Working with a brain injury

Certainly, it is possible.

A work disability refers to a condition, whether mental, psychological, physical, or sensory, that hinders finding or performing work.

While a brain injury can constitute a work disability, the decision for recognition lies with the VDAB.

The individual's treating physician must complete a form available on the VDAB website.

🤝 Collaboration: The individual with a brain injury can also seek assistance from an expert at the VDAB's employment support measures department.

• One potential supportive measure is the Flemish Support Premium (VOP), which can offset any decrease in efficiency if, for instance, the individual works at a slower pace or requires more frequent assistance. Adjustments to the workplace or tools may also be considered.
• ⚖️ Legislation: With the introduction of Individual Customization (IMW), the VOP is phased out. Individual customization is set to be implemented from July 2023.In cases of mild brain injuries with minimal impact on functioning, an application for work disability recognition is typically not pursued.

Certainly.

If a person's brain injury results in workplace challenges, such as a reduced work pace or the need for fewer work hours per day, they can initiate an application for employment support measures, potentially with assistance.

To qualify for these measures, the brain injury must be officially recognized by VDAB as a work disability.

💪 Effective strategies commonly utilized for brain injuries in the workplace include:

• Flemish Support Premium (IMW = Individueel Maatwerk): Employers can receive a premium from the Department of Work and Social Economy to compensate for reduced productivity if the brain injury impacts work performance. Examples include working at a slower pace, requiring additional breaks, starting later in the day, or needing a modified schedule (e.g., daytime hours instead of shifts). Since July 1, 2023 IMW replaces the VOP.
• Reimbursement for Work Tools and Clothing: Costs for necessary adapted work tools and clothing that are not provided by the employer can be reimbursed to ensure effective job performance. For individuals with brain injuries, this may include items like noise-canceling headphones.
• Additional employment support measures may involve providing a free interpreter for individuals who are deaf or hard of hearing or reimbursing transport expenses.

Engage in discussions with the individual with a brain injury and their support network to evaluate the work-life balance.

Observe for any behavioral or emotional changes that may indicate an imbalance.

🚧 Challenge: If an imbalance is detected, offer assistance to the individual with a brain injury.

💪 Opportunity: Implement practical strategies to support them:

• Collaborate with the individual to create a detailed list of tasks at work and home.
• Explore reorganizing tasks for better balance.
• Discuss methods to alleviate stress.
• With consent, involve the treating physician or healthcare team. They can provide guidance for the individual's return to work and ongoing support for sustained employment.

Load capacity encompasses various aspects and should consider the physical, emotional, cognitive, and behavioral capabilities of individuals with brain injuries.

🚧 Challenge: Individuals with brain injuries often experience heightened and quicker physical and mental fatigue, requiring more time to recover.

• This limited load capacity is likened to an energy battery metaphor.
• Due to the brain injury, the battery no longer fully charges as before, depleting faster due to increased effort in activities and longer recharging periods.
• 💼 Helpful Tools: Self-report instruments can aid in assessing the feasibility of work options and stress levels. Examples include:
  • Work Rehabilitation Questionnaire (WORQ: Finger & Escorpizo, 2014): Identifies functional difficulties.
  • NAH Functioning Instrument (FINAH: Houben et al., 2020): Assesses daily life challenges specific to brain injury.
  • Signaling Questionnaire (Winkens et al., 2008): Identifies cognitive, emotional, and behavioral complaints.
  • Impact on Participation and Autonomy (IPA: Cardol et al., 1999): Highlights autonomy and participation challenges.

💪 Strategy: A neuropsychological evaluation is essential to comprehensively assess cognitive consequences, available options, and resilience in individuals with brain injuries. Inquire if such an assessment has been conducted during rehabilitation and seek permission to access relevant information.

💡 Tip: Ask the individual if there are additional insights available regarding their functioning for a more comprehensive understanding.

There is no singular type of brain injury, just as there is no one-size-fits-all job.

The suitability of work for individuals with brain injuries varies based on the injury's effects, the individual's priorities in the workplace, and their preferences.

