The usefulness of the Model of Occupational Self Efficacy (MOOSE) in returning stroke survivors to work in a rural community in Cape Town,South Africa

Abstract

BACKGROUND:

Individuals diagnosed with stroke have a poor return to work rate, particularly in rural communities.

OBJECTIVE:

The aim of the study is to describe the experiences and perceptions of individuals diagnosed with stroke about the usefulness of the Model of Occupational Self Efficacy (MOOSE) in assisting them in returning to their worker role.

METHODS:

The study utilized an explorative, descriptive, qualitative research design, furthermore the data was analyzed using thematic analysis, resulting in three themes. Seven stroke survivors and one key informant participated in the study.

RESULTS:

Theme one: Obstacles that affect the return to work of stroke survivors in a rural community. Theme two: Re-establishing a strong belief in functional ability through participation in occupation. Finally, theme three: The MOOSE enables transition to the worker role in a rural context.

CONCLUSION:

The findings indicate that the MOOSE is a useful model in facilitating the return to work of individuals diagnosed with a stroke. The participants struggled to return to work not only due to their loss of abilities but also their lack of knowledge with regard to how to return to work and their diagnosis of a stroke.

Keywords

Return to work adaptation coping skills and strategies vocational rehabilitation

1 Introduction

A stroke, also known as a cerebrovascular accident (CVA), occurs when the blood flow to the brain is interrupted. This could either happen when a blood vessel to the brain ruptures, causing bleeding, or becomes blocked by a blood clot. The affected brain cells then start to die due to a lack of oxygen and other nutrients. The severity of a stroke varies from a passing weakness or tingling in a limb to a profound paralysis, coma or death (Steyn, 2006). According to the World Health Organization (2016), stroke is the leading cause of disability in the world. In South Africa, stroke accounts for between 8–10 percent of all reported deaths and it is among individuals in their prime working ages. In addition to the mortality rates, stroke has an effect on disability (WHO, 2016). In an effort to combat the challenges which persons with disabilities face with regards to returning to work, the South African Employment Equity Act (EEA) of 1998, has created policies and several laws to address disability concerns in vocational settings. The Employment Equity Act is based on the premise of equal opportunities for all persons with disability in the employment market. The Department of Labour provides a monitory incentive in the form of tax rebates to appeal to medium and large companies in order to employ persons with disabilities (Employment Equity Act of 1998, online, 2015). In spite of these incentives there is only a small fraction of people with disabilities who are currently working after they have been injured with the minimal possibility of returning to work. According to Ball et al. (2006), the low employment rate after injury or a condition such as a stroke has fueled poverty rates in rural areas. According to Statistics South Africa (2011), in the Northern Cape there are 52,789 persons utilizing disability grants. As noted by the United Nations (2015), state parties should accurately identify the correct persons with disabilities who could return to work. The United Nations report further stipulates that state parties should promote the recognition of the right of PWD to return to work, including for those who acquire disability during the course of employment. In the view of exploring the experiences of individuals who were diagnosed with a stroke about returning to work after participating in rehabilitation model that used the Model of Occupational Self Efficacy (MOOSE), the current study seeks to explore the challenges and enabling factors that individuals diagnosed with a stroke experience when returning to work particularly in the rural setting of Calvinia in the Northern Cape, South Africa.

1.1 Literature review

1.1.1 Epidemiology of stroke in South Africa

In South Africa, stroke is responsible for an average of 25,000 deaths annually caused by various medical and contextual factors. There are 95,000 persons who suffered from stroke living with various forms of disability (Maredza et al., 2015). According to Maredza et al. (2015), there are few published studies that focus on the epidemiology of stroke in the rural parts of the country. The above authors state that there are many out of date evidence from these studies which indicates that as far back as the 1990s stroke was a major contributing factor to the cause of death in South Africa (Maredza et al., 2015). A significant portion of the 95,000 citizens living with disability after stroke in rural areas, find it problematic to attend hospital appointments and rehabilitation services due to low socio-economic circumstances and contexts (Maredza et al., 2015).

