Translating Research into Practice in the Employment of People with Disabilities: The Motivation Factor and Stages of Change Steve Williams, MD Bethlyn

Translating Research into Practice in the Employment of People with

Disabilities: The Motivation Factor and Stages

of Change

Steve Williams, MDBethlyn Houlihan, MSW, MPH

Jane Wierbicky, RNNew England Regional SCI Center

Boston Medical Center

ACRM-ASNR Conference Sept. 30, 2006

Copyright 2006, NERSCIC Reproduction w/ permission only

Learning ObjectivesParticipants will be able to…1. Describe up-to-date research on the employment of

people with disabilities in terms of the extent of the problem, predictors of employment, and related factors.

2. Summarize qualitative research findings exploring the motivation of people with disabilities in employment-seeking activities using the Transtheoretical Model (aka “Stages of Change”).

3. Understand the role of motivation and Stages of Change in guiding further research, and in translating current research findings into effective interventions to better serve people with disabilities, particularly at-risk and hard-to-reach populations.


Presentation Outline

• Existing Research: What We Know

• Translating Research Into Practice: Exploring Stages of Change in Relation to Motivation & Facilitators/Barriers to Employment

• Practice Recommendations & Future Directions for Research


The Ongoing Problem of Unemployment in SCI

• 78.5% of unemployed < age 34 want to work– Only 29% looking for work (Krause, 2001)

• Employment rates– 35% of people with disabilities (pwd) in paid work

FT or PT (NOD Disability Survey, 2004)– Versus: 25% of people with SCI (pwSCI) (Krause

et al,1999)

• Trends over time– 1986 = 34% pwd employed– Subsequent 8 years = 5% decline– Rebound by 2004


Impact of Being Employed on pwSCI

• More satisfied with life• More active• Fewer medical treatments• More education• Perception of fewer problems• Higher overall adjustment

(Yasuda et al, 2002, p. 180)


Predictors of Employment: Personal Characteristics

• Years post-injury (more)• Age (younger)• Age at injury** (younger)• Gender (male > female)• Education level** (esp. African Americans; 16+ yrs=

95% worked post-injury)• Race (Yr 3 > Yr 1) (Caucasians working more)• Physical and mental health**• Stamina• ~Injury level• Married (Yrs. 1&2 only)Yasuda et al, 2006NOTE: starred items are strong predictors replicated in several studies


Predictors of Employment: Job-Related Characteristics

• Able to return to pre-injury job– Professional occupation pre-injury = lower

physicality– ~75% need accommodation (Dowler et al, 1998)

• Physicality of prospective job– Shift towards administrative, clerical, finance

• Limited scope of job options presented/ available

• Hours per week: shift from full-time to part-time pre- to post-injury


Other Related Factors • Self-report barriers: (Castle, 1994 in Yasuda et al, 2002)

– Transportation, lack of benefits, physical limitations

– Employed: Lack of stamina & confidence; low morale

– Unemployed: Lack of skills; need for retraining & help in finding new careers

• Considerations in improving work satisfaction: (Wehman et al, 2000 in ibid)

– Employed: May need to change job or job structure (incl. duties, supervisor, hrs worked)

– Unemployed (if employed): Ongoing health problems; transportation; disability benefits


Other Related Factors (Cont’d)

• Vocational decision-making barriers (Krause & Anson, 1996 in Yasuda et al, 2002)

– Lack of info about employment opportunities– Uncertainty (about abilities and in general)– Lack of knowledge of occupation types

• The above are related to gender, age, race, level of injury

• Return to work = dynamic process


Questions for Discussion

• Are these factors correct in your experience?

• Are there others that should be included?


Qualitative Employment Research at NERSCIC

1) Employment intervention for chronically unemployed: convenience sample; rehab as point of entry; weekly check-in; peer mentors; community linkages for referrals.

