Return to work

Often, the long-term goal of a burn rehabilitation program is return to work because this indicates an achievement of significant community participation. In a multicenter study, Brych and colleagues determined that among individuals with burn injuries who were employed outside of the home at the time of their burn injury, the average time off work was 17 weeks. The study reports that 66% of the subjects were employed at the 6-month follow-up and 90% had returned to work at 2 years after the burn injury. In other studies, between 60% and 80% of individuals returned to work at 1 year after injury. In a study of soldiers with burn injuries sustained in Operation Enduring Freedom/Operation Iraqi Freedom, 67% were able to return to military duty and 33% were discharged from the military due to their injuries.

An important personal factor that influences community participation, such as employment after a burn injury, is the employment status of the individual at the time of the burn injury. In a multicenter study of 770 individuals admitted to a burn center with severe burn injuries (average total body surface area [TBSA] 20.2%), Fauerbach and colleagues reported that only 70% of the patients were employed outside of the home at the time of their burn injury. They also noted that of the employed group, 42% sustained their injury at work. The study reports that those individuals who were not employed at the time of injury had significantly higher levels of history of pre-existing disability, medical problems, and history of psychological problems and were more likely to have a positive toxicology screen for alcohol at the time of the injury. Individuals who were employed at the time of injury were more likely to have sustained a hand burn and require hand surgery. Individuals not employed were more likely to sustain an inhalation injury. This is consistent with the likely mechanism of injury. Individuals who are employed are more likely to be injured at work in an open space or factory where they are less likely to sustain an inhalation injury, but their hands are more exposed to a heat source and more likely to be burned. Individuals burned in a nonwork setting, such as at home or in a vehicle, are more likely to sustain an inhalation injury. This study points out the personal factors (employment, preinjury disability, and psychological issues) that can have an impact on long-term outcome.

Several studies have identified burn injury–related and other factors that predict return to work. Many studies identify indicators of burn injury severity (percentage TBSA, length of hospitalization, and length of ICU stay) as predictors of not returning to work. An inhalation injury is another injury characteristic found to limit return to previous activities. In many patients, hand burns are a factor limiting the ability to return to work, but in a study of injured soldiers, the presence of a hand burn was not a significant predictor of the ability to return to military duty. As indicated in the ICF model, there are many environmental and personal factors that influence participation after a burn injury. In a study of 225 individuals with severe burn injuries admitted to the University of Alabama burn center, injury severity indicators were not significantly related to employment. The variables that increased the probability of employment after a burn injury were being white race, not blaming oneself, receiving workman’s compensation, and being employed before the injury. Preinjury employment status was a significant predictor of postinjury employment and this was seen other studies. In a study by Schneider and colleagues, significant predictors of being disabled longer than 12 months included length of hospitalization, receiving inpatient rehabilitation, burn injury occurring at work, and an electrical injury as the etiology of injury.

Brych and colleagues reported that at 6 months and 24 months after injury, a psychiatric history significantly reduced the odds of returning to work. Postinjury psychological issues are also associated with work status. Studies from Sweden have studied individuals years after burn injuries and reported that predictors of employment include burn-related factors and personality-related factors. Individuals not working demonstrated worse psychosocial health, such as greater fear avoidance and posttraumatic stress symptoms, compared with those employed. Those unemployed also reported a lower health-related quality of life compared with those working. Chronic pain is also a common problem that limits employment and quality of life. In one study, pain was reported in 60% of the unemployed group and in only 18% of those working.

Several studies have looked in detail at specific barriers to returning to work after a burn injury. In one study of patient self-reported barriers to returning to work, physical abilities, working conditions, and wound issues were important factors within the first few months after the burn injury. In those individuals with longer-term disability who had not returned to work within 6 months after the injury, psychological and social factors were more important barriers. These included barriers, such as concern about appearance and working with others, being afraid to leave home or being afraid of the workplace, and depressed mood. In another study, review of medical records showed that the most common reported barriers to return to work included pain, neurologic problems, impaired mobility, and psychiatric issues. A study from Sweden identified facilitators and barriers to return to work through interviews of individuals who had sustained burn injuries at an average of 4.6 years prior to the study. To a large degree, facilitators were individual characteristics, such as being able to set up goals in rehabilitation, being persistent, having willpower, and the individuals’ own ability to take action. Support from individuals’ families and social network were identified as important facilitators. Identified barriers to returning to work included the lack of an individualized rehabilitation plan and lack of psychological support. Physical impairments, such as pain, wound issues, and strength, were barriers early in the rehabilitation but not considered significant long-term barriers to return to work.

Return to work after severe burn injuries is a complex interaction of factors involving injury severity, personal characteristics, work-related issues, social support, and medical and rehabilitation treatment. In a qualitative research study that examined patient characteristics in relation to employment status, Mackay and colleagues placed patients in 5 categories: (1) defeated, (2) burdened, (3) affected, (4) unchanged, and (5) stronger. The defeated group was characterized by history of manual labor, injury at work, fear of the workplace, symptoms of depression, and being unsuccessful in attempts to return to work. The burdened group was unemployed prior to their injury and the physical and psychological impact of the burn injury compounded their previous problems. The affected group returned to work but struggled with physical and psychological issues, making stable employment challenging. The unchanged group returned to the same job and often benefited from a supportive employer. The stronger group returned to the same or different job, had strong social support, and found strength from their personality.

Individuals with electrical injuries often have challenges returning to work. One confounding factor is that electrical injuries are more likely to occur at the workplace. In one study, 91% of electrical injuries were work related. In long-term follow-up, 23% returned to the same work duties, 45% changed duties, and 32% remained unemployed. There are high rates of neuropsychiatric issues reported after electrical injuries that have an impact on a person’s ability to return to work. In addition, patients sustaining electrical injuries on the job are often afraid to return to the workplace. These problems are reported in both high-voltage and low-voltage electrical injuries.

In the treatment of burn injuries, it is important to have a coordinated medical team skilled in acute management and long-term rehabilitation of individuals with severe burn injuries. It is appropriate that treatment focus on the important issues of wound care, preventing scarring and contractures and improving function. But, it is equally important that treatment focus on other factors that influence an individual’s ability to return to participation in the community, including return to work. In several studies, psychological issues have been found to be important in returning to work. Therefore, it is important for patients to have access to psychological treatment during the acute phase after burn injury and during the longer rehabilitation treatment. It is also important for many patients to have the assistance of a vocational rehabilitation counselor. In a study by Öster and colleagues, facilitators to return to work included the ability to have modified work duties, a change in workplace, or an alteration in work hours. Having a supportive employer and coworkers was also identified as a facilitator to returning to work. A vocational rehabilitation counselor can coordinate a return to work plan with the injured worker and the employer. The goal is that the return to work plan be structured to optimize success. A patient who returns to full-duty employment too soon without an assessment of the physical and psychological demands may be unsuccessful, leading to long-term disability. A well-planned return to work with modified work duties or hours, coordinated with a supportive employer, can lead to a permanent return to work.