The use of the Model of Occupational Self Efficacy in improving the cognitive functioning of individuals with brain injury: A pre- and post-intervention study

1Introduction

Traumatic brain injury is described as an unexpected, damaging blow to the head, or a sharp object penetrating the head that results in the disruption of the functioning of the brain [1]. The brain is launched into a collision with the cranium, resulting in bruising of the brain as well as the severing of nerve fibers and hemorrhaging inside the skull. Archiniegas, Held and Wagner [2] describe TBI as a sudden trauma to the head, which causes injury to the head and the brain; such injuries could result in impaired physical, cognitive, emotional, and behavioral functioning. According to the Kwazulu Natal Department of Health there are an estimate of 89 000 new cases of traumatic brain injuries that are reported annually in South Africa [3]. Fifty percent of all head injuries were due to motor vehicle and motor- pedestrian accidents, 25% have been due to falls, 20% have been due to violence and another 5% due to other injuries [3].

In the medical model, the individual with an injury or disability is regarded as having problems that require mainly medical-biological intervention, with little or no attention given to the difficult process of reintegrating the individual with disability back into society [4]. The medical approach may result in feelings of disempowerment on behalf of the individual with disability regarding the rehabilitation process [4, 5]. The lack of success of current rehabilitation interventions could be seen as a result of an inability to generalize outcomes of rehabilitation in a clinical setting to the skills needed to return to work or re-integrate into the community. This study explored whether the Model of Occupational Self Efficacy could be used practically by an occupational therapist with regard to their time and resources in order to reintegrate individuals with TBI to their worker roles.

2Literature review

Mild, moderate and severe TBI’s are classified using the Glasgow Coma Scale. The Glasgow Coma Scale is described by Gill, Reiley, and Green [6] as the most commonly used scoring system to measure an individual’s consciousness following a traumatic brain injury. The classification of mild, moderate and severe is scored and relates to the time it takes the individual with brain injury to regain consciousness following an assault to the brain. According to Norman [7] the main causes of head injuries in South Africa are road traffic collisions, violence and assaults. Road traffic accidents are amongst the top 3 leading causes of mortality in South Africa.

Holistically, there is evidence that traumatic brain injury negatively affects post injury employment status [8]. Post injury, survivors of brain injury experience a variety of physical, psychological, emotional, cognitive limitations and behavioral problems, which limit their ability to adapt to their worker role [9]. Shames and Giaquinto [10] indicated that individuals with brain injury (IBI) experience limitations with executive functions i.e. problems with goal setting, self-monitoring, and planning that usually impair the individual’s ability to return to work successfully. According to Tyreman [11] these difficulties include a limited work performance and difficulties in applying the coping skills learnt during the vocational rehabilitation (VR) process. Individuals experience difficulty in planning, prioritizing and organizing work to achieve objectives and meet deadlines. Inflexibility to changes in their work role, poor judgment and poor social control are all factors that reduce an individual’s ability to adapt to their worker role. Lefebvre [12] indicated that due to the age and stage that individuals sustain a brain injury, they are often young male workers, the injury results in severe role loss within their families and social circles. Due to these losses they no longer see themselves as contributing members of society. Most often these individuals with brain injury are no longer able to fill their roles as breadwinners in their families.

Occupational therapy is a profession that offers services that improve, maintain and restore an injured or ill individual’s ability to engage in occupations such as work related activities, leisure and self-care [13]. The Model of Occupational Self Efficacy developed by Soeker [14] is an occupational therapy practice model designed to effectively return individuals with brain injury to work. The MOOSE consists of 4 stages (see Fig. 1) namely, Stage One: “A strong personal belief in functional abilities”. During this stage the occupational therapist will facilitate a process of introspection and reflection in the client in order to develop new insights into his or her ability to cope in their work and social environment. Stage Two: “Use of Self”. During this stage the occupational therapist continues to act as a facilitator and through a process of introspection and inner strength development, the client reaches a level of autonomy which allows participation in more occupational activities such as activities of daily living, work and leisure. Stage Three: “Creation of competency through occupational engagement”. During this stage the client may be referred to vocational rehabilitation and a functional capacity assessment or screening. The client will be asked to identify a difficult workplace scenario; thereafter the occupational therapist and the client will role play the scenario in order to identify coping strategies for the client. The client will be placed in an actual work setting to practice his or her work skills. Stage Four: “Capable individual” is the final stage of the model. During this stage, the client will view him or herself as a capable worker and will be able to participate in the worker role with maximum independence and the occupational therapist will gradually withdraw as a facilitator.