1.1.2 Work as an occupation and influence on wellbeing

According to Soeker (2017), stroke impacts day to day activities and disrupts the client’s future plans. Once the stroke survivors return home, it is then that the true impact of the stroke are felt as their ability to engage in everyday tasks and future goals are affected. Part of the real-life challenges faced by stroke survivors are that they struggle to deal with the loss of their ability to plan for their future. The loss of the individual’s ability to plan for the future often leave the stroke survivor feeling distressed, as the plan to travel, to be more active and spend time with children and grandchildren and the ability to return to work are now affected by the stroke. Waddell and Burton (2006) considered the importance of employment and re-employment for the sick and persons with disability such as stroke. They indicated that re-employment leads to an improved self-esteem, improved general and mental health, and reduced psychological distress (Waddell & Burton, 2006). The benefits of employment according to Waddell & Burton (2006) are that it is therapeutic, it promotes recovery and rehabilitation and leads to better health outcomes. By returning to work or re-entering work it promotes full participation in society and independence, reduces poverty and improves quality of life and well-being (Waddell & Burton, 2006).

1.1.3 Vocational rehabilitation for individuals diagnosed with stroke

Rehabilitation measures body functions and structures, activities and participation, environmental factors, and personal factors (Kennedy, 2012). According to Kennedy (2012), most emphasis on rehabilitation is placed on physical rehabilitation, cognitive rehabilitation and the client regaining their functionality, with little emphasis placed on reintegration into the workplace (Koehler et al., 2011). Once the client has reached their physical peak of functionality they are discharged into the community. The problem that arises, is the lack of re-employment or reintegration, mostly in rural communities. Vocational rehabilitation is a strategy, which aims to enable person(s) with disability to secure or retain appropriate employment. This aids the stroke survivor to reintegrate into society. Vocational rehabilitation services include vocational guidance, vocational training, placement and employment (Coetzee et al., 2011). According to Buys (2015) vocational guidance refers to the planning phase in terms of returning the client to work, vocational training is seen as improving the client’s ability to work, by improving the clients formal and informal work skills, such as work hardening, management of stress and work simplification methods (Buys, 2015).

Supported employment is characterized by Wehman (2012), as paid work in integrated work settings with ongoing support for individuals with disabilities in the open labor market. Paid work for individuals means the same payment for the same work as for workers without disabilities.

1.1.4 Model of occupational self efficacy

The Model of Occupational Self Efficacy (MOOSE) was established by Soeker (2019) (see Fig. 1). The model is a dynamic framework, to help brain-injured clients to return to work. The model gives the therapist guidelines to operationalize the model. There are four stages that assist the brain-injured individual to resume their worker role: Stage one: A strong belief in functional ability, this stage focuses on the process of introspection and self-reflection of the individual’s life circumstances (Soeker & Pape, 2019). Stage two: Use of self, in this stage the individual progresses toward a realization that, the individual can take control of their life circumstances and can initiate tasks autonomously (Soeker & Pape, 2019). Stage three: Creation of competency through occupational engagement. In this stage the client, independently or with the therapist’s help increases their knowledge base (Soeker & Pape, 2019). Stage four: Capable individual: In the fourth stage it is hoped that a capable individual will emerge. Previously the MOOSE program was implemented with TBI women in the Western Cape and many of these participants could return to work (Soeker & Darries, 2019). Furthermore, in a pre-post intervention study conducted with individuals with mild to moderate brain injury, the participants that participated in the MOOSE had a significant improvement with cognition and 80% of them returned to work (Soeker, 2017). In a rural setting it is more difficult to have an individual with a disability return to work, because of the stigma attached to disability and the misconception that a person with disability will slow down production. The current study therefore sought to describe the experiences of stroke survivors from a rural community regarding the usefulness of MOOSE in enhancing their work skills.

