Natural supports in competitive integrated employment: A scoping review

1.2 Natural supports

One potential intervention that could be utilized in the workplace is “natural supports.” Nisbet and Hagner (1988) initially defined the term as the authentic help that coworkers provided each other in the workplace with or without guidance. They suggested natural supports were a sustainable option for workplace assistance once the employee with disabilities gained the Cartervocational and social skills needed for the job. Butterworth and colleagues (1996) described natural supports as having three components (1) the source of the support (e.g., coworkers), (2) the implementation process of the support, and (3) the relationship of support within the organizational culture. Therefore, a company that embeds these components into their workplace understands the value of natural supports for coworkers with and without disabilities in an authentic work setting.

While Nisbet and Hagner (1988) spotlighted utilizing natural supports in the workplace, there has been limited research on their effectiveness (Test & Wood, 1996;Wehman & Bricout, 1999). Few companies provide coworker or company training to improve their capacity to work with individuals with disabilities (Hagner et al., 1995). In addition, employees with disabilities may not know that natural supports are offered as an accommodation if the company does not provide that information (Wehman & Bricout, 1999). Barriers such as employer unwillingness and lack of qualified coworkers have prevented companies from embedding a natural support framework into employment (West et al., 1997). However, natural supports have been suggested as a sustainable solution to ongoing and consistent training of employees with disabilities due to the long-term cost of job coaches (Nisbet & Hagner, 1988).

Natural supports are generally used when describing adult employees with disabilities and their coworkers. However, this intervention has been used across age groups in PK-12 school settings and is known as peer-mediated intervention (PMI). Research shows that PMI is effective in elementary (e.g., Wu et al., 2020), middle (e.g., Jimenez et al., 2012), and high schools (e.g., Asmus et al., 2016) in improving social interactions and skills in academic and non-academic settings. Thus, implementing a structured natural support program in the workplace could potentially impact the interactions and employment skills of employees with and without disabilities. However, due to the conflicting information on the effectiveness of natural supports, a broad review of the research is warranted to determine whether natural supports are impactful in CIE and can provide adequate support for employees with disabilities.

1.3 Purpose

This scoping review aims to aggregate research conducted on implementing natural supports in CIE settings to build vocational or social skills for individuals with IDD. While the impact of PMI on enhancing academic and social skills in academic and non-academic school settings has been well-researched, considerably less research has addressed the effects of natural supports in CIE settings. Therefore, the following research questions guided the review:

What demographic characteristics, skills, and methodological approaches are presented in the literature?

2.1 Search procedures

The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews statement was followed to conduct this scoping review (PRISMA-ScR, Tricco et al., 2018; see Fig. 1). An extensive literature search was conducted in March 2024 using seven educational and social sciences databases: Academic Search Complete, APA PsycArticles, APA PsycINFO, CINHAL, Education Full Text, ERIC, and SCOPUS with the following search terms used: disability (intellectual disabilit*, developmental disabilit*, mental* retard*, autism*, asperger*, multiple disabilit*), intervention (peer mediate*, peer train*, peer tutor*, peer network*, peer support*, natural support*, peer mentor*), and setting (employment*, support* employment*, experience*, internship*, vocational* support*, rehab*, work*, job*, career*, custom* employment*). The terms were combined using the Boolean search operator “and” to include disability, intervention, and settings.

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Fig. 1

PRISMA-ScR flow diagram of the included articles

For this review, vocational skills were defined as basic employment skills that could be used in an integrated work setting. For example, vocational skills include money management, time management, organization, and planning. Social skills were defined as social interaction skills typically used in the workplace. Examples of social skills include interpersonal skills, basic communication skills, and problem-solving. To be included in the review, articles required the following criteria: (a) the implementation of natural supports in an integrated employment setting between individuals with and without IDD; (b) be a research study (e.g., quantitative, qualitative, mixed methods); (c) include individuals with IDD in the participant pool; (d) addressed building vocational or social skills; and (e) published in English. Also, there were no date restrictions on included articles because we wanted to explore all published material. Exclusion criteria excluded studies (a) that did not assess natural supports, (b) did not include individuals with IDD, (c) were not a data-based and published research article, (d) were not in English, and (e) were conducted in a segregated setting (e.g., sheltered workshop).

