FACTORS INFLUENCING RETENTION OF PATIENTS WITH TRAUMATIC BRAIN INJURY IN THE SOUTH AFRICAN NATIONAL DEFENCE FORCE Thembeka Victoria Maredi A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Science in Occupational Therapy. Johannesburg 2021 0 i Declaration I, Thembeka Victoria Maredi, hereby declare that this research report is my own work. It is being submitted for the degree of Masters of Science in Occupational Therapy at the University of the Witwatersrand, Johannesburg. It has not been submitted before for any degree or examination at this or any other university. Signature: 04th Day of November, 2021. ii Plagiarism Declaration Faculty of Health Sciences, Postgraduate Office Phillip V Tobias Building, 2nd Floor Cnr York & Princess of Wales Terrace, Parktown 2193 Tel: (011) 717 2745 | Fax: (011) 717 2119 Email: Mathoto.senamela@wits.ac.za PLAGIARISM DECLARATION TO BE SIGNED BY ALL HIGHER DEGREE STUDENTS SENATE PLAGIARISM POLICY: APPENDIX ONE I, Thembeka Victoria Maredi (Student number: 1754607) am a student registered for the degree of Occupational Therapy in the academic year two. I hereby declare the following: I am aware that plagiarism (the use of someone else’s work without their permission and/or without acknowledging the original source) is wrong. I confirm that the work submitted for assessment for the above degree is my own unaided work except where I have explicitly indicated otherwise. I have followed the required conventions in referencing the thoughts and ideas of others. I understand that the University of the Witwatersrand may take disciplinary action against me if there is a belief that this is not my own unaided work or that I have failed to acknowledge the source of the ideas or words in my writing. I have included as an appendix a report from “Turnitin” (or other approved plagiarism detection) software indicating the level of plagiarism in my research document. Signature: Date: 04th November 2021 iii Dedication This research is dedicated to all the participants who took their time to participate in the research and give their valuable inputs. This research would have not been possible if it was not for you, Thank you. iv Acknowledgments First, I would like to thank the Almighty God for showering me with blessings, the opportunity to be able to do this, the wisdom, strength and courage to complete the research. I would like to thank the University of Witwatersrand for affording me the opportunity to complete my master’s study. I would also like to thank the Department of Defence Force for granting permission and opportunity to conduct the research in the organization. I would like to express my greatest gratitude to my supervisors Ms Kirsty Van Stormbroek and Dr Denise Franzsen for their support, guidance, patience, motivation, enthusiasm and providing immense knowledge through the research. A special thank you to Major Schutte for your inputs and guidance as my military supervisor. To the head of Occupational Therapy and all my colleagues - thank you for your support by giving your time when taking up extra work when I had to be away for purpose of the research. Last but not the least I would like to say thank you to my family: My mom for your prayers and always being there for me, to my dad and sister (continue to rest in peace) your spirit is forever with me and guiding me, my beautiful daughters (Masego & Lekhethelo) for being my greatest inspiration, for your love and understanding. Also express my thanks to my siblings and cousins for always cheering for me. To my friends for their support and words of encouragement thank you. v Abstract Background: Service force members in the military are at an additional risk for traumatic brain injury (TBI) due the nature of their duties. Returning to active service after TBI is not an easy process and service force members with TBI struggle with meeting work demands because of residual functional limitations. Service force members require adequate rehabilitation and support in order to return to work (RTW) and to be retained in military service. Although evidence exists to inform rehabilitation for RTW, little is known about the factors that influence retention in the workplace. This study thus sought to investigate factors influencing retention of service force members diagnosed with TBI in active service in the SANDF after RTW on completion of the vocational rehabilitation programme in occupational therapy. Method: A quantitative descriptive methodology was employed. A questionnaire to determine factors related to retention in the military after return to work of service members with TBI was developed by the researcher based on a review of the literature. Factors covered in the questionnaire included demographics, work and military factors, cognitive factors and rehabilitation and occupational therapy factors. The participants were also evaluated using the Montreal Cognitive Assessment (MoCA) to screen their cognitive function. Results: A sample size of 86 service members was achieved. The results indicated that age is a significant demographic retention factor (p=0.001). Work and military factor findings, showed the following to influence retention: the time it takes a TBI patient to return to work after injury (p=0.005), success in the workplace (p=0.001), reasonable accommodations (p=0.002), communication with supervisor (p=0.045), taking prescribed medication while on duty (p=0.012) and ability to perform military duties (p=0.001). Cognitive factors that influenced retention were concentration (p=0.000), ability to make decisions (p=0.000), ability to problem solve (p=0.000) and memory (p=0.000). Service force members, both those retained and not vi retained in the SANDF after return to work, reported that they were not rehabilitated using tasks that related to their duties or alternative duties to which they returned and that occupational therapists providing vocational rehabilitation rarely did work site visits. Conclusion: Findings of this study offer evidence that occupational therapists providing vocational rehabilitation should consider the factors demonstrated in this study affecting retention in military service after TBI. Work simulations that are close to the service force members’ military duties are recommended. It is recommended that the transformation management policy looks into the ranking system in the SANDF when considering reasonable accommodations for injured/disabled service force members for appropriate redeployment into a rank position. For future research literature indicated that psychosocial trauma was reported to be negatively influencing recovery and exacerbating symptoms of TBI in the military rather than other resultant outcomes of the TBI Further research on the influence of PTSD and substance abuse on TBI patients is recommended. The research on the influence of chronic pain including headaches is recommended. Further research on factors influencing retention of TBI patients from the supervisor’s perspective is recommended. vii Table of Contents Declaration .......................................................................................................................... i Plagiarism Declaration ........................................................................................................ ii Dedication ......................................................................................................................... iii Acknowledgments ............................................................................................................. iv Abstract .............................................................................................................................. v Table of Contents ............................................................................................................. vii List of Tables ..................................................................................................................... x Operational definitions ....................................................................................................... xi Abbreviations ................................................................................................................... xiii CHAPTER 1: INTRODUCTION ......................................................................................... 1 1.1 Background of the study ........................................................................................ 1 1.2 Statement of the problem....................................................................................... 3 1.3 Purpose of the study .............................................................................................. 3 1.4 The research question ........................................................................................... 3 1.5 The research aim ................................................................................................... 4 1.6 Objectives .............................................................................................................. 4 1.7 The significance of the study ................................................................................. 4 1.8 Layout of the study ...................................................................................................... 5 CHAPTER 2: LITERATURE REVIEW ............................................................................... 6 2.1 Introduction .................................................................................................................. 6 2.2. Traumatic Brain injury in military service ..................................................................... 6 2.2.1 Return to service or RTW post traumatic brain injury ........................................ 8 2.3 Factors influencing RTW post traumatic brain injury .................................................... 9 2.3.1 Demographic factors. .......................................................................................10 2.3.2. Military and workplace factors .........................................................................11 2.3.3. The neuropsychological and cognitive factors. ................................................13 2.3.4. Rehabilitation and occupational therapy factors ..............................................15 2.4 Summary ....................................................................................................................21 CHAPTER 3: METHODOLOGY .......................................................................................23 3.1 Study Design ..............................................................................................................23 3.2 Study Setting ..............................................................................................................23 3.3 Population of the study ...............................................................................................24 3.3.1 Sample of the study .........................................................................................24 viii 3.3.2 Sample size .....................................................................................................25 3.4 Research Instrumentation ...........................................................................................25 3.4.1 Questionnaire – Perceived barriers and facilitators for return to work in military service ......................................................................................................................25 3.4.2 Montreal Cognitive Assessment (MoCA) ..........................................................26 3.5 Research procedure and Data collection ....................................................................27 3.5.1 Data Management ...........................................................................................27 3.6 Data analysis ..............................................................................................................27 3.7 Ethics..........................................................................................................................28 CHAPTER 4: RESULTS ...................................................................................................30 4.0 Introduction .................................................................................................................30 4.1: Retention in the military after traumatic brain injury ....................................................30 4.2 Demographics and work categories ............................................................................31 4.2.1: Demographics .................................................................................................31 4.3. Work Factors .............................................................................................................32 4.3.1 Time since injury before return to work ............................................................32 4.3.2: Work categories ..............................................................................................33 4.3.2: Perceived success of return to work ................................................................34 4.3.3: Relationship with supervisor and their involvement in rehabilitation ................35 4.3.4: Changes made on return to work, sufficiency of tasks given and contribution made at work ............................................................................................................37 4.3.5 Perception of coping and amount of leave taken after return to work ...............39 4.4. Military Factors related to members with health conditions ........................................40 4.4.1: Taking prescribed treatment while at work ......................................................40 4.4.2: Health limitations recorded on the system .......................................................41 4.4.3: Ability to carry out work/duties and stigma ......................................................42 4.5. Cognitive Factors .......................................................................................................43 4.5.1: Cognitive factors at work - concentration, decision making, problem solving and memory ..............................................................................................................44 4.5.2: Loss of temper/getting angry at work ..............................................................46 4.5.3. The Montreal Cognitive Assessment (MoCA) ..................................................47 4.6. Factors related to Rehabilitation in Occupational Therapy .........................................48 4.6.1 Occupational therapy for return to work............................................................48 4.6.2 Follow up and further occupational therapy after return to work .......................49 4.7 Summary ....................................................................................................................50 CHAPTER 5: DISCUSSION .............................................................................................53 5.1. Introduction ................................................................................................................53 ix 5.2. Demographics of the sample .....................................................................................53 5.3 Factors influencing retention in the South African national Defence Force after traumatic brain injury ........................................................................................................54 5.3.1 Demographic factors ........................................................................................54 5.3.2 Work-related factors .........................................................................................55 5.3.3 Military-related factors ......................................................................................60 5.3.4. Cognitive factors .............................................................................................62 5.3.5 Factors related to rehabilitation in Occupational Therapy .................................65 5.4. Study strengths and limitations ..................................................................................66 CHAPTER 6: CONCLUSION & RECOMMENDATIONS ...................................................68 6.1. Introduction ................................................................................................................68 6.2 Conclusion and main findings of the study ..................................................................68 6.3 Clinical Recommendations .........................................................................................70 6.3 Recommendations for further research .......................................................................73 References .......................................................................................................................75 APPENDIX A ....................................................................................................................84 APPENDIX B ....................................................................................................................96 APPENDIX C ....................................................................................................................99 APPENDIX D .................................................................................................................. 102 APPENDIX E .................................................................................................................. 106 APPENDIX F .................................................................................................................. 106 APPENDIX G ................................................................................................................. 109 APPENDIX H .................................................................................................................. 112 APPENDIX I ................................................................................................................... 114 x List of Tables Table 4.1 Retention and months before return to work in the military after traumatic brain injury (n=86). ....................................................................................................................30 Table 4.2 Personal demographics of participants .............................................................31 Table 4.3 Combat related injury ........................................................................................32 Table 4.4 Time since injury before return to work .............................................................33 Table 4.5 Work categories of participants .........................................................................33 Table 4.6 Reported success of return to work ...................................................................34 Table 4.7. Reported supervisor involvement in rehabilitation. ...........................................35 Table 4.8 Reported relationship with supervisor prior TBI .................................................36 Table 4.9 Reported changes made on return to work .......................................................37 Table 4.10 Participation in sufficient duties, and contribution made after return to work....38 Table 4.11 Level of coping and amount of leave taken after return to work .......................39 Table 4.12 Taking prescribed treatment while at work ......................................................40 Table 4.13 Health limitations on the system ......................................................................42 Table 4.14 Ability to carry out physical work/duties and stigma .........................................43 Table 4.15 Cognitive factors - concentration, decision making, problem solving and memory at work ................................................................................................................44 Table 4.16 Reported frequency on loss of anger in the workplace ....................................46 Table 4.17 Results of the Montreal Cognitive Assessment. ..............................................47 Table 4.18 Occupational therapy for return to work ..........................................................49 Table 4.19 Follow up and further occupational therapy after return to work ......................50 xi Operational definitions • The Assessment of Military Multitasking Performance (AMMP) – is a battery was composed of three dual tasks concurrently tasking finite cognitive processing resources with physical and sensorimotor challenges (Scherer, et al., 2013, p. 1260) • Military skills: “A collection of individual soldering skills deemed critical to soldier survival, including activity-level competencies such as proficiency with weapons handling, communication skills, or negotiating obstacles” and battle drills - “integrated, multi-person, unit level activities which require RTW readiness” (Scherer, et al., 2018, p. 1258). • Polytrauma: a diagnosis that has been used to diagnose patients that have suffered several body system injuries. It has been defined as “Two or more injuries to physical regions or organ systems, one of which may be life threatening resulting in physical, cognitive, psychological or psychosocial impairments and functional disability” (Gray, et al., 2017, p. 2). • Reasonable accommodations: Any modification or adjustment to a job or to the working environment that will enable a person with disability to have access to, participate or advance in employment (Department of Public Service and Administration, 2014). • Retention: – For the purpose of this study retention implies an employee being retained in a job after injury and enjoying the benefits of the job same as before the injury. It includes “job enrichment, financial rewards, and employee benefits, training and development opportunities, work environment and work life balance. Retention strategies as career development opportunities, employee engagement and learning attitudes” (Kundu & Lata, 2017), p.2. • Return to work: The process of returning an injured worker to work (Schultz et al., 2007, p.330). xii • Traumatic brain injury (TBI): “An alteration in brain function, or other evidence of brain pathology, caused by external force” (Memon, et al., 2010, p. 1637) • Vocational Rehabilitation: a process consisting of medical, psychological, social, and occupational activities among sick or injured people with a work history to re-establish work capacity to enable return to the work force (Escorpizo, et al., 2010),p128. • Decision Making: for the purpose of this study decision making has been defined as a process of making basic daily decisions regarding a service force member’s daily routine for own occupation. • Problem Solving: for the purpose of this study problem solving has been defined as a service force member’s own ability to solve even basic problems that arises in their daily routine in their occupation. xiii Abbreviations AMMP Assessment of Military Multitasking Performance CAF Canadian Armed Forces (CAF) DOD Department of Defence PEMT Patrol-Execution Multitask PTSD Post-Traumatic Stress Disorder RWT Return to work SANDF South African National Defence Force TBI Traumatic Brain Injury VR Vocational Rehabilitation 1 CHAPTER 1: INTRODUCTION 1.1 Background of the study Internationally, and in South Africa (SA), traumatic brain injury (TBI) is known to be one of the leading causes of disability and it has been estimated that 89 000 new cases of TBI are