Fig. 1

Model of occupational self efficacy.

1.2 Objectives

The aim of the study is to describe the experiences and perceptions of individuals diagnosed with stroke about the usefulness of the MOOSE in assisting them in returning to their worker role, particularly in a rural setting. The objectives were:

To describe the experiences and perceptions of individuals with stroke regarding the usefulness of the MOOSE in facilitating the transitioning to their work role.

To describe the experiences and perceptions of individuals with stroke about how their worker identity has changed after participating in the MOOSE.

2 Method

2.1 Methodological approach

Qualitative researchers study topics in natural settings, interpreting phenomena in terms of the significance people bring to them (Denzin, 2005). The current study was positioned in the socio-constructive paradigm specifically using an exploratory descriptive research design. Descriptive research may be used to develop theories, make judgements and also to justify current practice (Burns & Grove, 2003). The descriptive research design was chosen within this study as it allowed the researcher to make judgements, by utilizing the perspectives of the research participants, with regards to the usefulness of MOOSE in enabling them to return to work in a rural community.

2.2 Description of the MOOSE program as applied to individuals living with stroke

The participants participated in a rehabilitation program using MOOSE. It is important to note that all seven participants in the current study completed the eight week intervention program, each participant participated in two, one hour sessions per week (See Appendix 1 for a description of the program).

2.3 Population and sampling

Seven participants were purposively sampled from the statistical records of the occupational therapy department of Abraham Esau Hospital, in the district of Calvinia, Western Cape. Purposive sampling was used because the researcher wanted to explore the specific experiences of individuals living with a stroke about successfully transitioning to open labor market employment after rehabilitation. Seven individuals diagnosed with a CVA were purposively selected to ensure the researcher explored various perceptions and experiences of how MOOSE influenced the participants’ ability to return to work. Saturation was determined by the number of interview sessions per participant in the current study. In the context of the current study the researcher obtained saturation of information after the third interview with each participant. Saturation was achieved when the same information or recurring themes were presented by the participants. The inclusion and exclusion criteria are set out in Appendix 2. Although the researchers made every effort to include participants from various racial backgrounds, it was mainly participants classified as colored who consented to participate in the study. In terms of age, the majority i.e., 60% of the participants were in the age bracket 30–45 years of age. Three of the participants were employed in administrative related jobs and four were employed in manual or semi-manual related occupations. Six of the participants had a high school level of education and one of the participants had a tertiary school level of education. At the time of the study, all of the participants were employed in the open labor market (competitive employment) and one was employed in his own business. All seven participants were classified on level 10 according to the Ranchos Amigos scale of cognitive functioning (Mandaville et al., 2014). This level indicates that the stroke survivor is independent with functional activities but may require compensatory strategies. The demographics of the participants indicated that they were deemed as representative of typical stroke survivors living in the area of Calvinia (Western Cape, South Africa). With regard to the socio-economic context of the participants, all of the participants came from a below average to average socio-economic background i.e., average to above average middle class).

2.4 Data collection

The researchers conducted three semi-structured interviews with each of the seven participants, including the one key informant (See Table 1). The researchers were qualified occupational therapists who completed training in the area of conducting qualitative research, which includes methods of preparing and conducting interviews with research participants. The principal investigator has a PhD degree and has completed several qualitative research projects. The names of the participants were obtained from the statistical records of NGOs and protective/sheltered employment workshops. The researchers also made use of social media in order to invite participants to participate in the study. Example, an advert related to the recruitment of participants were placed on a hospital notice board, and then the participants were given the opportunity to contact the researchers themselves. When the participants contacted the researchers, the requirements of the study were described in more detail. The study participants received no financial compensation for participating in the study. The researchers used a semi-structured interview guide to ask the participants questions relevant to the study (See Appendix 3). The researcher piloted the semi-structured interview guide with two participants, the questions and probes of the interview guide were easily understandable and the researcher opted to utilize the current guide in the main study.

