Abstract
Objective
To analyse usefulness of the SPASE programme, a coordinated facility programme to assist traumatic brain injury (TBI) persons in returning to work and retaining their job in the ordinary work environment.
Design
A retrospective study including 100 subjects aged over 18 who had suffered traumatic brain injury (GOS 1 or 2). The criterion for return to work (RTW) success was the ability to return to the job he/she had before the accident or to a new professional activity.
Results
Factors associated with RTW success were at short-term (2–3 years): the presence of significant workplace support OR = 15.1 [3.7–61.7], the presence of physical disabilities OR = 0.32 [0.12–0.87] or serious traumatic brain injury OR = 0.22 [0.07–0.66]. At medium-term (over 3 years) these factors were: significant workplace support OR = 3.9 [1.3–11.3] and presence of mental illness OR = 0.15 [0.03–0.7].
Conclusion
This study suggests that a case coordination vocational programme may facilitate the return and maintain to work of TBI persons. It reveals that the workplace support is a key factor for job retention in the medium-term.
Résumé
Objectifs
Analyser la pertinence du programme SPASE, qui fournit une aide personnalisée aux lésés cérébraux dans un projet d’insertion professionnelle et dans sa mise en œuvre.
Méthode
Étude rétrospective de 100 sujets de plus de 18 ans traumatisés crâniens (GOS 1 ou 2). Le critère d’un retour à l’emploi (RAE) réussi était la capacité de la personne à reprendre et se maintenir dans son ancien emploi, ou bien l’orientation réussie vers une nouvelle activité professionnelle.
Résultats
Les facteurs associés à la réussite du RAE étaient sur le court terme (2–3 ans) : la présence d’un soutien significatif au sein de l’entreprise OR = 15,1 [3,7–61,7], l’absence d’un handicap physique OR = 0,32 [0,12–0,87] ou d’un traumatisme crânien sévère OR = 0,22 [0,07–0,66]. À moyen terme (plus de 3 ans) ces facteurs étaient : soutien significatif au sein de l’entreprise OR = 3,9 [1,3–11,3] et absence d’une pathologie mentale OR = 0,15 [0,03–0,7].
Conclusion
Cette étude suggère qu’un programme d’accompagnement personnalisé peut faciliter le retour à l’emploi et son maintien après un traumatisme crânien. Cette étude montre que le soutien au sein de l’entreprise est un facteur clé pour se maintenir dans l’emploi à moyen terme.
1
English version
1.1
Introduction
Among the 150,000–180,000 traumatic brain injury (TBI) persons in France, 10,000 of them get serious sequels and 8500 had serious reinsertion problems . As with many other health events the return to work (RTW) of people who have suffered TBI is a major healthcare challenge, both in terms of quality of life for the individual and as a public health issue .
Medical treatment is becoming ever more advanced with ever-increasing numbers of survivors, rehabilitation programs are becoming more and more standardised and the clinical factors correlated with RTW are better understood . However, RTW rates remain quite low . In addition to rehabilitation, several types of vocational support have been proposed to facilitate RTW in TBI. But TBI persons often consider these programs to be insufficiently coordinated and managed . Case coordination programs have been proposed, in which individuals are monitored by a coordinator who assesses their needs and refers accordingly . Such programs seem to enable higher employment and productivity outcomes , with 80% of subjects engaged in some kind of community-based employment, including 50% in paid competitive jobs . Although these programs are promising for RTW, their usefulness in terms of job retention in the medium-terms remains to be assessed. This is the objective of the present retrospective analysis of the SPASE programme.
1.2
Methods
1.2.1
SPASE programme
The SPASE programme (personalized service of accompaniment and follow-up to employment) is a facility for workplace reintegration of TBI persons in the ordinary work environment developed in the area of Grenoble France. It is one of the services provided with by the CRLC (resource center for brain injury persons) and its main objective is either to keep people in their previous jobs or to find them new employment and, if possible, relevant training. Other complementary CRLC services are UEROS (evaluation and training to social life return) and ESAT (specific workshop for these workers) An important part of the programme SPASE program is focussed on the workplace: developing direct lines of communication with the employer or other contacts in the workplace in order to explain and clarify the difficulties experienced by the brain-injured worker and to provide them with all the necessary rehabilitation assistance.