2.3 Study selection

The search was not limited by publication date and yielded 1,271 articles. First, a graduate student (4^th author) was trained to screen titles and abstracts to identify potential articles following inclusion criteria. Next, a reliability check to decrease researcher bias was conducted across 21.5% (n = 273) of the possible articles by the first author and averaged 85.8% reliability. Discrepancies were resolved through discussion between the first and fourth authors. Sixty-nine articles were subsequently identified, and full-text copies were retrieved. Then, three authors (LA, EF, EB) conducted a more in-depth screening and a reliability check to confirm the study methods, study context, and study participants of the 69 articles. Twenty articles were checked for reliability (29%) and averaged 91.9% reliability. Again, any discrepancies were resolved through discussion. Following this second screening, 11 articles were identified to be included in this review. Finally, a reference list review and forward search were conducted on each article resulting in an additional six articles for a total of 17 papers included in this review.

2.4 Data extraction

A codebook was created to collect specific data from each article. These data included (a) participant demographics (e.g., the number of participants, ethnicity, gender, age); (b) disability type (e.g., autism, intellectual disability, severe, other); (c) country where the study was conducted; (d) employment setting (e.g., restaurant, grocery store, hotel); (e) research methodology (e.g., quantitative, qualitative, mixed methods); (f) quantitative methods (e.g., group, descriptive-quantitative, single-case research design, other); (g) qualitative methods (e.g., phenomenological, case study, other); (h) data collection methods (e.g., formal and informal rating scales, direct observation, survey, interviews, focus groups); (i) data analysis (e.g., statistical analysis, visual analysis, thematic or content analysis, grounded theory, other); and (j) outcomes (e.g., social, vocational, other).

Several inputting methods were used to extract data into an Excel spreadsheet. For example, the total number of employees with disabilities was entered into the column “Number of employees with disabilities,” as well as “Employees with Disabilities” ethnicity and gender columns. If the study did not report the ethnicity or gender of the employees, a “1” was entered into the “Not Clearly Specified” column. For binomial categories such as data collection methods or methodology, a “1” or a “0” was entered into the column. For example, if the study utilized a single-case research design, a “1” was entered into the “Single-case research design” column, and a “0” was entered into the other quantitative research designs. Reliability was conducted on 30% (n = 5) of the data extracted from the included articles and averaged 91% reliability. Again, discrepancies were resolved through discussion.

3.1 Research question 1: Demographic information, skills, and methodological components

In Group 1 (n = 11, see Table 1), the studies included 56 employees with IDD, 58 without disabilities, and 12 other participants (e.g., job coaches, comparison groups). Of the studies that reported gender information, 22 employees with IDD were male, 14 were female, and two studies did not report gender or the gender distribution among participants was unclear. Only two studies reported the gender of employees without disabilities (Lee et al., 1997;Storey & Garff, 1997). When reported, age was similar for coworkers (18–54 years) and individuals with disabilities (17–51 years). Eight studies included individuals with intellectual disabilities, one study with autism spectrum disorders, and two studies with severe disabilities. Nine studies were conducted in the United States, one study in Australia, and one study in the United Kingdom. Finally, studies were conducted in various employment settings, such as restaurants, hotels, grocery stores, retail, retirement homes, and country clubs.

In Group 2 (n = 6), the studies included 568 individuals with IDD and 385 without disabilities (i.e., vocational rehabilitation agencies). Two articles did not report or were unclear about participant ethnicity or gender (Cimera, 2001; West et al., 1997), and one did not report participant age (West et al., 1997). All six studies focused on individuals with intellectual disabilities and assessed either state or national data about employees with disabilities in CIE.

Included studies addressed social outcomes, vocational skills outcomes, and more broad vocational issues (e.g., wages, inclusion, hours worked). For example, studies addressing social outcomes focused on interactions between coworkers with and without IDD or generalizing social interaction training. Furthermore, studies addressing vocational skills focused on coworkers without IDD training those with IDD on work tasks or coworkers with IDD completing work tasks. Studies assessing broad vocational issues included studying wages, inclusion into the workplace, or hours worked per week. All, but one study utilized a quantitative research design to assess the impact of natural supports. Kaehne & Beyer (2013) conducted a mixed-methods study using descriptive-quantitative and case-study designs. There were two group studies (e.g., group comparison), six single-case design studies (e.g., multiple-baseline, alternating treatments design, intervention design, etc.), eight descriptive-quantitative designs, and one intervention study that did not report their design (Curl et al., 1992). In addition, the majority of studies (n = 9) collected data through direct observation to monitor whether the intervention was impacting specific social or vocational skills. However, only one study collected data by directly interviewing the participants (Kaehne & Beyer, 2013). Finally, conducting statistical analyses of the data was the most used data analysis method in the studies (n = 11), and one study did not report any clear data analysis (Chadsey et al., 1997).