Table 1
Describing the demographics of participants

Name Gender Race Age Diagnosis Education Work history

P1 (GW) Male Colored 30 Stroke Theological studies Pastor

P2 (LW) Male Colored 55 Stroke High school Taxi driver

P3 (JF) Male Colored 59 Stroke High school Car mechanic

P4 (JL) Male White 46 Stroke High school Administrator

P5 (MN) Male White 43 Stroke High school Assistant in an abattoir

P6 (BT) Male Colored 38 Stroke High school Assistant in a restaurant

P7 (TT) Male White 30 Stroke High school Admin clerk

Key informants

Profession Years of experience Organization

K1 OT 4 NGO

Name	Gender	Race	Age	Diagnosis	Education	Work history
P1 (GW)	Male	Colored	30	Stroke	Theological studies	Pastor
P2 (LW)	Male	Colored	55	Stroke	High school	Taxi driver
P3 (JF)	Male	Colored	59	Stroke	High school	Car mechanic
P4 (JL)	Male	White	46	Stroke	High school	Administrator
P5 (MN)	Male	White	43	Stroke	High school	Assistant in an abattoir
P6 (BT)	Male	Colored	38	Stroke	High school	Assistant in a restaurant
P7 (TT)	Male	White	30	Stroke	High school	Admin clerk
Key informants
Profession	Years of experience	Organization
K1	OT	4	NGO

2.5 Data analysis and trustworthiness

The researchers used the data analysis method described by Tesch (1990), that consists of eight core steps in order for it to be analyzed effectively. First, the researchers carefully read through the transcripts and wrote their thoughts in the margins. Second, there were stand-out points referred to as codes, which were documented. When that task was completed for all documents, the researchers made a list of topics, also known as sub-categories. Step three, these topics are grouped into columns identified by the three themes. For steps five through eight, the researchers decided on the most descriptive wording to become the categories for the names of the topics. The researchers then grouped certain categories in order to avoid any repetition of categories and sub-categories. In the last step of data analysis, the researchers relooked at the data and double checked whether any new categories and themes emerged. The researchers independently read and analyzed each transcript according to the methods described by Tesch (1990), they then met as a group in order to obtain consensus of the themes, categories and sub-categories. The researchers managed discrepancies by discussing each transcript in depth and then deciding collectively on the best descriptions of the themes, categories and sub-categories. Strategies such as credibility, transferability, dependability and confirmability were used in order to ensure the trustworthiness of the data (Krefting, 1991). Credibility was ensured by the dense description of the lived experience of the research participants. Credibility was also enhanced by triangulation. Triangulation was ensured by the use of more than one source of collecting data: for example, within this study, participants living with a stroke and the key informants. Transferability was ensured by the detailed description of the research methods, contexts, and the lived experience of the participants. Dependability was ensured by means of dense descriptions, peer examination, and triangulation. The study was documented in such a manner that the readers were able to follow an audit trail. Confirmability was ensured by the process of reflexivity whereby the researcher’s own biases or assumptions were made apparent by means of a reflexive journal.

3 Results

3.1 Theme one: Obstacles that affect the return to work of stroke survivors in a rural community (barriers)

Theme one represents the participants experiences of the effects of stroke on their former selves. The theme depicts the shift in the participant’s capabilities as a result of their new realities due to psychosocial, emotional, physical and cognitive changes. Theme one highlights the lack of knowledge among participants regarding returning to work and the services offered in a rural community. The barriers were explored through the following categories.

3.1.1 Category: Loss of functional abilities affected the return to work of stroke survivors

This category focuses on the participant’s loss of their functional capabilities. It describes how the stroke affects their capacity to perform a wide range of occupational roles and tasks. In the first stage of MOOSE, which is the introspection phase, there is a lack of understanding as to how the stroke affects their mental, physical and emotional functioning. One participant reflected on the first stage of the process, and stated:

“That was very bad, because I wanted to go back to work, and I wanted to get better, but no one wanted to help me. No one could tell me who I needed to speak to.” (P6; SL)

The above statement indicates that as a result of insufficient information regarding diagnosis and rehabilitation, participants feel helpless. The participants find themselves in a phase of occupational dysfunction. The participants find it difficult to make adaptations if they did not receive or have the resources and insight into their disability and how it affects their function.

