Experiences and perceptions of facilitators of The WORKS

Abstract

BACKGROUND:

Some people who have a mental illness may require vocational rehabilitation and support to assist their participation in activity and employment. The WORKS is a vocational rehabilitation group intervention program, co-facilitated by Peer-Support Workers and Occupational Therapists. These facilitators provide support and guidance to people with a mental illness through practical activities and goal development.

OBJECTIVE:

This study aimed to explore the lived experiences and perceptions of facilitators of The WORKS.

METHODS:

The Integrating Theory, Evidence and Action (ITEA) method was used in this study, employing a phenomenological approach. Facilitators of The WORKS at a metropolitan Australian mental health service were purposively sampled, and four participated in semi-structured interviews. Data was transcribed verbatim and member checked, before being coded and analysed with reference to the Model of Human Occupation.

RESULTS:

Five themes emerged from the data; Consumer Growth [Volition], Facilitator’s Occupational Identity [Volition], Role of Facilitators [Habituation], Workload of Facilitators [Performance Capacity], and Adaptation of The WORKS Resources [Performance Capacity].

CONCLUSIONS:

All participants perceived benefits related to The WORKS however discussed a co-facilitation power imbalance between facilitators. Therefore, more development is needed around the co-facilitation relationship between Occupational Therapists and Peer-Support Workers.

Keywords

Vocational rehabilitation Occupational Therapy Peer-Support Work employment

1 Introduction

Work is important for everyone, as it provides opportunities for personal development and community participation [1]. However, people with a mental illness may experience challenges in their readiness to obtain or return to work, due to the impact of both symptoms and stigma [2]. A recent survey of Australian mental health service users (known as consumers) found that 76% of respondents were unemployed [3], which is a figure which has not substantially changed for the past twenty years. To address this issue, strategies to improve employment outcomes for consumers in recent years have included vocational counseling, workshops and supported employment [4].

These interventions are generally known as vocational rehabilitation, which refers to all measures taken by a range of health professionals and other stakeholders to assist consumers develop skills for employment [5]. The role of health professionals (such as Occupational Therapists (OT’s)) is to provide specialised assessments and interventions, using a consumer centered approach [6]. The role of a Peer-Support Worker (PSW) has a different focus, as their expertise lies in supporting consumers from their shared lived experience [7].

Recently, several challenges around the provision of vocational rehabilitation have been reported [8]. Devlin, Burnside and Akroyd [8] surveyed twenty four mental health OT’s in Northern Ireland using an open-ended questionnaire to explore perceptions of local vocational rehabilitation services. Whilst there was limited description of the methodology, OT’s identified time management as a challenge to their provision of vocational rehabilitation due to the impact of their large clinical caseloads. In comparison, Hillborg, Danermark and Svensson [10] conducted in-depth interviews with eight mental health vocational rehabilitation professionals in Sweden, to explore their perceptions of providing mental health vocational rehabilitation. Rather than focusing on disciplinary issues, participants highlighted the value of inter-professional collaboration to improve consumer outcomes [10].

Audhoe, Hoving, Sluiter and Frings-Dresen [9] completed a systematic literature review in the Netherlands to explore the relationship between work participation and vocational rehabilitation, and found there was weak evidence supporting implementation of these interventions in mental health, thus highlighting a need for further evaluation of programs [9]. However, there have been some recent Australian studies identifying positive outcomes for consumers from vocational rehabilitation. One study sought to evaluate the lived experiences of consumers who participated in vocational rehabilitation [11]. Data was collected from nine consumers, who reported vocational rehabilitation enabled them to work towards their own employment goals through engagement in activities targeted at relevant occupations (i.e. job skills) [11]. Castle et al. [12] explored the implementation of a community based mental health vocational rehabilitation group program facilitated by mental health professionals and PSW’s, who supported consumers who had a mental illness to develop health or employment focused goals. Descriptive data was obtained from three hundred and sixty four consumers about their perceptions of the program, which showed two thirds of respondents reported the program enabled them to obtain valued social roles relating to volunteering, study or work, and improved their self-efficacy [12].