The delay between TBI and inclusion in SPASE program was between one and 10 years (average 2.5 years), depending on persons’ disability and motivation to return to work. TBI persons were referred to SPASE team by any caregiver or physician (often physiatrists), or by any services involved in the follow-up: UEROS, re-employment services, CRLC, or social services. Then after interview of the person, a committee including CRLC and SPASE managers made the decision about the eligibility according the following criteria: ≥ 18 years old, Handicapped Worker Status (under the provisions of the French Law of 02/11/2005), traumatic brain injury with a Glasgow Outcome Scale (GOS) 1 or 2, wishing to return to the ordinary work environment (with adaptations if required); reasonable feasibility based on a consensus involving physicians in physical medicine and rehabilitation and occupational medicine, social workers, and the SPASE team (occupational therapists, ergonomists, work psychologists, human resources, leaders trained in professional education). All these actors have experience in workplace rehabilitation and are very familiar with the problems caused by traumatic brain injury. All actors, including the person with TBI, were involved in the search of the most suited job. The programme offers tailored assistance to persons via several steps:
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worker needs analysis;
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analysis of employability both in supervised activity to prepare for occupational tasks, and immersion in the workplace;
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search for a suitable job if necessary;
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intervention implementation.
This consists of identifying the person in the factory who will be the contact, i.e. both the companion of the worker and the SPASE contact. SPASE defines and adjusts with this contact how follow-up will be done, from simple checks over the phone to involvement of the SPASE team in the workplace. The total assistance time lasts between several months and several years, depending on the speed of the individual’s reintegration, with an average of 40 hours of support per worker per year.
1.2.2
Design of the study and variables analysed
We conducted a retrospective analysis of the first 100 consecutive TBI persons who had a SPASE follow-up of over 3 hours/year and benefited from short-term (2–3 years) and medium-term (over 3 years) follow-up. Among 122 persons who were initially eligible for this study, 22 were lost to follow-up.
Information was collected by an occupational health physician from the individual SPASE record, from an interview done by the vocational rehabilitation specialist who had assisted the worker, and from a directed structured interview with the worker over the phone. Details regarding the SPASE programme for a given worker was collected both from the record and from his/her vocational rehabilitation specialist. Each worker was asked about his/her professional history since the SPASE programme. TBI was considered to be serious if it was associated with a coma (initial or therapeutic) of > 8 days and/or an initial stay in a medical facility of > 3 months. Disabilities were assessed by a specialist in physical and rehabilitation medicine and classified as follows:
- •
physical disabilities were considered moderate if subjects did not require technical aids daily, and significant otherwise;
- •
cognitive disabilities were considered moderate if one cognitive function was limited (executive or instrumental), and significant if more than one cognitive was altered. The assessment of cognitive disabilities was performed by neuropsychologists either in reeducation center if the inclusion in the SPASE program occurred soon after the TBI, or later in months preceding the SPASE program inclusion if the delay between TBI and return to work decision was longer (UEROS);
- •
behavioural disabilities and mental illness, without distinction were considered moderate if they had no impact on social integration, and significant otherwise.
The quality of RTW was assessed by the following items:
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possible return to the job the worker had before the accident, with or without adjustments, and number of days worked;
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the presence of workplace support was considered significant if a designated mentor from within the company was present daily at work to help the worker when necessary, to find solutions for doing what was required to retain his/her job; it was considered moderate if this support was occasional and not formalised;
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complementary family support was considered significant if a family member was present and active in the reintegration process.
The criteria for short-term “success” of reintegration have therefore been defined as having an employment situation that is progressing positively in the second and third year following the start of SPASE assistance: for example, obtaining a contract of employment in a case where the person did not previously have one; transition to a more stable employment situation (with a contract of more than 2 months); or keeping a job in the former company with full or part-time hours.
Criteria for “success” of reintegration in the medium-term have also been identified, involving the same parameters, taking into account the period after the 3rd year following the start of SPASE assistance (4–8 years).
1.2.3
Statistical analysis
Statistical analyses were performed using SPSS software, version 11. Social and occupational situations 1 year before and 1 year after SPASE and factors that might have potentially influenced the RTW were analysed individually with Chi 2 tests; statistical significance was set at 0.05.
Forward logistic regressions were performed on variables from Table 2 in order to analyse, using a multivariate approach, the factors associated with prediction of RTW in the short and in medium-term. The models tested the variables in Table 2 that have a statistical significance of less than 0.15. The overall fit of these models is approximated using the Nagelkerke R 2 , which tests the proportion of total variance explained by these models.