2) Employed/Unemployed focus groups to assess: facilitators/barriers, role of readiness/stages of change, & recommendations

3) Employment agency interviews


Five Stages of Readiness to Change:1) Precontemplation: Not thinking about change; May be resigned

2) Contemplation: Weighing benefits/ costs of behavior change 3) Preparation: Experimenting with small changes 4) Action: Taking a definitive action to change

5) Maintenance: Maintaining new behavior over time

Conceptual model in public health, originally for addictions

Rationale: Most interventions target those ready to change; 70% of smokers not ready to take action on own, so need interventions to increase readiness

Stages of Readiness forBehavior Change (Zimmerman et al, 2000)


Focus Group Description

Employed Group w/ SCI (N=7)

Unemployed Group w/ SCI (N=6)

Participant

Criteria

Employed for the past 6+ mos and employed for 9 of the past 12 mos

Unemployed for > 1 yr and interested in employment (actively seeking not required)

Demographics Gender

Male Female

43% (n=3) 57% (n=4)

100% (n=6) 0% (n=0)

Educational Level High School Assoc./Bach.

Masters

0% (n=0) 72% (n=5) 28% (n=2)

33% (n=2) 50% (n=3) 17% (n=1)

Race/Ethnicity Caucasian

African American Hispanic

100% (n=7) 0% (n=0) 0% (n=0)

66% (n=4) 17% (n=1) 17% (n=1)

Focus Group Analysis

Stages of Change &

Application to Employment


Stages of Change in Employment: Pre-Contemplation

Application to Employment Readiness

Participant Quotes

Adjustment to injury; Not sure how to function independently in life

“Seemed like I couldn't do anything in my chair, so I was home watching soap operas for 3 yrs.” “You don’t know what the day is going to bring tomorrow; how my injury is going to affect my daily life...”


Stages of Change in Employment: Contemplation


Participant Quotes

Considering the idea of working; Gaining independence; Exploring own job abilities and how life would be affected by working

“It finally dawned on me that everyone was telling me I can do this stuff, well guess what, I’m going to do it.” “I’m not sure that I was—I don’t know if it’s emotional or psychologically—ready to work; however, I would have appreciated the information…’ here’s your situation, here’s your options.’”


Stages of Change in Employment: Preparation


Participant Quotes

Gathering information for jobs; Gaining skills and confidence; Locating services and resources

“I got in touch with [State Rehab Commission], and I knew that I needed to be reschooled.” “It’s been 4 years since I got hurt, and for 2 years I’ve been trying to work. For 2 years, how to...find an assistant to help me do my financial aid papers, or...learn on the computer how to do a resume.”


Stages of Change in Employment: Action


Participant Quotes

Active job search; Using available services/ resources

“I went to [State Rehab Commission]; everyone always told me about [State Rehab Commission], but I never went.” “I just had a meeting with my [State Rehab] counselor and [another] counselor. They looked over my resume and gave me suggestions.”


Stages of Change in Employment: Maintenance


Participant Quotes

Requesting necessary Accommodations; How to fit work into life w/ SCI

“...agency has a kid file my stuff in the office” “It’s hard, my life is very planned around work/ personal care. I’m exhausted all the time.” “Flex time, [to keep] routine in morning…”


Questions

• Does Stages of Change seem like a useful model?

• In what ways does it make sense to apply?

• What are its limitations?


Resources/Logistics

Perceptions of Ability

Individual Characteristics

Disability & Health

Skills Training & Education

Information/ Knowledge

Existing Services/ Programs

Focus Group Analysis: Major Employment Domains

Individual L

evelC

omm

unity L

evel


Individual Resources/ Logistics•Transportation•Financial•Family support•Time availability•Accessibility of environment•Personal care assistance

Perceptions•Individual --own ability --anticipated discrimination•Employer & coworker response --disability- related --race-related --level of qualifications

Individual Characteristics

•Interests•Skill set•Marital status•Ability to initiate

Disability & Health•Physical and mental health status•Age at injury•Level of injury•Self-care routine•Cognitive ability

Individual Level Domains


Skills Training & Education

•Computer/Internet skills•Job-seeking skills•Training opportunities (interning)•Educational status

Information/ Knowledge

•Existing services/ programs•Rights under the ADA•Scope of job options•Job physicality fit w/ personal ability

Existing Services/ Programs

•Knowledge level of service provider•Coordination of services•Getting the “word” out•School assistance•ADA & other government policies/programs•Scope of job options•Benefits