While previous studies have addressed the perceptions of both health professionals and consumers of mental health vocational rehabilitation services and interventions, few have focused on the implementation of these interventions in a group format. One example of a mental health vocational rehabilitation group is The WORKS, which is co-facilitated by PSW’s and OT’s. The WORKS program provides tools and activities to assist consumers in the early stages of vocational development, to develop employment assets and skills [13]. To date, only one study has been published regarding The WORKS [13], although another is currently being prepared for publication. Furthermore, there are also few studies exploring co-facilitation between mental health staff from different disciplines or backgrounds, which is an increasingly common approach in this field, specifically between OT’s and PSW’s. Therefore, there is need for further research into the implementation and efficacy of mental health vocational rehabilitation group programs.

1.1 The WORKS pre-vocational rehabilitation group program

The WORKS is a mental health pre-vocational rehabilitation group program, developed in the United Kingdom by Sally Bramley, a Consultant OT [13]. The WORKS is a manualised intervention that provides tools and information for the provision of pre-vocational interventions in mental health settings [13]. There are three stages of The WORKS [13]. The Starting Out phase is targeted at consumers who doubt they will secure employment due to personal obstacles in their lives, such as low self-esteem and minimal self-belief [13]. The Moving Forward phase targets consumers who have had previous work experience, are eager to identify their own work related skills, and/or wishing to explore available work opportunities [13]. Finally, the Keeping Going and Growing phase targets consumers who are employed, but are looking for new work opportunities, and/or consumers who are undergoing workplace difficulties (i.e. difficulty maintaining their worker role or are undergoing adverse health related employee difficulties, such as dismissal) [13].

To date, one previous article has been published on The WORKS program. Cassinello and Bramley [13] presented a descriptive case study outlining the successful transition of a WORKS consumer into employment, in the United Kingdom. The authors noted the importance of maintaining partnerships between The WORKS facilitators and consumers, and recommended that consumers be referred to the right stage of The WORKS program, to promote successful consumer outcomes [13]. Although positive findings were reported, they must be interpreted with caution as the experiences of only one consumer were reported.

In Australia, The WORKS program was implemented at a metropolitan mental health service. This service provides assessments and interventions for persons aged fifteen years of age and over, who have an acute and/or ongoing mental illness. At this mental health service, The WORKS was co-facilitated by mental health OT’s and PSW’s. Therefore, this study aimed to explore the lived experiences and perceptions of facilitators of The WORKS at an Australian metropolitan mental health service.

This study adds to a small evidence base around the lived experiences and perceptions of facilitators of mental health vocational rehabilitation group interventions, and is the first to explore a co-facilitation relationship between health professionals and PSW’s facilitating The WORKS. Without an understanding of co-facilitator perceptions, relevant and appropriate development of The WORKS may not be possible, and potential barriers around the co-facilitation model may not be sufficiently addressed.

2 Methods

This study used the Integrating Theory, Evidence and Action method (ITEA) [14] to guide the research process. The ITEA method supports practitioners to integrate theory into practice through seven steps [14], including determining a clinical question, determining a theoretical framework, identifying the required evidence, deconstructing data, critically analysing data in relation to the chosen theoretical framework, reconstructing data, and disseminating and transferring findings to practice [14].

Ethical and governance approval was obtained from the local Human Research Ethics Committee and ratified by the associated University prior to commencement of the study [QA2015140].

2.1 Step One: Determining a clinical question

Following on from the previously stated aim, the clinical question guiding this study was ‘What are the lived experiences and perceptions of Occupational Therapist (OT) and Peer-Support Worker (PSW) facilitators running The WORKS mental health pre-vocational rehabilitation program?’

2.2 Step Two: Determining a theoretical framework

The Model of Human Occupation (MOHO) [15] was chosen as an overarching theoretical framework for this study, to enable analysis of data from an occupational perspective. The MOHO is an evidence-based, validated Occupational Therapy model, used to explain people’s motivation, patterns and performance of occupations [15]. The MOHO conceptualises humans into three interrelated yet separate domains; volition, habituation, and performance capacity [15]. Volition refers to people’s personal causation, values and interests of occupations, habituation refers to people’s internalised roles, habits and routines of occupations, and performance capacity refers to people’s lived experience and performance of occupations [15]. The MOHO recognises people’s volition, habituation and performance capacities are influenced by the environment, which is the physical and social environmental aspects that influence a person’s performance [15]. Whilst the environment can be influential on human occupations, it was not a specific focus in this study due to the research question’s emphasis on the intra-personal aspects of lived experience.

