The identification of research priorities for UK occupational therapists in work rehabilitation. International (7). pp.

Background/Aims: UK occupational therapists are recognised as having key skills in work rehabilitation, but there is limited evidence to underpin this. In order to use research resources to best effect, it is vital to identify the research priorities of occupational therapists in work rehabilitation. This study aims to gather the views of those with a special interest in the field in order to identify their research priorities. Methods: An online survey was developed and administered electronically to members (n=173) of the College of Occupational Therapists’ Specialist Section–Work (COTSS–Work). Respondents were asked to: i) prioritise and comment on research areas; ii) propose research questions. A final sample of 42 surveys was collected and analysed thematically. Results: Responses reflected the diversity and complexity of work rehabilitation. Identifying a rank order of research priorities proved challenging as the majority (≥62%) of respondents considered all of the topic areas listed a high priority. Research into the following areas were included in the survey: interventions; outcome measurements; assessments; management and/or service delivery; planning and/or commissioning; education. However ‘interventions’ was rated highest overall. Conclusions: Occupational therapists in the UK need more evidence to justify their role in the health and social care system. Greater opportunities are required for occupational therapists in clinical practice, as well as those involved in research, to address areas in which evidence-based practice is lacking and the mechanisms to disseminate this knowledge base.

S ickness absence and work disability have significant economic and social consequences. The last decade has thus seen a considerable investment by the UK government in policies and services to address the needs of those whose health is affecting, or is affected by, their work [AQ Pleaese provide reference]. In the UK, there are no workers' compensation schemes-the majority of employees are unable to access occupational health services and the remit of such services is variable. Most patients are therefore reliant on health professionals such as general practitioners, physiotherapists and occupational therapists for any advice or support with regards to work.
Several reviews have identified the key role of clinicians in helping to support their patients return to, remain in and access work (Black, 2008;Waddell et al, 2008;Black and Frost, 2012). Occupational therapists are recognised as having relevant skills and expertise in this area and have been key players in governmentfunded work rehabilitation/retention initiatives and pilot schemes (Department for Work and Pensions (DWP), 2006;2008;2012), contributing to both policy formation and the delivery of interventions (DWP, 2008; College of Occupational Therapists (COT), 2009). Occupational therapists are also expected to play a major role in the Fit for Work programme; a phased roll-out of the referral service started on 9 March 2015 (DWP, 2013a;2013b). In spite of this, there is a lack of UK-based peerreviewed evidence on the effectiveness of work rehabilitation interventions that occupational therapists provide. A review of evidence published by the DWP (Dibben et al, 2012) on the support needed to help people with common health conditions stay at or return to work highlighted the weak evidence base in the UK and the problem of poor transferability of evidence from other countries as a result of structural, social and cultural differences.
There are a number barriers to producing evidence underpinning occupational therapy in the UK. First, therapists may not have the opportunity to deliver work-relevant interventions as there is no structured work rehabilitation pathway. NHS rehabilitation does not typically address work issues as work rehabilitation is often seen as 'non-essential' due to competing commissioning priorities (Sinclair et al, 2014). Second, where such interventions are available, they tend to be delivered by multidisciplinary teams. Isolating and evaluating the impact of one profession and obtaining funding for unidisciplinary research is challenging. Third, the occupational therapy profession has a historically limited evidence base, with therapists reporting a lack of time, confidence and support to engage in research activity (White et al, 2013).
However, in recent years, a number of papers have been published by UK occupational therapists on work rehabilitation. Some have sought to identify patients' and employers' needs, for example, in multiple sclerosis (Sweetland et al, 2007), or have developed training programmes in work rehabilitation (O'Brien et al, 2013). Others have described aspects of current practice in work rehabilitation in various conditions, for example, in traumatic brain injury (Phillips et al, 2010), musculoskeletal conditions (Coole et al, 2013a) and stroke (Grant et al, 2014). The role of occupational therapists working in different work rehabilitation settings has also been reported (Reagon, 2011) and practice models have been developed for work support for people with cancer (Eva et al, 2012). Despite these advancements, few have investigated the efficacy of occupational therapy as an intervention, and those that have are cohort comparisons or small feasibility studies (Macedo et al, 2009;Coole et al, 2013a;Radford et al, 2013), rather than randomised controlled trials (RCTs). There is, therefore, a need for UK-based research to focus on work rehabilitation.
With finite resources, it is vital to identify research priorities before conducting such research. One way of achieving this is to gather the views of therapists with a particular interest in the field. The College of Occupational Therapists (COT) supports a specialist group of occupational therapists with an interest in work rehabilitation-known as the College of Occupational Therapists Specialist Section-Work (COTSS-Work)-who represent a wide range of service settings and client groups. At the COTSS-Work annual conference in 2002, members of COTSS-Work identified a list of research priorities concerning work rehabilitation (COT, 2003) (Table 1). These have been used to inform funding bodies and applications and were published by the COT in 2007 in a wider review of research priorities (COT, 2007). In 2013, the COTSS-Work National Executive Committee acknowledged that these research priorities may no longer be relevant and it was agreed that a member survey be conducted to identify areas of research that UK occupational therapists regard as most important. [This study is a report of the data collected from this survey XXXXXXXXX]