Community Level Domains


Focus Groups: Top Factors Impacting Readiness

• Individual Level– “Motivated” w/ self esteem (Type A vs. Type B)– Young age at injury (<18 yrs old)– Interests in line w/ offered job options– Able to drive independently– Married– Home computer/ Internet access

• Community Level– Info not available re: future vocational options early on; benefits

impact; job task fit w/ physical abilities; scope of job options to fit interests, incl. non-traditional & self-employment; existing services. (Barrier)

– Outreach in years 1& 2 at home


n=4

n=5

n=4

n=1

n=0

n=1

0

10

20

30

40

50

60

70

80

90

100

Age at Injury < 18

Married, SpouseWorking

DrivesIndependently

% Y

es Employed

Unemployed

Individual Factors


“Self-Motivated” Personality vs. “Free spirited”: Employed Group

(Type A vs. Type B)• The employed group described themselves as

being self-motivated and persistent when asked what helped them become ready to find a job:

“I was self-motivated...I had an inner resolve within me that I didn’t know existed until the going got

tough.”“After my injury, I went right back to school and

said I’m going to do this and that, and I just did it.”

“I was fortunate to have a personality to seek out stuff.”


Motivation: Unemployed Group

• Many in the unemployed group described themselves as more free spirited and exploratory, both in life and in their job choices pre-injury:

“Before my accident...I just took jobs that would give me more time to play...work part-time and have some fun.”

“Prior to my accident, I probably was on that same “odd job” path...working part time at a hospital,

I would pretty much yell out the codes…And also I was DJ’ing weddings.”

“Prior to my accident, I had no aspirations for schooling. I was doing physical labor, and that suited me fine.”


Confidence in Job-Seeking w/ a Disability: Employed Group

• The employed group described gaining a sense of confidence to be ready to successfully seek out a job:

“Confidence. It takes time to get confidence back and feel comfortable asking for the help you need.”

“[I] had almost given up, went into [book store] and noticed they have an employee in a wheelchair...went right up

and said ‘Can I have an application? I notice you have a disabled person working here.’ I was very bold about it.”“I find it’s all in attitude and how you portray yourself.

Once people see you’re ok, then they’re ok.”


Confidence: Unemployed Group• The unemployed group was less confident overall, and felt

that w/ an education, they can gain respect and confidence:“People judge you by what they see. It also serves as a barrier

for myself because it makes me feel that there are less things that I am able to do, which may or may not be the case.”

“Where there are ten other people that can do the job without [accommodations] … that’s going to be difficult to

overcome. That’s probably my hang up more than someone else’s, or somebody on the other end hiring.”

“I’ve always seen education as like a weapon…so that someone else can’t prevent me from getting an opportunity.”

“First, I would like to get an education. That way, you get that respect. If you’re disabled, you need...that degree.”


Diverging Experiences of Services: Employed Group

• The employed group expressed fewer barriers, and that available services greatly assisted w/ readiness:

“I was encouraged to start working right away because [State Rehab Commission] wanted to get people working

right away.” “...after college, I really felt all the doors were open to me

and I had hope for a future—[State Rehab] helped me, helped me get my van, helped me find work. Really they

were the ones that kind of started me on the path to rehab.”

“...peer mentor, he called me out of the blue to see how I was doing. He said, ‘Have you contacted [State Rehab]?’

And he set up a meeting and that’s how it all started.”


Diverging Experiences of Services: Unemployed Group

• Most in the unemployed group found few services available, little information, and few competent employment professionals:

“You don’t get too much support out there, you know…I’m tired of [employment agencies] already.

‘I’ll call you back tomorrow….’ Five months after, they still didn’t call you back.”

“A lot of agencies just want to get you to work, but they don’t tell you all the parts that are going to be affected

after.““Small Business Administration...they are archaic! They

had no idea how to start a computer-based company!”


Limited Job Options & the Pigeon-Hole Effect: Employed Grp

• All in the employed group could return to previous job, or pre-injury interests in working w/ people, a good match w/ state vocational agency’s traditional focus on human service and disability advocacy job options.

