Vocational rehabilitation for young stroke survivors in Gauteng public healthcare: Occupational therapists’ perceptions 1

Abstract

BACKGROUND:

The prevalence of working-aged stroke survivors is increasing yearly. Stroke is an expensive disease, causing financial burden to the government, the family and caregivers of the patient, thus making it imperative for working-aged stroke survivors to work to remain financially independent. Survivors’ need to work necessitates occupational therapists to shift their focus from basic activities of daily living, to rehabilitating work.

OBJECTIVES:

This study aimed to determine the perceptions of occupational therapists working with younger stroke survivors in public hospitals and clinics in Gauteng South Africa, about rehabilitating working-aged stroke survivors’ work ability.

METHODS:

Ethical clearance was obtained. A qualitative research design was used to obtain narrative, descriptive data from six focus groups. Therapists from public healthcare settings, who had more than six months’ experience and had worked in neurological rehabilitation within the six months preceding the focus group, were invited to participate. Focus groups were audio recorded and transcribed. Inductive content analysis was used to identify themes and categories.

RESULTS:

Few participants are involved in rehabilitating younger stroke survivors’ work ability or facilitating return to work (RTW). The study identified perceived barriers and enablers to rendering OT services that meet working-aged stroke survivors’ needs.

CONCLUSIONS:

Despite enabling employment equity laws in South Africa, OTs working in the public sector appear to experience a sense of futility when trying to rehabilitate young stoke survivors to RTW. Fragmentation of the public sector and limited resources impede successful RTW for working-aged stroke survivors. Survivors’ employment status and motivation to RTW facilitated rehabilitating work ability.

Keywords

Occupational therapy vocational rehabilitation attitudes perceptions working-aged stroke survivors

1 Introduction

In 2006, it was estimated that 20%of stroke victims in South Africa were younger than 65, thus in the economically active phase of life [1] and it is predicted that by 2030, 41%of working-aged South Africans will suffer from premature death as a result of cardiovascular disease [2]. Rehabilitation of younger economically active stroke survivors is reported to be a challenging and complicated process [1], as they have more diverse and complex ways of spending their time than older stroke survivors. Their time use may be influenced by their responsibility for taking care of family members and being an active part of the work force [1]. However, it seems that rehabilitation services do not reflect the complexity of younger people’s life roles [3]. Rather, the hospital-based rehabilitation of younger stroke survivors appears to have focused primarily on the early developmental categories of occupation such as basic activities of daily living (BADL), e.g. dressing and grooming [4]. From there the rehabilitation focus moves onto leisure and social participation, with very little time (if any) spent on rehabilitating these patients’ work ability [1]. With an average admission duration of 12 days in public sector hospitals, medical treatment (i.e. getting the patients’ blood pressure under control and treating secondary symptoms) takes preference and rehabilitation is placed on the back burner [1].

Researchers suggest that whenever possible, return to work should be prioritised during the rehabilitation of young stroke survivors, because work and the ability to earn an income is an especially important occupation during the economically active years (18 –60 years) of one’s life [3]. Return to work, in spite of the disability, will allow stroke survivors to continue earning an income and have a positive effect on their self-efficacy and self-worth [3, 5]. It will also reduce the burden [6] on the family or social support such as a disability grant, thereby creating financial independence for the younger stroke survivor.

Rehabilitation professionals have been found to be pre-occupied with acute treatment, thus tending to neglect the all-important later phases of rehabilitation, especially community integration [7], which includes return to work. In the private sector there are not necessarily more resources for rehabilitation, as managed health care limits resources available for such rehabilitation [8]. Thus, this study aimed at establishing the perceptions of occupational therapists working with younger stroke survivors in public hospitals and clinics in Gauteng South Africa, about rehabilitating working-aged stroke survivors’ work ability. This paper will first provide a brief overview of the literature to contextualise return to work and rehabilitation for stroke survivors in a developing country such as South Africa, after which the method and results will be described.

2 Literature review

Stroke is no longer only a disease of old age [1 , 9–11]. Developing countries, such as South Africa, experience a myriad of factors that affect the incidence of strokes, particularly among working-aged people. These include HIV/AIDS [12], significant population growth, industrialisation. In addition, lifestyle factors, such as increased consumption of western diets, use of cigarettes, overconsumption of alcohol and physical inactivity, cause a high prevalence of hypertension, diabetes and obesity, thus resulting in an increase in younger, working-aged people affected by stroke [11]. Despite an increase in strokes among working-aged people and the World Federation of Occupational Therapy’s emphasis on the occupation of work in its 2016 Minimum Standards for the Education of Occupational Therapists [13], there is a dearth of literature regarding occupational therapists’ attitudes and perceptions regarding stroke and work-related rehabilitation. This literature review briefly explores three themes around stroke, RTW and occupational therapy as a rehabilitation profession in the context of a developing country. Firstly, a bird’s eye-view of the South African health context is described, focusing on the context in which the research took place, i.e. the Gauteng public health setting. We provide reasons for situating vocational rehabilitation services in the public health context, and specifically at all levels of health service provision. Lastly, stroke survivors’ perceptions and priorities for rehabilitation are explained.

The public healthcare sector in South Africa supports approximately 80%of the population [14]. Despite this, only roughly half of the total healthcare expenditure is allocated to the public sector [14], resulting not only in a lack of resources [15], but also social injustice. It is therefore imperative that treatment protocols are appropriately prioritised to optimally address diseases such as stroke, to minimise residual disability [11, 16] and consequently workforce-erosion.

Healthcare facilities are usually the first-place people go when they are injured, disabled or ill. Therefore, it makes sense for vocational rehabilitation services to be based within the healthcare system, as this will allow for speedy intervention [17]. Interestingly, vocational rehabilitation is seen as a continuum of services from hospital- to community-based intervention [18]. Furthermore, evidence suggests that persons suffering from chronic conditions benefit from community-based vocational rehabilitation services [18, 19], necessitating a good referral system between levels of care. This also means that vocational rehabilitation services must be available at all levels of care, in one form or another. Since work is a category of occupation [4, 13] and occupational therapists work in all levels of healthcare [13], occupational therapists are well-placed to perform this service.

It is well-known that stroke is a costly disease, and that reductions in the financial burden of stroke are not likely [20]. The indirect costs of stroke, e.g. loss of income due to failure to RTW, burden on family members to provide care and assistance with living costs, could be alleviated at least to some extent by rendering vocational rehabilitation services, especially in the public health arena. Research suggests that individuals who do not RTW are prone to developing psychosocial dysfunction [21]. Work and the satisfaction of earning a living, being part of the working class of the country and supporting oneself and family can contribute to self-esteem, self-worth and give a sense of meaning and purpose to life after stroke, enhancing a sense of independence [21]. In addition, working enables social interaction, and provides a sense of purpose, identity within society and fulfilment of social needs [22].

Coetzee, et al. [22] have found evidence which shows that the sooner people RTW after the injury or disability has occurred, the more cost-effective on the economy, employer and individual, and the more beneficial to the individual financially, as well as mentally. The result of no or poor vocational rehabilitation facilities or processes, especially in the public healthcare system, has a negative impact on the commerce and industry of South Africa [23]. Therefore, the sooner intervention can take place the better, holistically, it will be for all involved.