METHOD Procedures
The question areas included in the survey were initially devised by the research team, informed by previously identified research priorities (COT, 2003). These were commented on and revised via email consultation between the research team and members of the COTSS-Work Executive Committee until an agreement was reached.
For the purposes of this study, the term 'work rehabilitation' was used rather than 'vocational rehabilitation'. This is because 'vocational rehabilitation' is often viewed in the UK as referring to specialist case management rather than workfocused interventions, which may be carried out by occupational therapists in a diverse range of settings. The survey was then piloted with seven occupational therapists who were experienced in research and/or work rehabilitation but were not members of COTSS-Work. Amendments were made in response to their feedback. The final list of survey questions and topics are shown in Table 2. The research priorities previously identified by the COT (2003) ( Table 1) were not made available to participants so as to reduce possible respondent bias. The first two questions asked respondents about their primary and secondary work roles. Respondents were then asked about their priorities for research under six broad topic headings. These were selected to cover the main areas where the need for research might be indicated and were informed by the previously identified research priorities (COT, 2003). It was acknowledged that there might be some overlap in participant responses. For each question, respondents were asked to select whether each area was a high, low or medium priority, then to add comments as to how they would like to see research funds used, e.g. research questions or broad topic areas. If there were particular client groups that respondents wished to prioritise, they could identify up to five groups. If respondents had priorities that were not covered by the available headings, they were invited to use the additional response option provided.
The link to the survey and information about the study were emailed to all the members (n=173) of COTSS-Work in October 2013. An introductory paragraph explained that the purpose of the survey was to identify areas of research that members regarded as important in work rehabilitation, which would be used to develop a strategic plan to inform funding bodies and the profession's research agenda. Reminders were emailed on two occasions before the survey was closed on 30 November 2013.
Ethical approval for this study was obtained from the University of Nottingham Medical School Ethics Committee.

Analysis
Quantitative data were analysed descriptively. Qualitative data from Questions 3-8 and Question 10 were analysed thematically, and was mainly deductive. The qualitative data was analysed independently by one of the research assistants from the research team and the lead researcher. The data was then reviewed collaboratively to select the themes. The research assistants were not occupational therapists and could therefore provide a more objective view.

RESULTS
A total of 62 responses were submitted. Of these, 20 responses were excluded as respondents had completed only the first two questions, leaving 42 responses available for analysis (response rate: 24%).

