Individual Placement and Support is the keyhole: Employer experiences of supporting persons with mental illness

2.1 Sampling of participants

Eligibility criteria included employers in the southern parts of Sweden with experience of participating in the IPS network, providing on-worksite support, and taking IPS service users into their workforce. The study was approved by the Regional Ethical Board in Lund, Sweden, (Dnr 202/2008). The employers were recruited gradually; after the first interview had been transcribed and subjected to preliminary analysis, the next employer was theoretically chosen on the basis of how he/she could contribute to the development of the analysis (see data collection below). This is in line with the concept of theoretical sampling (Corbin & Strauss, 2007). The process implied that we included employers of different ages and gender from both public and private sectors and from workplaces with different levels of profitability. Participants were recruited in three steps. First, the ES introduced the employer to the study and asked if he or she was willing to participate and be contacted by the interviewer (A.L.). Second, additional information about the study was given to the employer by the interviewer when an interview appointment was set. This information specified that no sensitive data, which could reveal the identity of the service user, should be revealed during the interview. Last, at the time of the interview, the information previously provided was repeated and supplied in a written form. All employers who were asked to participate agreed to do so (N = 9), provided written consent, and completed the interview.

The socio-demographic characteristics of the participants are presented in Table 1. Five employers provided competitive employment and four employers offered internship placements for IPS service users. While internship placements are not considered part of IPS a Swedish implementation study showed that there is a traditional and obligatory rehabilitation route for Swedish citizens who have been inactive in the labor market because of long-term unemployment or disability (Bejerholm, Larsson, & Hofgren, 2011). In this implementation study, internship rather than competitive employment was generally recommended to the IPS service users before competitive employment. In this situation, employers received economic compensation. Employers could also be compensated by various wage subsidies if they employed the persons later. As a result many employers consider offering such an internship placement before employment.

2.2 Data collection

As described earlier the data collection was directed by theoretical sampling, where the emerging analysis guided the selection of participants (Corbin and Strauss, 2007). Each interview lasted approximately 90 minutes and was conducted at the participant’s workplace. The interviews were conducted in the native language of the participants, i.e. Swedish, by the first author (AL), and were recorded digitally with consent of the participants. Initially, a pilot interview was conducted. The grounded theory interview format was a good way to get employers to share their views and experiences and corresponded to the research aim. The question areas were based on a structured literature search of the topic area. First, the employer was asked to recall events related to participating in the IPS network. Later in the interview, question areas included employer support, IPS professional support, work-related factors, views/attitudes, experiences, and society. If another topic of relevance was brought up, the employer was encouraged to share that as well (Corbin & Strauss, 2007). As the interviews were performed and analyzed, codes and preliminary categories gradually added more specific and modified question areas. After the first interview, questions on humanity, employer traits, and experience of mental ill health were added. After the second interview, the consequences of providing support, cooperation with the ES and the IPS network were included. The third interview resulted in questions on internship versus competitive employment, wage subsidies, social environment, and possibilities and limitations in a larger company. The fourth interview produced queries about the hiring process, disclosure, adapting a personal approach, and tolerance of diversity. After the fifth interview, questions on direct support strategies, goodwill, and differences in demands were added. Following the sixth interview, indirect support strategies and work complexity in relation to work ability were added. After the seventh interview, free labor, dependence on the welfare system, and possibilities and limitations within the industry were incorporated. This process of feeding initial results back into the data collection is viewed as essential in grounded theory (Corbin & Strauss, 2007). No additional ideas that added to the emerging categories appeared during the eighth and ninth interviews, and thus no further interviews wereperformed.

2.3 Data analysis

Throughout the analysis process, the program Open Code 4.01 was used as a structuring tool and memos were written to aid the analysis process. We preceded through the stages of open and axial coding (Corbin & Strauss, 2007). The process of open coding involved reducing data to manageable pieces and developing codes by identifying concepts and the properties and dimensions that represent the ideas contained in the data. Axial coding occurred in concurrence with open coding. During this process, crosscutting and related concepts were subjected to constant comparisons. This part of the analysis focused on codes and concepts that refer to the process, ie ongoing actions and interactions, employer emotions as they incorporated an IPS service user into their workforce and participated in the IPS network. One core category and six main categories were identified and illustrated in the conceptual process model.

Situational analysis was used as a supplemental approach during the analysis process. Abstract messy maps were used during the open coding and axial coding. The purpose was to open up the data and look at it from different angles. This helped plan further theoretical sampling. Relational analyses between the different codes in the map supplemented the grounded theory comparative analysis. Finally, a positional map was created to highlight the major positions taken or not taken by employers for the reasons they incorporated IPS service users. To increase the trustworthiness of the findings, data were coded separately after each interview by A.L. (first author/interviewer) and U.B. (co-author). All parts of the analyses were continuously discussed among all authors, until consensus was reached. The data collection and analyses took about eight months to complete.

