The effectiveness of the model of occupational self-efficacy in improving the quality of life and self-efficacy beliefs in individuals living with schizophrenia: A pre- and post-intervention pilot study

1.1 Literature review

1.2 Quality of life

Quality of life could be viewed as an important treatment outcome measure particularly for individuals diagnosed with schizophrenia. However, there have been few studies that specifically focused on QOL as an outcome linked to intervention programs as the focus of these studies has been on symptomatology (Eack & Newhill, 2007). According to Lehman (1988), QOL interventions have been mainly focused on improving an individual’s health status, access to resources, the individual’s subjective quality of life and satisfaction with life. The above studies therefore contribute to the need for studies to use QOL as an outcome measure in order to determine whether vocational rehabilitation/work skills programs enhance an individual’s ability to return to work as well as their QOL.

1.3 Self-efficacy and schizophrenia

Self-efficacy theory asserts that functional capacity alone is insufficient to generate a desired behavior (Bandura, 1982). Self-efficacy is also strongly associated with an individual’s judgement of his or her abilities before and during an event. These judgements therefore influence his or her thoughts, emotions and actions as well as the amount of energy that individuals are willing to utilize in order to complete an action. It could therefore be argued that individuals with a strong sense of self-efficacy will often be motivated to try harder to complete an activity than those with a poor sense of self-efficacy. Research has shown that higher levels of perceived self-efficacy led to an increase in performance while engaging in occupations such as work (Bandura, 1982; 1997). Unfortunately, many of the effects of schizophrenia, such as cognitive deficiencies, poor assertive and interpersonal relational skills, or a limited sense of direction in one’s life, all contribute to reduced feelings of efficiency and competence.

1.4 Examining the global trends of individuals with schizophrenia Returning to Work

Internationally in a country like Sweden the employment rate for individuals living with schizophrenia was estimated as being 20%, with the majority of individuals with schizophrenia being depended on a disability pension. Furthermore, in a population wide study conducted in Norway, the employment rate was estimated as being 10.24% (Evensen et al., 2015). According to the national mid-year population estimates of 2017, South Africa has a population of 56.52 million (Statistics South Africa, 2017). Recent statistics on the number of people with disability in South Africa are non-existent. However, based on the 2011 census, about 7.5% of the population had disabilities (Statistics South Africa, 2011). Should this statistical measure have remained constant, then South Africa’s current estimate of people with disabilities would be 4 239 000. Although a specific estimate of the employment rate for people living with schizophrenia in South Africa is not available at the time of writing this article, it could be argued that the employment rate is as low as 0.7% of the economically active people with disabilities in South Africa (South African Department of Labour, 2014). According to the 17th Commission for Employment Equity Annual Report of 2016 to 2017, the number of persons with disabilities employed has decreased since 2014 (Watkins, 2021).

1.5 Intervention strategies that facilitate RTW: Supported employment approach

Supported employment aims to facilitate the process of RTW for individuals with schizophrenia (including other mental illnesses) (Nuechterlein et al., 2008). A systematic review conducted in the United States of America, comprised eleven randomized control trials, and highlighted the success and positive outcomes achieved by supported employment in enabling individuals with disability to participate in competitive employment (Drake, 2018). Based on this review, individuals who participated in supported employment were more likely to be included in competitive employment (Drake, 2018).

1.6 Model of Occupational Self-Efficacy

The Model of Occupational Self-Efficacy developed by Soeker (2012) is an occupational therapy practice model designed to effectively return individuals with brain injury to work. The MOOSE consists of 4 stages (see Fig. 1) namely, Stage One: “A strong personal belief in functional abilities”. During this stage the occupational therapist will facilitate a process of introspection and reflection in the client in order to develop new insights into his or her ability to cope in their work and social environment. Stage Two: “Use of Self”. During this stage the occupational therapist continues to act as a facilitator and through a process of introspection and inner strength development, the client reaches a level of autonomy, which allows participation in more occupational activities such as activities of daily living, work and leisure. Stage Three: “Creation of competency through occupational engagement”. During this stage the client may be referred to vocational rehabilitation and a functional capacity assessment or screening. Stage Four: “Capable individual” is the final stage of the model. During this stage, the client will view him or herself as a capable worker and will be able to participate in the worker role with maximum independence and the occupational therapist will gradually withdraw as a facilitator.