Fig.1

(Permission was granted from the author to utilise the diagram of the MOOSE).

Graph 1

Graph indicating the test scores of the participants using the MOCA.

Graph 2

Results of the repeated measure ANOVA on completed cases.

3Results

In Table 1 the characteristics of the 10 participants [n = 10] reveal that [2/10] participants were female and [8/10] were male participants. Furthermore, the mean age of the participants were x¯ = 29 years old, with the youngest participant being 20 years old and the oldest participant being 36 years old. Regarding their education, [2/10] had a tertiary level of education and [8/10] had a secondary or high school level of education. Ninety percent [9/10] of the participants had a diagnosis of mild brain injury and 10 percent [1/10] of the participants had a diagnosis of moderate brain injury according to the Glasgow Coma Scale. All of the participants were employed before their injuries, 60 percent [6/10] of the participants were employed in semi-skilled/skilled occupations and 40 percent in unskilled occupations.

Table 2 describes the amount of sessions that each participant took at each stage of the research process. In stage 1 of the model, the average number of sessions was 23.20 sessions per individual. In stage 2 of the model, the average number of sessions was 18.8 sessions per individual. In stage 3 of the model, the average number of sessions was 17.8 sessions per individual. In stage 4 of the model, the average number of sessions was 14.2 sessions perindividual.

Table 3 describes the total scores of the participants after each stage of the MOOSE. The table also describes the means scores per stage, the table indicates the mean scores improved from the Pre-intervention phase to Stage 4 of the model.

As seen in the graph below, there is a gradual increase in the participants’ test scores from stage 1 to stage 4. This indicated that the program may have been successful and that the therapy given was beneficial and purposeful for the participants to regain their worker role.

4Discussion

The component areas on the MOCA that were assessed included visual spatial/executive function, naming, attention, language, abstraction, delayed recall and orientation. In the pre intervention there was a considerable limitation in the total scores (in all the component areas above) in particular participant 2, 4, 6 and 8 had a score that was regarded as “very poor” as they obtained scores below 10. According to the scoring criteria of the MOCA, a score of below 10 is indicative of severe impairment [21]. The component areas that the participant’s functioned poorly in were attention, language, abstraction and orientation. The participants in the study performed well in the component areas of visual spatial, naming and delayed recall.

