Professional competencies required by occupational therapists to facilitate the participation of persons with mental disability in work: A review of the literature

2.1 Search stage

The first author conducted a search of the literature for peer-reviewed articles on barriers and facilitators to participation in work for persons with mental disabilities and for work practice curricula in occupational therapy. Key search terms used for the search are shown in Table 1. The search was conducted on Academic Search Premier, Africa-Wide Information, CINAHL, Health Source: Nursing/Academic Edition, and MEDLINE research databases for articles published between 2012 and 2018. A total of 227 peer reviewed articles were identified from the search.

Only one criterion had to be met for sources to be included namely, key search terms had to appear in the title, abstract or body text. Articles that contained the key search terms in their title and abstracts but reported on subject matter not directly related to the research questions were subsequently excluded. A critical appraisal [25] was conducted and articles were appraised by reading through identified articles. A selection of 51 of the 227 articles informed the review.

2.3 Synthesis

Two aims, shown in Table 2, guided knowledge synthesis from the selected articles. Literature reflected both Global North and Global South contexts. This provided a contrast of the two contexts; literature from the Global South, especially South Africa, was seen as a proxy for the Zimbabwean situation where there is a paucity of research on the subject matter.

Articles were categorised according to the aims and further classified according to article type (primary research, review article, opinion article etc.) to guide the synthesis and integration process. Review articles, rich in literature previously reviewed, acted as conceptual guides in the current review while primary articles provided the necessary examples; the result was a typical narrative synthesis of the literature. The synthesis provides insights and ideas [25] on facilitators and barriers to work for persons with mental disabilities, as well as the competencies related to work practice in occupational therapy curricula in relation to the Zimbabwean context.

The information obtained was critically appraised for its applicability to the Zimbabwean context. Thereafter, an analysis of the competencies required for work practice in occupational therapy related to informing interventions for persons with disabilities to overcome barriers and utilising facilitators to work was done. A holistic synthesis of findings was then done. Finally, recommendations were made for further research in view of the existing gaps.

3.1 Barriers to participation in employment of persons with mental disabilities and facilitators to promote the experience of work

Persons with mental disabilities were found to experience many obstacles to their participation in employment [26]. In the Global South, barriers included stigma, unaccommodating environments, low educational levels, legislation and policies that are deterrent to employment [10, 28]. In Global North contexts low-level education, psychiatric disability, lack of access to rehabilitation services, absenteeism, lack of supportive legislation and policies, lack of motivation and consequently poor work output were identified as barriers to employment [29, 30]. Facilitators were any factors or opportunities that promoted the participation of persons with mental disabilities in work. Facilitators included any interventions found to minimise or overcome the effects of barriers to work [30]. These included addressing the needs of clients, for example increasing engagement with clients and their significant others, allowing for greater choice and autonomy over services received by clients as well as provision of skills training and support services could facilitate integrated work [31].

Barriers were differentiated using two categories, namely ‘personal’ and ‘structural’, in order to delineate the barriers by their characteristics. Rosenthal, Hiatt, Anderson, Brooks, Hartman, Wilson & Fujikawa [31] examined facilitators and barriers to integrated employment through focus groups and interviews with providers (n = 178), consumers of vocational rehabilitation and their families (n = 83). They found structural issues, such as an ignorance of available services, a lack of specialist services, unavailability of service providers and lack of synchronization of services were barriers to employment [31]. Persons with mental disabilities also experienced barriers, at a community and systemic level, which prevented them from entering and staying in work. These barriers included stigma, misconception of mental illness, society having little anticipation of their ability to gain and retain work, employment not being recognised as a treatment goal and patients’ fear to lose welfare benefits [32, 33]. The fear to lose benefits from disability grants was a major disincentive to seeking employment by persons with disabilities [32, 34]. Engelbrecht and Lorenzo [33] recommended that governments should ensure that welfare policies do not hinder mental health service users from seeking employment. Furthermore, confinement of services to hospitals and institutions was found to limit community access and social inclusion for persons with mental disabilities [12, 35] and these can be barriers to access work and employment opportunities in the community. These community and systemic barriers result in persons with mental disabilities experiencing occupational deprivation, occupational apartheid and occupational marginalisation [15, 37].

Personal factors related to symptoms of mental illness, such as poor concentration, low mood, problems with planning and organisation, low self-esteem, lack of self-confidence, boredom and lack of motivation to work were found to be barriers to persons with mental disabilities seeking and attaining work [33]. Other barriers associated with individuals’ work-related histories included long-term unemployment, low educational level, limited previous vocational achievement and lack of skills in a specialised trade [33].

Soeker, Tandokazi, Machingura, Msimango, Mos-waane and Sinazo [28] did a qualitative exploration of the challenges that employees with substance use disorders (n = 3) experienced while returning to work after the participation in an employee assistance program. They sought to explore the barriers and facilitators the workers experienced and found that reduced work performance coupled with failure to meet work obligations related to abuse of substances, as well as environments that did not support recovery were significant barriers to returning to work [28]. Further to this, mental health service users with a diagnosis of substance use disorders faced additional barriers to attain work such as educational disadvantages due to early substance use, poor motivation to work, hospitalisation due to onset of psychiatric symptoms, unreliable behaviours, poor personal hygiene and signs of substance use [33].