Perceptions of research areas and priorities
The level of priority allocated to each research area by respondents is shown in Table 4. The majority (≥62%) of respondents allocated at least a medium priority to all areas. Research into work interventions was scored as the highest priority by most respondents (n=34, 81%), followed by outcome measurement (n=30, 71%) and assessment (n=28, 67%). When combining high and medium priorities, research into work interventions and assessment were highly prioritised by almost all participants (n=41, 98%), followed by outcome measurement (n=40, 95%). The three remaining research areas-management and/or service delivery, planning and/or commissioning and educationwere identified as high priorities by 26 (62%) respondents. However, when combining high and medium priorities, research into management and/or service delivery and education were considered higher priorities than planning and/or commissioning.

Interventions
In the survey, respondents indicated that it is important for occupational therapists to: n Identify interventions more effectively n Have a good knowledge of the effectiveness of interventions.
Respondents suggested that there is a lack of evidence on the optimum timing, duration, frequency, location and service-base of interventions, as well as factors that determine the 'readiness' of patients to respond to these interventions. The need to investigate the long-term impact of interventions, their sustainability and acceptability was also identified. Respondents also highlighted the need for further research into the transferability of interventions. This included research on the success of reproducing evidence-based treatment approaches from other countries to the UK from one treatment setting to another, or from one health condition to another. Evidence is also needed on practical issues, such as the cost effectiveness of delivering interventions and the types of resources required (e.g. equipment and clinical space). With the budgetary constraints of the NHS, these issues were seen as particularly important. Lastly, the need to investigate the role of workplace support in the successful delivery of interventions was also identified.

Outcome measurement
Several respondents suggested that outcome measures should be used in treating patients with specific conditions, emphasising the benefits of pooling data on a wider scale. For example, a core outcome set might be used across conditions and facilitate comparison of trial results. Occupational therapists felt the profession needed to develop expertise in 'informatics' and collecting and analysing outcome data, with economic evaluation done for specific outcomes. The need to conduct cost-effectiveness and cost-benefit analysis was also stressed as this would help occupational therapists to better demonstrate the value of occupational therapy to managers and commissioners.
Respondents also recognised the need for occupational therapists to demonstrate the impact of occupational therapy on the number of people returning to work and moving from benefits to work, along with measures of sickness absence at work. Measuring successes along the 'return to work journey', such as the development of work-related skills, was suggested as well. Conversely, there was a perception that barriers to occupational therapists using standardised outcomes in practice exist, and that the reasons for this should be explored. Respondents were keen to know what outcome measures occupational therapists are currently using and how they are being recorded, reported and evaluated. Respondents further indicated that research is needed to establish the best outcome measures to use in work rehabilitation, and those that best reflect occupational therapy interventions. Where health-and socially-orientated outcomes were used, respondents requested evidence of how well these outcomes correlated with return to work outcomes, and some wanted evidence for specific conditions, such as mental health. Research is also needed to investigate the impact of socioeconomic factors (benefit status, injury claims, social circumstances) on return to work outcomes, as well as the future impact of electronic patient related outcome measures (PROMs). Identifying the outcome measures perceived as most useful by other stakeholders was also described as an important research priority, including, for example, the business community, commissioners and the government.

Assessment
Respondents wanted to know more about current practices among occupational therapists and the questions therapists were asking patients who were off sick. They requested evidence for the effectiveness of specific assessment tools, such as Functional Capacity Evaluations (FCE), and their impact on different client groups. In particular, respondents wanted to know: i) how objective, valid and reliable different assessments are; ii) he most effective screening questions to use. A further research priority raised was the need to identify the skills required to carry out these assessments, how these skills are interpreted and applied, and if there are any differences in outcomes of assessments across different health professions (e.g. occupational health practitioners).

Commissioning and delivering services
A lack of evidence for occupational therapy in work rehabilitation was identified as a barrier to funding new service models, which could then have an impact on patient choice. Respondents were keen to know what methods/models of work rehabilitation service delivery were being used by occupational therapists and how occupational therapy managers were engaging commissioners about the need for work rehabilitation.
Respondents also identified a need for evidence comparing specialist and generic services, specifically whether it was better to establish centres of excellence in work rehabilitation with specially trained therapists or to utilise those employed in existing community posts. Evidence on whether services should be condition-specific was also desired. Beyond this, there is a need to investigate where work rehabilitation services were best placed (primary or secondary care), and to compare the effectiveness of different routes of accessing work rehabilitation after returning to work. Other research priorities include exploring the perceptions of other stakeholders, such as service commissioners and users, and exploring the barriers to implementing evidence-based practice models.