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Fig. 1

(Permission was granted from the author to utilize the diagram of the MOOSE).

This study aimed to determine whether MOOSE is an effective model to enhance the self-efficacy skills of individuals with schizophrenia and their ability to return to work. The objectives were:

To determine whether MOOSE improves an individual with schizophrenia’s ability to return work after participating in a vocational rehabilitation program

2.1 Population and sampling

Simple random sampling was used to select nine (n = 9) participants from the statistical records of the occupational therapy department of one psychiatric hospital in the Western Cape, South Africa. The intake of patients at the psychiatric hospital is about 9 new participants over a period of 1 month, the researchers opted to focus the pilot study on 9 participants. A sample formula was not used to calculate a minimum sample, however according to Connely (2008), it is acceptable to pilot a study on 10% of a total sample, should the total population be 90 (i.e. 90 participants usually seen over a period of 10 months). The sample of the participants were identified based on the following inclusion criteria: the participants were diagnosed with schizophrenia according to the DSM 5, were employed in the open labor market prior to their admission, lived in the Western Cape, Metropole and were over the age of 18 years. Individuals who showed evidence of significant and habitual substance abuse, and individuals with active symptoms related to a psychiatric condition were excluded from the study. Nine individuals volunteered to participate in the study and all of them concluded their participation in the study.

2.2 MOOSE intervention program

The participants in this research study engaged in the vocational rehabilitation process using the MOOSE. Before the participants participated in the program, they had to provide informed consent and were informed about their right to withdraw from the study at any stage of the study. In Stage One: “A strong personal belief in functional abilities”, the participants engaged in a reflection process using the GIBS reflective cycle (Gibbs, 1998). During this stage the participants focused on the challenges related to them when returning to work. The types of activities they engaged in were creative writing, using a reflection journal, and group as well as individual discussions. In Stage Two: “Use of self”, the participants participated in activities that would enhance their individual capabilities, such as improving their endurance, muscle strength and cognitive skills. They participated in activities that enhanced their memory such as Kim‘s game and table top activities to improve their perceptual skills as well. In Stage three: “Creation of competency through occupational engagement”, the participants participated in simulated work tasks in order to specifically improve their work skills. During this stage, the participant engaged in tasks related to a specific job to which they wanted to return (e.g., security guard, shop assistant etc.). These participants would engage in tasks such as role-play activities in order to improve their coping skills, problem-solving skills and communication skills. They were then placed in a specific job (work-test placement) for a temporary period. Stage four: “Capable individual” which is the final stage of the model, the participant would either return to their pre-morbid jobs in the open labor market or a new job for a period of at least four (4) months. The participants continued to get support in the workplace if required, however the intensity of support given would be gradually reduced in order to ensure that the participant works independently in their jobs (See Fig. 1).

2.3 Reliability and validity

The researchers utilized the WHOQOL-SRPB Scale and the Generalized Self-Efficacy Scale. The WHOQOL-SRPB as a research instrument was found to have good reliability (a high internal consistency) and validity that grants the suitability of the tool for a person with schizophrenia (WHO, 2012). The WHOQOL- SRPB tool has six domain scores: physical health (3 items), psychological health (5 items), level of independence (4 items), social relationships (3 items), environmental health domain (8 items) and spiritual/religion/personal beliefs (9 items). Domain scores are scaled in a positive direction (i.e., higher scores correspond to a better quality of life). The Generalized Self-Efficacy Scale (GSE), is a 10-item self-report instrument that aims to measure an individual’s perception of self-efficacy (Schwarzer & Jerusalem, 1995). The scale was developed to assess a general sense of perceived self-efficacy with the aim of predicting an individual’s ability to cope with daily challenges and adaptation after experiencing a stressful life event. In samples from 23 nations, Cronbach’s alphas ranged from 0.76 to 0.90, with the majority in the high 0.80 s. The participants responded appropriately, and the questionnaire proved to have good face and content validity.