3.1 Stage 1: IPS is the keyhole

The employers experienced the support provided by the ES, the visual part of the IPS, as the keyhole. The IPS was expected to enable persons with SMI to enter and keep a job in the labor market. Employers described it as crucial that the ES was trustworthy and professional when promoting the IPS service user and themselves, making job inquiries, and negotiating on the IPS service user’s behalf. Among other things, the ES provided information on the comprehensive, individualized, time-unlimited, on-worksite support that could be provided. Employers viewed this as a necessity. Support of the ES was perceived as an asset, especially as the employer tried to remove barriers by using strategies to accommodate for the user’s work-related disabilities. The employers valued the support they personally received from the ES. They could rely on the ES for strength, a feeling of safety, for support, and to discuss and solve problems. Furthermore, active ES involvement at the worksite, ie, support given to the employer, colleagues and the IPS service user, was also greatly appreciated by employers. In this situation, the ES provided information on user abilities, disabilities, and reasonable accommodations that opened up new views on matters concerning the user and dealt with false expectations of user abilities and disabilities. ES support also included a mediation or support role in social interactions between the user, employer, and colleagues, as well as provision of hands-on support in work performance. If the IPS service user terminated the job, the ES often kept in touch with the employer afterwards. As shown in Fig. 1, from the employer perspective, ES support played a crucial role at several stages in the process.

3.2 Stage 2 and 3: Being ready to open the door and making a job offer

Employer previous experience, personal traits, and views were of importance for employer readiness to ‘open the door’ and include IPS service users in their workforce, and make a job offer of competitive employment or internship placement. Furthermore, external conditions also played a role (Fig. 2).

3.3 Stage 4: Removing barriers

This stage of the process involved the employer trying to remove barriers in the work environment. Direct and indirect support strategies were used to accommodate the IPS service user’s disabilities. Direct support strategies included making a job-person match, ie, assigning work tasks that were in line with what he or she was able to do, adjusting work hours, modifying work tasks, and adapting a personal approach. Adapting a personal approach could include having a tolerant and flexible approach. It could also mean having to remind, check, set boundaries, and nag: “It’s a little bit like being a mother. You must not be afraid to nag or correct the person”. Other mentioned strategies were to help the IPS service user cope with the mental illness and provide hands-on support in work performance. Indirect support strategies involved using ES support as an asset in the workplace. This is described more fully under the heading “IPS is the keyhole”. Employers also urged employees to take social responsibility and include the IPS service user at work. Sometimes supervisor responsibility was delegated to other employees. Another indirect support strategy used by the employers was to bring their own needs into account when making decisions. As evident in prior stages of being ready to open the door and make a job offer, the employers’ relied on previous experience when using these strategies. Personal traits and views, as well as external conditions, also had an influence(Fig. 2).

3.4 Stage 5: Achieving the goal

During the analyses, three goals emerged concerning employer reasons for taking on IPS service users: goodwill, win-win situation, and acquiring a productive employee (Fig. 1). To elaborate further on the different positions taken or not taken with regard to these goals, a positional map was created (Fig. 3).

Position A comprises employers in profitable larger companies who simply open their workplace because of goodwill, and allow the IPS service user to participate at the worksite without any specific job requirements. Position B includes employers of companies that see the opportunity of having subsidized labor as a win-win situation. The company gets an extra pair of hands, while the IPS service user gets work experience and references. This position was articulated by employers in larger profitable companies that were not dependent on the welfare system for internship and subsidized labor, as well as in smaller companies with constrained finances that use the welfare system as a survival strategy. Position C encompasses employers in larger and smaller companies who hire IPS service users based on merit, on the same premises as other employees, and the goal is acquiring a productive employee. The employers in smaller companies, who hire a person despite constrained finances, are driven by strong social engagement that goes beyond the company budget. Position D was not articulated in the data. It would, however, include employers in smaller companies with strained finances who simply participate because of goodwill, and allow the IPS service user to participate at the worksite without specific job requirements.

3.5 Stage 6: Pride mixed with negative feelings

According to employers, taking on IPS service users and being part of the IPS network evoked experiences of pride, mixed with negative feelings. They felt proud to be able to contribute to another’s development, to see someone grow, and to feel connected to him or her. These experiences served as a driving force that reinforced the employer’s social commitment. Incidents that created negative feelings had an adverse impact on the employer’s future willingness to consider opening the door. Employers could become frustrated and angry when the service user did not keep their promises. Employers felt stressed and inadequate if supporting the service user contributed to a larger workload. They might also be afraid to make demands that would affect the well-being of the service user. One employer said: “The meeting with the mental health personnel really affected me. They treated him as really vulnerable and afterwards I was really afraid to make demands for fear of causing him to relapse in his mental illness.” The employers also felt frustrated and sad when they had to deal with reactions and conflicts among the other employees. For example, lack of social skills of the IPS service user or differential treatment by the employer compared to other employees might cause issues. Furthermore, employers in smaller companies became frustrated when they had to struggle to manage sickness absence: “It is really difficult and you know that he is going to be on periods of sick leave because of his illness. We don’t really have that flexibility in our business”.