1.3
Results
The cohort was essentially male (80%) with 69% of subjects under 30 years old at the time of the brain injury; these data were similar to those of the 22 subjects not included in the cohort. The mean period of initial care was 7 months (acute cares then intensive rehabilitation). Ninety percent of subjects had presented a coma (24 days in average).
According to the information available from the SPASE record, and from vocational rehabilitation actor interviews, 19% of subjects had a mental illness (established psychiatric diagnosis), 46% had support from family; 73% of subjects received regular assistance from SPASE services and 27% received sporadic help (less than 3 hours). In addition, vocational rehabilitation actors considered that 28% of subjects have received significant and helpful support within their workplace.
1.3.1
Changes in social and employment situations after the SPASE programme
Table 1 presents changes in occupational, educational and social status before and after SPASE assistance: employment increased by 35%, subjects signed off work decreased by 19% and subjects who have worked for more than 6 months increased by 21.6%.
| Behaviour of 100 TBI patients | Before SPASE assistance Numbers (%) | After SPASE assistance Numbers (%) | Chi 2 | P |
|---|---|---|---|---|
| n = 56 | n = 72 | |||
| At work (full or part-time) | 34% | 69% a | 15.87 | 0.001 |
| Employed, but still signed off work | 22% | 3% | 11.16 | 0.001 |
| Mean annual duration of work > 6 months | 21.4% | 43.1% | 6.55 | 0.01 |
| Level of qualification required for the job, compared with level before the TBI | n = 43 | n = 52 | ||
| Lower | 9.3% | 23.1% | 3.16 | 0.07 |
| The same | 90.7% | 67.3% | ||
| Higher | – | 9.6% | ||
| Help to remain in work | n = 56 | n = 72 | ||
| Financial | 25.0% | 47.2% | 6.59 | 0.01 |
| Other | 10.7% | 29.2% | 6.39 | 0.01 |
| Network for help in finding work | 8.9% ( n = 56) | 23.6% ( n = 72) | 4.73 | 0.03 |
| Activities related to work (training, work experience etc.) | 32.0% ( n = 100) | 60.0% ( n = 100) | 15.68 | 0.001 |
| Financial compensation for harm | n = 95 | n = 95 | ||
| In progress | 35.8% | 14.7% | ||
| Obtained | 16.8% | 35.8% | ||
| None | 47.4% | 49.5% | 0.08 | 0.77 |
| Outcome for those in education at the time of the TBI | n = 36 | n = 36 | ||
| Employment | 41.7% | 69.4% | 5.55 | 0.01 |
| Education continued or restarted | 38.9% | 16.7% | 4.37 | 0.03 |
| Family situation | n = 100 | n = 100 | ||
| Lives alone | 30% | 44% | 4.18 | 0.04 |
| Lives with partner | 27% | 29% | ||
| Lives with family | 43% | 27% | ||
The number of subjects who have received help to stay in work (financial or otherwise) and the number of subjects who have undertaken activities related to work (training, work experience etc.) has also increased. The family situation of subjects has also improved greatly, with a fall in the number of subjects living with their families, showing that they had gained independence. At the time of the interview, 55% of subjects were working (37.4% on permanent contracts and 17.6% on fixed-term contracts or in casual employment), 17% were in an unstable situation or were looking for work, 4.4% were doing voluntary work, 3.3% were in training and 17% were in neither work nor training (5.5% for health reasons). According to the criteria set out above, short-term workplace reintegration was considered to be successful for 60% of persons and medium-term reintegration for 47.3% of persons.
1.3.2
Factors associated with workplace reintegration
Factors statistically associated with RTW success in the short and medium-terms are presented in Table 2 . Of these we should draw particular attention to workplace support, which was associated both with short-term and medium-term reintegration success. Other factors were not statistically associated with RTW success: cognitive disability, employment status before brain injury, family support, level of education and location of accident.