2.4 Data collection and data analysis

Prior to participation in the vocational rehabilitation program (MOOSE), the participants completed the Self-Efficacy Scale questionnaire and the QOL-SRPB. A score was obtained and this served as the baseline assessment of the participant’s perceptions related to their QOL and Self-Efficacy. The same questionnaires were completed after the program ended. Medical information was obtained from the client‘s medical records from the psychiatric hospital in Cape Town. Descriptive data were summarized in tables for analysis. Values were accepted as significant at the 5 % level (p < 0.05). Data were first captured in excel and analyzed using SPSS along with the assistance of a statistician. The repeated measure ANOVA was used to analyze the data.

3.2 Quality of life and its association with self-efficacy

The results indicated that there was a positive relationship between the two variables i.e., Post QOL and Post Self-Efficacy score, r = 0.684, n = 9, p = 0.042* (see Graph 3).

Although there was no statistical significance obtained regarding the positive association between the intervention (MOOSE) and QOL. When analyzing the pre-intervention total QOL mean scores to the post-intervention total QOL scores, there is a clear indication that there was an improvement in Domain 2 and Domain 4 of the QOL domains (see Graph 4). The score according to the WHO QOL domain score ranging from 0 representing a low score and 20 representing a high score. The pre intervention mean score for Domain 2 ( x ¯ = 14) and Domain 4 ( x ¯ = 11) compared to the post intervention score for Domain 2 ( x ¯ = 15) and Domain 4 ( x ¯ = 13). This could indicate that the participants’ perceptions of their feelings, cognition, self-esteem, their perception on managing relationships and the provision of support, improved after participation in the MOOSE vocational rehabilitation program. For the purpose of this article a mean score of above 11 was regarded as above average with regard to QOL. The above information also indicates that the MOOSE may have a positive clinical impact on the functioning of the study participants.

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Graph. 1

Pre vs post self-efficacy results.

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Graph. 2

Pre vs post quality of life results.

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Graph. 3

Post QOL vs post self-efficacy results.

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Graph. 4

Pre vs post QOL domain results.

All participants in the current study were unemployed before participation in the study; however, after the completion of the 5-month intervention program, all participants (n = 9) returned to work in the open labor market or competitive employment. This result was regarded as good as the aim of the MOOSE vocational rehabilitation program is to enhance the individual with disability’s work skills to the extent that they can obtain employment in the open labor market or competitive employment. The participants in the current study also reported a reduction in negative symptoms related to schizophrenia, and specifically reported experiencing no positive symptoms related to schizophrenia.

4.1 Return to work after participation in the vocational rehabilitation program (MOOSE)

The results of the current study indicate that all unemployed participants (n = 9) were employed after they had completed rehabilitation in MOOSE as a vocational rehabilitation model. The intervention consisted of, on average, 8 sessions per stage of the MOOSE model and that the intervention lasted for a period of 3 months. It is important to note that MOOSE utilized concepts that link to supportive employment and that supportive employment requires ongoing support to clients or participants. This ongoing support often in real life work settings, is time consuming, is expensive and may take many months before the individual with disability can work independently (Substance Abuse and Mental Health Services, 2009). In relation to other literature, MOOSE has been shown to be an effective model in returning to work other populations of individuals with disability, namely those with traumatic brain injury (TBI). A study conducted by Soeker and Pape (2019) indicated that the MOOSE facilitated a 100% RTW rate for individuals diagnosed with a mild and moderate TBI. The model also proved to improve the cognitive skills of individuals with TBI.