reported every year (Pretorius & Broodryk, 2013). Head injuries can have a devastating impact on people’s lives, both personally and socially (Webster, et al., 2015). These effects are also true for those in the military, since serving in the military may put service force members at extra risk for TBI due to participation in military training exercises and active combat. Other than weapon and blast injuries, TBIs in the military can also result from motor vehicle accidents, assaults and falls, as well as incidences that occur while service force members are off duty (Reid & Velez, 2015). Although literature on the prevalence of TBI for those in the military in South Africa was not found, research indicates an incidence rate of 1,811.4 per 100,000 service force members in the American armed forces, with a 92% higher incident rate for those in active combat areas (Agimi, et al., 2019). Traumatic brain injury is defined as “an alteration in brain function, or other evidence of brain pathology, caused by external force” (Memon, et al., 2010, p. 1637). Traumatic brain injuries often cause impairment of cognitive, perceptual, social, behavioural, psychological and physical functioning and therefore returning to active service after such an injury is not an easy process for a soldier. Military service is known to be physically and psychologically demanding (Arrabito & Leung, 2008), and the process of determining a service member’s readiness for RTW or combat in the military is complex. Service member competence goes beyond military skills (drills, parade, ability to perform under pressure). Additional skills required to execute duties include resilience, self-efficacy, the capacity for complex thought and various other personal factors (Scherer, et al., 2018). Therefore, in the military work context, service force members with TBI struggle with meeting work demands due to functional limitations caused by residual TBI symptoms (Artman & Mchon, 2013). 2 Artman and Mchon (2013) cite cognitive and emotional deficits as the most persistent deficits affecting employment and return to active military service. Functional limitations also include a wide array of symptoms that vary in type, duration or intensity and include sensory, gross and fine motor, physiological and communication impairments (Artman & Mchon, 2013; Brainline Military, 2013) This may result in major health and economic issues linked with increased use of medical care, the loss of active time duty and substantial compensation costs (Songer & LaPorte, 2000). Without adequate rehabilitation and support, this may mean the end of a soldier’s military career (Bates, et al., 2008). According to Scollon (2000), return-to-work (RTW) is an important endpoint with regard to measuring the effectiveness of rehabilitation among TBI patients (Scollon, 2000). Factors that influence return to service or work include severity of injury, the demographics of the patient in terms of skill and education, the complexity of their work, as well as the support received once they are back at work (Brainline Military, 2013). Consequently, when a soldier becomes injured, the objective for all concerned is to facilitate, where possible, the soldier’s return to health and full productivity in the military or to accommodate them in other duties (Bates, et al., 2008). Thus, based on an assessment of the service member with TBI in the military and the work context, the focus of treatment for an occupational therapist is both return to active service and retention in the military (Brown & Hollis, 2013; Cogan, et al., 2019). Follow up of the service member in their work context is essential, especially as they usually have some residual difficulties even when integrated back into service. Successful RTW can be influenced by a number of factors including demographic, military service or work, neuropsychological and cognitive factors, as well as rehabilitation services received and from occupational therapy (Cogan, et al., 2019). There is little understanding of the factors influencing retention in military service post TBI after return to work, and this requires research, as well as the role of vocational rehabilitation in facilitating this retention (McCrea, et al., 2008) 3 1.2 Statement of the problem The literature reports mostly on factors that influence return to work (RTW) after TBI, with little research on retention after RTW globally. Little research could be sourced on the factors that influence retention of service force members or patients with TBI who RTW or work in a military service with no published literature on this aspect in the South African context. The researcher has worked in the Occupational Therapy Department’s neurology section at 1 Military Hospital for 11 years. From her experience, RTW in the military service in the South African National Defence Force (SANDF) for service force members with TBI, is not always successful with some not retaining their positions or jobs. This can occur despite having received multidisciplinary team members rehabilitation (including occupational therapy intervention) in preparation to RTW. Some service force members report difficulties at work after a few weeks or months, while others are successful. The factors, why some service force members with TBI are not retained after return in military service in this context is unknown. 1.3 Purpose of the study The purpose of the study is to determine which factors (demographics, work, military, occupational therapy and cognitive function) identified in the literature as influencing RTW, to explored as to whether are also influencing retention in military service in the South African context. This study will consider factors that influence retention and non- retention of service force members with TBI in active service in the SANDF from patient’s perspective. The factors ta into consideration are those that influence retention after their RTW and they have completed the vocational rehabilitation programme in occupational therapy. 1.4 The research question What factors do service force members diagnosed with TBI report influence their retention after RTW in military service in SANDF? 4 1.5 The research aim To investigate factors influencing retention of service force members from their perspective, diagnosed with TBI in active service in the SANDF, after RTW. 1.6 Objectives • To determine the demographic factors (age, race, gender, marital status and educational level) influencing retention or non-retention in the SANDF, reported by service force members diagnosed with TBI, after RTW. • To determine the workplace and military factors influencing retention or non- retention in the SANDF reported by service force members diagnosed with TBI after RTW. • To determine the cognitive factors influencing retention or non-retention in the SANDF reported by service force members diagnosed with TBI after RTW and screened by the occupational therapist using the MoCA. • To determine the rehabilitation and occupational therapy factors influencing retention or non-retention in the SANDF reported by service force members diagnosed with TBI after RTW. 1.7 The significance of the study Results of this study will promote awareness of the factors that influence retention of service force members with TBI in the military service in order to improve their work transition programme by addressing barriers and facilitating success in their retention after RTW. The outcome of this research would also improve the value of work transition programme with service force members with TBI and as a result, improve the overall inputs of occupational therapy in multidisciplinary intervention in transitioning back to the community and work in patients following a TBI. Lastly, the study will assist in addressing the financial implications associated ( This may result in major health and economic issues linked with increased use of medical care, the loss of active time duty and substantial compensation costs Songer & LaPorte, 2000) with temporary 5 incapacity leave for both the member and military), as improved rehabilitation services for successful work placement will minimise temporary incapacity and increase productivity in the workplace of members who RTW after TBI. 1.8 Layout of the study This study follows the traditional layout for a research report. The initial introduction chapter presents the background, purpose of the study, research question and aim, objectives and significance of the study. Chapter 2 features a literature review. The methodology is described in the third chapter with results in the fourth chapter. Chapter Five presents the discussion of the results and Chapter Six presents the conclusion by outlining the main findings and the recommendations for clinical practice and further research. 6 CHAPTER 2: LITERATURE REVIEW 2.1 Introduction This chapter presents a review of literature on patients diagnosed with traumatic brain injury in military service and the factors influencing the retention of service force members with TBI injured in active service and in work. The factors explored have been proved to influence RTW in literature however have not been sufficiently proven that after patients with TBI RTW do those factors play a role in patients with TBI to be retained. The factors are explored also in comparison between the military service and civilian service. Demographic factors, work factors, cognitive factors and the role occupational therapy plays in RTW are also considered. The researcher utilised Google Scholar, Researchgate and PubMed databases to search for relevant literature. Literature was explored from 1993 to 2020 and keywords used for the searching literature included TBI, TBI in military, TBI and RTW, TBI and retention. 2.2. Traumatic Brain injury in military service Recent statistics show that 383 947 American military service force members sustained TBIs between 2000 and 2018 (Brainline Military, 2019). It is possible that non-reporting or under-reporting of TBI in the military makes this a conservative figure (Brainline Military, 2019). In the American military and veteran populations, TBI is a major health problem as it remains a “signature injury” for service force members injured in the line of duty (Beran & Bhaskar, 2018) or civilian life (Gray, et al., 2017). Service force members are at a significantly higher risk for TBI due to the inherent vocational hazards associated with military training, combat and war (Scherer, et al., 2018). Although no statistics on causes of TBI are available for the SANDF. A review of TBI in the military found gender (being male), longer deployment to active service and not having officer rank significantly increased the risk of TBI while in service. There was however no risk associated with race or level of education (Lindquist, et al., 2017). 