Category: Advancing Modules

The work environment includes the access and physical layout, the people we interact with and the expectations, policies and procedures of the organisation. All work tasks are carried out in the context of the work environment and that environment can significantly increase or decrease the demand of the activity on the person.

For example, talking to someone on the telephone in a busy front office with frequent interruption from visitors makes more demands on one’s attention and concentration than the same task carried out in a quiet office working in isolation. Similarly, distributing mail to colleagues who are located in individual offices over three floors of an office block will demand more physical ability than the same task with colleagues co-located in a large open plan office.

Often, the work environment is not ideal and employees will adapt the way they carry out the task to fit with the environment. This increases the demand of the task on the employee and can lead to work related illness or injury. The ability to adapt oneself to the environment may be affected following a stroke because of ongoing physical, cognitive, perceptual or emotional difficulties.

Environmental and task considerations for Rosemary as a teacher include:  working with children and associated risk assessment, local authority policy and procedure, the school and classroom layout and class size and age group / needs level.

Unexpected changes in work load and expectations.

The level of sensory and motor impairment will depend on the site, type and severity of the stroke (see physical management module). All work activities will demand a degree of physical activity and ability and the impact of a physical impairment will depend on how physically demanding the job is. Some jobs will require high level balance, strength, precision of movement, dexterity or manipulation. For example a landscape gardener would require physical strength and endurance, whilst an electrical technician would require manipulation and dexterity. Although some jobs, such as office work, may appear sedentary, they may also require reaching, lifting, moving, posture as well as fine motor control.

Sensory loss can significantly influence a person’s ability to carry out work activities. We need to be able to see, hear, feel and be aware of our body positioning to carry out specific tasks. Sensory loss may present an individual with specific dangers and risk assessment should be carried out to ensure the safety of the individual and their colleagues.

On returning to work after stroke, fatigue is a commonly reported problem, with many people finding they struggle to return to their previous level of activity. A phased return to work and flexible working conditions greatly improve success (Alaszweski A 2007).

Studies have shown severity of physical disability following stroke is a key indicator of a person’s ability to return to work (Busch M. A.et al 2009) (Tregor I et al 2007). A successful return to work will depend on their being a good fit between the physical demands of the job and the employee’s ability. Some adjustment may be necessary to improve this fit and you will learn more about this as you progress through the module.

For Rosemary: Although teaching is categorised as a light demands role (accordingly to the US Dictionary of Occupational Titles), it can involve frequent and sustained standing, walking, low sitting/kneeling.  Walking can be indoors and outdoors, sometimes considerable distances depending on things such as school size, layout and routine or special trips.

Throughout our working day we communicate in a variety of ways. We listen to and impart instructions to understand, explain or reassure, use written communication to send and receive emails, faxes, notes, memos and post-its and verbal communication to relate and receive information. Communication is a key component in developing effective working and team relationships and engaging in social conversation. It is a fundamental part of who we are.

Following a stroke, communication can be affected in many ways:

• Aphasia is a language disorder, which may affect a person’s ability to communicate, leaving other cognitive abilities intact. A person with aphasia may find it hard to talk, find words, form sentences, understand others when they speak, read or write. Difficulty communicating can cause frustration and distress. Aphasia can vary day to day and can appear worse if someone is tired, worried or upset.
• Dysarthria is a disorder of speech due to disturbances in muscular control of the speech mechanism. The content of what the person is saying (language) is not affected. All or any of the complex systems used to produce speech may be affected (respiration, resonance, voice, speech sounds (articulation) and speech rhythm (prosody). A person with dysarthria may sound slurred, mumbled and may be difficult to understand.
• Apraxia of speech affects the organisation and voluntary movement required for speaking. The person may often ‘struggle’ to produce a sound or word but the additional effort may not help. Words or phrases may be produced spontaneously but then cannot be repeated deliberately. This can be frustrating and bewildering.

Those left with communication deficits can often find the workplace “an alien environment” (Banks P & Pearson C 2003).

Rosemary has word finding difficulties and is slower to process written information.  Communication is a key skill within teaching, including processing and responding to verbal and written information in a busy, often noisy classroom environment.