The referral of patients in the Gauteng public health system happens between various levels of the healthcare system [24] (see Table 1). The referral system ideally involves a two-way movement and is intended to make up a continuum of care [24]. By structuring the referral pathway as such, the Department of Health (DoH) aims to enable vulnerable communities and populations to access healthcare services easily and cost effectively [24], in accordance with the WHO Workforce 2030 policy [25]. Problems with vocational rehabilitation in Gauteng public healthcare systems were identified by Van Biljon [26], who found that vocational rehabilitation services should be offered at all levels of healthcare and not only in tertiary or central hospitals [17]. This allows for easy access for all clients who will be using the service [17]. She also found that vocational rehabilitation is a specialised service and therefore needs dedicated spaces, posts and a multi-professional approach [17]. Other problems that were identified were with referrals, service efficiency and communication breakdown between health care professionals and healthcare facilities, as well as the practitioners’ interest in vocational rehabilitation which was vital for making vocational rehabilitation a success [17]. Return to work and vocational rehabilitation are considered as remediation and therefore not part of the scope of an occupational therapist working in the community. This contradicts international literature, which sees vocational rehabilitation as a continuum of services from hospital to community-based intervention [18].

Table 1
Referral structure of the Gauteng Provincial Health Department

Community level (CHC) (Entry point to access healthcare services; up-referral to PHC or District) •effectively delivered as close to people’s homes, schools, workplaces and communities as possible

•homes, school health teams, residential and day facilities for people with disabilities, the workplace and public spaces such as community facilities and public transport

•focus on overcoming participation restrictions

•health promotion and relapse/secondary prevention

•screening

•referred up to the PHC or CHC if they need further intervention

•down referred toward home-based outreach teams

•lateral referrals to NGO’s or support groups in the community

VOCATIONAL REHABILITATION SPECIFIC SERVICES:

None

Primary Health Care level (PHC) (Entry point to access services; Down-referral to CHC; up-referral to District, Regional or Tertiary level) •offer outpatient rehabilitation addressing impairments in body structures and functions, and activity limitations

•similar to what is offered at district hospital level, although resources and facilities may be restricted

•PHC is generally the most accessible level to offer such services.

•outreach clinics conducted by the OT (based at district, CHC or regional level)

•regular group programs, health education and follow-up conducted by the OTT under supervision.

VOCATIONAL REHABILITATION SPECIFIC SERVICES:

None

District Hospital level (Potential entry point to access healthcare services. Up-referral to regional, tertiary level, down-referral to PHC and CHC, lateral referral to rehab unit) •OT and OTT work closely with the multidisciplinary team at district hospital level to offer rehabilitation at both the acute and subacute levels for inpatients

•focusing on body structures and functions and activity limitations

•outpatient rehab for those who are able to access the hospital readily, or who require equipment and facilities not available at the PHC/CHC level

•also offers routine health promotion programs in partnership with different hospital departments

VOCATIONAL REHABILITATION SPECIFIC SERVICES:

None

Regional Hospital level (Potential entry point to access healthcare services. Up-referral to tertiary level, down-referral to district, PHC and CHC, lateral referral to rehab unit) •regional hospitals do vary greatly in their composition and roles due to geographical issues and resources

•role of occupational therapy is very much the same as at a district hospital, except where specialized units operate

•may act as consultants for therapists who work in the district hospital, PHC and CHC

•down-referral to these levels from regional hospitals is critical

VOCATIONAL REHABILITATION SPECIFIC SERVICES:

1. Screen for impairments likely to affect ability to work or return to work

2. Assess people’s capacity for work and advise on eligibility for Disability Grant

3. Complete DG assessment and report (complex cases requiring assessment of activity limitations and participation restrictions)

4. Provide opportunities for work experiences as appropriate during hospitalisation

5. Provide support and linking to opportunities for training and work

Tertiary/Quaternary Hospital level (Tertiary hospitals are a potential entry point to access healthcare services, although this is discouraged. Up-referral to tertiary level, down-referral to regional, district PHC and CHC, lateral referral to rehab unit) •specialist units

•therapy is provided mainly in the acute phase and on an inpatient basis, although may vary depending on the provincial and local organization of services

•the tertiary/quaternary hospital has a capacitating role to play for all the regional and district hospitals within its drainage area.

•training, outreach and other support functions should be coordinated from this level where possible

VOCATIONAL REHABILITATION SPECIFIC SERVICES:

1. Screen for impairments likely to affect ability to work or return to work

2. Assess people’s capacity for work and advise on eligibility for Disability Grant

3. Refer to District / Regional Hospital for completion of DG assessment and report after discharge

4. Referral to training centres, skills development NGO’s, small

Specialised Units (Dedicated Psychiatric facilities or rehabilitation step-down facilities. Some facilities can be accessed without referral from lower levels, especially psychiatric facilities. Upon discharge, chronic conditions are managed at PHC, CHC and/or District levels) •form of comprehensive inpatient rehabilitation or specialist services provided in community settings (e.g. vocational rehabilitation consultants who work on site or run work centers, specialists in learning disabilities who offer support to learners at school).

•provide highly detailed and specialized assessment, intervention and support.

•may provide medico-legal reports, and complete assessments required by employers to motivate for medical boarding, etc.

VOCATIONAL REHABILITATION SPECIFIC SERVICES:

1. Screen for impairments likely to affect ability to work or return to work

2. Assess people’s capacity for work and advise on eligibility for Disability Grant

3. Complete DG assessment and report (complex cases requiring assessment of activity limitations and participation restrictions)

4. Provide opportunities for work experiences as appropriate during hospitalisation

5. Conduct detailed standardised assessments and make recommendations on ability to (return to) work or qualify for compensation and make recommendations on ability to (return to) work or qualify for compensation

6. Provide support and linking to opportunities for training and work

7. On-site assessments of people’s ability to perform in the workplace

8. Pre-vocational training and work hardening programmes for people needing assistance with transition into or back to work

Community reintegration, including return to work (RTW) is notoriously difficult for people post neurological insult [27]. Importantly, a study among South African stroke survivors found that rehabilitation aimed only at restoring bodily functions, did not automatically facilitate RTW [28]. Therefore, intentional vocational rehabilitation is of great importance, and there is a grave need for it to be addressed as part of the rehabilitation process during both in- and out-patient services. Thus, by the time the individual is required to return to work, they will be confident and adequately prepared to embark on the new challenges which will most certainly be encountered [21]. Despite occupational therapists’ focus on restoring bodily functions [1, 28], patients’ needs [28] seem to suggest that vocational rehabilitation should be included as part of rehabilitation from the get-go, rather than an add-on at the end of rehabilitation.