3.1.2 Category: The perception of CVA in a rural community and the stigma related to CVA

In this category the participants expressed their experience and perception of stigmatization about CVA in a rural community. One participant expressed his anxiety about returning to work after the CVA:

“Uhm, no. . .I just know some of the guys were worried that people might feel unsafe with me. But I can do the job, I mostly went to the doctor, I did therapy, I know how to feel when I am tired or stressed.” (P2; PK)

Participants were routinely subjected to comments on how easy it would be to stay at home and receive a salary. One participant felt especially forced to do so as his wife had lost faith in his work skills and strongly encouraged him to apply for the grant as she felt he would never be capable of performing his previous vocational duties. He said:

“She just didn’t understand, she said that I was never going to go back to work.” (P3; JF)

Another participant stated that his brother had motivated him to apply for a disability grant instead of attending his therapy sessions. He said:

“They (family) also on my case about getting this grant a lot of them are on it. . ., they say I must go to SASSA, I say no, then all I will do is sit at home and drink, that’s. . .what we do in this town, get a grant, stay at home and drink.”(P2; PK)

Participants felt alone in the workplace when colleagues doubted their work abilities and would describe the experience as lonely due to the lack of awareness in the overall community with regards to CVA.

“The people at work did not understand what a stroke was. A lot of people told me that I should not work because I am slow. The people in town no longer want to hire me to clean their homes, because they were scared that I can no longer do the work.” (P6; BT)

3.2 Theme Two: Re-establishing a strong belief in functional ability through occupation (MOOSE enhances one’s work identity)

Theme two represents the transition of the participants in the MOOSE program. It presents the regress and progress of the participants moving toward self-reliance/self-efficacy within the rehabilitation and ultimately improving the stroke survivors work identity. The MOOSE program was utilized throughout the rehabilitation process. The clinical goal of the model is that the participants who participate in it will integrate the work-like behaviors, such as being punctual, adhering to the required dress code, employing good work ethic and achieving productivity. This theme will be further described in the following categories.

3.2.1 Category: Rehabilitation was used as a means to improve competency through client centered activities

In this category the participants expressed that by participating in the rehabilitation program they were able to improve their workability skills. The program facilitated their recovery through activities which were based on each of their specific jobs. By applying the principles of client-centered practice, the participants were to enhance their skills and knowledge to resume a worker role. Furthermore, the inclusion of the participants in the decision making with regard to the process of rehabilitation, allowed them to become part of a working community where they were able to make use of their work skills and apply what they have done in the program. One participant stated:

“I had to tell you what I like, so that you can make me feel included. I was very nervous when I came there, (laughs), uhm we did also or wait you did ask me what I do for a living like my work and so. You (occupational therapist) helped, because I got so tired after the stroke, I did feel like I had no energy, so you gave me tips, like to exercise or go for a walk. That helped, and it got better. I don’t feel like that anymore.” (P1; GW)

As a result of including the participants in the process of planning work tasks their attitudes shifted toward a more positive outlook. They had started to accentuate positivity by sitting down with the therapist to plan their work goals. One participant stated:

“Ek het soos a mens gevoel (Translated: I felt like a person) I mean when do people ask you what you think is important, not the doctors and not my baas (translated: boss). Nooit (Translated: Never).” (P2; PK)

3.2.2 Category: Holistic rehabilitation facilitates an improvement in motivation and belief in abilities

Due to the CVA affecting various functionalities of the participants, physically, psychologically and spiritually, they were treated holistically. For the participants to have an effective return to work, their home and work contexts needed to be taken into consideration. Through the use of the allied health team, the participants were not only attending occupational therapy to improve their functional capability and self-efficacy, but they attended physiotherapy, speech therapy and psychology as well. This sub-category is indicative of how these services affected their motivation and belief in abilities which enabled them to engage in their vocational duties effectively.