2.3 Step Three: Identifying the required evidence

The evidence required to answer the clinical question was identified as qualitative in nature. Given the focus on lived experience, this study used a phenomenological research approach to explore and understand the perceptions of The WORKS to facilitators [16], and used the MOHO [15] to lead the data analysis.

2.3.1 Recruitment

Purposive sampling was used to recruit participants who had facilitated The WORKS at the mental health service. All eight existing facilitators were invited to participate in this study via an email of invitation (which included a participant information and consent form), sent by a Chief OT at the mental health service who was not a member of the research team. The inclusion criteria for this study were 1) English as a primary language, and 2) Being an OT or PSW who had facilitated The WORKS at the mental health service between 2013 to 2016. Persons who did not meet the inclusion criteria were excluded from the study.

Initially, three facilitators volunteered to participate, therefore a reminder invitation email was distributed to encourage further participation. This resulted in one further facilitator volunteering to participate, resulting in a final response rate of 50% (n = 4). One further facilitator volunteered to participate, however they later withdrew prior to data collection due to personal circumstances. Creswell [16] states phenomenological research usually includes three to ten participants, therefore, the sample size reported here was within the accepted range for comparable studies.

2.3.2 Sample

Due to the limited number of facilitators at the service, specific demographic data was not collected to maintain confidentiality. However, all participants had English as their primary language, and had facilitated The WORKS at least once between 2013 and 2016. Three OT’s and one PSW participated.

2.3.3 Instrument

A semi-structured interview guide with ten open-ended questions was used to support discussion on lived experiences of facilitating The WORKS [16]. Draft interview questions were developed based on practice experience, the findings of the previous study of The WORKS [13] and associated research, and standard phenomenological practices. The interview questions focused on exploring the impact The WORKS had on facilitator’s own professional development, and their perceptions of the group’s dynamics and co-facilitation relationship. The interview guide was then trialed on three adults with previous experience working in group environments. These trial participants provided positive feedback and made no recommendations for changes to the interview guide.

2.3.4 Procedure

Individual, semi-structured audio-recorded interviews were conducted in quiet rooms at the mental health service between June 30th and July 15th, 2016. Two interviews were conducted in a clinical setting, and two at a research centre. Participants read the participant information and consent form, and had an opportunity to ask questions prior to providing written consent.

After interviews, recordings were transcribed verbatim by the lead author and stored on a password protected shared drive accessible only to the research team. After transcription, participants were emailed their transcript and provided an opportunity to complete member checking, to amend and/or confirm responses. One participant made amendments (altering two responses), however these amendments were minor and did not substantially impact their responses. After member checking, transcripts were printed off and data analysis began.

2.3.5 Trustworthiness

Measures were taken to ensure an optimal level of trustworthiness throughout this study. Credibility was maintained through triangulation, using multiple researchers and data collection methods, and member checking [17]. Transferability was supported by providing a detailed description of participants and the research setting, and using a representative sample [17]. However, due to the small sample size and adaptations made to The WORKS program to suit the local mental health service, transferability of these findings to other contexts must be considered with some caution. Dependability was upheld through having two researchers independently coding the data [17]. Confirmability was maintained through use of multiple data sources [17]; including interviews and member checking. In addition, regular peer review and debriefing were undertaken, through continuous communication between the researchers to maintain support and clarify questions [18].

2.4 Step Four: Deconstructing data

Data was deconstructed/broken down using interpretive phenomenological analysis, to understand facilitator perceptions of The WORKS [14]. Data from transcripts were independently read and coded by the two researchers. Codes identified by only one researcher were discarded from the analysis, with only data that had been coded by both researchers proceeding to further analysis. Data was then compared to determine which independently derived codes addressed the same concept, were conceptually congruent (i.e. spoke about closely related concepts), and were different. Codes that were different were compared and discussed between the researchers, and the meaning embedded in them collaboratively agreed upon. There was a high degree of agreement between the two researchers, with 91.43% of codes independently assigned being the same or conceptually congruent. All data was then classified into one of the three domains within the theoretical framework – volition, habituation and performance capacity – according to which of these concepts they most aligned.