Training and education
Respondents were keen to know what proportion of undergraduate and postgraduate courses cover work rehabilitation, the current practices in work rehabilitation education and training, and how it is being promoted and taught. There was a need to identify the key knowledge and skills required by occupational therapists in work rehabilitation at different levels, such as a national competency framework with standards. Respondents felt that research was needed to identify the key components in work rehabilitation training for different health conditions. A comparison of undergraduate courses and their effectiveness in educating occupational therapists was called for.
Respondents also identified a need to investigate what occupational therapists could learn internationally and from other professions in work rehabilitation and the value of specific training, for example, in FCE, compared with with more generic occupational therapy training. Regarding the experiences of therapists, there is a need to explore the perceptions of newly qualified staff about work rehabilitation and how confident they are in transferring core skills, for example, from home to workplace assessment

General observations
The limited evidence base for occupational therapy, particularly in the UK, was acknowledged. The need for high quality systematic reviews and meta-analyses required to provide a 'gold standard' evidence base for the profession was recognised, along with the lack of RCTs available for such reviews. Respondents also indicated that wider funded networks should be established to facilitate partnerships between clinical and academic occupational therapists to exchange knowledge and develop research ideas and proposals. Information on ongoing research in the field was also requested.

Why occupational therapy in work rehabilitation?
Based on the survey, work rehabilitation is viewed as being 'integral' to occupational therapy. There was a view that the profession is 'ready-made' for work rehabilitation because of the natural focus on the biopsychosocial model, and that it should have a higher profile in work rehabilitation. However, in contrast, there was uncertainty about the 'added value' of occupational therapy, how the profession is both unique and complimentary to others in work rehabilitation, and why others should invest in occupational therapy. Specifically, respondents indicated the need for evidence to demonstrate what occupational therapists are able to offer in work rehabilitation that other departments, such as human resources and occupational health, are unable to. Research was needed to demonstrate and explore the wider role of occupational therapy in work disability prevention and in the promotion of health and wellbeing at work.

Priority client groups
Respondents identified a wide range of client groups whose needs should be prioritised in relation to work rehabilitation ( Table 5).