| Variable analysed | Short-term | Medium-term | ||||||
|---|---|---|---|---|---|---|---|---|
| n | % reintegrated successfully | Chi 2 | P | n | % reintegrated successfully | Chi 2 | P | |
| TBI initial seriousness | ||||||||
| Yes | 72 | 54.2 | 3.65 | 0.06 | 65 | 47.7 | 0.02 | 0.89 |
| No | 28 | 75.0 | 26 | 46.2 | ||||
| Physical disabilities | ||||||||
| Significant | 36 | 47.2 | 3.83 | 0.05 | 33 | 42.4 | 0.48 | 0.49 |
| Not significant | 64 | 67.2 | 58 | 50.0 | ||||
| Cognitive disability | ||||||||
| Significant | 45 | 60.0 | 0.00 | − | 40 | 47.5 | 0.01 | 0.97 |
| Not significant | 55 | 60.0 | 51 | 47.1 | ||||
| Significant workplace suppor t | ||||||||
| Present | 27 | 88.9 | 13.23 | < 0.001 | 26 | 69.2 | 7.48 | 0.01 |
| Not present | 72 | 48.6 | 64 | 37.5 | ||||
| Regularity of assistance | ||||||||
| Sporadic | 27 | 44.4 | 3.73 | 0.05 | 67 | 47.8 | 0.03 | 0.87 |
| Regular | 73 | 65.8 | 24 | 45.8 | ||||
| Age | ||||||||
| < 23 years | 47 | 55.3 | 0.81 | 0.37 | 41 | 58.5 | 3.81 | 0.05 |
| ≥ 23 years | 53 | 64.2 | 50 | 38.0 | ||||
| Mental illness/behavioural disabilities | ||||||||
| Yes | 19 | 57.9 | 0.04 | 0.84 | 15 | 13.3 | 8.29 | 0.01 |
| No | 81 | 60.5 | 76 | 53.9 | ||||
| Employment status before traumatic brain injury | ||||||||
| Permanent contract | 42 | 66.7 | 0.06 | 0.81 | 39 | 53.8 | 1.48 | 0.22 |
| Other | 22 | 63.6 | 19 | 36.8 | ||||
| Family support | ||||||||
| Present | 54 | 63.0 | 0.56 | 0.46 | 48 | 54.2 | 2.33 | 0.13 |
| Not present | 45 | 55.6 | 42 | 38.1 | ||||
| Level of education | ||||||||
| Before BAC | 63 | 55.6 | 1.40 | 0.24 | 57 | 45.6 | 0.16 | 0.69 |
| BAC or after BAC | 37 | 67.6 | 34 | 50.0 | ||||
| Location of acciden t | ||||||||
| Work, work travel | 22 | 59.1 | 0.01 | 0.92 | 18 | 55.6 | 0.62 | 0.43 |
| Street | 78 | 60.3 | 73 | 45.2 | ||||
The relative weights of each factor linked to RTW success in the short-term and medium-term are presented in Table 3 . The most important factor associated with RTW success was the presence of workplace support, both for short- and medium-term analyses.
| Parameter | OR | 95% Confidence Interval |
|---|---|---|
| Model 1: successful reintegration in the short-term ( n = 99, Nagelkerke R 2 = 0.33) | ||
| Significant support in the workplace | 15.13 | 3.71–61.74 |
| Presence of physical disabilities | 0.32 | 0.12–0.87 |
| Serious traumatic brain injury | 0.22 | 0.07–0.66 |
| Model 2: successful reintegration in the medium-term ( n = 90, Nagelkerke R 2 = 0.35) | ||
| Significant support in the workplace | 6.47 | 1.96–21.34 |
| Family support | 4.66 | 1.57–13.80 |
| Associated Mental illness/Behavioural disabilities | 0.09 | 0.03–0.67 |
| Age < 23 years | 2.63 | 0.97–7.13 |
1.4
Discussion
Assessment of RTW following traumatic brain injury shows that post-accident reintegration rates are quite low when there is no specific assistance and that most often the jobs obtained afterwards require a lower level of qualification than the job held before the TBI . A few studies have shown that vocational rehabilitation services have a positive effect on worker reintegration, with a clear reduction in unemployment rates following involvement of a vocational rehabilitation centre , and a clear increase in employment levels in subjects who have undergone a course of rehabilitation .
Although less demanding in terms of intervention intensity and duration than previous studies the SPASE programme seems to be useful in facilitating RTW of TBI persons. Although the lack of a control group in our retrospective study prevents any conclusion being drawn regarding the effectiveness of the this programme, our results do suggest that a relatively light-touch, individualised follow-up programme, with vocational rehabilitation actors monitoring the person over at least a year, may increase employment activity (employment on fixed-term or permanent contract) and stabilise persons in employment. The regularity of the assistance provided by SPASE seemed to be a key factor, as it led to a 3-fold increase in the chance of successful “short-term” reintegration. One interpretation of the facilitating effect of SPASE for RTW is that it might be due to the improvement of the relationship between subjects and their employers. If subjects are reticent about informing their employers about their disabilities, or conversely employers refuse to make allowances for the trauma and make adjustments to the workplace, SPASE actors provide a useful mediation service. The selection of candidates for the SPASE programme, which favours those who have a good chance of keeping or finding a suitable job in a normal environment, also seems to be a determining factor.
