportunity to ask questions. Previous or successful past patients will be available to enable

employers to hear real life stories and have a discussion following.

WCMT Research Fellowship 29


The topics covered will be:

• Basic SCI 101

• Why it is beneficial to employ people with disabilities (SCI) - an accessible workplace is

safer for all staff and having disabled staff means more customers, better served

• Frequently asked questions of an employer

• Accessibility of a workplace

• Invited consumer to share their experience and answer any questions

Figure 1. Benefits to a company when employing a person with a disability

As a result of learning about the BAC that Rusk Hospital developed, Kaleidoscope will also seek

to formulate our own committee. We have created an Employer Network database and will seek

out potential industry leaders to become members of the BAC, as well as interested patient

employers, as time progresses.

WCMT Research Fellowship 30


‘Ability’ Awareness Learning Experience

Complimentary to the Great Expectations Project, and an experience which will provide a link

between schools, organisations and the SCI population, is the proposed Ability Awareness

Learning Experience. Educational experiences outside the classroom can enhance, reinforce, and

clarify classroom learning and be rewarding for a workplace to engage in. Exploring the role of

people with disabilities in the community will enable both pupils and employees to have an

appreciation of SCI. But also awareness of what people ‘can do’ and how they do it.

In the current world of the internet, to demonstrate the empowering role of technology in

enabling people with disabilities to lead independent lives is a tremendous opportunity.

The rationale behind the proposed education programme was due to observations made during

this research, conversations with Dr. Bernadette Cassidy about the educational programme she

developed and a long-standing intention of mine to engage the community further. This is

targeting schools and employers at a deeper level.

We have an aging and ever growing diverse and dynamic society. Employers will be able to

visualise how our patients can, without a great deal of difficulty, fit into their environments.

Meanwhile, pupils will learn about the role of people with disabilities in society, explore the

issues, make decisions, and learn how to work co-operatively with others who have an

impairment/disability.

The idea behind this proposal is to enable those in the community to explore changes in societal

attitudes and how these changes, along with the introduction of technology, have specifically

improved the lives of people with disabilities. This innovative experience will provide

participants with a first-hand experience of a learning and research centre set up to help people

with disabilities to live independently.

The programmes activities may feature the following:

• Wheelchair obstacle course

• ‘Driving’ a Hand controlled vehicle – Demonstrated by a staff member

• Observing a simulated car used by the Driving Assessment Team

• Using Co-Writer or Dragon Naturally speaking software (talking word prediction

Programme)

• Using a computer with head mouse (infra-red dot)

WCMT Research Fellowship 31


• Informal talks with NZST staff who have a disability

• Feedback on the session, opportunity to ask questions

Patient Workshops – Outreach and extension of service

I have been interested in the availability of either stand-alone workshops or a vocational series of

education for a group environment. At Rusk, I observed this in action and whilst 1:1 vocational

rehabilitation is without question an essential part of the journey, group sessions have potential

to add another dimension to the process.

For our patients, joining a group of unknown people may sound intimidating at first, but the

benefits can be shared experiences of navigating the job search process, a support network and a

sounding board external to the vocational consultants. Diversity is another important benefit in

that people have different personalities and background, and they look at situations in different

ways. By hearing how other people tackle problems and make positive changes, it is

Kaleidoscopes hope that patients will discover a whole range of strategies for facing their own

concerns.

In running the patient work preparation and job search workshops, an added advantage for the

facilitators will be observing patients in a group setting, interacting with others and problem

solving.

Those in the community with a SCI are the priority, and the project aim is to educate and build

confidence, inpatients will be invited during the course of their rehabilitation if appropriate. The

resourcing is in progress and the seminar series will offer the following:

1. Networking – Tapping into the hidden job market

a. Who are your support and work networks?

2. Skills Identification – Know your skills, know your value

3. CV – Purpose and tips for writing your CV

a. Task of starting to formulate a CV, before the following clinic

4. CV Clinic – Complete a CV

5. Job Search – Where do I start?

6. Interviews – Prepare and get the job you want!

7. Self-promotion/advocacy skills – Courageous Conversations

WCMT Research Fellowship 32


Conclusion

The key objective of the WCMT fellowship was to review selected international vocational

departments in an embedded hospital programme and their resourcing. Furthermore community

support available to patients following discharge from rehabilitation units, and ways to improve

community links and education around SCI. In terms of improving employer education the key

questions presented during the research were:

1. What do you promote as the benefits of employing someone with a disability?

2. At what stage do you engage with an existing employer?

3. What are the typical questions and concerns from employers?

4. Is there funding available to address equipment and accessibility needs?

5. How do you approach employers?

Employment rates after SCI vary widely depending on many variables, particularly however the

measure of employment. By measure of employment, I mean what the analysing person defines

as work, for example paid work, voluntary work, full-time work or paid work more than 5 hours

per week. Statistics also, do not necessarily reflect the complexities that sit alongside the return

to work process.