🔀 Indicators that a job is suitable for an individual include:

• Maintaining a balance between work and personal life, allowing energy for family, hobbies, and household responsibilities.
• Aligning the person's desires, capabilities, and needs with the job requirements and work environment.
• If work is well-suited, it can contribute to the individual's recovery process.🚧 Challenges:
• Job demands can be categorized into physical, social-emotional, and cognitive aspects.
• Consideration of the work context, including physical and cognitive factors like terrain or noise levels.

💪 Strategy:

• Gradual return to work is crucial for all parties to assess possibilities and challenges.
• Begin with part-time hours and gradually increase.
• Alternate workdays with rest days.
• Explore flexible start times to accommodate individual needs.
• Ensure all work domains align with the person's capabilities.

🔀 Possible scenarios:

• Returning to the same role with the current employer.
• Transitioning to a similar role with a different employer.
• Adapting the current role within the same organization.
• Seeking a new position elsewhere.
• Engaging in volunteer work to explore capabilities and capacity.

💡 Tip: Monitor for imbalances between work and personal life to prevent overload.

Every brain injury is different and the consequences are different for each person .

People with a brain injury may experience:

• physical effects, such as loss of strength in the limbs or swallowing difficulties.
• sensory consequences, such as loss of visual acuity or hearing impairments.
• communication consequences, such as problems expressing themselves or understanding spoken and written language.
• cognitive consequences, such as slower thinking or problems with planning and organisation.
• behavioural consequences, such as lacking initiative or being hyperactive.
• social consequences, such as feeling socially isolated.
• or a combination of these consequences which impacts their everyday functioning.

The consequences can make certain activities more challenging. For example, it is harder to step out with loss of strength or to perform under time pressure if you think more slowly. How the environment reacts to this (do they support the person or make it even more challenging for the person) or how the person itself deals with this (does he focus on strengths or on weaknesses) helps determine the impact.

The impact can vary from mild to very severe and the consequences can occur in isolation or in combination.

The consequences of a brain injury can also be broken down as follows:

• visible consequences, such as difficulty walking, balance problems, being partially paralysed.
• invisible (or less visible) consequences, such as fatigue, having trouble concentrating, forgetting appointments more easily, having trouble planning things or reacting differently (more/less emotionally) to certain situations.

🚧Challenges

• these consequences can impact the person's ability to function in all kinds of professions.
  • Moreover, the invisible consequences are often insufficiently recognised.
  • They also do not make it easy to assess which work tasks are still feasible.
• a brain injury often disrupts the course of one's life, but it may also impact the life of the social network (such as, partner, children, family, friends, colleagues and neighbours).
  • After the shock of a sudden stroke or accident, hospitalisation follows. This is often an uncertain period: which consequences are temporary and which ones are permanent? It takes time to get an accurate picture of the capacities and challenges of the person.
  • After rehabilitation the person with a brain injury can return home. What follows is a (long) process of adapting to new possibilities and finding the right balance.
  •  It is a quest for all who are involved, i.e. the person itself and the social network.

Yes.

A progressive return to work after a brain injury is different from returning to work after another health condition.

🚧Challenge: a person with a brain injury may have invisible consequences, such as cognitive, emotional or behavioural changes.

• In addition, they may misjudge themselves: many will overestimate themselves; some will underestimate themselves.
• Sometimes the invisible consequences become visible only when the person takes on multiple roles, such as that of parent and employee.

💪Opportunity: recognising, acknowledging and translating these invisible consequences to the workplace requires expertise and knowledge of (the consequences of) a brain injury.

Working with all relevant parties, it is essential to (re)integrate an individual after a brain injury so as to avoid the risk of overloading them.

• Map out what the person with a brain injury wants to achieve.
  • This requires the person to have a good understanding of their own ability to function, although impaired self-awareness can be a common consequence of a brain injury.
  • If it is hard for the person to appreciate the extent and implications of the challenges, the conversation can be difficult.
• In consultation with all relevant parties, discuss a plan to reach this target.
  • This may include signs for the person and/or their friends or colleagues to look out for that may indicate the person is doing too much and asking too much of themselves.
  • Such a plan may also include suggestions that can help or people they can talk to in order to resolve challenges.

💪Opportunity: use intermediate steps and regularly assess the impact of the required workload on how the person is coping.