There are several factors generally considered to be associated with successful reintegration into the workplace following TBI . Some factors are linked to the worker him/herself (good health before the accident, youth, etc.), others are linked to the seriousness of the trauma (coma and short-term post-traumatic amnesia) or to post-trauma effects (cognitive effects and moderate susceptibility to tiredness), and still others to social and employment conditions .
In our study, the presence of physical disabilities or serious initial brain injury were independent factors reducing the RTW at short-term; this suggests that SPASE program is less efficient on these criteria, which are known to be difficulty to RTW. In contrast, we did not find any influence of cognitive disabilities on RTW. This surprising result may be due to a more effective approach of space program to reduce the impact of cognitive difficulties on RTW. This consists in a specific accompaniment made with SPASE coordinator in order to find solutions to compensate for these difficulties at work.
At medium-terms, if the space support remains the major factor for maintaining the work; the role played by the family support increased. Conversely, the presence of mental illness/behavioural disabilities remains the main factor limiting the maintain to work. This is concordant with literature and suggests that SPASE program is not efficient on this criteria, which requires medical cares and follow-up.
1.5
Conclusion
This retrospective study suggests that assistance within the workplace may help TBI persons to return to work and, overall, to keep a job over the medium-term (4 to 8 years). These findings need to be confirmed by a prospective study with a control group. Finally, our study shows the crucial role of the environment (work and family support) to RTW and maintain the job.
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
Acknowledgements
The authors would like to thank the funding bodies that support SPASE: the French association for management of funds to reintegrate people with disabilities (AGEFIPH), the Isère Regional Council and the European Synchrotron Radiation Facility (ESRF); special thanks to S. Liaudy who performed bibliographic research.
2
Version française
2.1
Introduction
Parmi les 150 000–180 000 traumatisés crâniens en France, 10 000 d’entre eux souffrent de séquelles sévères et8500 rencontrent des difficultés importantes pour leur réinsertion professionnelle . Comme pour beaucoup d’autres pathologies le retour à l’emploi (RAE) des personnes avec lésion cérébrale acquise est une problématique de santé importante, premièrement pour la qualité de vie de la personne mais également en tant qu’enjeu de Santé Publique .
Les progrès de la prise en charge médicale font que le taux de survie de cette population augmente constamment, que les programmes de rééducation fonctionnelle deviennent de plus en plus standardisés et que les facteurs cliniques corrélés au RAE sont mieux compris .
Cependant, le taux de retour à l’emploi reste faible . En plus de la rééducation, plusieurs types d’accompagnement à la réinsertion professionnelle ont vu le jour pour faciliter le RAE des lésés cérébraux. Cependant, ces derniers déplorent un manque de coordination et un management insuffisant pour ces différents programmes . Des programmes individualisés ont été proposés, avec un référent évaluant la situation particulière et les besoins de la personne afin d’agir en conséquence . Ces services semblent générer un taux plus important de RAE ainsi qu’une plus grande productivité , avec 80 % des sujets bénéficiant d’un emploi au sein de la communauté, parmi eux 50 % de personnes occupent un emploi rémunéré dans un environnement compétitif . Bien que ces programmes soient prometteurs pour le RAE leur pertinence en termes de maintien dans l’emploi au moyen terme n’a pas été évaluée à ce jour. C’est donc l’objectif de cette étude rétrospective du programme SPASE.
2.2
Méthode
2.2.1
Programme SPASE
Le programme service personnalisé d’accompagnement et de suivi vers et dans l’emploi (SPASE) développé dans la région de Grenoble est un service de réinsertion professionnelle dédié au retour à l’emploi de la personne lésée cérébrale au sein d’un environnement professionnel ordinaire. C’est un des services proposés par le centre ressources pour lésés cérébraux (CRLC), avec pour objectif principal de permettre à la personne de reprendre son ancien emploi ou de rechercher une nouvelle orientation professionnelle adaptée avec, si possible, une formation spécifique. Les autres services complémentaires proposés par le CRLC sont l’unité d’évaluation, de réentraînement et d’orientation socioprofessionnelle (UEROS) et L’établissement et service d’aide par le travail (ESAT). Un volet important du programme SPASE consacré à l’entreprise consiste à mettre en place une communication directe avec l’employeur ou autres personnes ressources de l’entreprise afin d’expliquer et clarifier les difficultés rencontrées par le travailleur lésé cérébral et de leur fournir tout le soutien possible pour la mise en œuvre d’un retour à l’emploi.