2.5 Step Five: Critical analysis of data in relation to theoretical framework

Data was critically analysed in relation to each domain in the MOHO initially, before these findings were compared and contrasted for an overall understanding [14, 15]. Definitions of the three domains of the MOHO; volition, habituation and performance capacity [15] were reviewed by researchers, and used to categorise themes and sub-themes into the most appropriate domain of the MOHO. The first stage of analysis focused on understanding which codes were most prevalent, through completing a frequency count. Those with the highest frequency were identified as the major themes, while those that were less frequent were identified as sub-themes. Consolidation of codes also occurred at this point, where several infrequent but related codes were conglomerated into sub-themes. The researchers also looked for examples of comparison, correlation and consolidation. Comparison was completed through identifying different perspectives on the same MOHO domain, whilst correlation was completed through identifying perspectives found in the data of more than one participant. Consolidation occurred when the data was finally brought together into a cohesive, overall understanding [14].

2.6 Step Six: Reconstruction of data

Once themes and sub-themes were identified, and their relationship to the MOHO established, they were reconstructed into a statement of the facilitators lived experiences and perceptions. A series of mind-maps were used to support this process, as the relationships of each theme and sub-theme were interpreted both within the MOHO human system domains and across them. The outcomes of this step of the ITEA method forms the Results section of this paper.

2.7 Step Seven: Dissemination and transfer of findings

The formulation of this article is an example of how the findings of this study are being disseminated, and the study has also been presented at professional forums. The transferability and utilisation of these findings in further research or clinical practice are also reported in the Discussion section of this article [14].

3 Results

Five themes and nine sub-themes were identified through data analysis; 1) Consumer Growth (Volition), 2) Facilitator’s Occupational Identity (Volition), 3) Role of Facilitators (Habituation), 4) Workload of Facilitators (Performance Capacity), and 5) Adaptation of The WORKS Resources (Performance Capacity).

All findings are from the perspective of facilitators, although they do comment on their understanding of the experience of consumers.

3.1 Volitional aspects of facilitating The WORKS

Volition refers to people’s own feelings and thoughts of themselves in their environment, and is comprised of people’s personal causation, values and interests [16]. Two themes were identified related to volition; 1) Consumer Growth and 2) Facilitator’s Occupational Identity.

3.1.1 Consumer growth

Consumer growth refers to the facilitator’s perceptions of consumer development and progress. This theme included data related to consumer growth within The WORKS, consumer social acceptance and inclusion, and consumer growth beyond The WORKS.

3.1.1.1.Consumer growth within The WORKS. Consumer growth within The WORKS refers to perceptions of skills and knowledge developed by consumers through participation in The WORKS. All facilitators enjoyed observing consumers progress through The WORKS, and reported they saw consumers develop strengths in social skills and confidence during the group program. Furthermore, three facilitators identified how The WORKS supported consumers to develop, maintain and achieve specific vocational goals based on their existing skills and knowledge.

“The WORKS was a way to sort of show people that it’s not that they’re not good at anything, it’s just that they need to be reminded of what their strengths are and help grow them again.” (Participant 1)

3.1.1.2.Consumer social acceptance and inclusion. Consumer social acceptance and inclusion refers to facilitator perceptions of the social aspects of the group, which evolved for consumers through participation in The WORKS. Two facilitators reported observing the development of social inclusion and friendship amongst consumers as they progressed through The WORKS. All facilitators identified social inclusion as a major strength of The WORKS, and attributed its development to the inclusion of PSW’s as facilitators, through their engagement with consumers and ability to make them feel comfortable discussing their vocational journey.

“ … it broke that barrier down a little bit it made it more that we’re all in the group and we’re all working together and we’re all kind of just moving along with the flow of the group, as it evolves.” (Participant 2)

3.1.1.3.Consumer growth beyond The WORKS: Consumer growth beyond The WORKS refers to observations that indicated consumers were beginning to consider their vocational journey continuing after the conclusion of The WORKS. Two facilitators discussed consumer’s personal causation, and reported the program prompted consumers to realistically consider their current situation, reflect on their ability to ascertain, achieve and maintain their vocational goals, and re-consider their future vocational options, as outlined in the following quote:

“It was really great to see consumers by the end of the group really if anything starting to think about what is ahead for the future for me, what are my goals.” (Participant 2)

Two facilitators also discussed the importance of clinicians maintaining their knowledge of available local external vocational services to support consumers to continue on their vocational journey post completion of The WORKS. One facilitator reported:

“ … it’s not only about what we’re doing with the client here but what do we do once they’re discharged from our service?” (Participant 2)

3.1.1.4.Facilitator’s occupational identity. Facilitator’s occupational identity refers to facilitator’s individual personal interests [15], and skills developed through their engagement as a facilitator of The WORKS.