While there is little information about occupational therapists’ views regarding stroke and vocational rehabilitation, stroke survivors’ views have been documented, and should provide some guidance to practitioners regarding the focus of intervention. Research in Australia found that disorders of cognitive processing are the most influential in determining the loss of paid employment [29, 30]. One study found that an inequality exists whereby workers who have a physical disability are viewed more positively, and therefore are more likely to be accepted back into the workplace, than those with an intellectual or psychiatric disability [31]. Only a very small proportion of stroke survivors are able to return to work after the onset of a stroke due to the functional limitations they face [32 –34]. Factors which facilitated RTW in young stroke survivors were found to be a shorter duration in hospital, a milder stroke, mild cognitive and physical impairments, better participation in activities of daily living, and a supportive home and work environment [32]. In one study, from the perception of people with disability, participants confirmed that transport was one of the greatest barriers when returning to work, especially those with mobility impairments [31]. Factors such as low educational levels [35], social attitudes, beliefs, and societies’ misconceptions and pre-conceived ideas about people with disability are hindering especially younger working-aged people from securing and maintaining gainful employment. In addition, negative beliefs of the stroke survivors themselves also impede employment [6 , 36].

In conclusion, while there is little information about practitioners’ perspectives regarding (return to) work, vocational rehabilitation and stroke, this overview of the literature suggests that stroke survivors, especially those of working age, have clear views about barriers and facilitators to return to work. If practitioners are aware of these, it should enable them to render occupational therapy services at all levels of care that will ensure that stroke survivors remain economically active, rather than become a burden on their families, community and/or the social grant system. Additionally, the literature review aimed at providing some context of the referral system in the public health milieu in which this study occurred.

3 Methodology

3.1 Research design

A qualitative, descriptive focus group design was used to explore practitioners’ perceptions regarding work-related rehabilitation of working-aged stroke survivors [37]. A descriptive, approach was used to describe work-related rehabilitation of working-aged stroke survivors from the occupational therapists’ perspective. Practitioners who work with working-aged stroke survivors at the coalface were regarded as experts of their experiences related to this aspect of occupational therapy in this particular context. Their perceptions would therefore add valuable information that could inform future policies and practices.

3.2 Study population

The study population consisted of occupational therapists who were working at public hospitals (including district hospitals and tertiary academic hospitals) and public clinics in the Gauteng province of South Africa. Participants met the inclusion criteria of currently working with neurological patients or having worked with neurological patients for the last six months in the field of neurological rehabilitation, in and around Johannesburg and Pretoria in the Gauteng province of South Africa. Community service practitioners who rotate between fields of rehabilitation at their respective placements were excluded from the study, as they either did not have enough clinical experience in neurorehabilitation or their experience was not recent enough.

Maximum variation or heterogeneous, purposive sampling was used to identify hospitals from which to select willing participants, [38] to ensure a diverse sample. Primary, secondary, tertiary and quaternary facilities were included, to ensure diversity of experience among participants. Hospitals and clinics in at least three municipal areas in Gauteng were included, to ensure diversity regarding knowledge and experience of local governmental management and funding policies.

3.3 Data collection

The data were collected through focus groups run by the first author, using open-ended, semi-structured questions with subtle prompting and steering [37], as necessary, to draw out the needed information and encourage discussion from the research participants. This included questions such as: What do you feel your role is as part of rehabilitation of a young stroke patient? What does your treatment typically consist of with young stroke patients?

Focus groups took place after regional cluster meetings, which minimised time out of work and decreased travelling for participants. This arrangement could potentially have discouraged some participants, as described in the limitations section below.

Data saturation was achieved with the sixth focus group [39]. Each focus group was audio-recorded and transcribed verbatim, ex post facto.

3.4 Data analysis

Descriptive analysis was employed to analyse the demographic data. The qualitative data were analysed manually, with line-by-line inductive content analysis. A step-by-step analysis process was used, as described [39]. First, the transcripts were read during which we started identifying significant words and statements, which were winnowed down to codes. Inductive, in vivo and descriptive coding techniques were used [40]. Once all the transcripts were coded, a vertical analysis was carried out within each transcription to determine correlation between themes, categories and sub-categories. Codes were grouped into categories, which in turn were grouped into themes. Lastly, we organised the data into a table which represented all the codes, categories and themes emerging from the data [39].

3.5 Rigour

As reliability and validity is important in quantitative research, so rigour in qualitative research is established by ensuring trustworthiness. This study adhered to four strategies of trustworthiness, i.e., transferability, dependability, credibility, and reflexivity [41, 42]. Table 2 describes how each of these strategies were achieved in this study

Table 2
Strategies of trustworthiness in this study

Strategy of trustworthiness Application in this study

Transferability Providing a clear and detailed description of the context and characteristics of the participants

Dependability Giving a clear description of the method of selection of participants and by including the inclusion and exclusion criteria [42].

Credibility Immersion in the field and the data. This was ensured by conducting six focus groups with a duration ranging from one hour to ninety minutes to ensure that the researcher spent sufficient time in the field. The researcher also immersed herself in the data, by listening to the recordings and checking the transcriptions for any errors before coding. Once the coding was completed, both authors iteratively grouped and categorised the codes and organised the categories into themes. An iterative process was followed to remove any possible duplication in the categories and to refine the descriptions of the codes and the categories. Once coded, the second author and a colleague checked the codes to remove any bias [37] which the researcher may have imposed onto the coding.

Reflexivity Regular debriefing sessions with the second author [41, 62] as well as keeping a reflective journal [41, 42].

Strategy of trustworthiness	Application in this study
Transferability	Providing a clear and detailed description of the context and characteristics of the participants
Dependability	Giving a clear description of the method of selection of participants and by including the inclusion and exclusion criteria [42].
Credibility	Immersion in the field and the data. This was ensured by conducting six focus groups with a duration ranging from one hour to ninety minutes to ensure that the researcher spent sufficient time in the field. The researcher also immersed herself in the data, by listening to the recordings and checking the transcriptions for any errors before coding. Once the coding was completed, both authors iteratively grouped and categorised the codes and organised the categories into themes. An iterative process was followed to remove any possible duplication in the categories and to refine the descriptions of the codes and the categories. Once coded, the second author and a colleague checked the codes to remove any bias [37] which the researcher may have imposed onto the coding.
Reflexivity	Regular debriefing sessions with the second author [41, 62] as well as keeping a reflective journal [41, 42].

3.6 Ethical considerations

Due to the inclusion of hospitals and clinics in multiple municipal areas falling under the jurisdiction of two universities, ethical clearance had to be obtained from the Human Research Ethics Committees of both Universities (M150937 and 519/2015 respectively).

While participants in any one focus group were known to each other, their identities were not known to people outside of the respective focus groups and participant numbers were allocated to the participants in each focus group. Participant numbers were used in the transcriptions of the focus groups, rather than participants’ names, to ensure confidentiality.

Participants were provided with information sheets prior to the study and there was opportunity to clarify any questions they may have had prior to the focus groups. Signed, written informed consent was obtained prior to participating in the focus groups.

4 Results and discussion

4.1 Participants

Table 3 gives an overview of the 26 participants ages, genders, number of years’ experience at their current place of employment, in neurological rehabilitation as well as in public health. It also includes their favourite areas of occupational therapy and any additional occupational therapy related course they have completed.

Table 3
Summary of demographics

Participant Age(years) Gender Number of years of experience in the field of neurological occupational therapy Number of years of experience in public health care Number of years of experience at current place of employment Which area of OT do you enjoy most Any OT-related qualifications? What are they?