Le délai entre l’accident et l’inclusion dans le programme SPASE variait de un à 10 ans (délai moyen : 2,5 ans), ceci dépendait du handicap de la personne et de sa motivation à reprendre le travail. Les lésés cérébraux étaient orientés vers le programme SPASE par un professionnel de santé ou médecin (souvent un médecin de médecine physique et de réadaptation), ou par tout autre service impliqué dans le suivi de cette population : UEROS, réinsertion professionnelle, CRLC, ou service social. Ensuite, après entretien avec la personne, un comité composé de cadres du CRLC et du SPASE prenait la décision d’inclure ou non la personne dans le programme en fonction des critères suivants : ≥ 18 ans, bénéficier d’une reconnaissance de la qualité de travailleur handicapé (RQTH) délivrée par la CDAPH ou autre éligibilité au titre de la loi du 11 février 2005, lésion cérébrale acquise avec un score de 1 ou 2 sur l’Échelle de Suivi de Glasgow (Glasgow Outcome Scale ou GOS), souhait de la personne de reprendre le travail dans un environnement professionnel ordinaire (adapté si nécessaire) ; faisabilité raisonnable estimée par un consensus multidisciplinaire comprenant des médecins MPR, des assistantes sociales et l’équipe SPASE (ergothérapeutes, ergonomes, psychologues du travail, ressources humaines et managers formés à la formation professionnelle). Tous ces personnes ont une grande expérience de la réinsertion professionnelle et connaissent les problèmes liés aux séquelles d’un traumatisme crânien. Tous ces acteurs, y compris la personne lésée cérébrale, travaillaient activement à la recherche de l’emploi le mieux adapté.
Le programme offre une aide individualisée à travers plusieurs étapes :
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analyse des besoins de la personne souhaitant reprendre son emploi ;
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analyse de sa capacité à reprendre un emploi à travers une préparation au retour à l’emploi et des mises en situation professionnelle en entreprise ;
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recherche d’un nouvel emploi si nécessaire ;
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mise en œuvre du projet.
Ce dernier point consiste à identifier la personne ressource dans l’entreprise pour mettre le projet à exécution, c’est-à-dire celle qui accompagnera l’employé au poste de travail et fera le lien avec le contact SPASE.
L’équipe SPASE définit et ajuste avec l’entreprise les modalités de suivi du travailleur lésé cérébral, cela peut aller d’un simple suivi par téléphone jusqu’à l’implication de l’équipe SPASE au sein de l’entreprise. La durée d’accompagnement et de suivi varie de plusieurs mois à plusieurs années en fonction de la rapidité de la réinsertion professionnelle avec une moyenne de 40 heures de suivi personnalisé par employé et par année.
2.2.2
Paramètres de l’étude et variables analysées
Cette étude rétrospective concernait les 100 premiers travailleurs lésés cérébraux ayant bénéficiés d’une aide individualisée SPASE de plus de 3 heures/an avec un suivi à court (2–3 ans) et moyen terme (plus de 3 ans). Parmi les 122 sujets susceptibles d’intégrer l’étude, 22 étaient perdus de vue.
Un médecin MPR a colligé les éléments à partir du dossier SPASE, d’un entretien mené par un spécialiste de la réinsertion professionnelle ayant aidé la personne et enfin d’un entretien structuré avec l’employé par téléphone. Les détails sur le programme SPASE émanaient du dossier ainsi que du référent chargé de la réinsertion professionnelle de la personne concernée. Des questions sur l’évolution professionnelle depuis le programme SPASE étaient posées à chaque employé.