Stroke is a sudden, immediate event which can have a devastating impact on the individual. After stroke, many people go through a grieving process, grieving the loss of function, role and control. A stroke might make the individual question and fear their own mortality and they may experience increased anxiety of further strokes or dying. Social isolation may occur, with many stroke survivors becoming unable or unwilling to participate in previous social or leisure activities or returning to work.

In addition to this, stroke may result in physical and mental changes and sometimes changes in physical appearance. In some cases these changes may be disfiguring. Difficulty controlling emotion can occur after stroke and people may become upset more easily. Lack of communication or cognitive deficits can be equally debilitating.

All of these factors can affect an individual’s body image, sexuality and self esteem leading to depression. (Hatchett M L, Anderson CS 2005) A high incidence of depression is reported in stroke survivors with studies reporting between 15 – 41% of all stroke survivors are classified as depressed (Eriksson M et al 2004) (Wade et al 1987).

Rosemary is experiencing stress due to her financial situation. She is anxious about how she will manage at work, and lacking confidence after having been off for a prolonged period as well as being due to how the stroke has affected her.

Cognition is a vital part of our working life. We use cognition to get to work on time, plan our day, follow instructions, process information, carry out learned tasks and attend to our work activities. We interpret, store and retrieve information, maintain our attention, carry out a number of tasks simultaneously, prioritise and filter out irrelevant stimulus.

As problems or challenges occur in our working lives we use cognition to work through these. We make judgements based on knowledge and experience, develop, apply, monitor and evaluate solutions and adjust as necessary to reach a satisfactory solution.

Perception of self, environment and how we interact within it is core to our normal functioning. Perception is an automatic process which allows us to make sense of the world around us and how we operate within it and includes such skills as visual perception, visual attention, spatial awareness, body positioning and perception of movement.

Many people who have had a stroke will face impairment of cognition or perception that will impact on their ability to carry out their job and cognitive deficits are found to be the most significant barrier to returning to work. (Tregor et al 2007).

Rosemary now takes longer to process information, which would impact on planning and activities in class.

There are a number of ways that stroke can impact a person’s ability to return to work.

You have identified the financial benefits that Rosemary might be eligible for, but what other benefits are there for Rosemary going back to work?

Reason	Explanation
Social and Cultural	Work is central to our culture, providing social status, social contact, social networks, inclusion and acceptance. For many adults, work is their main form of social contact.
Financial	Paid work provides a means to support self and family. Studies have shown that half of young stroke survivors experience a substantial drop in income and therefore it is important to address the issue of work when appropriate.
Roles and Identity	Work provides a sense of identity, a clear role and gives routine and structure to daily life. A change in role from bread-winner to financial dependent has a negative impact on an individual’s sense of self. Studies have demonstrated that returning to work after stroke was seen as the ultimate point of recovery, regaining control and giving a sense of achievement and productivity.
Health and Well-being	The role of work in helping people maintain their physical and emotional well-being is widely recognised and research has shown that lack of work has a negative impact on health and well-being. Work provides opportunities for physical and mental activity, to maintain and develop skills, improved physical and mental health and prevention of further ill-health.

Work can be defined as ‘A valued activity that uses a person’s skills and facilitates social inclusion’. Work can therefore take many forms and may be: formal, informal or carried out in private and may also be paid or unpaid. Supporting someone to return to work may not mean to full time, paid employment and a range of options to participate in meaningful activity which makes use of the person’s skills and allows them to feel socially included can be explored. You can help Rosemary by reassuring her of her capability, and that returning to work will be good for her, at the right time and with the right support.

Rosemary is a primary school teacher who previously worked full-time. She is employed by the local authority and is currently in receipt of full pay through her employer’s occupational sick pay scheme. Her husband, Bill, works as a bus driver and their two children, Rory, aged 14 and Lucy, aged 17, are both still at school.

A few days before she is due to go home, you notice that Rosemary is upset. She tells you that she has had a letter from her employer to say that her sick pay will soon be cut. Rosemary says she is very worried about how they will cope financially as they previously relied on both incomes to meet their daily living expenses. Lucy is starting University soon and will need financial support. Rory is a keen sportsman and hopes to pursue a professional skiing career. Rosemary and Bill pay for all his coaching, travel and equipment. Rosemary says that she will have to get back to work as soon as possible but she is worried about how she will manage.