1 24 F 2 2 2 Paeds 0

2 34 F 8 4.5 1.5 Neuro 1 PGDip Hands

3 27 F 3 4 < 1 Neuro 2 Msc OT

NDT

4 32 F 2 2 2 Voc 0

5 25 F 3.5 3.5 3.5 Psych 0

6 32 F 10 10 6 Community 0

7 26 F 4.5 4.5 4.5 Paeds 1 Intro to Bobath

8 25 F 0.5 0.5 0.5 Paeds 0

9 38 F 14 14 14 Paeds 0

10 23 F 1.5 1.5 1.5 Hands 0

11 28 F 5 5 5 Neuro 0

12 25 F 2.5 2.5 2.5 Psych 0

13 25 F 4 4 4 Neuro 6 DIR

NDT

Tiny Hands

Aquatic Therapy

SI 1

Novice Clinical Supervision

14 25 F 1.5 1.5 1.5 Paeds 0

15 25 F 3.5 3.5 3.5 Neuro 0

16 23 F 0.5 0.5 0.5 Neonatal 0

17 32 F 9 9 9 Neuro 1 Basic Seating

18 25 F 1 3 3 Neuro 0

19 29 F 3 2.5 2 Physical 1 Basic Seating

20 26 F 3 3.5 < 1 Neuro 1 Basic Seating

21 26 F 1.5 3 2 Spinal 1 Advanced Seating

22 25 F 4 4 4 Neuro 0

23 26 F 2 2 1 Psych 0

24 24 F < 1 < 1 < 1 Neuro 0

25 28 F 6 6 1.5 Neuro 2 NDT

Intermediate Seating

26 28 M 6 6 6 Neuro 0

Participant	Age(years)	Gender	Number of years of experience in the field of neurological occupational therapy	Number of years of experience in public health care	Number of years of experience at current place of employment	Which area of OT do you enjoy most	Any OT-related qualifications?	What are they?
1	24	F	2	2	2	Paeds	0
2	34	F	8	4.5	1.5	Neuro	1	PGDip Hands
3	27	F	3	4	< 1	Neuro	2	Msc OT
								NDT
4	32	F	2	2	2	Voc	0
5	25	F	3.5	3.5	3.5	Psych	0
6	32	F	10	10	6	Community	0
7	26	F	4.5	4.5	4.5	Paeds	1	Intro to Bobath
8	25	F	0.5	0.5	0.5	Paeds	0
9	38	F	14	14	14	Paeds	0
10	23	F	1.5	1.5	1.5	Hands	0
11	28	F	5	5	5	Neuro	0
12	25	F	2.5	2.5	2.5	Psych	0
13	25	F	4	4	4	Neuro	6	DIR
								NDT
								Tiny Hands
								Aquatic Therapy
								SI 1
								Novice Clinical Supervision
14	25	F	1.5	1.5	1.5	Paeds	0
15	25	F	3.5	3.5	3.5	Neuro	0
16	23	F	0.5	0.5	0.5	Neonatal	0
17	32	F	9	9	9	Neuro	1	Basic Seating
18	25	F	1	3	3	Neuro	0
19	29	F	3	2.5	2	Physical	1	Basic Seating
20	26	F	3	3.5	< 1	Neuro	1	Basic Seating
21	26	F	1.5	3	2	Spinal	1	Advanced Seating
22	25	F	4	4	4	Neuro	0
23	26	F	2	2	1	Psych	0
24	24	F	< 1	< 1	< 1	Neuro	0
25	28	F	6	6	1.5	Neuro	2	NDT
								Intermediate Seating
26	28	M	6	6	6	Neuro	0

The number of years the occupational therapists were working at their current place of employment brings into question the retention of staff as the majority of the staff had been at their current place of employment less than a year. When considering the number of years of experience practicing in occupational therapy and the ages of the occupational therapists, it is evident that the participants were mostly young with limited experience. This could explain their reluctance to challenge Gauteng public health policies and procedures, and their perceived lack of confidence to engage with employers and other occupational therapists within their referral areas in relation to implementing new services and challenging the status quo. The most significant demographic finding was that only one of the 26 participants indicated vocational rehabilitation as a favoured area of practice. It was also notable that Neurological rehabilitation was by far the participants’ favourite field of practice. Interestingly, however, this did not correspond with the additional postgraduate courses participants had completed, with only a handful of therapists acquiring further training applicable to neurological intervention and treatment.

4.2 Themes, categories and codes

Three themes emerged from the data, the first of which, attitudes towards vocational rehabilitation relates to the first research objective. The second two themes relate to the second research objective. Table 4 provides an overview of the three themes with their respective categories and codes.

Table 4
Overview of themes

Theme Category Sub-category Codes

Theme 1: The world of work is full of complexity Work is regulated Scared of actual legalities around work

Nature of the job Manual Labour Informal, contract work

Residual disability

Higher cognition &executive function White collar workers

Specialist skills are difficult to assess and simulate in a public hospital Miners

Forklift drivers

Driving

Theme 2: We need more training Undergraduate training is insufficient Not enough focus on vocational rehab in UG training

We don’t have skills

Postgraduate specialist training isn’t worthwhile Expensive

Little incentive from the employer

Theme 3: Vocational rehabilitation (VRH) is a complex process VRH requires systems and processes Service-delineation and levels of care Government-determined demarcation

Rehabilitation-focus at PHC level precludes VRH

Add-on Not my preference

Experts must do it

Programmes are not in place

VRH requires resources Physical resources Staff

Costly equipment

Variety of tasks

Logistics Transport for work visits

Space

Theme 4: Treatment priorities do not favour VRH Treatment follows a hierarchy Treat OPAs sequentially

First work on the physical, then basic cognition, then RTW

Patients’ needs drive priorities Employed vs unemployed

Younger strokes

4.2.1 Theme 1: The world of work is full of complexity

4.2.1.1.Work is regulated:Some research participants felt that the legal aspects and technicalities involved with vocational rehabilitation are complex and therefore intimidating. They experience the legislative framework as daunting and they are afraid of the consequences of doing something wrong in what they perceive to be a highly regulated arena. One example is gaining consent and advising patients on their rights and responsibilities. One of the participants stated:

“it’s just knowledge in terms of legislation, ‘cause many times I have to go ask our voc therapist, are they [the patients] allowed to do this, are they [the patients] allowed to know, should their employer wait, how long must they wait before incapacity leave, so I think things like that also can . . . ja –I think it’s just knowledge on how it works.” 4B

With the general population’s increased awareness regarding the law and individuals’ rights, participants felt that getting involved with vocational rehabilitation was risky and intimidating. Buys [43] reports that competency in vocational rehabilitation require basic skills which any occupational therapist should have the ability to carry out [43]. This confirms Van Biljon, et. al.’s [17], findings that the level of knowledge and skills of occupational therapists working in the various Gauteng public healthcare settings varied greatly.