7 Improved battlefield medicine and protective equipment have increased the survival rates for military personnel who have sustained complicated injuries from exposure to blasts, including TBIs (Luethcke, et al., 2011). The sequalae of blast injury TBIs do not differ from TBIs from other causes (Luethcke, et al., 2011). Over 80% of TBI diagnosed in American military personnel are reportedly mild (Lindquist, et al., 2017). Traumatic brain injury research on military service force members has indicated that the clinical manifestation of mild TBI may also be complex (Dillahunt-Aspillaga, et al., 2017). Although symptoms usually resolve soon after a single exposure, there are significant residual post-concussive symptoms. Service force members with mild TBI reported more post-concussive symptoms than those with moderate/severe injuries, although emotional stress was the most prominent post-concussive symptom. Soldiers with mild, and moderate to severe TBIs require rehabilitation and need to be assessed in terms of their ability to RTW (Gray, et al., 2017). After rehabilitation, soldiers who are fit for work should be able to RTW. The careful and considered transition of defence force personnel back into the SANDF workforce is needed (Republic of South Africa, 2002) as the Labour Relations Act (1995) and the Employment Equity Act (1998) do not apply to members of the National Defence Force. To this end a disability committee in the military reviews the disability issues for defence force personnel. There are processes and procedures for transformation management in the Department of Defence (DOD), to eradicate unfair discrimination in the SANDF and to ensure equity for people with disabilities as well as (Parliamentary Monitoring Group, 2015). Thus, the ultimate goal for a person with a TBI in the military is return to active service and retention in the military with the support of amongst other the occupational therapists (Cogan, et al., 2019). Determining the factors that support the retention of a person with a TBI in their work context in the service of the SANDF which is the intension of this study will contribute to in the implementation of such transformational policy. This understanding will assist with the successful integration and retention of service force members with TBI who 8 still have some residual difficulties which need some minor accommodation or whose injury resulted in disability who may need some other redeployment 2.2.1 Return to service or RTW post traumatic brain injury In the military, the success of services and missions is dependent on the service force members’ ability to perform coordinated actions under physically, cognitively, and psychologically demanding conditions. Return to work readiness involves the all members being able to fulfil their allocated duties by participation in “complex tasks, including a range of activities from dismounted patrolling to casualty evacuation in order to be ready to react and survive. Therefore, in order for the DOD to be deemed mission ready, a service force member should be able to perform those types of complex military tasks according to the existing military operational competence standards” (Scherer, et al., 2018, p. 1258). For these reasons there is a need for military-based assessment tools so that when a service force member has sustained a TBI, their readiness and competence for RTW can be effectively and efficiently evaluated. Assessment tools need to evaluate participation in warrior tasks, battle drills and other foundational competencies or standards for a soldier (Scherer, et al., 2018). Warrior tasks are defined as “a collection of individual soldiering skills deemed critical to soldier survival, including activity-level competencies such as proficiency with weapons handling, communication skills, or negotiating obstacles and battle drills are known as “integrated, multi-person, unit level activities which require RTW readiness” (Scherer, et al., 2018, p. 1258). The readiness of service force members with TBIs for RTW in the military should include proficiency in these tasks and drills; this usually requires above average fitness, speed of movement and cooperation. Where service force members are unable to demonstrate this, an alternate placement need to be considered (Scherer, et al., 2018). Return to work has benefits for both the employer and employee (Arrabito & Leung, 2008) and the US military emphasises the use of resource (personnel, treatment equipment) facilitation for successful RTW after brain injury. The RTW programme for 9 those with TBI who are considered able to go back to military service, facilitates the restoration of their physical and mental health by assisting them to reintegrate into the workplace as soon as they are medically fit to work (Arrabito & Leung, 2008). This programme bridges the gap by coordinating rehabilitation and vocational goals, providing on-the-job evaluations and supervisor education, as well as follow up in case where the service force members’ need change (reasonable accommodations -RA) when they RTW (Brainline Military, 2013). In a study in the USA examined RTW of service force members after moderate to severe TBI. They reported that 70% were retained in the military after cognitive rehabilitation in hospital or at home, having returned to work 5-8 months post injury (Salazar, et al., 2000). Successful RTW is reported to be influenced by a number of factors including demographic, type of military service or work, neuropsychological and cognitive factors as well as the rehabilitation services from occupational therapy (Cogan, et al., 2019). Factors influencing retention in military service post TBI, as well as the role of occupational therapy rehabilitation in RTW, therefore require further research (McCrea, et al., 2008). 2.3 Factors influencing RTW post traumatic brain injury Dillahunt-Aspillaga et al. (2017) reported there is insufficient research with regard to patients with TBI in the military. This holds true, especially for factors influencing retention of service force members with TBI in the active force. Factors provided in literature focus more on RTW than on retention. Dillahunt-Aspillaga et al. (2017) argue that civilian-based researchers have failed to identify the context specific factors that influence retention after RTW for military service force members. Consequently, little information is available on the factors that influence retention of military service force members following a TBI. Most of the available research has considered civilians with TBI in retention after RTW. Therefore, factors reported to have an influence on RTW and on retention for civilians with a TBI were sourced and are reported below. 10 2.3.1 Demographic factors. The demographic factors found to influence RTW included patient gender, age, marital status, race and level of education. Patients in Canada who were male, younger than 50 years old, single and white, and who had post matric tertiary qualifications were reported to have better prospects for RTW (Scollon, 2000). The pre-work status of patients with a TBI also played a role in the process of RTW, as did the pre-injury educational status, rather than just the age (Scollon, 2000). Scollon (2000) further indicated good family support pre-accident and during rehabilitation contributed to good RTW prospects (Scollon, 2000). However, factors influencing their retention after theyRTW were not identified. In South Africa, the post-TBI RTW rate has been reported to be less than 32% for civilians (Watt & Penn, 2000). Demographic factors that contribute to detrimental prospects for RTW were reported to be first language and pre-TBI educational levels, as well as communication difficulties (Watt & Penn, 2000). Although Scollon (2000) and Watt and Penn (2000) also found the level of education to be an important predictor of employment retention for persons with TBI in the civilian population, contrary results in the military regarding level of education influencing retention were reported by Dillahun- Aspillaga et al., (2017). They argued that level of education might have an influence on RTW but has nothing to do with retention in the workplace, specifically in the military. They however acknowledge that classification of educational level might have been different to other studies. These authors also disputed age and marital status as being a factor, since they found being older and single had little to do with retention in the military. They argued that being retained in a job might be described differently in other studies. However, this must be viewed in light of their study participants having an average age of 23 years. With regard to retention in the military, DilahuntAspillaga et al. (2017), identified the deployment factors before the TBI and the position in the military as significant in retention in the service. 11 The severity of a TBI was found to be a predictor of retention in the military. The retention of service force members with mild TBI was less likely when compared to members with moderate and severe TBI. In the military mild TBI is reported to have a significantly negative impact on retention and community integration, particularly when members with mild TBI also have PTSD (DillahuntAspillaga, et al., 2017). This is in contrast to civilian studies that have reported the better retention of patients with mild TBI in work compared to patients with moderate and severe TBI, regardless of their age (Dillahunt-Aspillaga, et al., 2017). Therefore, severity of the TBI and retention in the workplace may not be related when comparing the military and for civilian populations. However, when service force members have a severe TBI, and leave acute inpatient rehabilitation lacking independence in daily activities, this usually precludes RTW (Dillahunt-Aspillaga, et al., 2017). 2.3.2. Military and workplace factors A South African civilian study found that pre-work history, work performance, work habits, interpersonal relationships with co-workers and supervisors play a substantial role in RTW of patients with TBI (Watt & Penn, 2000). In addition, the vocational skills the TBI patient acquired pre-injury have also been found to influence return and retention in the workplace. Fewer patients with TBI who had previously worked with a job classification of unskilled work RTW as compared to those with a job classification of semi-skilled and skilled work (Watt & Penn, 2000). This supports international literature that reports that Canadian patients with TBI who had jobs with high mental demands pre-injury, such as those in specialised skills training, were more likely to RTW when compared to patients in unskilled manual jobs (Scollon, 2000). Outcomes for RTW were also better if the patient with TBI had been in their job for more than six months and , full time employees achieved better outcomes than those who did piece or temporary jobs pre-TBI (Scollon, 2000). Research on RTW after TBI in the military, however, suggests that supervisors struggle to decide if the service member is ready to return to their military duties due to limited 12 medical knowledge of the residual problems and prognosis (Scherer, et al., 2018). The military environment is reported to be unique and requires specific competencies for certain duties. Service force members are required to have physical, cognitive and psychological capacity to execute timely, coordinated actions in pressurised situations that demand special military skills capacities since the safety of others may depend on their performance (Scherer, et al., 2018). Supervisors need to be assured that the service member can perform at the expected level. In addition, the researchers noted that workplace stigma exists towards injured service force members who are unable to perform their military duties. This stigma can interfere with the creation of a supportive work environment, which is critical for unit cohesion, morale and ultimately operational effectiveness (Arrabito & Leung, 2008). Stigma and discrimination have been attributed to a lack of understanding among supervisors and colleagues about how a service force member’s bodily function can affect their ability to carry out their military duties (Scherer, et al., 2018). Authors suggest that this stigma must not be ignored as it has a negative impact on work retention and has been associated with greater occupational stress for injured workers (Aikins, et al., 2020). Occupational stress has been identified as one of the factors that further affects the recovery, health and wellbeing of service force members with TBI, and hinders their work performance (Aikins, et al., 2020). Service force members may avoid seeking assistance regarding their occupational stressors if they believe this will result in being undermined by supervisors and colleagues (Aikins, et al., 2020). Therefore, even though it may be difficult and time-consuming to address stigma, its reduction is necessary if injured members are to have a better outcome when navigating the successive phases of recovery, rehabilitation and return to and retention in military service (Arrabito & Leung, 2008). Service force members may also avoid seeking assistance as every consultation is added to their profile. 