Characteristics influencing employment after SCI include demographic variables, injury-related

factors (age at injury, level of impairment, functional capacity), employment history or in many

cases a limited history of work, psychosocial issues such as transport, physical health, life skills,

motivational level/expectation to work and not forgetting, very importantly the support systems

available.

It is well reported that those individuals with SCI who are working, experience significantly

better quality of life, sense of purpose and other benefits. However, the barriers to returning to

meaningful work can be daunting and numerous. I have learnt that the most common issues of

the countries I visited were access to transport, housing and flexibility of carers.

Vocational rehabilitation programmes that address these barriers are essential. Vocational

rehabilitation programmes in the acute setting, are even more beneficial to reduce the potential

learned dependency of a person and to bridge the gap between employers and the individual. The

area of acute vocational rehabilitation needs to be a focus of research, to understand, better

communicate and improve vocational rehabilitation outcomes among this population of

individuals with SCI.

WCMT Research Fellowship 33


My fellowship will contribute to the patient journey and recognises a ‘whole of person’ holistic

approach, is committed to improving community awareness and support for employers and

ultimately influence attitudes in the area of disability. Initiatives will be actioned in these areas

and an insight has been demonstrated in this document.

The exposure to the vocational settings and support during my fellowship both challenged and

encouraged me. I was encouraged that New Zealand and specifically Kaleidoscope, is delivering

results comparitible to much bigger better resourced programmes. I was challenged to develop

SCI vocational rehabilitation and progress initiatives, but with an acute awareness that

resourcing is a significant problem.

Vocational rehabilitation is an integral part of SCI rehabilitation. There is much that can be done

moving forward; with a commitment to collaborate, improve services and continue to listen and

learn.

WCMT Research Fellowship 34


References

ACC and the Ministry of Health. 2014. New Zealand Spinal Cord Impairment Action Plan 2014-

2019. Wellington: ACC

Māori health models – Te Whare Tapa Whā

Retrieved from http://www.health.govt.nz/our-work/populations/Māori-health/Māori-healthmodels/Māori-health-models-te-whare-tapa-Whā

DeJong, G. (1979). Independent Living: From Social Movement to Analytic Paradigm.

Retrieved from https://enablemob.wustl.edu/OT572D-

01/RequiredArticles/IndependentLivingFromSocialMovementtoAnalyticParadigm.pdf

WCMT Research Fellowship 35


Appendix 1. Model Explanation of ‘The Kaleidoscope Way’

Model Explanation of ‘The Kaleidoscope Way’ TM

Creation Actions is about clients

regularly taking actions that are

consistent with ‘creating’ their

preferred vocational future and

RTW. This approach promotes

ownership, independence,

responsibility, action & pride in

realising one’s RTW potential.

This approach also has the client

in communication with ‘their

world’ and promote self efficacy

& a diminished reliance on VR

services.

‘The Kaleidoscope Way’ model of

vocational rehabilitation is

fundamentality grounded in the

‘world’ of the client, their hopes,

dreams & aspirations. This

clientcentric approach is supported

by well developed life/career

conversations, utilising the Powhiri

model of engagement it is culturally

sensitive, organic, and fluid (i.e. a

non-linear process). It assumes and

promotes the client as ‘the expert’ of

their own rehabilitation & RTW.

Kaleidoscope has developed

S.W.I.F.T.E.R which is a specific

goal setting tool for SCI clients,

this denotes goals as being:

Stepped, Well-informed,

Idiosyncratic, Fluid, Thorough,

Energising & Resourced. Goal

optimisation works from a

strength based approach of

leveraging off abilities,

opportunities and resources to

overcome barriers to a RTW.

Research & Preparations avails the

client the opportunity to explore

RTW possibilities in a nonthreatening,

explorative &

appreciative manner. RTW Research

& Preparations can continue

alongside other rehabilitation

initiatives & priorities and

progressively lays the foundation for

a well informed, planned, and

executed RTW

‘The Kaleidoscope Way’ TM 2010 ©

‘The Kaleidoscope Way’ TM 2010 ©

WCMT Research Fellowship 36


Appendix 2. Return to work in the context of Kaleidoscope

In the language of the ‘rehabilitation trade’, getting work or getting back to work is vocational

rehabilitation. There are many definitions of the rehabilitation process, but for the individual

recovering person it is the outcome that matters most. Success for each person means reinclusion

in society’s mainstream and independence; work in the broadest sense is purposeful,

constructive activity meaningful to the person. I was asked by an ICU specialist recently what I

want to achieve, when meeting people in the acute setting. To this I responded, that it is different

for everyone. However we have a process and number one is respecting the patient, assessing

their needs and recognising where they are at.