4.2.2 Nature of the job

4.2.2.1.Manual Labour:According to the study participants most of the patients who come through the public healthcare system have manual, blue-collar jobs, with no other skills or education/qualifications, such as construction work, packers and bricklayers. Where participants have residual deficits/disability, these could make carrying out these types of work challenging thus making to return to work difficult

4.2.2.2.Executive functioning is difficult to assess:A few of the participants in this study mentioned that assessing stroke survivors with white collar employment who have jobs that require executive functioning, was extremely challenging, especially the simulation of the actual work environment. One participant gave an example:

“Like I have a lawyer now, so he, like, can do the admin things you know, filing, and that with MODAPTS and maybe computer work, but the actual executive functioning at the practice or if he’s in court, shoo, it’s just . . . I think higher functioning . . . ” 4B

As cognitive functioning, for example, reduced efficiency, pace and persistence of thinking, being unable to adapt to new and difficult situations [29], is likely to be affected after suffering a stroke, some of the occupational therapists felt that stroke survivors who held white-collar jobs in the open labour market were difficult to assess and treat, primarily due to the executive functioning requirements of their work. One study found that, despite the current trend in carrying out evidence-based practice, there are limited cognitive assessments available or suitable for assessment tools that are reliable and valid, readily available to specifically assess the cognitive ability and behaviour suited in a workplace environment [29].

4.2.2.3.Specialist skills are difficult to assess and simulate: Participants reported that rehabilitation of some jobs requiring specialist skills are difficult for two reasons: firstly, because occupational therapists need additional skills to assess these, and secondly because in some industries the jobs are not available after suffering a stroke.

One example that was mentioned repeatedly was that of taxi drivers. After suffering a stroke, an on-road driving test is required before they are allowed to continue driving per se, let alone meet the requirements to obtain a Public Driver’s Permit. In South Africa, these services are only offered in the private occupational therapy sector. One participant reported that:

“So, we do the driving screening here and then if they need an assessment, we refer to [the expert private practitioner], but that’s only in the private sector, patients can’t pay for that so then their driving gets halted.” 5B

Another reported, and several of the participants in this study agreed that:

“a lot of them work in, like, taxi drivers, they do not have, like . . . it is formal employment, but not formal employment, so the taxi [owners] are not going to take them back . . . ” 3I

It was also reported to be difficult to assess and treat specialist skills such as a forklift driver or an individual who operates heavy mining machinery, especially with regards to work simulations, not only from an equipment perspective, but also from the perspective of knowledge of the job:

“ . . . if it is like specific things, like they were operating a forklift or something, I think we don’t have the resources for that. So, if it is something simple like cognitive stuff, they had to improve in memory yes, then we can do that or budgeting, maybe we can do it if it’s like that . . . But when it comes to . . . they need work hardening in order to return as a miner, then . . . maybe the . . . I don’t know. We don’t have enough exposure to see what they do.” 1A

4.2.3 Theme Two: We need more training

This theme ties in with the notion that practitioners are scared of the complexity of the legislative framework around work, labour relations and employment, indicating that they need more training and capacitating. The theme has two categories, related to under- and postgraduate training respectively.

4.2.3.1.Undergraduate training is insufficient:Some of the occupational therapists felt that they were not knowledgeable or skilled enough to carry out certain aspects of the vocational rehabilitation process such as the report writing or making recommendations about reasonable accommodations. Some of them felt that they were inexperienced in this field and had not had much exposure to it even during undergraduate training, not to mention since. One participant stated:

“So, I know in my varsity I never, we never had [vocational rehabilitation] exposure we never even had a [vocational rehabilitation] block. So, the first time I realised there was even anything [vocational rehabilitation] related was when I came back and started working independent practice . . . ” 6B

Another research participant agreed:

“when we study at University level there isn’t focus really on work in [vocational rehabilitation] because in fourth year I get one or two lectures and got trained on MODAPTS, we had a look at like the standardized assessments that you do and that was it.” 1B

A previous study also found the lack of knowledge in terms of predetermined time standards, such as MODAPTS, to be a practice problem in terms of knowledge, skills and confidence [17]. Despite annual VRTT training in MODAPTS and a readily available manual following Van Biljon’s research [44], the results of this study seem to suggest that participants still feel inadequately empowered.

Since the majority of the participants in this study were relatively inexperienced, it stands to reason that in the absence of experience, practitioners rely on standardised assessment and treatment protocols. However, in the absence of standardised protocols, assessment and intervention methods come down to experience. For inexperienced occupational therapists, this can be a challenge [29].

4.2.3.2.Postgraduate specialist training isn’t worthwhile:Many participants felt that the cost-benefit ratio of additional specialist training in vocational rehabilitation, whether at postgraduate degree level or merely attending courses and training in specific FCE protocols (e.g. WorkWell^TM or ErgoScience^TM), did not justify the expense and thus was not worthwhile, especially if not subsidised or otherwise incentivised by the employer:

“ . . . I think also [the employer] needs to take the therapist for training, because you need to be trained in work where, in ErgoScience^TM and so and that is costly. Because I have approached them as well and then . . . because I got a quotation, it was around . . . for the job analysis at the FCE and so forth . . . it was around R60 000 or R70 000. I told them [the employer] and then they like, they are not interested and so now also I told them, like, if I have to pay for that, what will make me stay, whereas I could just go into private?” 2A

Others felt that they had not been properly trained by the Gauteng Health Department on how to use resources such as the screening tools, which are available, and therefore felt incompetent in their skills to carry out the vocational rehabilitation process. However, participants felt strongly that additional training needs to be affordable if not subsidised. Participants felt that despite literature acknowledging the benefits of vocational therapy in terms of social benefits, work place performance and community re-integration [45, 46], the Gauteng Department of Health is not investing in their employees, in acquiring the necessary accreditations and skills to become proficient in carrying out these services. Thus, it is felt that the South African government should invest in vocational rehabilitation, not only in the health sector but in order to save costs in the long-term.

4.2.4 Theme three: Vocational rehabilitation is a complex process

Participants felt that vocational rehabilitation itself is complex and requires systems and processes as well as resources.

4.2.4.1.Vocational rehabilitation requires systems and processes

Service-delineation and levels of care: Participants felt hamstrung by the way the provincial health department delineated services to be rendered. Primary health care level and some district and rehabilitation hospital occupational therapists reported that the way in which government has structured the vocational rehabilitation process is hindering their ability to carry out vocational rehabilitation. Primary health care settings and district hospitals especially only have access to the vocational rehabilitation screening tool and therefore that is the most they are able to do in terms of vocational rehabilitation. One participant stated:

“For Government has kind of done it like that . . . from head office they have said that Bara will do it, Jo’burg General will do it and Dr. George will do it and all the other hospitals will refer to them, because they have trained therapists.” 1C

Occupational therapists report that the policy of the majority of the hospitals, at both tertiary and district level, is that they are not allowed to do work visits. This is perceived to be the role of community-based occupational therapists. One participant in this study stated:

“Ja, so work visits, we unfortunately unable to, due to staffing so our [vocational rehabilitation] unit has only 3 staff members and 1 has been away for some time, so it’s two people in the department and so work visits are limited to PILIR (policy and procedure on incapacity leave and ill-health retirement) cases, which are referred to us by the CEO and we do in-house.” 6B

The functional capacity assessments take place at tertiary hospitals which are situated far from patients’ homes. Patients then must travel between tertiary hospitals and clinics or district hospitals and get lost in the system. Some patients are treated at clinic level, which is a free service and then are referred to a tertiary hospital for the vocational assessment for which the patient then needs to pay. Consequently, patients do not go for the assessment. One participant commented:

“You see, myself, I work in the clinic, ne, the patients do not pay and nobody with their companies they need to pay for you to assess the patient. I can say okay, you know I did not want to patient to go up and down that is why I did that assessment, because sometimes you refer a patient and then you know they go up and down, at the end they do not get what they want. So I just said okay, because I received the patient let me do the assessment and then . . . ja. Because that one it was easy, it was closer to my workplace. So I am not supposed to do that because firstly there are no charge, the patients are not paying. So it means we will do the assessment for free whereas if it was a private company they have to pay.” 2C

4.2.4.2.Vocational Rehabilitation is an add-on:Some of the occupational therapists agreed that vocational rehabilitation is not their area of interest. They prefer to treat the neurological client factors rather than the performance areas using neurological techniques. They agreed that work is important but are grateful to pass it on to someone else when the time is right. One participant stated:

“It also depends who’s the other . . . who’ll do it, but I don’t want it, I want to do my Neuro, I must focus on my Neuro, so if there’s somebody who loves voc, they must do voc. I don’t mind doing the screening tool to see if he needs an assessment, that’s not a problem, but I don’t want to do the hardening . . . ” 4A

Consequently, participants felt that a dedicated vocational rehabilitation team would be better suited to carrying out this role. There are a lot of logistics involved with contacting the employers, staying in contact with employers, carrying out work visits, doing the assessment and re-assessment, writing the reports, following up on a continuous basis, arranging work hardening/conditioning programmes, researching specific cases, such as job descriptions, prognosis, etc.:

“There is definitely the perception that [vocational rehabilitation] is a specialised therapy and that someone else does it . . . not . . . ja, us.” 5A

Where vocational rehabilitation processes are not established, it becomes difficult to implement vocational rehabilitation or return-to-work services:

“We do not actually have a like, work, there is no, . . . , no work hardening program.” 3A

“I think the voc rehab process itself at this hospital isn’t established, it isn’t. We are currently . . . in the beginning stages of doing research to benchmark and to establish a more evidence based voc rehab . . . If there was a set voc rehab program ABC then it would be easier. Much easier.” 5B

4.2.4.3.Vocational rehabilitation requires resources:Occupational therapists from all three levels of the healthcare sector mentioned that lack of resources and available facilities is a big problem in general, but especially for vocational rehabilitation. The financial resources and budgets allocated to the public healthcare system affects the tools and equipment, the buildings and amount of space available, as well as the number of occupational therapists working at each level of healthcare. The cost implications involved in purchasing the assessment tools take a substantial portion of the budget which would be better spent elsewhere. Lack of human resources is also a barrier, as there is not enough staff to cover all patients’ general rehabilitation and perform vocational rehabilitation-related tasks that are not part of general rehabilitation. A few of the participants stated, and several others agreed, in some cases interrupting each other, that in summary the resources required are:

“Staff, human . . . and . . . skills . . . time” 1C,

“equipment . . . resources” 1B

Another participant agreed:

“ . . . in terms of resources we have and the amount of time we have . . . ” 3G

Some of the occupational therapists who are attempting to carry out work hardening, reported that there are no resources in order to carry it out successfully. In order to do so they bring tools and equipment from home. One participant stated that:

“I think resource-wise we try push back on that because we keep using our own stuff for it.” 3B

Another participant in this study agreed, and stated:

“ . . . Work simulation that I’ve done in the past have been things that I bring personally from home, like my own sewing supply and my own bar tending supplies.” 5B

In the long-established Occupational Therapy departments, there were workshops and tools which were used for simulating a range of jobs as well as work hardening. However, this has fallen away over the years. One participant stated:

“ . . . you know we don’t have like tools like we did with the old OT departments had a workshop with tools. It’s fallen away that thing ‘cause you’re not seeing that therapy . . . doing woodwork.” 4A

Another agreed that:

“We want to down refer for clinics and catchment areas to continue with the good work we’ve done, but then you look at how understaffed clinics are and you realise that are not even coping with helping people with their basic functions.” 6A

Logistics, such as transport to do work visits was also raised as necessary resources that often are not available. Participants complained of a dearth of adequate resources to properly implement vocational rehabilitation services. Lack of financial resources has a domino effect on all other resources and services offered. The public health care system in South Africa is notorious for being poorly funded [17, 44]. The Gauteng DOH faces an increase in burden of disease, population, medical inflation, budget growth and immigration. This, together with the number of medico-legal claims and internal management of resources has led to the public health care sector being underfunded [47], making acquisition of additional, usually costly, vocational rehabilitation equipment and resources nearly impossible. This study reinforces the challenges practitioners face when trying to provide vocational rehabilitation services to stroke survivors of South Africa highlighted by a prior study, namely underfunding, insufficient therapist to patient ratios and high staff turnover in public hospitals [17]. These challenges result in long waiting times for patients to obtain vocational rehabilitation services, inadequate vocational rehabilitation services and/or programs due to lack of resources available to carry them out efficiently and long distances for patients to travel in order to access these services. By the time the young stroke survivor has overcome all these challenges, the employer has made alternative arrangements and the job is no longer available, which is not unique to South Africa [48]. Assisting young stroke survivors to find formal or informal employment if they were unemployed or assisting them to return to their previous work place, will benefit the national economy of South Africa, in turn decreasing the burden on the health care system [17]. Occupational therapy has been found to be the only medical profession which actually saves the health department costs [46], however it is imperative that vocational rehabilitation be carried out timeously.

While the Gauteng Department of Health structured its referral pathways to ensure easy access to healthcare services [49] and aligned to the WHO Workforce 2030 policy, participants in this study found the referral system cumbersome. They found the referral system to impede rather than enhance access, because patients often are not in the financial position to reach tertiary hospitals, thus allowing patients to get “lost” in the system. Patients getting lost in the system is not an unfamiliar phenomenon, locally, [50] or internationally [51]. Better integration of services between the levels of care is needed, [52] which should go a long way to ensure that patients are followed up at higher levels of care as intended. Centralised electronic patient records, while it has pitfalls [53], could assist in better tracking of patients. This is confirmed by Van Biljon who found that there was misunderstanding as to what exactly vocational rehabilitation entails and what the role of the occupational therapists is within the public sector [17]. Due to the constant referring up and down, it is understandable that patients give up on the process and end up defaulting treatment: those who are on unpaid leave or are unemployed have limited funds available to keep travelling to services at the various levels of care, which are not guaranteed assist them in returning to work or finding employment. International vocational rehabilitation users also agreed that lack of access to these services can be detrimental to finding and maintaining employment [54]. In the experience of the participants, by the time that this whole process has taken place, most of the employers have already employed someone else to do the job and therefore are no longer willing to reemploy the stroke survivors. Therefore, starting the services early on in the intervention plan is essential. In the absence of a properly integrated health system, this ties the hands of participants who want to offer good vocational rehabilitation services. Van Biljon [17], similarly found that occupational therapists feel hopeless and as a result, vocational rehabilitation services are suffering. It is well known in the literature that clinician turnover affects continuity of care [18] and very recent findings also indicate a link between client non-attendance and clinician turnover [55], thus the findings of it impacting negatively on vocational rehabilitation services are unsurprising.