DiScUSSiOn
This is the first study conducted on the research priorities of UK occupational therapists in work rehabilitation. Identifying the rank order of research priorities proved challenging due to the diversity of responses, but analysis of the findings identified a range of research areas and questions prioritised by occupational therapists in the UK.
When comparing the findings of this study with the research priorities identified by members of COTSS-Work in 2003, it is interesting to note that many research areas that were previously identified remain relevant, with the majority (≥62%) of respondents rating these as of 'high importance'. However, there are still concerns about the occupational therapy role and how it is perceived by others. The need for research into standardised assessment, outcome measurement and treatment models that apply to the UK was also identified. Measurement of the effectiveness and cost effectiveness of interventions is still a priority, as is the impact of organisational factors on the ability of therapists to deliver work rehabilitation.
Respondents participating in this study placed considerable emphasis on education and training needs and the commissioning and delivery of services. This may reflect the current economic climate, the impact of GP commissioning, the increasing recognition of the links between work and health (Waddell and Burton, 2006), as well as the growing expectation of health profession-als to have a greater place in work rehabilitation. The challenge of whether work rehabilitation services should be delivered according to health condition or other socioeconomic factors is illustrated by the diversity in client groups prioritised by respondents (Table 5).
Despite the fact that many research questions remain unanswered, it should be acknowledged that, since 2003, a wide range of research has been published about UK occupational therapy in work rehabilitation, with many studies funded by the United Kingdom Occupational Therapy Research Foundation (UKOTRF) since its establishment in 2006. As an addendum to this, the difficulty of conducting systematic reviews and meta-analyses when insufficient trials have been conducted is acknowledged. Systematic reviews often focus too narrowly and are unable to draw firm conclusions due to insufficient evidence (Prior and Hammond, 2014). Until more trials of occupational therapy in work rehabilitation have been conducted, it may be more relevant to conduct other methods of evaluating practice, such as best-evidence synthesis. It may also be appropriate to more closely examine the evidence available from outside the UK and identify practices that are transferable to the UK.
The need to develop and embed work rehabilitation in occupational therapy training was highlighted by respondents. These findings should be of interest to student occupational therapists and their supervisors who are considering undergraduate or postgraduate projects in work rehabilitation and are looking for suitable topics to study. The utility of published research priorities in evidencebased practice by identifying topics for student physiotherapy projects has previously been highlighted by Rushton and Moore (2010).
In a discussion on how best to utilise the findings of this study, the researchers posited that COTSS-Work could develop a greater role in conducting small research studies and scoping exercises; however, this is often time consuming, which may prove challenging as the committee members are all volunteers. COTSS-Work could make increased efforts to keep members informed about current research studies (a research database of UK occupational therapy studies in work rehabilitation is already available to members) and this could be extended to include audits and service evaluations. Greater opportunities for networking may also help to increase awareness within the establishment of online discussion groups among its members.
At present, there is no easily accessible forum for communication and debate. The authors encourage the creation more opportunities for clinical and academic occupational therapists to meet and develop research projects specific to occupational therapy and work rehabilitation. The COT have produced a series of resources known as support practice evidence and resources (SPEaR), which could answer some of the research priorities raised in this study. Other models of sharing work-related research findings could be considered, such as the new online database developed by the Institution of Occupational Safety and Health Research Committee (2015). Structuring the development, collection and dissemination of evidence-based practice, for example, by treatment setting or health condition, may be indicated. The options put forward could then be evaluated by COTSS-Work and the COT.

Limitations
The response rate was lower than anticipated, which may have been due to the online format or the presence of open questions, which would have required more effort to answer. Also, it was not possible to compare the characteristics of nonresponders with responders for any systematic differences as section membership data was incomplete. A larger survey could have been conducted to include members of other specialist occupational therapy networks (e.g. independent practitioners), multidisciplinary networks (e.g. Vocational Rehabilitation Association) and those who are not members of specialist networks.
Although COTSS-Work members have a particular interest in the field of work rehabilitation, they may not necessarily be 'experts' in the field, with only 10% of respondents having a research role. As a result, some members may not have had an opinion or may have felt unable to comment, while other members' responses may have been shaped by a different understanding of research methodology. Additionally, different methods of collecting data may have yielded more responses or facilitated consensus-other studies of occupational therapists' research priorities have used Delphi surveys (Bissett et al, 2002) or conferences (Sprigle et al, 2007). However, these methods would have required greater resources than were available.
Finally, the design of the study may have affected the findings. An open-ended approach was used to facilitate as broad a range of responses as possible. While this led to the collection of a large amount of data, much of the data was related to strategic issues or specific concerns rather than research priorities. The Individual placement and support service recipients broad topic areas were chosen to provide some structure to the survey, but may have resulted in response bias. In view of this, a more systematic, prescriptive quantitative approach, with predetermined research questions, may have yielded clearer priorities. cOncLUSiOnS A diverse range of research questions concerning work rehabilitation were identified by respondents in this study, reflecting the complexity of this field of practice. The majority of respondents indicated that all of the research areas identified in the survey were a high priority, with work rehabilitation interventions, assessment and outcome measures ranked the highest. Many of the research priorities identified reflect those published by the COT in 2003, albeit with a greater focus on education, service delivery and commissioning. Although more work rehabilitation research is now being conducted by UK occupational therapists, this study has shown that there is still much more that can be done. The availability of more opportunities and support for clinical and academic occupational therapists are required to address the areas most in need of evidence and to disseminate the knowledge base.