4.2 Quality of life and self-efficacy (QOL vs Self-Efficacy)

The results of the study indicate that the participants’ self-efficacy improved after participation in the MOOSE vocational rehabilitation model. The results were statistically significant and indicated that as the individuals with schizophrenia’s confidence improved so did their self-efficacy. It could be argued that self-efficacy has a strong association with coping skills (Schwarzer & Jerusalem, 1995). As MOOSE particularly focuses on setting goals, introspection, motivation and coping by participating in work skills, it is expected that after stage four of the model an individual’s self-efficacy beliefs would improve. This therefore assists the individual to plan and confidently participate in work-related tasks.

The results of the current study indicated a statistically significant association between QOL and self-efficacy beliefs post intervention (i.e., after they participated in the MOOSE rehabilitation program). The above finding is justified in research conducted by Kvarme et al. (2009) where they argue that as an individual’s QOL improves so would their confidence in their ability and skills. Another study conducted by Kiaei et al. (2016) on women with breast cancer undergoing chemotherapy further reinforces a strong association between QOL and self- efficacy. In the latter study the authors argue that the research participants saw an improvement in their QOL as their self-efficacy beliefs improved, particularly as they perceived chemotherapy as an intervention to cure cancer. In a qualitative study conducted by Soeker and Pape (2019) that focused on the experiences of individuals with TBI about MOOSE on their ability to RTW, the study participants indicated that the MOOSE enhanced their QOL by enabling them to engage in work-related occupations that enabled them to sustain their families.

The results of the study indicated that although overall statistical significance after the completion of the vocational rehabilitation was not obtained, there was an increase in QOL in domain two and domain four. Possible reasons for not obtaining statistical significance with regard to QOL could relate to the fact that many of the participants may have felt that although they were capable of returning to work that they may still have experienced challenges in reintegrating back to their home environments. It could be argued that the participants felt that they may still struggle with their physical ability and independence while at home or in the workplace (Domain one and Domain three). The fact that individuals with schizophrenia still experience stigma in the workplace could explain the negative interpretation that the participants had about their environment (Domain five). Domain two relates to the individual’s perception of positive feelings, cognition, self-esteem body function and negative feelings. The latter finding may indicate that after completion of the vocational rehabilitation program (MOOSE), the participants felt more confident in participating in tasks that require the use of cognition. Furthermore, successful engagement in work-related tasks and life skills sessions may enhance positive feelings in the individual as well as aid them in managing negative feelings that may affect their overall QOL. Research has proven that those interventions that focus on life skills and the provision of ongoing coaching and support in the workplace has a positive effect on their overall well-being, hence their QOL (Tomotake, 2011; Bell et al., 2014; Dziwota et al., 2018).

Domain four relates to the individual’s relationships, support and view of sex in their lives. Similarly, the vocational rehabilitation program (MOOSE), has a strong focus on enhancing the individual’s communication skills and its link with building good relationships in the workplace and home environment. It could therefore be argued that the research participants internalized the concepts taught in the life skill sessions and work test placement phases, namely Stages 2 to 4 of the vocational rehabilitation model (MOOSE). The research participants therefore score higher in both domain two and domain four. Similar results were found in research conducted by Lowey et al. (2021) as well as Bell et al. (2014) that explored the benefits of cognitive remediation and supported employment for individuals with schizophrenia. They indicated that cognitive remediation and supportive employment greatly enhanced the quality of life of individuals with schizophrenia by facilitating community integration.

4.3 Limitations of the study

A major limitation of the current study is the fact that the study was viewed as a pilot study, hence the study utilized a small sample size. Therefore, the results of the study cannot be generalized to the larger population of individuals with schizophrenia. It is also suggested that future research should utilize a randomized control trial (RCT) with a larger sample size in order to obtain generalizable results. Another limitation was the fact that mainly male participants participated in the study.