4.2.5 Theme four: Treatment priorities do not favour vocational rehabilitation

4.2.5.1.Treatment follows a hierarchy:The participants were adamant that occupational therapy intervention is hierarchical: before addressing work as category of occupation, it is necessary to first address what they perceive to be more important categories such as basic ADLs, then instrumental activities of daily living and then only once these have been fully established, work:

“When it comes to specific voc rehab tasks like work simulation or work condition tasks, then that happens after your normal rehab.” 5A

“And the patient does sort of need to dress themselves and brush their teeth before they can get to work in the open labour market anyway . . . ” 5B

The participants all felt that work was the final stage of rehabilitation and could only be addressed once all the other OPAs are in place. The stroke clinical practice guidelines for the management of adult stroke rehabilitation, by Duncan, et. al., seem to concur with this train of thought [56]. The guideline was developed in order to ensure that maximal function and independence of the stroke survivor is established in order to achieve quality of life [56]. Participants also agreed their treatment hardly ever gets to a stage where work or vocational rehabilitation could be carried out, usually as a result of persisting physical limitations or poor compliance to home programs or follow up visits. Despite being exceptionally important, vocational rehabilitation is often perceived to be less of a priority than interventions aimed at improving other occupational performance areas, not only in this study, but also in other studies [34, 48]. Hierarchy in the occupational therapy treatment process seems to belie clinical reasoning [57, 58] and client-centred, [55, 59] evidence-based practice [50]. Further research is needed to better understand the concept of hierarchy-based intervention. In keeping with client-centred practice, vocational rehabilitation should be addressed throughout the whole rehabilitation process, being the ultimate goal for the end of intervention and thus taken into consideration from the beginning.

4.2.5.2.Patients’ needs drive priorities:Participants agreed that they treat according to the patients’ aims and goals. Consequently, if the patient did not express the need to return to work then they ignored it:

“If they express a need and they want to return to work we could do that.” 3E

“If a patient does not want to return to work, well there is very little we can do besides motivate as to why you need to go back to work.” 3J

Where stroke survivors were either employed previously or indicated a need to RTW, participants perceived younger stroke survivors as more motivated to participate in rehabilitation:

“Ja, they are also naturally motivated when they are younger to get better, like they are willing to go the extra mile. They do their exercises. We never have to check up on them, there’s never a problem with them in the ward. They are like willing to . . . you know, fight basically, to get better, the young ones.” 1B

Stroke survivors’ employment status affected whether participants perceived themselves performing vocational rehabilitation services, as well as the outcome of vocational rehabilitation. Very few stroke survivors admitted to public hospitals have formal employment:

“Firstly, we don’t get a lot of formally employed people, candidates, so now they were already unemployed when they got here so you can’t really think they can go back to work if they were never employed. Honestly, I think it is hard enough for an able-bodied person to find competitive work in the open labour market, if you have any kind of disability, even though you are protected by the Employment Equity Act and you are protected by the Labour Relations Act, in reality, the chances are slim of getting back to work.” 5C

Regardless of prior employment status, most of the stroke survivors who are motivated to work end up in the informal employment sector running their own informal businesses such as tuckshops:

“It is often self-employment. I had a patient yesterday, she makes, hmm . . . ‘magwinya’ . . . those vetkoek [fat cakes] and so the rehab has, specifically voc, assisted her just to be able to do that skill . . . it’s not really like proper work, formal sort of work hardening and stuff to go back to formal employment.” 1A

The results of this study seem to suggest that participants often do not have positive experiences around vocational rehabilitation, RTW and access to adequate resources. Due to the nature of patients who access public healthcare services and their jobs, RTW is often very difficult or impossible.

4.2.6 Vocational rehabilitation is a complex process

Literature describes work hardening and conditioning programs as relevant and effective as a treatment strategy even with challenging clients [60]. Importantly, the literature does not describe a hierarchical approach to rehabilitation, and describes work hardening and conditioning programs as graded therapeutic programs [60]. It is therefore possible that participants may have a misconception of these terms. South African practitioners’ understanding of work hardening and work conditioning programs needs to be further explored in future research.

4.2.7 We already have too much work

Vocational rehabilitation as part of occupational therapy also includes working with individuals who are unemployed or those who are not able to return to their current job due to the severity of their impairments. Participants felt that this creates an added responsibility for the occupational therapist to include job seekers’ groups or explore alternative employment opportunities, thus potentially contributing to therapists’ workload and therefore reinforces their view that vocational rehabilitation is time-consuming. This confirms the findings of an earlier study in Gauteng [17], that occupational therapists feel obliged to investigate alternatives such as entrepreneurial, sheltered or protected workshop options or to assist patients with actual job seeking or volunteering [61]. However, contrary to earlier studies, this study’s findings seem to show that participants view vocational rehabilitation as an add-on service increasing their day-to-day workloads, which confirms an earlier study’s findings [44].

5 Limitations of the study

Contextual factors limited some potential participants’ ability to participate in the study. While the study design attempted to accommodate practitioners by conducting the focus groups at regional cluster meetings, thus limiting time out of work and ensuring participation from occupational therapists from multiple settings in each focus group fostering diverse views, this meant that multiple occupational therapists from the same hospital/clinic shared transportation. Shared transportation discouraged participation, as potential participants whose colleagues were ineligible for participation, either had to request their colleagues to wait for them, or be left stranded at the venue of the meeting.

While likely to be a function of the post structure in the Gauteng Provincial Health Department, participants in this study were mostly inexperienced, which could have affected the richness of data. It may also account for what appears to be a lack of confidence in their professional knowledge and abilities. Although it is useful to learn more about inexperienced practitioners’ views and this paper holds important implications for further occupational therapy education and training, we nevertheless view it as a limitation because more experienced practitioners may have provided deeper and perhaps richer experiences and perceptions.

6 Conclusion

Most of the participants felt resigned and have a negative perception of vocational rehabilitation, especially due to the lack of available resources, time and insufficient staff numbers to assist with carrying out the workload. The nature and severity of the stroke as well as individual patients’ motivation, impacted their ability to return to work, in these participants’ experience. The high unemployment statistics and nature of employment of the South African workforce makes returning to hard, manual labour with a physical impairment challenging, which is a worldwide phenomenon [6]. Occupational therapists should identify all patients skills and training, and they and other members of the multidisciplinary team (including social workers) should be au fait with strategies and policies that could facilitate patients’ retraining/reskilling, e.g. the South African Skills Development Act. Further research is necessary to understand practitioners’ knowledge and use of such instruments and the perceived success thereof, particularly in contexts where work generally is scarce.

Few facilitators to vocational rehabilitation were mentioned. Practitioners mentioned private NGOs were accommodating and there were a number of learnerships available for young people with disability. They also mentioned that legislation regarding employment of people with disability was a strong enabler and gave stroke survivors the upper hand in returning to paid employment, despite participants’ reported lack of confidence and knowledge of the legislation. Further education and training should thus focus on ensuring occupational therapists’ competence and confidence in applying the legislation.