• This can help to improve the person's understanding.
• In this way, working with relevant parties, you can see whether an increase in working hours or an expansion of tasks is already an issue.
• Focus on specific questions:
  • How can you reduce the person’s workload?
  • How can you adjust the task content?
  • How can you change the working environment?
  • What are the possible working arrangements, e.g. flexible working/a change working hours?

🚧Challenges: look for possible signs that someone with a brain injury is overdoing things at work such as, being short tempered, reacting emotionally to questions, being irritable or having conflicts with colleagues.

• There may be other indications such as, making more mistakes, being forgetful or not completing tasks.
• There may also be signs at home, where, for example, the person's partner may notice that the person is continuing to work at home in order to get everything done or is sleeping a lot after the working day and at weekends to recover from fatigue.
• This may indicate that the person is doing too much or make the effects of the brain injury more visible in the workplace. It is also possible that workplace expectations are too high and the range of tasks is not suitable.

💪 Strategy: If the signs indicate that the person is asking/expecting too much of themselves, there are several options:

• Have a calm discussion with the person about how their reintegration is going and the available options for addressing the challenges.
  • This requires the person to have a good understanding of their own ability to function, although impaired self-awareness can be a common consequence of a brain injury.
  • If it is hard for the person to appreciate the extent and implications of the challenges, the conversation can be difficult.
• In consultation with the occupational doctor you can schedule a meeting with the person to discuss the progress of their return to work.
  • Strive for open communication.
• Advise the person to discuss issues with their doctor and/or rehabilitation team .
  • Together, you can look for ways to address certain challenges by changing the range of tasks or the working environment (e.g., more remote working)
• Ask the person if there is an action plan or relapse prevention plan.
  • This may include signs for the person and/or their social environment to look out for that may indicate the person is doing too much and asking too much of themselves.
  • Such a plan may also include suggestions that can help or people you can talk in order to resolve challenges.
• Consider specialised job coaching .
  • If the person is struggling at work because of their brain injury, you can hire a specialised job coach who can support you, your team and the struggling employee.
  • The coach can help look for solutions.
  • The coach can help the employee to integrate and function smoothly and quickly.
  • The coach can show you and your colleagues how you can best support the employee.
  • The coach can suggests adjustments to the workplace.

Opportunity: if someone from the rehabilitation centre supervises the reintegration process, you can discuss the progress and your concerns with this person.

• 🤝Together: in liaison with other parties you can gather further information.
  • How can you reduce the employee's workload?
  • How can you adjust their tasks?
  • How can you change the working environment?
  • What are the possible working arrangements, e.g., a flexible working/a change working hours?
• Be aware that returning to work after a brain injury is often difficult for the person as well as for their social environment, but it can also raise many issues for you, as an work mediator/job coach . You can get support for this, e.g., from the rehabilitation team .

💁Meer weten?

• Bekijk dan deze informatie van het Nederlandse Hersenz: Tips over hersenletsel en werk
• Bekijk dan deze informatie van het Nederlandse Hersenletsel-uitleg: Nog meer tips over hersenletsel en werk
• Surf dan naar de Nederlandse website over werken met een hersenletsel
• Lees dan dit Nederlandstalig artikel uit 2016 over werkhervatting na een niet-aangeboren hersenletsel

It is possible, but ...

🚧Challenge: many people with a brain injury may experience reduced endurance and residual challenges.

As a result, full-time work is not always possible. The person might not be able to return to their previous work rate.

💪Opportunity: part-time or volunteering work can be a great way to remain active in the workplace.

• Regardless of whether a return to full-time work is feasible, the person with a brain injury can start part-time. This is called a progressive return to work.
• The employment contract is then suspended due to disability and the employee can resume some tasks in the workplace.
• Returning to work part-time does not necessarily mean that a person works 50% of a full-time job.
• It is better for someone with a brain injury to build up their hours at work slowly.
• In this way, the impact of the brain injury on how they function in different areas can be monitored.
• Consider the combination of work, household tasks or the combined role of employee and for example, parent.

💡Tips & tricks: often fatigue does not occur immediately, it is therefore useful to monitor the return to work over a longer period of time.

• Together with the person , agree which tasks they will/will not resume.
• The choice should partially depend on the risks involved in performing the task, for example, can the individual maintain their balance long enough when standing?
• Regularly assess how the work is going with the employer .
  • ⚠️Be aware: an employer will say more when you alone are there to hear it. You can feed this back to the person later. Pay specific attention to work rate and independence.