4.1 Methodological considerations

Grounded theory is considered as an appropriate method for approaching the study aim since it is explanatory in nature and little is known about the employer point of view. As data collection and analyses were directed by theoretical sampling and performed in parallel, the data were deepened, interpretations could be checked, and the evolving categories could be tested. By contrast, many qualitative researchers collect much of their data prior to analysis and this may limit the depth of the data (Corbin & Strauss, 1990). Situational analysis was a helpful, supplementary, analytic tool during the analysis process of making abstract messy maps and relational analyses, and when making a positional map to highlight the major positions. Grounded theory alone may have limited the depth of the data and narrowed the chance to reflect on the data and its complexity in a broader perspective.

Corbin and Strauss (2007), and Chiovitti and Piran (2003) provide guidelines to enhance quality and rigor in grounded theory research, and these guidelines were used throughout the study. To increase study credibility and make the results truly reflective of employer experiences and views, the Swedish employer context was described. In addition, participants were allowed to guide the inquiry process by feeding initial results back into data collection. Employers had the opportunity to comment on the analyses, and in vivo codes were applied in the coding process. Moreover, memos were written continuously about researcher experiences and pre-conceptions. The analysis was developed among the authors, who had backgrounds in occupational therapy, sociology, and global health, as well as different competencies with regard to the IPS approach and grounded theory situational analysis methodology. These differences made it possible to challenge each other’s interpretations. Additionally, the draft article was reviewed by an external expert in grounded theory situational analysis methodology. A thorough methodological description was made to further enhance credibility and auditability. To allow readers to assess transferability of the results to other settings, details of sample characteristics and settings are provided. To further enhance transferability, a positional map that reflects the results in relation to the Swedish context was made. It was through this map that the results on internship became evident, since some employers’ viewed the internship placements as a win-win situation. It is noteworthy, however, that the context specific features of internship were not decisive for the main results of the study. The opportunity of subsidized labor in combination with high employer taxes, as reflected in the Swedish culture of free labor that forms part of the traditional and obligatory rehabilitation route, may have influenced employer readiness to open the door. The group of socially committed employers in the present study can reasonably be assumed to be transferable to other national contexts since similar findings are found in other countries (Gilbride et al., 2003; Ju et al., 2013).

Only employers where the IPS-service user had chosen to disclose that he or she has a mental illness or disability and with experience in providing on-worksite support and participating in the IPS network were interviewed for this study in order to protect the IPS service users’ confidentiality. Consequently, this study does not reflect the experiences of all employers who hire persons with SMI. It is also possible that this study reflects employer experiences and views of taking on IPS service users with more severe disabilities than those with only off-worksite support. This may be the reason why nearly half of the employers provided internship placements. As described earlier, in the Swedish employer context, internship is often recommended as a stepping-stone to the labor market and is part of the traditional route of vocational rehabilitation (Bejerholm et al., 2011). Our results are in agreement with previous research findings (Bejerholm et al., 2011; Gustafson et al., 2013), and illustrate the risk that Swedish employers expect such a placement, or win-win situation, if a person has been on sick leave for a longer period. Additional research in other contexts and countries is needed to explore further employer experiences of being part of an IPSnetwork.

The positional map (Fig. 3) shows that employers in smaller companies with constrained finances, who simply open their workplace because of goodwill, and allow the IPS service user to be at the worksite without specific job requirements, were not found in the data. According to the ES, who mediated contact with likely employers, employers in such companies did not exist among their clients. It is conceivable that employers with constrained finances are less likely to hire a person with SMI, based on goodwillalone.

According to Creswell (2007), a grounded theory study should include a larger number of interviews. In spite of the limited number of interviews, however, we believe that we gained a greater understanding of employers’ experiences and views. This may be because the study aim targeted a limited group of employers with common characteristics. They were socially committed, had unique and similar personal experiences, traits and views, and the interviews were comprehensive and detailed. The implications are, however, that there is a need to corroborate the findings in larger samples and in different contexts. The results of this study should be considered part of a larger puzzle of knowledge related to the field that generates hypotheses for furtherresearch.

4.2 Conclusions and implications for practice

The study results suggest that professionals in vocational rehabilitation who work according to IPS principles may find it essential to:

systematically develop collaborative relationships with employers based on trust and professionalism, in line with the eighth IPS principle.