Historically, return to work has been a distant goal, was seldom addressed early in the

rehabilitation process, and where information was available, outcomes were poor. At

Kaleidoscope, we promote that vocational rehabilitation runs succinctly with other rehabilitation

initiatives, whilst respecting that no person, injury or journey is the same. All over the world

health services deliver rehabilitation within, what Gerben DeJong (1979), describes as, the

Rehabilitation Paradigm. I learnt rather quickly from my two mentors, that by this he meant that

the process is controlled by rehabilitation professionals. In New Zealand, Professor Alan Clarke

described it as heavily medicalised.

DeJong proposed a shift to what he called the Independent Living (IL) Paradigm, where the

rehabilitation process is controlled by the recovering person (consumer) and based on high

quality information. Recovery is then more likely to be seen for what it really is – learning to get

back into the groove or ‘flow of life’.

The Allan Bean Centre was established in 2001, for research and learning in rehabilitation at

Burwood Hospital. It was built to serve recovering people and their families within the

Independent Living Paradigm of DeJong. The approach has been described by my predecessors

as The New Rehabilitation and encourages the recovering person with his/her family to take

control of the pathway to recovery as soon as possible. Sadly the Allan Bean Centre was

condemned due to the Canterbury Earthquakes, however the culture and purpose remains and a

new space will relaunch in 2016.

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Whilst Kaleidoscope’s core role is supporting a

vocational journey, we cannot expect to move forward

without a foundation and an understanding of each

patient. Where they have come from, what is important to

them; rapport and respect are vital. A Kaleidoscope

patient in 2010 provided this feedback which aligns with

my statement regarding rapport and respect.

“I met Mel from Kaleidoscope and her approach brought

me back to the real world. She used the word work and it actually devastated me. In my mind I

wished that she would go away, but in the conversation we had it wasn’t what I said; but it was

certainly how I felt.

As time has gone on, Mel kept coming back and quietly just worked through some of the issues.

She has given me the opportunity to work through and look at the things I might want to do in the

future; these weren’t necessarily all around work. We talked a lot about my past and we both

had some fun as I recalled some of the things that had happened. I’ve had lots of jobs, done a lot

of things and what this support has done, using the process that Kaleidoscope has in place, has

allowed me to find an area that maybe in the future I can move in to.”

“It’s been hard but it has been

important and as I said the process

that was used and the way it was

presented to me made it real easy

and now I’m leaving

here……..there is something for

me in the future” (Kaleidoscope

patient)

The tools for success include hope, love of life, confidence, self-esteem, excitement of challenge,

high quality information and recognition of the need for hard work and determination. Further to

this is support from professionals, friends and family and guarantee of long term (strategic)

quality improvement through research. For example a patient commented to me recently “I am

not here for a holiday, I am here to work and I am making good progress”.

Vocational Rehabilitation is a process that starts during an individual’s initial admission to

hospital and continues, in many cases, following their return home. It is critical that when

discharged from hospital, there is continuity in their vocational plan and that the person has

access to quality information and support.

“It is never too late to be what you might have been”.

George Eliot

WCMT Research Fellowship 38


Appendix 3.

Te Whare Tapa Whā - One model for understanding Māori health and that aligns strongly with

Kaleidoscopes philosophy and operational guidelines is the concept of ‘te whare tapa whā’ – the

four cornerstones (or sides) of Māori health.

Explanation of the model

With its strong foundations and four equal sides, the

symbol of the wharenui illustrates the four

dimensions of Māori well-being.

Should one of the four dimensions be missing or in

some way damaged, a person, or a collective may

become ‘unbalanced’ and subsequently unwell.

For many Māori modern health services lack

recognition of taha wairua (the spiritual dimension).

In a traditional Māori approach, the inclusion of the

wairua, the role of the whānau (family) and the

balance of the hinengaro (mind) are as important as

the physical manifestations of illness.

Taha tinana (physical health)

The capacity for physical growth and development.

Good physical health is required for optimal development.

Our physical ‘being’ supports our essence and shelters us from the external environment. For

Māori the physical dimension is just one aspect of health and well-being and cannot be

separated from the aspect of mind, spirit and family.

Taha wairua (spiritual health)

The capacity for faith and wider communication.

Health is related to unseen and unspoken energies.

The spiritual essence of a person is their life force. This determines us as individuals and as a

collective, who and what we are, where we have come from and where we are going.

A traditional Māori analysis of physical manifestations of illness will focus on the wairua or

spirit, to determine whether damage here could be a contributing factor.