💁Meer weten? Bekijk dan deze informatie van Handicap en arbeid over deeltijdse werkhervatting

Every brain injury is unique and every person is unique.

So , the adjustments that they will find valuable varies greatly depending on the person and their situation.

Options: possible adjustments can be tangible, intangible or organisational.

• tangible, such as a lift, sloping surfaces, a sit-stand desk, an adapted office chair, one-handed work equipment or a calm, quite working space.
• intangible, such as adaptating work tasks, assigning a work buddy or providing extra guidance during tasks.
• organisational, such as adjustments in working hours, extra breaks, permission to work from home or take extra breaks.

💡Be aware that accommodating a brain injury does not always involve expensive aids or complex adjustments. An example of a simple change could be a short(er) working day.

🤝Together: you, as a work mediator/job coach , can discuss this with the individual :

• what could be a valuable change for this person?
• to what extent does the government provide financial assisstance for this?

There is no one single answer to this question.

🤝Together: the 'right' moment is not set in stone.

• This is a personal decision that is always made in consultation with the person and their personal network (friends and family , healthcare professionals and other parties).
• It is important to tackle the subject of work early on, by informing the person with a brain injury and their friends and family.
  • This can give them some perspective and address any concerns, even if an actual return to work is not yet an issue.
  • An early focus on work means that the person:
    • knows who will give them permission to return to work.
    • knows their rights and obligations.
    • can considers any issues that need improvement before a desired return to work.
    • can think about what might help them to return to work even with certain challenges.
    • can consider what they still want and are able to do.

🚧Challenges: the time when someone can actually return to work depends on many factors. Consider, for example:

• the degree of severity of the brain injury
• the consequences of the brain injury:
  • are there cognitive, physical, behavioural and/or emotional consequences?
• how those consequences are manifested in the workplace:
  • what does the employer expect from the person with a brain injury?
  • what are the required tasks?
  • what is the person’s working environment? Alone at a desk or with many colleagues and machines in a production environment?
• the time investment required for rehabilitation and whether this is compatible with returning to work.
• the possibilities to adapt the work.

💡Tips & tricks: guiding the person with a brain injury back to work in the form of a return-to-work plan is only possible if a number of conditions are met:

• the person must be ready to return to work. This must also be medically possible.
• the person must have time in their weekly schedule to return to work.
  • For example, if the person is still attending rehabilitation four hours a day (excluding travelling time), there may not be enough time to take steps to return to work.
• the person should have achieved a certain level of ability to rest and recover.
• the person should have a good work-life balance.
• the person should be able to travel safely (commuting).
• the effects of the brain injury must be compatible with performing previous or modified tasks.

Is it clear to you, as a work mediator/job coach , why it is difficult to discuss issues in performance?

🚧Challenges: there may be several explanations for this:

• the person with a brain injury may underestimate the challenges and overestimate its own abilities because of a reduced/impaired level of self-awareness (due to the brain injury).
• processing loss and grief make it hard to name and acknowledge the consequences of the brain injury.
• this is a journey for the person; they do not yet have a clear view of what is feasible and what is difficult.
• it can also be hard for the employer/manager , and colleagues to deal with changes in the person's workload.

🤝Together: get support from professionals expert in a brain injury and working, e.g., someone from the rehabilitation team or a job coach from a specialised employment service

We can speak of a successful reintegration after brain injury if several conditions are met:

• there is a suitable job, i.e., one that matches the person's remaining abilities and also takes into account challenges.
• there is a good work-life balance of energy whereby the employee can also perform roles and tasks at home.
• the employee feels good in the workplace.

💪Opportunity: for people with a brain injury, staying in work is often an even greater challenge than returning to work. This means that it is important to assess the success of the reintegration on a regular basis.

🤝Together: as a work mediator/job coach , you can help monitor whether the reintegration is sustainable and discuss whether it may be appropriate to talk to an expert who can analyse the work situation and give advice.

You need the permission of the person with a brain injury to share medical information. What the person does or does not tell their employer is often a question for the person themselves, as well as their friends and family and the employer .