13 All service force members profile is created when joining the force. When service force members suffers from illness/ disease/injury that result in functional limitations, it is recorded on their profile so that they can be accommodated in the service if necessary. Service force members with TBI that result in functional limitations, are recorded in their profile, which documents the service member’s health condition and the impact of the condition on their ability to perform duties and may limit their geographic assignment (Bates, et al., 2008). To accommodate issues with performance following a TBI, usually injured service force members return to support duties and are exempted from warrior tasks and battle drills. If the service member cannot resume employment in their military occupation after injury or illness, they may remain in military service in an alternative position, provided they meet minimum operational standards for that position related to the service (Arrabito & Leung, 2008). 2.3.3. The neuropsychological and cognitive factors. Amongst civilians with TBI in South Africa, the strongest predictor for failure to RTW is mental skill impairment (Watt & Penn, 2000). An inability to manage behaviour, such as aggression, and other cognitive skills resulted in an inability to maintain employment in pre-injury jobs (Moller, et al., 2017). Such TBI suffers struggle in work environments due to their mood changes, lack of insight and disrupted interpersonal skills related to impaired self-awareness of their abilities and limitations (Scollon, 2000). The other impairments after TBI which impair RTW are reported to include deficits in body image, neuropsychological and executive function (Scollon, 2000). Earlier findings by Brooks et al. (1987) concur with the above, stating that mental abilities, social interaction and personality deviations contribute to RTW incapacities of patients with TBI more than body function deficits (Brooks, et al., 1987). The ability of a service member to perform duty related activities has also been associated with other factors such as post concussive, neurocognitive, sensorimotor, or somatic sequelae (Scherer, et al., 2018). It has been reported that service force members with TBI who were retained in the military, were those with fewer limitations 14 in cognitive and motor functioning, and fewer psychiatric symptoms (Dillahunt- Aspillaga, et al., 2017). Those who did not use mental health services for a year were also more likely to remain in the military workplace. This suggests that the absence of psychiatric symptoms may also have an influence in the retention in the workplace (Dillahunt-Aspillaga, et al., 2017). However besides absence of psychiatric symptoms other residual physical, psychosocial or cognitive limitation can affect retention in the workplace. Service force members with TBI often present with several residual or comorbid difficulties, due to other injuries which accompanied the TBI. This is described as polytrauma, defined as “two or more injuries to physical regions or organ systems, one of which may be life threatening resulting in physical, cognitive, psychological or psychosocial impairments and functional disability” (Gray, et al., 2017, p. 2). Other conditions, such as chronic pain and soft tissue injury, may also affect cognitive symptoms, which may produce new or more severe symptoms affecting retention in the work place at a later stage (Lees-Haley & Brown, 1993). Concurrent polytrauma and TBI has be associated with psychiatric conditions such as post-traumatic stress disorder, depression, anxiety and substance abuse (Kennedy, et al., 2010). These also include high rates of psychological and neurobehavioral symptoms, such as memory deficits, mood symptoms and a demotivation that may, or may not be, directly related to the TBI (Frénisy, et al., 2006). Service force members with TBI, especially those who suffer more than one mild TBI, may also be at risk of neurodegenerative diseases (DeKosky, et al., 2010). Research on the cognitive functioning in service force members, even those with mild TBI, revealed difficulties with memory, attention, concentration and irritability, as well as sleep disturbances. Poor tolerance to noise was also reported at 3 months follow up appointments (Luethcke, et al., 2011). Luethcke, et al. (2011) suggests there is clinically significant impairment in cognitive processing seen in patients with TBI in the military, irrespective of the cause of the TBI. Thus, the severity of the head injury alone 15 may not predict the neuropsychological and cognitive symptoms with which patients present (Luethcke, et al., 2011). In addition to symptoms of physical discomfort, sensory instability or disorientation, acutely concussed service force members with mild TBI, may experience deficits in activity or participation-level performance in previously highly practiced and well-trained military occupational competencies (Scherer, et al., 2013). In these patients “post-concussive activity level deficits in service force members which may include marksmanship (stemming from gaze instability, visual or central cognitive processing capabilities) or difficulty engaging in radio communications due to central auditory or cognitive processing impairments) included with a number of highlighted symptoms and impairments believed to degrade RTW readiness” (Scherer, et al., 2013, p. 1257). Thus, due to the need to execute timely, coordinated actions in pressurised situations, rates of retention of service force members with TBI, especially those with mild TBI, may be low (Stergiou-Kita, et al., 2011). 2.3.4. Rehabilitation and occupational therapy factors The ultimate goal of rehabilitation following TBI is to assist force members to RTW or to make an optimal return to civilian life if the extent of their injuries necessitates a medical boarding (Gray, et al., 2017). According to Dilahaunt-Aspillaga et al. (2017), community integration, positive affect, and social support after rehabilitation discharge can significantly influence the quality of life after TBI, whether in a military context or not. Being productive in the workplace has shown to be an important part of people’s daily life with or without TBI (Dilahaunt-Aspillaga et al. 2017). Not returning to work following a TBI can influence quality of life and psychological wellbeing (Pugh, et al., 2017), and is linked to regression of health status. Pugh et al. (2017) stated that work difficulties or unemployment can negatively affect wellbeing. They reported that addressing employment issues can assist in preventing regression of health and functioning. Vocational rehabilitation should therefore be an important focus for individuals who have sustained TBI. 16 Service force members with TBI require multidisciplinary rehabilitation, which should include vocational rehabilitation and ongoing vocational support for the multiple challenges related to the complex interaction of physical, cognitive, and emotional impairments (Salazar, et al., 2000). Before 1994 force members with a major injury were usually released from the service, today however, where accommodation technology (RA including assistive devices) exists and where opinions and attitudes have changed, these service force members can potentially RTW and continue to serve in the military (Bates, et al., 2008). Occupational therapists are important team members in providing vocational rehabilitation and are responsible for functional capacity evaluations of TBI service force members (Scherer, et al., 2018) as well in South Africa context. This rehabilitation usually takes place in a military or veterans’ hospital followed by a home-based programme, with the occupational therapist usually recommending a suitable work placement (Salazar, et al., 2000). Ideally, service force members should return to their own occupation without reasonable accommodation within the limits of the residual problems from brain injury (Silverberg, et al., 2017). Some service force members with TBI however dare reported to require reasonable accommodation in the workplace (Pugh, et al., 2017). Reasonable accommodations are any adaptations to duties or work context recommended and put in place whenever a service force member returns RTW following an injury such as a TBI. This may include service force members who return to their own occupation with modified duties or limited hours, those who returned to a different occupation and other modified work stations with less physically and cognitively demanding occupations (Pugh, et al., 2017). In rehabilitation following a TBI successful RTW an essential goal, but careful monitoring of the patient is essential so they do not attempt to RTW too soon or late. A RTW goal is more likely to be achieved if the patient and therapist are both realistic about the type of work the patient can manage initially and at a later stage, and when 17 the RTW is managed so that it is within the patient’s residual capabilities (Stergiou-Kita, et al., 2011). Generally, for civilians with TBI, Scollon (2000) reports that the duration of rehabilitation is typically an indication for future possible RTW. If the patient with TBI only requires only a few months in rehabilitation they have a good chance of returning to work compared to those who require more than a year of rehabilitation (Scollon, 2000). Significant progress in the first six months of recovery following TBI has also been associated with RTW in 60% to 90% of patients (Silverberg, et al., 2017). 2.3.4.1 Assessment of functional capacity Accuracy of the vocational assessment completed, as well as the skills and competency of the assessors can influence the outcomes of RTW in adults with TBI (Stergiou-Kita, et al., 2011). However, despite the need for reliable and accurate functional capacity assessment methods, there is a great variability in how vocational evaluations are completed in practice. Evaluators have challenges including describing the specific purpose of an evaluation, selecting proper evaluation tools and issues with interpreting their findings when completing vocational-related evaluations (Stergiou- Kita, et al., 2011). Due to the nature of military environment and the complexity of military duties, the assessment tools used have to be relevant and realistic to the military in terms of function and performance for RTW and may differ compared to RTW assessments in the civilian environment. Available standardised assessment measuring tools have not all been validated for military service force members. If work samples used to assess RTW of service force members, these work samples should resemble the real-work duties, including the environment in which the duty takes place. In the military, there is a need for protocols that integrate ecologic (war zone environments/environments were duty takes place) aspects when making recommendations in relation to RTW (Scherer, et al., 2018). 