Le traumatisme crânien était considéré comme sévère si il était associé à un coma (initial ou thérapeutique) supérieur à 8 jour et/ou à un séjour initial en centre de soins supérieur à 3 mois. Les séquelles invalidantes étaient évaluées par le médecin MPR et classées comme suit :
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la déficience physique était jugée comme modérée quand la personne n’avait pas recours aux aides techniques de façon quotidienne, et comme importante dans le cas contraire ;
- •
la déficience cognitive était jugée comme modérée si une seule des fonctions cognitives était lésée (exécutive ou instrumentale), et significative si plus d’une fonction cognitive était altérée. L’évaluation de cette déficience cognitive était réalisée par des neuropsychologues en centre de rééducation fonctionnelle si l’inclusion dans le programme SPASE intervenait peu de temps après le TC, ou plus tard au cours des mois précédant l’inclusion dans le programme SPASE si le délai entre le TC et la décision de reprendre le travail était plus longue (UEROS) ;
- •
troubles du comportement et pathologie mentale, sans distinction étaient considérés comme modérés si ils n’avaient aucun impact sur l’intégration sociale, et significatifs dans le cas contraire.
La qualité du RAE était mesurée en s’appuyant sur les éléments suivants :
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retour possible de la personne dans l’emploi occupé précédemment avec ou sans ajustements et nombre de jours travaillés ;
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l’accompagnement au sein de l’entreprise était considéré comme significatif si un mentor était désigné au sein de l’entreprise pour être quotidiennement présent auprès de l’employé si nécessaire, pour trouver des solutions afin d’accomplir les tâches requises ; l’accompagnement était jugé modéré si ce soutien était sporadique et non formalisé ;
- •
le soutien familial complémentaire était jugé significatif si un membre de l’entourage familial du patient était présent et participait activement au projet de réinsertion professionnelle.
Les critères au court terme d’un retour à l’emploi « réussi » étaient : situation professionnelle évoluant positivement dans la seconde et troisième année après le début de l’aide individualisée SPASE : par exemple, obtention d’un contrat de travail quand la personne n’en avait pas auparavant ; transition vers une situation professionnelle plus stable (avec un contrat de travail de plus de 2 mois) ; ou maintien de l’emploi dans la même entreprise qu’avant l’accident à temps plein ou temps partiel.
Les critères au long terme d’un retour à l’emploi « réussi » ont également été identifiés et reprenaient les mêmes paramètres, prenant en compte la période après la 3 e année suivant le démarrage du programme SPASE (4–8 ans).
2.2.3
Analyses statistiques
Nous avons utilisé le logiciel SPSS, version 11. Nous avons analysé individuellement à l’aide du test Chi 2 les situations sociales et professionnelles 1 an avant et 1 an après le SPASE ainsi que les facteurs ayant pu influencer le RAE ; la significativité statistique était fixée à 0,05. Nous avons appliqué des régressions logistiques de type Forward aux variables du Tableau 2 pour une analyse multivariée des facteurs corrélés à un retour à l’emploi réussi sur le court et moyen terme. Les modèles ont permis de tester les variables du Tableau 2 ayant une significative statistique < 0,15. Nous avons utilisé le coefficient de détermination ajusté R 2 de Nagelkerke, qui teste la proportion de la variance totale ; pour évaluer la vraisemblance de ces modèles.
2.3
Résultats
La cohorte de l’étude était essentiellement masculine (80 %) avec 69 % des sujets âgés de moins de 30 ans au moment du traumatisme crânien ; ces données étaient similaires à celles des 22 sujets non inclus dans la cohorte. La période moyenne de prise en charge initiale était de 7 mois (soins intensifs suivi d’un séjour en centre de rééducation fonctionnelle). Au total 90 % des sujets ont eu un coma (24 jours en moyenne).
Selon les données issues des dossiers SPASE et des entretiens avec les acteurs de la réinsertion professionnelle, 19 % des sujets avaient une pathologie mentale (validée par un diagnostique psychiatrique), 46 % bénéficiaient d’un soutien familial ; 73 % des sujets recevaient une aide régulière de la part des services de la SPASE et 27 % recevaient une aide sporadique (moins de 3 heures par an). De plus, les acteurs de la réinsertion professionnelle, rapportaient que 28 % des sujets avaient reçu un soutien significatif et utile au sein de leur entreprise.
2.3.1
Changements socioprofessionnels après le programme SPASE
Le Tableau 1 liste les changements de statut professionnel, social et éducatif avant et après le SPASE : on note une augmentation de l’emploi de 35 %, une diminution des licenciements de 19 % et une augmentation des personnes employées depuis plus de 6 mois de 21,6 %.
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