MOCA was administered after the completion of each stage of intervention. After Stage 1 was completed, the participants struggled in the following areas: visual spatial relations, naming, attention, language, abstraction, orientation and identification. The participants performed well in the delayed recall sections of the test. However the results also indicate that participant 6, 7, 9 and 10 had a decline in their total scores when comparing their pre-intervention total score with their total score in Stage 1 of the MOOSE. This is in contrast to other participants who had an improvement in their scores. A possible reason for this could be that these participants who participated in Stage 1 of MOOSE could have experienced deficits in cognitive functioning or struggled with concentration at the time when the test was completed. The latter could have affected their ability to complete the MOCA questionnaire accurately, therefore resulting in a decline in their total scores on the MOCA questionnaire. After Stage 2 was completed the participants struggled in the following areas: visual spatial relations, naming, attention, abstraction and orientation. The participants’ performance improved in the following areas: delayed recall and identification sections of the test. During Stage 1 and 2 of the test there was an indication that the clients were still struggling with visual spatial relations, naming, attention, abstraction and orientation. However, the mean scores on the tests improved from Stage 1 to Stage 2. During Stages 3 and 4 of the test, the mean scores gradually improved. This could be attributed to the fact that the participants were exposed to more tasks in the intervention programme that helped them enhance their cognitive skills. Example, participants were required to do simulated tasks where they had to read and remember instructions in order to do work tasks. Based on a study conducted by Olver, Ponsford and Curran [22], the participants in their study also struggled with attention, language, abstraction, delayed recall and orientation. It could be argued that the nature of a brain injury could affect an individual’s ability to do tasks that require executive functioning. Despite the focus of intervention being mainly on improving the client’s cognitive functions, communication skills and physical endurance, these clients continued to struggle. Although it was difficult to predict an exact period of time when each stage of the model was completed, it was clear that more intervention may be required after the completion of Stage 4 of the intervention. The test results indicate that younger individuals and individuals with a higher education level performed better over the course of the programme. Furthermore, many individuals had good performance in the visual spatial and naming components particularly during Stage 3 and Stage 4 of the intervention programme. One possible explanation for this was the fact that the participants were exposed to activities that were work related such as doing filing, data capturing and performing certain work tasks according to the sequence required to do the tasks (simulated tasks). During Stage 3 of the study, the participants were involved in doing simulated tasks (i.e. practicing the actual work that they wanted to return to or perform in the Open Labour Market). In Stage 4, the participants were placed in a job in the open labour market (work test placement) in order to obtain a real life work experience (i.e. working an 8 hour work shift, working with the tools of the particular job and interacting with work colleagues and customers if required). A study conducted by Law, Polatajko, Baptiste and Townsend [23] indicated that most interventions by occupational therapists utilized functional activities such as activities of daily living (ADL) whereby their approach was either remedial and/or compensatory. In the remedial approach, the occupational therapist would focus on table top activities such as memory games to improve the client’s cognitive function. Whereby compensatory approaches would focus mainly on modifying the client’s environment (e.g. adapting the tools the client uses) or adapting the manner in which the client does a work task (e.g. changing the client’s work routine). The therapists using the MOOSE mainly used the remedial approach during Stages 1 and 2, where the focus was on improving the client’s cognition, communication and physical functioning. Whereby in Stages 3 and 4, the therapists focused on the functional skills in preparation for the placement of the participant in work-related tasks. It was quite interesting to note that of the ten participants who completed the programme, seven participants returned to work.

During the study, it was noticed that activity choices were crucial to the participants’ responsiveness to the treatment given. Activities that were seen as not meaningful or unfamiliar to the participants tended to be paper based. This was mostly due to the participant’s lack of exposure to paper based activities as most of the participants were manual labourers prior to their injury (worked practically with their hands, did not engage in clerical related tasks). Chamberlain, Mosser, Ekholm, O’Connor, Herceg and Ekholm [24] described work to be the most important aspect of the human life span. Work is an important aspect of how people define themselves. The negative consequences of unemployment include depression, impaired social functioning, and various physical ailments. Considering the negative psychosocial and physical health consequences associated with TBI/ABI, which includes loss of self-awareness, depression, and inappropriate social behaviors, people with TBI/ABI may be more deeply impacted by unemployment than the general population [25].

The findings from the current study revealed that most participants were the recipients of disability grants despite the fact that tests revealed that they cognitively and physically did not meet the criteria for a disability grant, yet were receiving this financial assistance due to their impoverished social circumstances. A limitation to the MOOSE was that despite all efforts of going through the model, it did not guarantee a positive outcome (not all of the participants were successfully placed in working environments due to shortage of employment opportunities) which leads to demotivation and a reduction in self-efficacy.

5Conclusion

This study revealed that MOOSE was an effective model in returning clients to work in that 70% of the participants returned to work after participating in the return to work programme. Of the 30% that did not return to work, the causes of them not returning to work were mainly related to the shortage of available jobs in their communities and not due to their inability to be productive in the open labour market. The results of the study revealed a statistically significant effect of the intervention (i.e. MOOSE) on cognitive functioning measured using the Montreal Cognitive Assessment, F(4, 6) = 15.95, p = 0.002. The participants in this study could maintain employment in the open labour market for a period of at least 12 months, these individuals were formally followed up. In conclusion, the MOOSE proved to be a useful model in enhancing the clients’ cognitive skills, as well as adapt to their worker roles.

Conflict of interest

The author certifies that there was no conflict of interest during the completion of the research project.