18 There is reluctance in the military to use self-report tools of cognitive function because service force members may be hesitant to report their symptoms in detail if they feel it will jeopardise their military duties and reliability of people with head injuries is a concern is civil society as well. Any self-reporting assessment tools used need to be supported by other objective assessments if decision makers (multidisciplinary team) are to generate proper recommendations on the service member’s readiness to return to RTW (Brainline Military, 2013). Higher order mental skills and good work habits need addressing in rehabilitation, especially for patients working in high-level jobs (Scollon, 2000). While there are valid and reliable assessment tools available to assess limitations or other adverse results in terms of neuropsychological and cognitive function following a TBI, or more severe neurologic pathology, these assessments are not suitable for service force members (Sherer et al., 2013). The available assessment tools lack normative values in the typical age and activity range of the service force members. Consequently, the scoring values on many standardised assessments do not match the abilities that require assessment (Scherer, et al., 2013). In the USA, occupational therapists have relied on sports concussion literature when assessing readiness of service force members with mild TBI for RTW. However, Sherer, et al. (2018) have found that the sports concussion literature references are not applicable in the military to determine RTW as sports concussion focuses more on musculoskeletal than the cognitive limitations in TBI. Scherer et al. (2013) reported on extensive developments in virtual reality applications that are usable in the assessment and recommendations for RTW readiness of service force members post TBI. These applications provide flexibility in carrying out complex, scenarios of duties in the real work world of the service force member. The establishing of these new assessment methods address “immersive virtual reality environments, field-based scenario-driven assessment programs, and militarized dual-task and multitask-based approaches for the evaluation of sensorimotor and cognitive function 19 following TBI” (Scherer et al., 2013, p: 1264). Military rehabilitation teams are still researching complex, dual and multi task evaluations in order to obtain accurate measures for RTW readiness of service force members. For assessment of successful RTW, the participation in/completion of complex tasks are well suited, since they consider the performance of tasks with real-world demands (Scherer, et al., 2013). A battery of novel dual tasks and multitasks were created by a multidisciplinary team of military and civilian clinician-scientists, to address competency related to known TBI- related residual problems in combat service force members (Scherer, et al., 2013). The Assessment of Military Multitasking Performance (AMMP) battery was composed of three dual tasks concurrently tasking finite cognitive processing resources with physical and sensorimotor challenges. However, adding endurance to participate in the tasks was a problem. The development of the Patrol-Execution Multitask (PEMT) was to concurrently probe for symptoms of post-concussive exercise intolerance using an exertion task while engaged in a virtual reality patrol to replicate the experiences of a deployed, dismounted war fighter. The PEMT scenario requires engagement of cognitive resources, including situational awareness, memory and decision making under conditions of moderate exertion” (Scherer, et al., 2013, p. 1260). Technically, multitasking is the need to engage in multiple activities at the same time with serial switching of attentional priorities between activities. The PEMT diverges from the traditional clinical definition of multitasking. The assessment is characterised by discrete interleaving tasks typically punctuated by interruptions, and used to identify executive dysfunction. The PEMT and AMMP battery are not available for the South African context and thus rehabilitation professionals are using assessment batteries available for the civilian population (Erasmus, 2013). Occupational therapists use various assessments same as used by other occupational therapist civilian society, not military specific, to test readiness for work of service force members with TBI. Although many factors influence RTW, the most important is the capacity of the TBI patient to fulfil the requirements of 20 the job to which they are returning. The higher cognitive skills of an individual are the determinants of whether a person can complete a goal-orientated task. Patients with TBI, specifically those in management positions, struggle in these particular positions due to affected high cognitive skills functioning (Erasmus, 2013). Trudel et al. (2007) agreed with Sherer et al., (2013) that psychometric and practical issues hamper the available clinical assessment methods used to assess injured service force members. They reported there is an absence of sensitivity to high-level functioning limitations in the assessment methods used by physical and occupational therapists. The assessments fail to detect deficits when used on combat populations. Batteries currently used do not contain validity (not measuring military skills) or measure function related to combat specifically for service force members (Trudel, et al., 2007). The focus of an assessment of the patient and the work context, for the occupational therapist of a service member with TBI is not just the return to active service, but also most importantly retention in the military. For them to be successfully retained in the workplace, factors that influence their retention need to be known. 2.3.4.2 Retention after return to RTW An accurate functional capacity evaluation and vocational rehabilitation is important but retention in the workplace may not be assured without further follow up and support of service force member. The rehabilitation team should ensure the patient with TBI has adequate endurance, work habits and does not experience under-productivity or loss of productivity (Silverberg, et al., 2017). Patients with TBI who have returned to work reported various cognitive, physical and emotional symptoms of moderate severity (Dillahunt-Aspillaga, et al., 2017). Additional severe subjective symptoms of depression, anxiety and Post-Traumatic Stress Disorder (PTSD), as well as post- concussive symptoms have been associated with retention in the workplace (Dillahunt- Aspillaga, et al., 2017). 21 According to Silverberg et al. (2017), RTW does not guarantee productivity when patients with TBI still struggle with residual symptoms. These residual symptoms that affect productivity may result in difficulties in retaining their job. Retention in the workplace could also be affected by absenteeism. The cost of productivity loss may outweigh that of absenteeism and disability leave resulting in the employer not wishing to retain the employee with TBI (Silverberg, et al., 2017). Dillahunt-Aspillaga et al. (2017) reported other factors that may interfere with retention of service force members with TBI after they RTW include attendance at rehabilitation/follow up appointments, access to transportation for rehabilitation/medical services and family responsibilities. Retention studies have highlighted the importance of an accurate functional capacity evaluation using relevant assessment tools for the military service force context, but most of these studies have been undertaken in the United States. The recommendations from current study would thus address the gap with regard to improving the current rehabilitation procedures and assessment methods in the SANDF. Traumatic brain injury effects are more detrimental in SA as there is loss of skilled employees and sustaining unemployed persons with TBI worsens the load on the economy (Erasmus, 2013). 2.4 Summary In military and veteran populations, TBI is a major health problem due to the residual symptoms that do not completely resolve. Statistics indicate military service force members may have a higher rate of TBIs than civilian population. In previous years, active service force members with TBI were typically released from service; while more recently, there are attempts to retain them (Gray, et al., 2017). Traumatic brain injury leads to varying levels of disability resulting in health and economic concerns linked with increased use of medical care, the loss of active time RTW and substantial compensation costs. The short-term and long-term changes in cognitive, behavioural, psychological and physical functioning are consequences of TBI that can impact on a person’s ability to return, maintain employment, or obtain 22 alternative employment as well as community re-integration. Furthermore, there is often a link between the persistent symptoms and complex co-morbidities, such as chronic pain, irritability, sleep and mental disorders (e.g., depression, anxiety, anger management or PTSD) that can affect work performance and participation in daily activities (Dillahunt-Aspillaga, et al., 2017). The effects of physical, cognitive and psychological deficits in patients with TBIs, as reported in previous civilian studies, also hold true for those in military service (Songer & LaPorte, 2000). Military service is physically and psychologically demanding (Arrabito & Leung, 2008). For a service member there are foundational competencies or standards required with regard to military tasks and combat drills (Scherer, et al., 2018). Therefore, once a soldier is injured, returning to active service after an injury, such as a TBI, is not an easy process. Without adequate rehabilitation and support, this may mean the end of a soldier’s career in the military (Bates, et al., 2008). The researcher identified observed difficulties in retention of service force members with TBI in the military. Those difficulties have devastating effects on the health and well-being of service members, as well as on the economy. Even after rehabilitation, skilled trained service force members may not be retained in the workplace. There seems to be a gap in the literature in identifying the factors that influence retention of TBI patients, specifically in the military in the South African context. Therefore, this study’s aim was to investigate factors that influence retention and to promote awareness of the factors that influence retention of service force members with TBI in the military service in order to improve their work transition programme by addressing barriers and facilitating success in their retention in the South African SANDF context. 23 CHAPTER 3: METHODOLOGY 3.1 Study Design The study employed a quantitative descriptive, cross-sectional design. Quantitative research was chosen because the service force members were describing their perspectives rather than assumptions of the situations by the researcher. The descriptive report included the study of certain variables with no manipulation of the variables (Sukamolson, 2007). The cross-sectional study was selected since data were collected at one point in time (Olsen & St George, 2004). The study was quantitative because data was numerical and analysed with statistical procedures. 3.2 Study Setting The South African National Defence Force has four arms of service, which included the South African Army, South African Air Force, South African Navy and South African Health Military Services. The South African Health Services offered medical support to all arms of the services, at one of three hospitals, 1, 2 and 3 Military Hospital, based in Pretoria, Cape Town and Bloemfontein respectively. The study was undertaken at 1 Military Hospital, which is the biggest of the three hospitals. Occupational therapy formed part of the medical support provided to the four arms of services in all three hospitals. The Occupational Therapy Department at 1 Military Hospital consisted of 13 occupational therapists, three community service occupational therapists and two occupational therapy technicians, with three sections offering services in child, psychiatry and neurology and orthopaedic rehabilitation. Occupational therapy provided services to injured and sick service force members and their families for a wide variety medical conditions. Although this research was conducted in the neurology section of the occupational therapy department, in all sections the role of occupational therapy with ill and/or injured service force members emphasised the successful integration back in to the workplace. 