3.1.1.5.Personal interest. Personal interest refers to a key factor that influenced the facilitator’s professional engagement in The WORKS. All facilitators reported The WORKS provided them with an opportunity to explore areas of personal interest, such as putting theory into practice, or co-facilitation with PSW’s within mental health services. Two facilitators reported that facilitation of The WORKS enabled them to develop their knowledge regarding the external services available to consumers in the local area, and that the group enabled them to apply and further consolidate their skills in a group environment.

“ … generally I had an interest in looking in how we can be utilising peer work within the service a little bit more so it seemed like a good, um, fit with my interests … ” (Participant 1)

3.1.1.6.Further develop skill set. All facilitators reported co-facilitation improved their group and professional communication skills, and assisted them to develop their flexibility and presentation skills.

“ … furthered developed further consolidated um my group skills, but it also um consolidated some of my leadership skills, and my interpersonal skills, a really around the domain of how to sit with working with challenges, and working with differences of opinion with my colleagues.” (Participant 4)

3.2 Habitual aspects of facilitating The WORKS

Habituation refers to a person’s internalised roles and habits (15). The data gathered from facilitators did not address habits, but did strongly relate to the role of facilitators.

3.2.1 Role of facilitators

The role of facilitators refers to the facilitation role of both OT’s and PSW’s in regards to The WORKS. Two sub-themes were identified in regards to this role; 1) Co-facilitation Power Imbalance and 2) Peer-Support Worker Role.

3.2.1.1.Co-facilitation power imbalance. Co-facilitation power imbalance refers to the perceived differences in control and influence within The WORKS group between OT’s and PSW’s. Three facilitators identified a co-facilitation power imbalance between OT’s and PSW’s during facilitation of The WORKS, with the group being mostly led by the OT’s. The PSW’s were seen to be performing in a supporting capacity rather than taking leadership, even though all facilitators attempted to maintain equality. Furthermore, all facilitators felt there were different expectations placed on PSW’s, due to their past history as mental health consumers.

“ … there tends to be a bit more of a spotlight on the Peer Worker obviously because of their history and all of that sort of thing … ” (Participant 1)

Two facilitators perceived it was difficult for PSW’s to ‘hold their own’ due to the lived experience workforce being relatively new in Australian mental health services. These facilitators discussed complex role dynamics between OT’s and PSW’s, and stated they had tried to maintain an awareness of these potential co-facilitation complexities while performing the role.

“ … a key thing around these two (workforces) coming together is, um, thing to consider in those complexities is the idea of power imbalance, and how does that impact on the Peer Worker particularly if they have been a user of that particular service, um, inherently the clinician holds the power, um, and around just sort of um addressing that I guess in a way that’s going to enable both to be empowered to work together equally … ” (Participant 1)

Whilst all facilitators believed co-facilitation was a positive experience overall, two facilitators perceived that co-facilitation presented challenges including differences of opinion and expectations.

“ … it was challenging sometimes to (pause) maintain my approach and facilitation style … alongside [others] sort of working in their style … ” (Participant 1)

However, a complementary aspect between the roles of OT’s and PSW’s in The WORKS was also acknowledged. Whilst the OT’s could provide knowledge and skills, the PSW’s contributed invaluable lived experience unique to the consumer’s vocational journey and needs.

“ … after every session there was feedback about how invaluable, how comforting, how supportive they [consumers] felt it was to have a consumer presence in the room, and that the feedback time and time again was about even if they weren’t very clear about the contribution that the consumer co-facilitator was making, they [consumers] were very clear that they were bringing something to the participant group experience that clinical staff couldn’t bring and weren’t bringing.” (Participant 4)

3.2.1.2.Peer-Support Worker role. Peer-Support Worker role refers to perceptions of the specific role played by PSW’s during co-facilitation of The WORKS. All facilitators unanimously characterised the role of PSW’s as providing lived experience examples to consumers, which were perceived to be invaluable to consumers as a means to allow them to experience comfort and safety in discussing their vocational journey. Two facilitators also highlighted that whilst OT’s had their own lived experience from their own vocational journey, such experiences were not as useful to consumers as those related to firsthand experience of mental illness and the impact it has on employment.