Mental health service users and their families were found to need support for self-directed engagement and skills training according to best practices [31]. Envisioning employment as a treatment outcome for persons with disabilities was also considered an important facilitator to employment as health care professions will strive to make it one of their outcomes [32]. Taskila, Steadman, Gulliford, Thomas, Elston and Bevan. [32] recommended that inter-sectoral intervention plans and evidence-based interventions, with all stakeholders having clear responsibilities, should be implemented. There is further support for evidence-based inter-sectoral interventions in the African context and Zimbabwe in particular [4, 8]. Coetzee, Goliath, van der Westhuizen and Van Niekerk [4] recommended implementing an integrated, inter-sectoral work practice model and argued that such a model will yield better outcomes and improve service user satisfaction. Nhunzvi and Mavindidze [8] recommended an inter-sectoral work practice model to overcome limitations in service delivery and improve on competitive employment outcomes.

Another facilitator for work participation by persons with mental disabilities is the availability of occupational therapy services that need to focus on addressing the work needs of this group [8, 12] and enable them to meet their occupational needs [38]. Soeker et al. [28] recommended incorporating occupational therapy services in order to strengthen employee assistance programmes, especially occupation-based interventions that provide a holistic view of the client. Machingura and Lloyd [18] highlighted that occupational therapists advocate for patients’ engagement in work. Occupational therapists match clients’ capabilities to the job demands thereby facilitating engagement in work and reducing barriers [18]. They go on to argue that occupational therapists promote the clients’ engagement in work through developing work skills and making environmental adaptations to overcome barriers [18]. They concluded that occupational therapy plays a significant part in work practice to address challenges faced by persons with mental disabilities [18]. It is therefore necessary that occupational therapists consider stakeholders’ perspectives on facilitators and barriers to employment and work for persons with disabilities. However, the question arises whether occupational therapist possess the necessary competencies to promote participation in work and reduce barriers to employment for persons with mental disabilities.

3.2 Professional competencies

Professional competencies are the collective sum of all the knowledge, skills and values that a practitioner has that are relevant for them to perform effectively their professional duties [17]. Professional competencies reflect how entry-level graduates are prepared for practice and therefore influence curriculum design [39]. In a review Adam, Gibson, Strong and Lyle [40] identified knowledge, skills and professional behaviours occupational therapists and physiotherapists required to enter work practice. Fundamental knowledge requirements identified included knowledge that was specific to practice of the profession, knowledge of stakeholders’ roles, knowledge of workplace regulations and rehabilitation legislation, knowledge of workplace health and safety, knowledge of workers compensation and rehabilitation, and knowledge of anatomy and human function [40]. Practitioners should also possess necessary skills in communication, job/activity analysis, exhibit professionalism, consideration of ethical issues and have an understanding of boundaries with other professionals [40].

Buys [17] sought to identify professional competencies occupational therapists in South Africa required for vocational rehabilitation. She conducted a Delphi process and asked occupational therapists specialised in vocational rehabilitation (n = 35) to rate suggested knowledge, skills and values items [17]. Her findings, highlighted in Table 3, show the knowledge, skills and values occupational therapists require for vocational rehabilitation. Furthermore, 16 professional competencies emerged from the knowledge, skills and values. A systematic review by Adam, Peters and Chipchase [21] disaggregated professional competencies for occupational therapists and physiotherapists starting practice in work-related rehabilitation into generic competencies and profession specific competencies. Nine themes emerged in the meta-synthesis and these include workplace injury and illness prevention, injury and illness management and rehabilitation, work place knowledge, clinical reasoning, client-centred approach, communication, work assessment and intervention, self-reflection and evaluation, professional presence and confident and comfortable in a wide range of settings [21]. In a follow-up study, Adam, Strong and Chipchase [39] conducted interviews with occupational therapy and physiotherapy educators (n = 19) to describe the curricula at in Australian and New Zealand universities that train occupational therapists and physiotherapists for work-related practice. Table 3 highlights their findings. Findings also revealed that educators perceived that entry level therapists from their schools where prepared to practice with minimal supervision for most topics identified [39]. The competence focuses differ depending on the context and the work practice orientation of the country where the occupational therapist is working [20]. However, there are some shared competencies across contexts such as job or occupational analysis, understanding work related legislation and knowledge of work settings [17, 40].

There is a clear relationship between barriers to work and occupational injustice. More research is however needed to explicate the promotion of occupational justice as a facilitator of work engagement within the Global South. Further investigation is needed on the role occupational therapy curricula can play in work practice development within the field of occupational justice. Hocking and Townsend [14] recommend that occupational therapy educational programmes should focus on driving social change through commitment to human rights and occupational justice. These educational reforms will position occupational therapists to develop interventions that promote occupational justice, thereby contributing to development of more inclusive societies [14].