24 3.3 Population of the study Service force members diagnosed with TBIs and treated at 1 Military Hospital in the last five years who have RTW having completed an occupational therapy vocational rehabilitation programme. 3.3.1 Sample of the study The method of sampling used was convenience purposive sampling. The selection of the participants was due to the suitability of the study Acharya et al., 2013). The researcher went through the occupational therapy records systematically and identified 109 service force members diagnosed with TBI at 1 Military Hospital who have returned to work and had or had not been retained in active service. The service force members that met the inclusion criteria below were contacted and those that were easily available were invited to participate the study. Service force member patients with TBI recommended for RTW in active service, with and without reasonable accommodations, irrespective of the severity of the TBI were included in the study. Inclusion criteria • Service force members who had sustained TBI as active members who have received occupational therapy vocational rehabilitation service from 2014 to 2019. • Service force members with TBI who were able to complete a questionnaire independently, or an interview format • Service force members with TBIs who were older than 18 and younger than 60 Exclusion criteria Service force members with TBIs that presented with pre-existing psychiatric conditions 25 3.3.2 Sample size From the reviewed of records at 1 Military Hospital over the last five years, there were 109 service force members with TBIs who returned to work and had or had not been retained in the military from in the five-year period under review . According to Cochrane’s formula, a minimum of 85 service force members should have completed the questionnaire to achieve no more than a 5% margin of error if the sample is to be representative of the population (Bartlett, et al., 2001). 3.4 Research Instrumentation 3.4.1 Questionnaire – Perceived barriers and facilitators for return to work in military service The researcher did not find an existing tool suitable for the study and thus developed her own for the patients with TBIs who had returned to work (Appendix A) Questionnaires on RTW exist but were not suitable to address the objectives of the study, which focused on work retention in the military service. Items included in the questionnaire were based on the reviewed literature (Rationale in Appendix B) and the Employee return-to-work following long-term sickness absence- BOHRF survey (Hicks, 2017). The questionnaire included a number of questions that could be answered using a Likert-scale. The questionnaire had 37 items and was self-administered. The researcher administered the questionnaire in an interview format for participants unable to complete the questionnaire Survey Validation A survey validation was conducted to strengthen the content validity and utility of the questionnaire. Five experts with at least five years’ experience in the field of Vocational rehabilitation received the questionnaire for validation. The experts were asked to critique the questionnaire and made recommendations to assist to strengthen the validation of the questionnaire. The results of the survey validation were used to refine the questionnaire. Six TBI patients, who were not part of the study, also pre-tested the 26 questionnaire. The testing of the questionnaire aimed to address ambiguity and ensured ease of completion. Ten questions underwent correction based on the feedback received (see Appendix C). Grammar was also corrected as per recommendations. 3.4.2 Montreal Cognitive Assessment (MoCA) The Montreal Cognitive Assessment (MoCA) (Appendix D) screened the participants’ cognitive function. The design of the MoCA was as a rapid screening instrument for mild cognitive dysfunction that takes approximately 10 minutes to administer. The tool assessed the following cognitive domains: attention and concentration, executive functions, memory, language, visuo-constructional skills, conceptual thinking, calculations and orientation. The MoCA was used in this study prior to training being made mandatory by the developers in 2019 (Nasreddine, 2019). The MoCA screened whether higher cognitive skills needs further assessment depending on severity of the results and assisted in determining if the patients will be able to complete questionnaire. The highest total score is 30 points, with a score of 26 or above being considered normal (Nasreddine, 2019). The MoCA is a valid assessment tool for assessing gross cognitive ability in patients with TBI (intra-cranial haemorrhage) (Wong et al., 2013). The tool demonstrated high specificity and sensitivity for detecting mild cognitive impairment (Nasreddine, 2019). Nasreddine and colleagues (2005) also determined the internal consistency of the MoCA on standardised items (Cronbach’s alpha = 0.83). Their assessment of the test-retest reliability demonstrated the mean change in scores was 0.9. The tool can track cognitive abilities over time in geriatric patients with cognitive impairment, but there was no evidence for the tool’s responsiveness in a TBI population (Nasreddine, et al., 2005). The MoCA has been validated on a healthy South African cohort (Beath et. al., 2018) so was considered suitable for use in this study 27 3.5 Research procedure and Data collection Approval for the protocol was obtained from Faculty Graduate Studies Committee at the University of the Witwatersrand and School of Therapeutic Sciences Postgraduate Committee. After permission was granted for the research contacts details of potential participants were taken from 1 Military Hospital’s occupational therapy records. The research was explained to the participants. The researcher set up appointments telephonically for visits with the service force members. The visits were either at the workplace or at the nearest military unit for participants not retained, and in the SANDF sites for those retained. Each participant completed a MoCA, administered by the researcher. After completion of the MoCA, the participants were given the research questionnaire to complete. While the participants were filling in the questionnaires the researcher was available for assistance and clarification. English language was used with participants. It took 20-30 minutes for participants to complete both the MoCA and questionnaire. 3.5.1 Data Management The capturing of the collected data was via Microsoft Excel on the researcher’s computer, which was password secured. The data underwent cleaning and coding in Microsoft Excel and the accuracy of the data entered checked. Backing up of data occurred regularly on a separate storage device. The data was accessible to the researcher and the supervisor as well as the involved research committees if required. It will be stored for 5 years on the computer which is password secured. 3.6 Data analysis Demographic data was analysed using descriptive statistics. Analysis sought to describe the profile of TBI patients retained in the workplace and those not retained. Categorical data from the questionnaire was summarised as frequencies and 28 percentages. Frequency tables were used to present data. The comparison between those retained and not retained were analysed using the Chi Square test. It was used for comparing ordinal variables between the retained and no retained service force members. Data were analysed using Statistica v 13.2 The presentation of the results of the MoCA was as a median and interquartile range using the Mann Whitney U test. The Mann Whitney U Test determined differences between those retained and those not retained. The Mann-Whitney U test is a non- parametric statistical technique used because the data were ordinal data and analysed differences between the medians of two data sets (Milenovic, 2011). The performing of all analyses was at a 95% confidence interval. 3.7 Ethics Ethical clearance for the study was provided by the Human Research Ethics Committee at the University of the Witwatersrand (M180423) (Appendix E) as well as ethical clearance and permission from 1 Military Hospital Research Ethics Committee (1MH/302/6/03.01.2018) (Appendix F) prior to conducting the research. The ethical principles adhered to during the study included: Autonomy Participants were given the right to exercise their choice in accepting or declining participation within the study respected their autonomy (Panter, 2011). The respondents were informed of the nature of the study to be conducted and that participation in the research was entirely voluntary. Participants were able to refuse, or cease to participate without stating any reasons. Each participant was provided with an information sheet (Appendix G) and asked to sign informed consent (Appendix H). Confidentiality Confidentiality and privacy of records of names of patients diagnosed with TBIs in the South African Defence Force was ensured, as participants were not required to put 29 their names on the questionnaires. Data was kept confidential; it was not made accessible to other people other than the researcher and supervisor and the stated research ethics committees upon request. Respondents’ names did not appear on questionnaires (Appendix A) during data collection. Respondents’ data is non identifiable and will not be identifiable on published results, as the privacy, dignity and information of the participants remains confidential. Beneficence Participants received notification that there were no potential benefits for them in participating in the study. Non-maleficence There was no potential or documented harm for respondents in this study. Justice All participants received equal treatment, and their contributions were recognised and valued. Information collected was for the purpose of the study, and the researcher honestly presented the research findings. The researcher acknowledged all the assistance, collaboration, sources of information and financial support received. 30 CHAPTER 4: RESULTS 4.0 Introduction This chapter includes presentation of the results from 86 participants, more than required, who completed the questionnaire on factors associated with retention and non-retention of service force members with TBIs in the SANDF. The questionnaire included questions on demographic and work factors> This chapter includes a comparison of these factors for participants retained and those not retained after returning to work post TBI in the SANDF. The Montreal Cognitive Assessment (MoCA) was used to evaluate the participants to determine their cognitive function and retention associated with this variable, as well as factors related to their rehabilitation and occupational therapy experiences. The factors related to military procedures for members with health conditions such as TBI are also presented. 