Taha whānau (family health)

The capacity to belong, to care and to share where individuals are part of wider social systems.

Whānau provides us with the strength to be who we are. This is the link to our ancestors, our

ties with the past, the present and the future.

Understanding the importance of whānau and how whānau (family) can contribute to illness

and assist in curing illness is fundamental to understanding Māori health issues.

Taha hinengaro (mental health)

The capacity to communicate, to think and to feel mind and body are inseparable.

Thoughts, feelings and emotions are integral components of the body and soul.

This is about how we see ourselves in this universe, our interaction with that which is uniquely

Māori and the perception that others have of us.

WCMT Research Fellowship 39


Appendix 4. Winston Churchill Memorial Trust Fellowship schedule, May 2014

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

4 5 6

7

8

9

10

TRAVEL

CHRISTCHURCH

– NEW YORK

RUSK CLINICAL

AND

VOCATIONAL

RUSK CLINICAL

AND

VOCATIONAL

BURKE

REHABILITATION

HOSPITAL

REST DAY

11

12

13

14

15

16

17

REST DAY

TRAVEL

NEW YORK

- ZURICH

TRAVEL

SWISS

PARAPLEGIC

CENTRE

(Schweizer

Institut fur

Beruffindung)

SWISS

PARAPLEGIC

CENTRE

(Schweizer

Institut fur

Beruffindung)

SWISS

PARAPLEGIC

CENTRE

(Schweizer

Institut fur

Beruffindung)

SWISS

PARAPLEGIC

CENTRE

(Schweizer

Institut fur

Beruffindung)

SWISS SPINAL

INJURIES

ASSOCIATION

18

19

20

21

22

23

24

TRAVEL

ZURICH -

LONDON

REST DAY

STOKE

MANDEVILLE

HOSPITAL

(NSIC)

STOKE

MANDEVILLE

HOSPITAL (NSIC)

SPINAL

INJURIES

ASSOCIATION

UK

Potential

observations at

Headley Court –

Military

Rehabilitation

Centre

Transcriptions

and work

25

REST DAY

26

REST DAY

27

REST DAY

28

TRAVEL

LONDON –

AUCKLAND -

CHRISTCHURCH

29

TRAVEL

LONDON –

AUCKLAND -

CHRISTCHURCH

30

COMPLETE

31

WCMT Research Fellowship 40


Appendix 5. Example Schedule – Swiss Paraplegic Centre, Notwill

Date Time Appointment Where

Wednesday, May

14

08.30 Introduction to Swiss Paraplegic Centre Main entrance of the clinic

08.30 - 09.45

Nursing Management – Acute Ward with

the Clinical Nurse Manager

Ward D

09.45 - 10.00 Coffee Break Ward D

10.00 - 12.00 Occupational Therapy Office of Therapies Director

12.00 - 13.00 Lunch time

13.00 - 14.00

Nursing Management – Activities with

student nurses and rounds

Ward D

14.00 - 15.00 Vocational Department Introduction

Institute for Vocational

guidance

15.00 - 16.00 Consultant Paraplegiology Office Dr

Thursday, May 15

09.00 Coffee with the team Restaurant

09.15 - 10.00 Visit of the teaching lessons Vocational guidance

10.00 - 11.00 Vocational counsellor Office 1

11.00 - 12.00 Vocational counsellor Office 2

12.00 - 12.30 Lunch time Restaurant

12.30 – 14.00 Vocational discussion

14.00 – 16.00 Vocational Teacher

Institute for Vocational

guidance

Workshop Vocational

guidance

16.00 – 18.00 Occupational Therapy OT

WCMT Research Fellowship 41


Friday, May 16 Time Appointment Where

06.00 – 09.45 Physiotherapy PT

09.45 - 10.00 Coffee Break PT

10.00 – 12.00 Swiss Paraplegic Research GZI

12.00 - 13.00 Lunch time

13.00 – 15.00 Area Manager for Life Guidance Swiss Paraplegic Association

15.00 – 16.00 Short break

16.00 – 17.00 Area Manager of Culture & Leisure Swiss Paraplegic Association

WCMT Research Fellowship 42


Appendix 6. Pictorial Fellowship highlights

Left – Right and Top – Bottom Rusk pediatric activity space, myself and both the Director and Manager of Rusk Vocational

Department, Notwill Ward D staff visual representation, Notwill art as viewed from a patient room (representation of a broken

vertebrae), me at Notwill lake, Notwill assistive technology mouse example, handcycles at Burke gym, Notwill institute aerial

view, Notwill patients wheelchair skills on an escalator and lastly a field in Notwill.

WCMT Research Fellowship 43

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