“ … when there is a Peer um Support Worker in there you notice a difference because they’ve gone through the process themselves before … ” (Participant 2)

Furthermore, all facilitators observed the introduction of PSW’s as group facilitators was undertaken on a trial and error basis due to it being the inaugural attempt at such a relationship. Two facilitators highlighted that the PSW’s did not receive any specific training to facilitate The WORKS, with one facilitator reporting:

“ … it’s new for the consumer co-facilitators doing it, it’s new for the OT’s doing it, so we were both in a sense working in the dark, being really patient with each other, um walking in each others shoes if you like, to, um, and sort of um almost learning as you go type model … ” (Participant 4)

3.3 Performance aspects of facilitating The WORKS

Performance capacity refers to persons lived experience and performance of occupations (15). Two themes were identified in regards to performance of The WORKS facilitation; 1) Workload of Facilitators and 2) Adaptation of The WORKS Resources.

3.3.1 Workload of facilitators

The workload of facilitators refers to perceptions of the associated tasks and capacity arising from facilitation of The WORKS. Two facilitators reported that the workload associated with being a facilitator of The WORKS was difficult to manage alongside their other duties, and that resolution of these issues would be important for the sustainability of The WORKS into the future. Two facilitators also noted the need for a champion to drive sustainability of the program within the service. All facilitators wanted more preparation time prior to each session of The WORKS, to ensure everyone was well prepared to work with the consumers.

“ … I think we reflected and felt like there could have been a little bit more time to prepare at the beginning of each session, so covering, just spending your own time kind of covering the content, you know, getting your head straight on what you’re going to say and that sort of thing.” (Participant 1)

3.3.2 Adaptation of The WORKS resources

Adaptation of The WORKS resources refers to the suitability of The WORKS resources to consumer needs and performance skills. All facilitators reported that consumers of The WORKS were at different stages in their vocational journey and had diverse needs. Therefore, there was a need to continually adapt and review resources to ensure resources were appropriate to the attending consumers.

“ … people are different learners and more hands on at times as well, so we kind of adjusted it and I feel like um it could be adjusted a little bit around different learning types … ” (Participant 3)

4 Discussion

Five themes and nine sub-themes emerged from data analysis in relation to the MOHO [15], which illustrated both the positive and challenging aspects of facilitating The WORKS.

The findings regarding consumer growth were similar to findings from a recent Australian study by Castle et al. [12], which explored consumer perceptions of a mental health group vocational rehabilitation program similar to The WORKS. Castle et al. [12] also found consumers experienced increased self-efficacy and obtained a valued social role through participation in a group vocational rehabilitation program. The facilitators in this study also discussed the intrinsic skills developed by consumers through participation in The WORKS, such as communication skills and confidence. This suggests that facilitator’s abilities to assist consumers in developing intrinsic skills for employment may support employment prospects and opportunities for consumers post completion of The WORKS. The development of these skills provides a gateway to accessing the wider benefits of vocational participation, such as the sense of belonging for consumers identified by employers in a recent Swedish study by Lexén, Emmelin and Bejerholm [1].

Facilitators reported their decision to facilitate the program was influenced by personal interests; indicating intra-personal volitional aspects influenced facilitator’s decision to facilitate the program. This suggests The WORKS may promote occupational adaptation and identity development for both facilitators and consumers, albeit in differing ways [15].

Facilitators discussed the presence of a co-facilitation power imbalance between OT and PSW facilitators, with the predominant perception being that OT’s embodied a lead role, and PSW’s embodied a support-based role. Such findings are supported by Silver and Nemec [19], who reported PSW’s may experience phenomena similar to a co-facilitation power imbalance, such as potential prejudice, due to exposing their history of having a mental illness. In the present study, two facilitators affirmed that co-facilitation on an equal basis was a challenge for PSW’s to maintain, and discussed the need to maintain awareness of the complexities associated with the PSW role as a facilitator. Although all facilitators reported that co-facilitation with a different workforce was an overall enjoyable experience, some challenges and complementary features were also identified.