4.1: Retention in the military after traumatic brain injury Table 4.1 shows that 82.5% of participants were still active service force members at the time of the study, indicating the retaining of this proportion of members following a TBI. Of the other participants, 17.4% (n=15) were not retained, of which 5.8% (n=5) were veterans and 11.6% (n=10) left the force following medical boarding. The 86 participants all returned to work after completing a rehabilitation programme; some returned to work after few months and some after a year or more. Table 4.1 Retention and months before return to work in the military after traumatic brain injury (n=86). Category n Percentage Retention No 15 17.4 Yes 71 82.5 31 4.2 Demographics and work categories 4.2.1: Demographics Table 4.2 indicates that 69 (80.2%) males and 17 (19.7%) females participated in the research. The majority of participants were African (n=70, 81.3%), married (n=33, 38.3%) and had a Grade 12 (n=49, 56.9%) level of education. Table 4.2 Personal demographics of participants T (n otal =86) Re ( tained n=71) Not retained (n=15) Category n % n % n % p value Gender Male 69 80.2 58 81.6 11 73.3 0.616 Female 17 19.7 13 18.3 4 26.6 Age 20-30 years 5 5.8 5 7.0 0 0 0.001** 30-40 years 27 31.3 24 33.8 3 20 40-50 years 35 40.6 30 42.2 5 33.3 50-60 years 19 22.0 12 16.9 7 46.6 Ethic group African 70 81.3 57 80.3 13 86.66 0.669 Caucasian 12 13.9 10 14.1 2 13.3 Indian 1 1.1 1 1.4 0 0 Coloured 3 3.4 3 4.2 0 0 Marital status Married 33 38.3 24 33.8 9 60.0 0.098 Divorced 10 11.6 9 12.6 1 6.6 Cohabitation 17 19.7 14 19.7 3 20.0 Single 26 30.2 24 33.8 2 13.3 Highest level of education Grade 12 49 56.9 39 54.9 10 66.6 0.620 Post-matric certificate 8 9.3 7 9.8 1 6.6 Diploma 23 26.7 21 29.5 2 13.33 Degree 6 6.9 4 5.6 2 13.33 Significance p≤ 0.05* p≤ 0.01** 32 Results show that the majority (n=35, 40.6%) of the participants were in the age range 40-50 years and with the fewest participants (n=5, 5.8%) in the 20–30-year category. The only demographic factor for which there was a significant difference in the participants that were and were not retained was age (p=0.001). 4.2.2 Traumatic brain injury Only 13.9% (n=12) of participants reported that their injuries were combat related and none of the non-retained participants had combat related injuries (Table 4.3). However, the difference between the participants who were and were not retained was not significant for whether the injury was combat related or not. Table 4.3 Combat related injury Variable Was your injury combat related Total n=86 Retained n=71 Not retained n=15 n % n % n % p value 0 = No 74 86.0 59 83.0 15 100.0 0.089 1 = Yes 12 13.9 12 16.9 0 0 Significance p≤ 0.05* p≤ 0.01** 4.3. Work Factors 4.3.1 Time since injury before return to work Table 4.4 reflects the months before participants returned to RTW/work. There was a significant difference in the time taken to RTW for participants with TBI who were and were not retained in the military (p=0.005). Of the participants who were retained in service, 80.2% (n=57) returned to work within one year compared to 46.6% (n=7) of those who were not retained. A higher percentage of participants (n=2: 13.3%) who were not retained only returned to work 25-36 months after injury compared to those who were retained (n=2: 2.8%). 33 Table 4.4 Time since injury before return to work Total (n =86) Retained (n=71) Not retained (n=15) Months before return to RTW n % n % N % p value 2-6 months 30 36.6 29 40.8 1 6.6 0.005** 7-12months 34 42.2 28 39.4 6 40.00 13-18 months 10 8.4 8 11.3 2 13.3 19-24 months 5 7.0 2 2.8 3 20.0 25-36 months 4 5.6 2 2.8 2 13.3 Don’t remember 3 3.5 2 2.8 1 6.6 Significance p≤ 0.05* p≤ 0.01** 4.3.2: Work categories Of the participants, 37.0% (n=33) were in occupations that had medium physical demands followed by those in sedentary occupations (n=19: 22.0%). (Table 4.5). Table 4.5 Work categories of participants Variable Work categories of participants Total (n=86) Retained (n=71) Not retained (n=15) n % n % N % p value Light to sedentary 9 10.4 7 9.8 2 13.3 0.470 Sedentary 19 22.0 17 23.9 2 13.3 Medium 33 37.0 29 40.8 4 26.6 Light 9 10.4 7 9.8 2 13.3 Light to medium 6 6.9 4 5.6 2 13.3 Medium to heavy 8 9.3 5 7.0 3 20.0 Significance p≤ 0.05* p≤ 0.01** 34 The lowest percentage of participants (n=6: 6.9%) were those who performed light to medium occupations since they do sedentary work with some components of light occupation. There was no significant difference in the categories of work for those retained and not retained in the military after TBI. 4.3.2: Perceived success of return to work Table 4.6 shows how the participants felt about the success of their RTW after TBI. Return to work was very or mostly successful for 35.1% (n=25) of the participants who had been retained. A further 46.6% (n=33) indicting fairly successful RTW and 18.2% (n=13) reporting fairly/mostly unsuccessful. Of the 15 participants not retained, 26.6 % (n=4) reported they had returned to work and this was fairly successful/unsuccessful, but they had since been boarded or retired, while the other 73.3% (n=11) indicated their RTW was unsuccessful. There was a significant difference for reported successful RTW for those retained and not retained in the military after TBI (p=0.001). Table 4.6 Reported success of return to work Variable How successful has RTW been: T n otal =86 Retained n=71 Not retained n=15 n % n % n % p value 1 = Very successful 6 6.9 6 8.4 0 0 0.000** 2 = Mostly successful 19 22.0 19 26.7 0 0 3 = Fairly successful 34 39.5 33 46.4 1 6.0 4 = Fairly unsuccessful 12 13.9 9 12.6 3 20.0 5 = Mostly unsuccessful 8 9.3 4 5.6 3 20.0 6= Very unsuccessful 7 8.1 0 0 8 53.3 Significance p≤ 0.05* p≤ 0.01** 35 4.3.3: Relationship with supervisor and their involvement in rehabilitation In Table 4.7 t slightly more than one third of participants (n=32: 37.2%) reported that they received some support from their supervisor during their rehabilitation. Table 4.7. Reported supervisor involvement in rehabilitation. Variable Was supervisor involved in rehabilitation Total n=86 Retained n=71` Not retained n=15 p-value n % n % n % 0.534 1 = Not at all 30 34.8 26 36.6 4 26.6 2 = To some extent 32 37.2 26 36.6 6 40.0 3 = To a moderate extent 11 12.7 8 11.2 3 20.0 4 = To a large extent 13 15.1 11 15.4 2 13.3 How frequently did supervisor communicate with you/family during rehabilitation 1 = Never 38 44.1 35 49.2 3 20.0 0.045** 2 = Occasionally 33 38.3 25 35.2 8 53.3 3 = Frequently 8 9.3 6 8.4 2 13.3 4 = Very frequently 7 8.1 5 7.0 2 13.3 Significance p≤ 0.05* p≤ 0.01** A slightly lower percentage of participants (n=30, 34.8%) reported they had no support at all from their supervisor during their rehabilitation. A higher percentage of participants (n=11, 73.3%) not retained received support from their supervisors during their rehabilitation compared to 63.3% (n=45) of retained participants. The difference in support for those retained and not retained was not significant. However, there was a significant difference for reported communication with their supervisors between themselves and/or family for those retained and not retained in the military after TBI (p=0.045). The participants not retained (n=12: 80%) had occasional, frequent or very frequent communication with their supervisor compared to 50.6% (n=36) of those participants who were retained 36 Table 4.8 shows that none of non-retained participants had an excellent relationship with their supervisors prior to their TBI. Table 4.8 Reported relationship with supervisor prior TBI Variable Relationship with supervisor prior your injury Total n=86 Retained n=71 Not retained n=15 n % n % n % p value 1 = Excellent 6 6.9 6 8.4 0 0 0.850 2 = Good 26 30.2 19 26.7 7 46.6 3 = Fair 39 45.3 34 47.8 5 33.3 4 = Poor 12 13.9 10 14.0 14 13.3 5 = Very poor 3 3.4 2 2.8 1 6.6 Relationship with supervisor after your injury 1 = Excellent 6 6.9 6 8.4 0 0 0.522 2 = Good 28 32.5 20 28.1 8 53.3 3 = Fair 34 39.5 30 42.2 4 26.6 4 = Poor 6 6.9 5 7.0 1 6.6 5 = Very poor 12 13.9 10 14.0 2 13.3 Significance p≤ 0.05* p≤ 0.01** Of those who were retained, only six (8.4%) had an excellent relationship with their supervisor. It is interesting to see only a small percentage (n=2; 2.8% and n=1; 6.6% respectively) between the retained and the not retained participants had a very poor relationship with their supervisor prior the injury, while n=10; 14.0% and 13.3% respectively had a very poor relationship with their supervisor after the injury; therefore a higher percentage of participants reported having a very poor relationship with their supervisors after the injury. There was not a significant difference in relationships with the supervisors between those who were retained and not retained prior to and after the TBI. 37 4.3.4: Changes made on return to work, sufficiency of tasks given and contribution made at work Table 4.9 shows reasonable accommodations implemented for service force members with TBIs on their RTW. There was a significant difference for reported changes on RTW for those retained and not retained in the military after TBI (p=0.002). Table 4.9 Reported changes made on return to work Variable In which ways did the workplace make changes to support you when you returned to work? Total n=86 Retained n=71 Not retained n=15 n % n % n % p-value Reduced working hours 6 6.9 3 4.2 3 20.0 0.002** Reduced working hours, reduced working tasks, different work 3 3.4 0 0 3 20.0 Different work 18 20.9 16 22.5 2 13.3 Reduced working hours, reduced work tasks 8 9.3 6 8.4 2 13.3 Reduced work tasks 31 35.9 28 39.4 6 40.0 Reduced working hours, different work 1 1.1 0 0 6.6 No changes were made 18 20.9 17 23.9 1 6.6 Reduced work tasks, different work 1 1.1 1 1.4 1 6.6 Table Significance p≤ 0.05* p≤ 0.01** A higher percentage of those retained were accommodated with different work (n= 16, 22.5%), reduced work tasks (n=28, 39.4%) or no change (n=17, 23.9%). Of the 15 participants who were not retained, 40.0 % (n=6) reported reduced working hours with a combination of accommodations, such as reduced working hours, working tasks and different work. Only 6.6% (n=1) of these participants reported no changes were made. There was a significant difference on the finding related to changes that were made on RTW for both groups. 38 Table 4.10 Participation in sufficient duties, and contribution made after return to work Variable Were you given tasks to do at work Total n=86 Retained n=71 Not retained n=15 n % n % n % P-value 1 = Not at all 16 18.6 9 12.6 7 46.6 0.000** 2 = To some extent 28 32.5 22 30.9 6 40.0 3 = To moderate extent 16 18.6 14 19.7 2 13.3 4 = to large extent 26 30.2 26 36.6 0 0 Variable Do you feel that you're able to make meaningful contribution to tasks in current work place n % n % n % P-value 1 = Unable to contribute 20 23.2 8 11.2 12 80.0 0.000** 2 = Able to contribute minimally 19 22.0 17 23.9 2 13.3 3 = Able to contribute adequately 27 31.3 26 38.0 1 6.6 4 = Able to contribute substantially 19 22.0 19 29.4 0 0 5 = Able to concentrate adequately 1 1.1 0 0 0 Significance p≤ 0.05* p≤ 0.01** Reintegration into work was dependent on the participants’ ability to cope at work and complete the tasks they were given. Table 4.10 indicates the participants not retained reported they did not get enough tasks to do at their workplaces. The results indicate 46.6% (n=7) of these participants felt that they did not have sufficient duties to do at their respective workplaces compared to 12.6% (n=9) of those who were retained. There was a significant difference for reported sufficiency of work tasks or participation in duties at work for those retained and not retained in the military after TBI (p=0.000). The lack of contribution at work was reported by 80% (n=12) of participants who were not retained. Feelings of not being productive at the workplace and making a meaningful contribution were reported in relation to this. About 38% (n=26) of the participants with TBI who were retained felt they were making satisfactory contributions 39 to the organisation. There was a significant difference for reported meaningful contribution for the organisation for those retained and not retained in the military after TBI (p=0.000). 4.3.5 Perception of coping and amount of leave taken after return to work Participants not retained perce