“The doctor told me I must go to occupational therapy and I said ok. I didn’t know what it was really, I also saw the physio en die (translated: and the) psychologist at the hospital.” (P4; JL)

“Once they (Participants) could see they were improving in counseling (psychology) sessions and their physiotherapy sessions they were more willing to face the RTW process. They engaged more in the program with eagerness”. (K1)

3.3 Theme three: The MOOSE enables transition to the worker role in a rural context (Facilitators)

Throughout the MOOSE program the participants were encouraged to reflect on their experiences during and after sessions. By doing this the participants were able to identify their growth in the program. Through self-reflection the participants were able to identify which areas they felt they needed to focus on more, such as being able to recognize when they became overwhelmed or stressed.

3.3.1 Category: Enhancing skills by participating in MOOSE

Through participating in the MOOSE program, the participants were able to acquire new skills based on their personal contexts. The participants engaged in not only simulated work tasks but were educated on how to handle stress factors in their lives which might affect their home and work contexts. One participant stated:

“The OT did teach us how to bend and pick up heavy goed (translated; goods), and how to make the work space better. You (occupational therapist) helped, because I got so tired after the stroke, I did feel like I had no energy, so you gave me tips, like to exercise or go for a walk. That helped, and it got better. I don’t feel like that anymore.” (P3; JF)

Through the engagement in physical activity the participants were able to adapt their environments to make it more ergonomically safe, allowing it to cause less strain on their bodies.

Another participant echoed this:

“I learnt how to work better with my time. Now when I have to preach at church, I am able to plan better and plan what I want to say in the service like we did in the sessions.” (P3; JF)

The skills taught in the program were aimed at ensuring that the participants were able to maximize their occupational self-efficacy by educating them on time management as well as budgeting. These are skills participants could make use of at work and in their home contexts.

3.3.2 Category: Strategies to enhance MOOSE

Occupational therapists play an integral role in enabling ongoing participation by optimizing function and management of symptoms. To ensure that this model is effectively used in practice, specifically in the rural context recommendations were suggested by the participants. The participants felt that the model was flexible and easily applied in the sessions and that it was context specific. One participant stated:

“They can’t expect that everyone’s boss will be happy that they take off from work for so long. Now we take off work then who is going to pay us. And the hospital isn’t going to give me the same pay as my boss does.” (P2; PK)

4 Discussion

This section of the discussion, namely 7.1 and 7.2, will specifically focus on describing the findings linked to objective one of the current study.

4.1 The barriers that affects the implementation MOOSE in practice

According to the World Health Organization (2016), barriers are defined as the factors that are present in an individual’s environment that may limit their functioning. Theme one describes the barriers that affected the stroke survivors ability to participate in the MOOSE program. Various barriers such as stigma, marginalization, lack of knowledge and attitudes within their home contexts and work environments hindered the stroke survivor’s ability to complete rehabilitation programs. The latter ultimately affected their ability to return to work.

4.1.1 Barriers to work participation for stroke survivors in a rural community

The participants experienced a negative change in their functional performances after the stroke, some worse than others. Once the stroke occurred they came to realize that tasks and activities which they could once perform, before the stroke, they could no longer perform as efficiently because they had lost former knowledge and abilities. According to Burkman (2010), one of the biggest fears, for both patients and families, is the fear of the unknown. As well as “what to expect?” and “what happens next?” Burkman (2010) further explains that for the majority of stroke patients, the road to recovery is a long one that includes many hours of therapy aimed at restoring both physical strength, language capacity and often not considered medically, a loss of self-esteem (Burkman, 2010). The loss of self-esteem could therefore hinder the stroke survivor’s ability to complete rehabilitation programs such as MOOSE that enables them to return to work.