Concerns with policy, both the development and implementation thereof, were voiced. In the context of concepts such as Occupational Justice and Occupational Deprivation, occupational therapy practitioners are encouraged to get involved with policy makers in order to give on-the-ground, first-hand, practical input and feedback. This will allow practitioners to become a part of the policy-making process and therefore will be able to use these policies to the advantage of both patients and themselves, when providing vocational rehabilitation services in Gauteng public health. By becoming involved, they may feel more empowered to affect resource-allocation, which in the long run will enable patients to contribute to the economy.

This study identified a need among participants for training to improve their skill in relation to a variety of aspects of vocational rehabilitation, including better knowledge of the vocational rehabilitation process and enhancing practitioners’ confidence regarding the legal aspects around vocational rehabilitation. Multiple occupational therapy structures provide continuing professional development courses, which should be tailored for these practitioners and must be affordable. Practitioners interested in attaining higher degrees, or those interested in professional development should be accommodated. Courses should address a variety of topics, including occupational justice-related issues, as well as high-level advocacy and practical skills related to facilitating RTW.

Footnotes

Acknowledgments

The authors would like to acknowledge the occupational therapists in the Gauteng Department of Health who participated in the research study.

Conflict of interest

The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.

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Community level (CHC) (Entry point to access healthcare services; up-referral to PHC or District)	•effectively delivered as close to people’s homes, schools, workplaces and communities as possible
	•homes, school health teams, residential and day facilities for people with disabilities, the workplace and public spaces such as community facilities and public transport
	•focus on overcoming participation restrictions
	•health promotion and relapse/secondary prevention
	•screening
	•referred up to the PHC or CHC if they need further intervention
	•down referred toward home-based outreach teams
	•lateral referrals to NGO’s or support groups in the community
	VOCATIONAL REHABILITATION SPECIFIC SERVICES:
	None
Primary Health Care level (PHC) (Entry point to access services; Down-referral to CHC; up-referral to District, Regional or Tertiary level)	•offer outpatient rehabilitation addressing impairments in body structures and functions, and activity limitations
	•similar to what is offered at district hospital level, although resources and facilities may be restricted
	•PHC is generally the most accessible level to offer such services.
	•outreach clinics conducted by the OT (based at district, CHC or regional level)
	•regular group programs, health education and follow-up conducted by the OTT under supervision.
	VOCATIONAL REHABILITATION SPECIFIC SERVICES:
	None
District Hospital level (Potential entry point to access healthcare services. Up-referral to regional, tertiary level, down-referral to PHC and CHC, lateral referral to rehab unit)	•OT and OTT work closely with the multidisciplinary team at district hospital level to offer rehabilitation at both the acute and subacute levels for inpatients
	•focusing on body structures and functions and activity limitations
	•outpatient rehab for those who are able to access the hospital readily, or who require equipment and facilities not available at the PHC/CHC level
	•also offers routine health promotion programs in partnership with different hospital departments
	VOCATIONAL REHABILITATION SPECIFIC SERVICES:
	None
Regional Hospital level (Potential entry point to access healthcare services. Up-referral to tertiary level, down-referral to district, PHC and CHC, lateral referral to rehab unit)	•regional hospitals do vary greatly in their composition and roles due to geographical issues and resources
	•role of occupational therapy is very much the same as at a district hospital, except where specialized units operate
	•may act as consultants for therapists who work in the district hospital, PHC and CHC
	•down-referral to these levels from regional hospitals is critical
	VOCATIONAL REHABILITATION SPECIFIC SERVICES:
	1. Screen for impairments likely to affect ability to work or return to work
	2. Assess people’s capacity for work and advise on eligibility for Disability Grant
	3. Complete DG assessment and report (complex cases requiring assessment of activity limitations and participation restrictions)
	4. Provide opportunities for work experiences as appropriate during hospitalisation
	5. Provide support and linking to opportunities for training and work
Tertiary/Quaternary Hospital level (Tertiary hospitals are a potential entry point to access healthcare services, although this is discouraged. Up-referral to tertiary level, down-referral to regional, district PHC and CHC, lateral referral to rehab unit)	•specialist units
	•therapy is provided mainly in the acute phase and on an inpatient basis, although may vary depending on the provincial and local organization of services
	•the tertiary/quaternary hospital has a capacitating role to play for all the regional and district hospitals within its drainage area.
	•training, outreach and other support functions should be coordinated from this level where possible
	VOCATIONAL REHABILITATION SPECIFIC SERVICES:
	1. Screen for impairments likely to affect ability to work or return to work
	2. Assess people’s capacity for work and advise on eligibility for Disability Grant
	3. Refer to District / Regional Hospital for completion of DG assessment and report after discharge
	4. Referral to training centres, skills development NGO’s, small
Specialised Units (Dedicated Psychiatric facilities or rehabilitation step-down facilities. Some facilities can be accessed without referral from lower levels, especially psychiatric facilities. Upon discharge, chronic conditions are managed at PHC, CHC and/or District levels)	•form of comprehensive inpatient rehabilitation or specialist services provided in community settings (e.g. vocational rehabilitation consultants who work on site or run work centers, specialists in learning disabilities who offer support to learners at school).
	•provide highly detailed and specialized assessment, intervention and support.
	•may provide medico-legal reports, and complete assessments required by employers to motivate for medical boarding, etc.
	VOCATIONAL REHABILITATION SPECIFIC SERVICES:
	1. Screen for impairments likely to affect ability to work or return to work
	2. Assess people’s capacity for work and advise on eligibility for Disability Grant
	3. Complete DG assessment and report (complex cases requiring assessment of activity limitations and participation restrictions)
	4. Provide opportunities for work experiences as appropriate during hospitalisation
	5. Conduct detailed standardised assessments and make recommendations on ability to (return to) work or qualify for compensation and make recommendations on ability to (return to) work or qualify for compensation
	6. Provide support and linking to opportunities for training and work
	7. On-site assessments of people’s ability to perform in the workplace
	8. Pre-vocational training and work hardening programmes for people needing assistance with transition into or back to work

Theme	Category	Sub-category	Codes
Theme 1: The world of work is full of complexity	Work is regulated		Scared of actual legalities around work
	Nature of the job	Manual Labour	Informal, contract work
			Residual disability
		Higher cognition &executive function	White collar workers
		Specialist skills are difficult to assess and simulate in a public hospital	Miners
			Forklift drivers
			Driving
Theme 2: We need more training	Undergraduate training is insufficient		Not enough focus on vocational rehab in UG training
			We don’t have skills
	Postgraduate specialist training isn’t worthwhile		Expensive
			Little incentive from the employer
Theme 3: Vocational rehabilitation (VRH) is a complex process	VRH requires systems and processes	Service-delineation and levels of care	Government-determined demarcation
			Rehabilitation-focus at PHC level precludes VRH
		Add-on	Not my preference
			Experts must do it
			Programmes are not in place
	VRH requires resources	Physical resources	Staff
			Costly equipment
			Variety of tasks
		Logistics	Transport for work visits
			Space
Theme 4: Treatment priorities do not favour VRH	Treatment follows a hierarchy		Treat OPAs sequentially
			First work on the physical, then basic cognition, then RTW
	Patients’ needs drive priorities		Employed vs unemployed
			Younger strokes