Green, Janoff, Yarborough and Paulson [20] reported the presence of group dynamic challenges between vocational rehabilitation consumers. However, participants in this study focused on the group dynamic challenges between facilitators, inherently due to their different workforce roles, despite being asked to also comment on group dynamics between consumers. Knaeps, Neyens, Donceel, van Wheeghel and Audenhove [21] also reported collaboration challenges might be experienced between facilitators due to differing beliefs and values.

All facilitators reported PSW’s brought invaluable lived experience that other workforces could not necessarily provide, which provided a supportive environment for consumers to share their vocational journey. Green, Janoff, Yarborough and Paulson’s [20] quantitative evaluation of a co-facilitated community based mental health group intervention found that consumers enjoyed co-facilitation between PSW’s and clinicians and felt the two workforces complemented one another. Crane, Lepicki and Knudsen [7] also support these findings, through reporting the sharing of lived experiences and challenges between consumers and PSW’s facilitates a sense of camaraderie.

Facilitators discussed logistical challenges, including time management, workload, and preparation time, which impacted their ability to maintain a desired performance capacity in facilitating the program. To overcome such challenges, Green, Janoff, Yarborough and Paulson [20] suggest training for vocational rehabilitation groups should focus on minimising co-facilitation challenges between PSW’s and clinicians. As co-facilitation between OT’s and PSW’s is relatively new at the mental health service in this study, it may be that these work tasks are yet to be properly integrated into the workload systems of the service. However the identification of a champion may support this integration into the service, as highlighted by two of the facilitators. Damschroder et al. [22] also suggests that successful intervention implementation is achieved through adapting interventions to meet organisational and individual needs, and that implementation of interventions may be promoted by champions within workplace settings.

All facilitators felt The WORKS resources could be better adapted to meet consumer’s differing needs. The authors of this paper support adaptation and modification of The WORKS manual and resources to suit local conditions. The National Centre on Universal Design for Learning [23] provides a set of guidelines acknowledging people have different interests, skills and needs. The guidelines provide a basis for the adaptation and development of adjustable materials that meet individual needs, and may support the recommendation of adaptation of The WORKS resources.

4.1 Limitations

Use of a small sample size from one mental health service setting will limit transferability of results. Sampling more OT’s than PSW’s may have influenced results, with potential bias being presented from an Occupational Therapy perspective. Although the study sought to explore facilitator’s perceptions of The WORKS, facilitators commented on their perspective of the consumer experience. This could be quite different to consumer’s experiences; therefore it would be beneficial to collect the perceptions of the consumers themselves. There was also variability in the time since facilitators had engaged in The WORKS, as some were new to the program and others had time to reflect on their experiences, which may have influenced facilitator’s responses in the study.

4.2 Future areas of research

Research into whether The WORKS translates into consumers obtaining employment would be an important area of future longitudinal research. It would be beneficial to research provision of The WORKS in settings other than mental health services, such as the private sector and primary care, to determine whether The WORKS is transferable to different areas of practice. It would also be beneficial to further explore the co-facilitation relationship between health professionals and PSW’s, to encourage in-depth exploration of the reported co-facilitation power imbalance reported in this study.

5 Conclusion

This study has provided a unique perspective into the experiences of OT’s and PSW’s who facilitated The WORKS at an Australian metropolitan mental health service, and has identified areas of adaptation that may support the sustainability of the program into the future. While some of the findings are congruent with previous research, this study has made a distinctive contribution to the evidence base of both The WORKS specifically and co-facilitation between different workforces more generally. This study has described the lived experiences and perceptions of facilitators of The WORKS program, and has found that although they are quite complex, they are mostly positive and productive.

Conflict of interest

None to report.

Footnotes

Acknowledgments

Many thanks to participants for sharing their lived experiences and perceptions of The WORKS.

References

Lexén

, Emmelin

, Bejerholm

. Individual Placement and Support is the keyhole: Employer experiences of supporting persons with mental illness. Journal of Vocational Rehabilitation. 2016;44(2):135–47.

Ramano

, Buys

, de Beer

. Formulating a return-to-work decision for employees with major depressive disorders: Occupational therapists’ experiences. African Journal of Primary Health Care & Family Medicine. 2016;8(2):1–5.