4.1.2 The perception of a CVA in a rural community and the stigma related to CVA

The participants experienced stigma in their communities and were often faced with various challenges as a result of the stroke. Many of the participants were confronted with the thought of applying for a disability grant as many of their friends or family members were supportive of them doing so. The participants expressed that they found that people in the community and family members did not understand the diagnosis and thought that the participants would never be able to return to work. This reiterates the lack of knowledge regarding stroke in rural communities. According to Urimubenshi and Rhoda (2011), a major challenge which stroke participants face is the lack of support from friends and family especially among unemployed participants. The stigma experienced by stroke survivors therefore affected their ability to complete rehabilitation programs such as MOOSE in order to enhance their work skills.

4.1.3 Stigmatization in the workplace due to a misconception of stroke

Based on the findings and the responses from the participants, the participants experienced social barriers within their work environments because of their stroke. As a result of the misconception regarding stroke within the participants’ work and home environments they experienced social isolation and faced attitudinal barriers. According to Maclaughlin, et al. (2004), stigma in the workplace toward persons with stroke has a negative impact on work satisfaction and work reintegration. Acceptance in the workforce and home context is critical for the socialization process, which can ultimately impact work satisfaction and commitment (Mclaughlin et al., 2004). The participants experienced that work colleagues mistrusted them and could not understand how they could return to their previous work positions, such as management positions. The stigma experienced by stroke survivors therefore affected their ability to complete rehabilitation programs such as MOOSE in order to enhance their work skills.

4.2 The facilitators that affects the implementation MOOSE in practice

The World Health Organization (2016), defined facilitators as environmental factors in an individual’s environment, which can positively affect function if present. Theme three describes the facilitators of the current study that enabled stroke survivors to complete rehabilitation programs include, a belief in their functional ability, the use of a client centered approach in rehabilitation.

4.2.1 Re-establishing a strong belief in functional ability through occupation

According to Wolf et al. (2014), occupational therapy practitioners can assist clients with stroke improve their occupational performance and social participation through various intervention strategies. The strategies that the authors mention is not limited to remediation or development of skills, compensatory strategies, activity modification and environmental accommodations. The aim of the previous mentioned approaches is aiding the clients to engage in occupations, by making use of occupation-based interventions (Wolf et al., 2014). The Model of Occupational Self Efficacy (MOOSE) facilitated the participants’ independence within their homes and workplace by engagement in occupation-based intervention. In the vocational rehabilitation program, there was an expectation for the participants to integrate work-like behaviors when they attended the sessions, such as dressing appropriately, being punctual, good work ethic and achieving productivity in the work environment (Soeker & Pape, 2019). According to Soeker (2019), the MOOSE could be seen as a facilitatory strategy as it works directly on the individuals’ motivation to engage in activities that improve their skills so that they are capable of being successful in the return to work process and in doing so maintaining positive work roles.

4.2.2 Rehabilitation was used as a means to improve competency through client-centered activities

Person-centeredness also known as client-centeredness, is a philosophy for organizing and delivering healthcare based on patients’ needs, preferences and experiences (Jesus et al., 2016). A client-centered therapy is based on what the client needs, and it is the therapists’ role to promote self-understanding and independence in their rehabilitation (WHO, 2016). In Stage 1 of the MOOSE, the participants attended a session where they could express their concern regarding the rehabilitation program in which they would participate. The session focused on the expectations of the participants about the program and their views of returning to work. The aim of the MOOSE was to encourage greater self-efficacy in the participants; however, as a result of the participants experiencing various emotions such as despondency and frustration, the therapist had to create a supportive environment that met the abilities of the participants. According to Jesus et al. (2016), often client-centeredness is misunderstood, it is not about giving the clients what they want or just providing information. Client-centeredness is about interacting with the client with dignity, compassion and respect. Therefore, it is important to make use of work-related activities that are meaningful to the individual with stroke. It is about the occupational therapist seeing the participant as an individual and expert in themselves as well as placing the client and their family in the center of decisions (Jesus et al., 2016).