“I probably wouldn’t do something in this field probably if I wasn’t injured, but different things happen in life, and

your path changes. But I would do something with people, I’m sure. (State Vocational Counselor)

“After injury, I was home for quite a while, not knowing what I wanted to do with my life, but I knew I wanted to

do something with people.” (Dir. Of Volunteer Svcs)“I always knew that I wanted to help people...I don’t really

think my views changed much…” (Social Worker)


Limited Job Options & the Pigeon-Hole Effect: Unemployed Grp

• For the unemployed group, who could not return to previous job, state voc. agency couldn’t individualize job options to match their alternative and/or exploratory job interests. This led to the “Pigeon-Hole Effect”.

“There are jobs I could take...Wal-Mart or something—greeting...but c’mon. For me, I

don’t feel like these are jobs that use me to my full ability of what I can offer…Will I be

satisfied emotionally or mentally and will it provide for me financially?”


Pigeon-Hole Effect: Unemployed Grp (Cont’d)

“I’m working with [State Rehab] and they’re kind of pushing me towards a specific goal, a vocational goal,

which is rehab counseling...one of my major concerns is that the opportunities that are out there are not visible enough, so I feel like I’m only left to go to school.

That’s my only option.”

“I didn’t go through [State Rehab] because I found them to be wanting to pigeon-hole you into a particular job...

They’re not willing to step beyond the box to let somebody experiment with something different, something new.“


What do Consumers Want at Each Stage?

1) PRECONTEMPLATION: Education in acute rehab about the reality of working & beginning steps to build future readiness (housing, transportation, etc.)

2) CONTEMPLATION: Wider scope of job options to fit skills, interests, and physical capabilities, incl. computer-based jobs; Job peer mentors


What do Consumers Want at Each Stage?

3) PREPARATION: More readily accessible info (ex. Website portal); Coordination of existing service agencies; Training program for people with disabilities, including internships, to get experience to gain a better job; Regular networking lunches, not just for the job ready

4) ACTION: Networking opportunities; Computer-based jobs (& training)


Employment Agency Interviews Compared to Focus Groups

Differences

(Overlooked by EA)

•Marital Status (Domain: Individual Characteristics)

•Age at Injury (Domain: Disability & Health)

•Call Right time/Right place (Domain: Existing Services/ Programs)

Similarities

•Many Individual and Community Domain items from focus groups were echoed by employment agencies (EA)


Employment Agency Interviews: Unique Recommendations

• Develop more effective ways for active outreach to SCI non-service seekers (who are not job ready); utilize existing approaches more

• Develop more community connections for referrals for those not job ready, incl. vocational counseling

• Recruit diverse staff as service providers to improve cultural competence & linguistic capacity

• Promote state vocational agencies--many individuals not aware of services provided

• Engage employers w/disability; > understanding


Employment Agency Interviews: Unique Recommendations (Cont’d)

• Market to schools, pharmacy centers, hospitals, DMR, DMA, etc.

• Develop early intervention programs, provider fairs, and job training programs

• Focus not just on job skills, but job-related skills (“professionalism”)

• Focus more on pre-employment options for pre-contemplation, contemplation, preparation: volunteering, interning, self-assessment & evaluation

• Post-employment maintenance difficult; provide support to prevent absenteeism, etc.


Applying Stages of Change

• In understanding case studies: NERSCIC & others• To translate findings of public reports: Best

Practices in State Government & Best Practices in Home-Based Employment

• To shape recommendations from NERSCIC findings & previous research for policy and intervention


Future Directions of Research• Further quantification of factors and effects of

employment/unemployment, using Stages of Change paradigm

• Services used and most useful for behavior change at different stages

• Research: how to impact motivation & other psych factors ignored to date (Murphy et al, 2003)

• Survey to establish research priorities of pwd• Use ICIDH-2 for common disability definitions• Expand definition of successful outcomes: short- and long-

term; change in readiness; matched to individual’s priorities


Questions

• In your experience, what impacts a person’s readiness to begin a job search? What helps them to keep searching?

• Employment is a complex issue with many contributing factors. What priorities does the field need at this time?


Acknowledgements

• This project was made possible through the National Institute of Disability & Rehabilitation Research Model SCI Systems Grant (Grant # H133N000024)

Contact Information

Bethlyn Houlihan

[email protected]

Ph: (617) 638-7380

Documents

Translating Research into Practice in the Employment of People with Disabilities: The Motivation Factor and Stages of Change Steve Williams, MD Bethlyn