In Group 1, nine studies deemed natural supports effective in building vocational skills, social interactions between employees with and without disabilities, and obtaining and maintaining CIE (see Table 2). Additionally, the studies reported increased wages, hours worked per week, and job tenure for employees with disabilities. However, two studies (Chadsey et al., 1997; Kaehne & Beyer, 2013) found mixed results when implementing natural supports. Chadsey and colleagues (1997) implemented two interventions to assess social interactions between employees with and without disabilities. The first intervention modified the workplace environment to be more socially inclusive, and the second intervention trained coworkers on interaction strategies. While neither of these interventions demonstrated improved social interactions among the employees, Chadsey and colleagues (1997) observed that the presence of job coaches decreased socialization among employees with and without disabilities. Kaehne and Beyer (2013) assessed the impact of a peer support model that could be used to deliver supported employment in CIE. This article reported the results of a smaller sub-study within a more extensive program evaluation and reported that employees with and without disabilities socially interacted at work but did not continue these interactions outside the workplace.

In Group 2, five studies deemed natural supports effective for increasing wages, meaningful social interactions between employees with and without disabilities, and job training and monitoring phases of supported employment. However, one study (Cimera, 2001) demonstrated mixed results for natural supports in the workplace. Cimera (2001) found that natural supports did not significantly improve relationships between coworkers with and without disabilities or the cost efficiency of supported employment programs. However, he identified that natural supports did increase the length of time the supported employees maintained the job.

4.1 Limitations

There were several limitations identified in this review. First, participant demographics were rarely reported. Without this information, it may be difficult to generalize these results to different CIE settings. Future research should include detailed participant demographics to evaluate specific factors (e.g., age, gender, education) and the effect these factors may have on outcomes for employees with IDD. Second, only one study utilized a qualitative methodology to explore the impact of natural supports on the participants. Kaehne and Beyer (2013) applied a mixed method methodology by including a case study and conducting interviews with the participants in their paper. Future research needs to focus on applying qualitative methods and methodologies to present a holistic picture of how natural supports in the workplace impact the employees with and without disabilities, the employers, and the organizational culture. Third, study quality was not conducted because most articles (n = 16) were published before 2005. Finally, only published articles and articles written in English were included in the review. It is possible that we missed studies in gray literature (e.g., dissertations, books) or articles published in other languages. These could include studies with additional participant demographics or different methodologies.

4.2 Implications and recommendations

This scoping review highlights the need for more research that evaluates the effectiveness of natural supports on vocational and social skills for individuals with IDD in CIE settings. Thus, several recommendations for future research and practice regarding natural supports in employment settings exist. First, several studies identified mixed results on the impact of natural supports and the employee’s vocational and social skills. Furthermore, the last published study addressing natural supports in CIE was in 2013. Thus, additional quantitative and qualitative studies need to be conducted to provide solid evidence of how and why natural supports are effective in CIE and evaluate natural supports in current employment settings.

Next, research on how natural supports influence the employment outcomes for coworkers without disabilities is also necessary. Peer-mediated interventions have demonstrated positive outcomes for participants without disabilities across the age span and setting (e.g., Athamanah & Cushing, 2022; Athamanah et al., 2020; Carter et al., 2017; Schaefer et al., 2016). Therefore, future research on natural supports should include the effects on coworkers without disabilities, their perceptions about working with employees with IDD, and how to possibly improve the implementation of natural supports using qualitative methods to understand their experiences as natural support coworkers.

Finally, if individuals with IDD are to secure and maintain post-school employment alongside coworkers without disabilities, then practicing vocational and social skills in segregated settings is not consistent with generalizing skills into different settings. Therefore, transition and vocational education programs should include vocational opportunities for individuals with and without IDD to build skills together while accessing authentic work settings in the community. This opportunity to work collaboratively in an inclusive environment, with teacher support and guidance, may improve all participants’ vocational and social skills. It may also offer individuals with IDD opportunities to practice and generalize the learned skills in different work and work-based learning settings with coworkers, preparing them for post-school employment.