Hitch

, Vernon

, Dun

. Work and beyond: Vocational participation for mental health service users. Australian & New Zealand Journal of Psychiatry. 2016;1(n.a):1.

Chalamat

, Mihalopoulos

, Carter

, Vos

. Assessing Cost-Effectiveness in Mental Health: Vocational Rehabilitation for Schizophrenia and Related Conditions. Australian and New Zealand Journal of Psychiatry. 2005;39(8):693–700.

Phillips

, Kaseroff

, Fleming

, Huck

. Work-related social skills: Definitions and interventions in public vocational rehabilitation. Rehabilitation Psychology. 2014;59(4):386–98.

Baxter

, Prior

, Forsyth

, Maciver

, Meiklejohn

, Irvine

. Mental health vocational rehabilitation - occupational therapists’ perceptions of individual placement and support. International Journal of Therapy and Rehabilitation. 2012;19(4):217–26.

Crane

, Lepicki

, Knudsen

. Unique and common elements of the role of peer support in the context of traditional mental health services. Psychiatric Rehabilitation Journal. 2016;39(3):282–88.

Devlin

, Burnside

, Akroyd

. Mental Health Vocational Rehabilitation: An Overview of Occupational Therapy Service Provision in Northern Ireland. The British Journal of Occupational Therapy. 2006;69(7):224–338.

Audhoe

, Hoving

, Sluiter

, Frings-Dresen

MHW

. Vocational interventions for unemployed: Effects on work participation and mental distress. A systematic review. Journal of Occupational Rehabilitation. 2010;20(1):1–13.

10.

Hillborg

, Danermark

, Svensson

. Professionals’ perceptions of and views about vocational rehabilitation for people with psychiatric disabilities. Work (Reading, Mass). 2013;44(4):471–80.

11.

Netto

, Yeung

, Cocks

, McNamara

. Facilitators and barriers to employment for people with mental illness: A qualitative study. Journal of Vocational Rehabilitation. 2016;44(1):61–72.

12.

Castle

, Crosse

, Morgain

, McDowell

, Rossell

, Thomas

, et al. Helping people with a mental illness obtain work: The Health Optimisation Program for Employment. Australasian Psychiatry. 2016;24(4):337–41.

13.

Cassinello

, Bramley

. Keeley’s journey: From service user to service provider. Work. 2012;43(1):91–7.

14.

Hitch

, Pepin

, Stagnitti

. The Integrating Theory, Evidence and Action (ITEA) Method: A Procedure for Helping Practitioners Translate Theory and Research into Action. The British Journal of Occupational Therapy. 2012;77(12):592–600.

15.

Kielhofner

. A model of human occupation: Theory and application. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2008.

16.

Creswell

. Research design: Qualitative, quantitative, and mixed methods approaches. 4th ed. Thousand Oaks, California: SAGE Publications, Inc., 2014.

17.

Henderson

, Rheault

. Appraising and incorporating qualitative research in evidence-based practice. Journal of Physical Therapy Education. 2004;18(3):35–40.

18.

Creswell

. Qualitative inquiry and research design: Choosing among five approaches. 3rd ed. Los Angeles; SAGE Publications., 2013.

19.

Silver

, Nemec

. The role of the peer specialists: Unanswered questions. Psychiatric Rehabilitation Journal. 2016;39(3):289–91.

20.

Green

, Janoff

, Yarborough

, Paulson

. The Recovery Group Project: Development of an Intervention Led Jointly by Peer and Professional Counselors. Psychiatric Services. 2013;64(12):1211–7.

21.

Knaeps

, Neyens

, Donceel

, van Weeghel

, Audenhove

. Beliefs of Vocational Rehabilitation Counselors About Competitive Employment for People With Severe Mental illness in Belgium. International Rehabilitation Counseling Research. 2015;58(3):176–88.

22.

Damshroder

, Aron

, Keith

, Kirsh

, Alexander

, Lowery

. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science. 2009;4(50):50–64.

23.

National Centre on Universal Design for Learning [Internet]. Wakefield, MA: CAST; c2012. Universal Design for Learning Guidelines. 2014 Dec 11; 2014 [cited 2016 Oct 27]; [about 2 screens]. Available from: http://www.udlcenter.org/aboutudl/udlguidelines_theorypractice.