This section of the discussion, namely 7.3 will specifically focus on describing the findings linked to objective two of the current study.

4.3 The development of work identity

Theme two describes how the work identity of the stroke survivors were enhanced for the purpose of returning to work after their participation in the MOOSE program. Pallesen (2014) defined self-identity as the awareness of the qualities that distinguishes the self from others. The authors further mention that the qualities that constitutes self-identity are unique and persistent and are the basis of the experience of inner sadness and continuity. Pallesen (2014) indicated that one’s self-identity is linked and affected by a person’s thoughts and feelings about themselves. It could be argued that if an individual has a positive self-identity, then he will have a positive work identity. The participants expressed that they experienced melancholy when they realized they had a stroke. The participants could no longer skillfully perform the tasks that they could before they had the stroke. In the current study the participants showed poor judgment and reasoning when it came to setting goals for future employment. The lack of skills impacted on their self-esteem, efficacy and how they chose activities in which they wanted to engage in and which they had previously engaged in. Pallesen (2015) identified that for a stroke survivor, there will be a mismatch between performance and existing self-knowledge because they once could perform tasks skillfully and suddenly no longer could due to the stroke. This could in turn result in a disorganization of the stroke survivor’s work identity. Christiansen (2004) stated that there is a resilient connection between occupation and the individual’s identity. The author states that participation in occupation contributes to the construction of one’s identity and that one builds identity through participation in occupation.

According to Soeker (2019), the creation of competency refers to the participant’s ability to develop their self confidence in their functional skills by engaging in an occupational task and adapting to their worker role. The participants engaged in simulated work tasks during the rehabilitation program. Klinger (2005) further states that the process of adapting to ones changing of bodily and mental functioning, ultimately results in a redefinition of self-identity.

4.4 Limitations of the study

One major limitation is the fact that only male participants participated in this study. Another limitation is due to the shortage of employment opportunities, it was difficult to recruit participants for the study as many of them could not find the time to be interviewed due to work commitments. Another general limitation of qualitative research is that the findings provide an exploration of a particular phenomenon i.e., the perceptions of individuals diagnosed with a stroke who returned to work after participating the MOOSE, and this does not render itself to generalization due to the smaller sample sizes that are used in qualitative research.

5 Conclusion

The findings of the study revealed that the participants experienced both barriers and facilitators that influenced their ability to complete the MOOSE rehabilitation program. The barriers that were identified in this study, titled as Obstacles that affects the return to work of individuals with CVA in a rural community, acknowledge the challenges that affected the individuals with CVA’s return to work process and the adaptation into their work environments. Despite the several barriers that could impede the return of the participants to their worker role, facilitators were identified in the study. The facilitators that emerged were discussed in theme two Re-establishing a strong belief in functional ability through occupation. The Model of Occupational Self Efficacy (MOOSE) facilitated an environment where participants were able to feel supported and enabled. Due to the model encompassing principles that address the participants holistically, it enhanced the participants’ return to work probabilities. Participants felt that they would rather apply for the social grant as they knew that finding a job in the community would be difficult without a CVA.

The use of the MOOSE as a model to support work identity formation and workplace reintegration should be implemented as part of traditional vocational rehabilitation programs.

Footnotes

Acknowledgments

The authors would like to acknowledge all research participants for their involvement in the research project.

Conflict of interest

The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethics statement

The study was approved by the Institutional Review Boards of the University of the Western Cape (#HS/16/6/16).

Funding

The project was funded by the National Research Foundation (NRF) of South Africa (funding number 17/2/4).

Informed consent

The research participants were provided with information relating to the study. Their written and verbal consent was obtained prior to their participation in the study.

The Appendices are available in the electronic version of this article: .

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