If the employer has a good understanding of brain injuries, it is helpful to understand the impact of the brain injury on how the person functions on a daily basis and at work:

• what is going well?
• what is hard(er)?
• what may be helpful for the person?
• how can colleagues support the person?

Discuss how you approach this reintegration process with the person.

🚧Challenge: every brain injury is unique and consequently uniquely affects how the person functions. It is therefore important to share general facts about brain injuries, but also to talk specifically about the brain injury has changed that person's life.

💪Opportunities

• Reflecting on its impact at home and in the workplace and thinking about solutions can ensure better understanding.
• Think about the visible and invisible consequences.
• Discuss how the person can share this with their employer and/or colleagues.
• 🧰Tool: for example, the person could write a 'brain story'.
  • In it, the person writes how the brain injury has changed their life, what the consequences are in the workplace and what could be helpful for the person.

🤝Together: get support from people who are experts on brain injuries.

• Consult the occupational doctor on ways to approach this.
• If the person has undergone vocational rehabilitation, someone from the rehabilitation team can help the person prepare for this during rehabilitation.
• You, as a mediator from a specialised employment service who supports the person, have a good understanding of their functions. You can give practical tips for the workplace.
• Specialised job coaching is possible.
• Also involve friends and relatives in the preparation.

💡Tips & tricks: sharing a 'brain story' or experience.

• The person can circulate this story in writing and explain it verbally, depending on the person’s preference.
  • The person can write a general story:
  • who was I (before the brain injury)?
  • how did the brain injury occur?
  • how does the brain injury manifest itself in my daily life?
  • how have I changed my life to live with the brain injury?

• The person can also write this specifically for the workplace:
  • who was I professionally before my brain injury?
  • what typified me?
  • what was I good at?
  • how did the brain injury occur?
  • how does it affect my professional life?
  • what can help me to change my professional life?

Workload capacity is a broad concept.

Pay attention to the physical, emotional, cognitive and behavioural capacities of the person with a brain injury .

🚧 Challenge: people with brain injuries are often more quickly and severely (physically and mentally) fatigued.

• They also need more time to recover from fatigue.
• This is called a limited workload capacity which can be explained using the metaphor of a battery. A brain injury means that the battery can no longer be fully charged. In addition, the battery drains faster, because activities require more effort, and it takes more time to recharge the battery.

🧰 Useful Tools: it is often difficult for the person themselves and their friends and family to assess what (work) opportunities are still feasible. You can use self-reporting instruments to get a better picture of what a person can handle, such as:

• the Work Rehabilitation Questionnaire (WORQ: Finger & Escorpizo, 2014): this is a general questionnaire, not specifically for people with a brain injury. You can use the questionnaire to find out in which areas the person is experiencing challenges.
• the Impact on Participation and Autonomy (IPA: Cardol et al., 1999): this is also a general questionnaire, not specifically for people with a brain injury. The list identifies the challenges the person experiences around autonomy and participation.

💪Opportunity: a neuropsychological examination is needed for a proper assessment of the cognitive consequences and residual abilities of the person with a brain injury . Ask the individual if this was done during rehabilitation and if the information can be shared with you, as a mediator.

💡Tip & tricks: ask the person if they have any other information about their ability to function.

Yes, in the Netherlands and in Great Britain.

In 2021, the Dutch Association of Rehabilitation Physicians, in consultation with a multidisciplinary working group, developed the revised 'Brain Injury and Work Participation' guidelines. The guidelines are based on which recovery stage the person is at and covers the following topics:

• recommendations in the acute phase, recovery phase, near-to-work phase and the long-term phase
• predicting a return to work
• work participation interventions
• information and recommendations about Dutch social security
• information and recommendations if the person with a brain injury is unemployed

The British guidelines were developed in 2003 and include:

• definitions of key terms,
• vocational outcome and vocational rehabilitation after brain injury,
• a review of NHS brain injury services,
• occupational health services
• Jobcentre Plus services
• and other occupational/educational provision.

This is followed by a recommended framework for joint inter-agency working and detailed guidelines for the following provision:

• return to previous employment, education or training
• vocational/employment assessment
• vocational rehabilitation (including Work Preparation programmes)
• WORKSTEP (supported employment programme)
• occupational/educational provision