Practices and roles of Irish occupational therapists ’ with adults with intellectual disabilities who access supported employment services

Purpose – Work is good for one’s health and well-being. Work for people with disabilities should be encouraged because it is therapeutic and improves participation in the society, leading to better health outcomes. It develops interpersonal relationships and enhances life quality. Work is an aspiration for many people with intellectual disability. Within research literature, there appears to be a lack of research into the experience of occupational therapists in Ireland who refer adults with intellectual disabilities to supported employment services. The purpose of this paper was to explore the experience of Irish occupational therapists who refer adults with intellectual disabilities to supported employment services. Design/methodology/approach – Semi-structured, in-depth interviews were conducted with four occupational therapists recruited through the Association of Occupational Therapists of Ireland (AOTI). Data were analysed using thematic analysis. Findings – Themes that emerged were as follows: occupational therapy participants did not directly refer adults to supported employment but received referrals; occupational therapy roles included assessments, task analysis and development of client’s skills are major components of current practice; pragmatics involved factors that facilitate and challenge; and future roles. Originality/value – This paper contributes to occupational therapy practice knowledge by providing a perspective on supported employment in Ireland. Occupational therapists should continue to work in the area of supported employment to support social inclusion and enable participation. Further research with occupational therapists working in this field is required to inform practice.

Introduction/literature review Work, employment and intellectual disability Many descriptions of work and/or employment and its benefits exist within occupational therapy literature.Work involves the application of physical or mental effort, skills, knowledge or other personal resources (Warr, 1987), including activities needed for engaging in remunerative employment or volunteer activities (Mosey, 1996) (cited in American Occupational Therapy Association, 2008).Besides employment being a right (UN General Assembly, 1948), employment is a source of meaning in people's lives (Saunders and Nedelec, 2014).In relation to rights for people with disabilities, Inclusion Europe (2001) highlight that employment is important, and the 2005 Disability Act (Houses of the Oireachtas, 2005) endorses this right in Section 37 (b).Within the social model of disability, Oliver (1996) emphasises the importance of rights, access, choice and control for individuals with intellectual disabilities.
Various gains are associated with work/employment and occupation for people with disabilities.Evidence suggests work is beneficial to health and well-being (Dickie, 2003;Bond, 2004).Work for people with disabilities should be encouraged because it is therapeutic, improves participation in the society, leads to better health outcomes, develops interpersonal relationships and enhances life quality (West et al., 2005;Waddell & Burton, 2006).For many people with an intellectual disability, work is an aspiration (Jahoda et al., 2008) and an important goal for improving the quality of life (Siperstein et al., 2013).Hall and Wilton (2011) state that work is a key route to social inclusion for people with a disability.Employment and work have the potential to contribute to addressing social exclusion.Harrison and Sellers (2008) refer to social exclusion as being where individuals have limited opportunities to participate in activities such as work.
Despite knowing positive benefits of work/employment, available statistics indicate that people with disabilities are under-represented in employment.They are half as likely to be in employment as others of working age (Government of Ireland, 2015) with less than 10 per cent of people with intellectual disabilities employed (McConkey andMezza, 2001 cited in Hensel et al., 2007).Additionally, Rose et al. (2005) maintain that people with intellectual disability are amongst those in the society with the lowest employment rate.In Ireland, there are approximately 27,000 people with an intellectual disability on the register of the National Intellectual Disability Database (Inclusion Ireland, 2008).

Supported employment in Ireland
Supported employment is a current practice in Ireland with a number of services nationally.Individuals with intellectual disabilities form part of the cohort of individuals who access these services.Supported employment enables people with intellectual disabilities to enter employment (Wilson, 2003).Ireland has a history in supported employment going back to 1988 (Nic Suibhne and Finnerty, 2014).There are a number of agencies that provide supported employment services to employers and employees in Ireland, and the Irish Association for Supported Employment (IASE) support these agencies.IASE represents almost 900 members who work with almost 5,000 individuals (Nic Suibhne and Finnerty, 2014), including individuals with intellectual disabilities.There are various models associated with supported employment.For example, the Individual Placement and Support (IPS) (Bond et al., 2001) model which has been used most commonly with individuals with severe mental health difficulties in the USA.In Ireland, "place and train" (Turner, 2009) is a method used, and more recently, in Ireland, the Job Shadow Initiative (JSI) from IASE has been providing individuals with the opportunity to experience the world of work, supporting the focus on employment of people with disabilities (Nic Suibhne and Finnerty, 2014).
Nic Suibhne and Finnerty (2014) highlight that assistance should be provided to the employee and the employer before, during and after obtaining a job, and Turner (2009) supports this concept where "support for the employer as well as the placed employee increases the likelihood of success" (Turner, 2009, p. 17) with regard to supported employment.Support is often provided by a job coach when an individual is receiving the services of supported employment.Job coaches provide individuals with what Nic Suibhne and Finnerty (2014) describe as individualised support and on-the-job training.Supported employment facilitates the integration of people with disabilities into paid employment in the open labour market, [Foras Aiseanna Saothair (FAS), 2008; European Union of Supported Employment (EUSE), 2010] providing support to assist with this integration process and meeting the labour requirements of employers [Foras Aiseanna Saothair (FAS), 2008].Best practice advocates that supported employment is driven by the individual [European Union of Supported Employment (EUSE), 2005] with substantial evidence demonstrating the effectiveness of supported employment (Marshall et al., 2014) with reduced discrimination, enhanced financial status, security and self-worth (West et al., 2005;O'Bryan et al., 2000).Interestingly, Casper and Carloni (2007) claim that supported employment services are under-utilised, and the rationale used by practitioners to refer individuals to supported employment is not broad enough.

Literature review
Much of the available evidence and research on supported employment is from the perspective service users with mental health difficulties.Findings reported by Strong (1998), Legault and Rebeiro (2001), Kennedy-Jones et al. (2005) and Corrigan et al. (2007) all report on the experience of people with mental health difficulties.They note the positive impact supported employment had on their recovery often discussing such factors such as stigma and barriers to employment.
Less is reported by service users with intellectual disabilities.The evidence that pertains to their experience includes barriers that exist.According to Lemaire and Mallik (2008), these barriers include client factors such as inattention, interpersonal problems, literacy difficulties, behaviour problems, inadequate work quality, poor attendance and environmental factors, such as inadequate transportation, risk of losing benefits, limited employment opportunities and mobility issues.
In a small qualitative study, Siporin and Lysack (2004) looked at the quality of life for three service users and found that the service user's own perceptions of their quality of life was not always in tandem with that of staff or family, but overall, they appeared to prefer their work in supported employment than in the previous setting of sheltered employment.Further research conducted by Jahoda et al. (2008) investigated the socio-emotional impact of work on people with intellectual disabilities and indicated that there is a positive change in levels of autonomy experienced by individuals with intellectual disabilities who are in competitive employment but a lack of perceived social acceptance amongst those with intellectual disabilities in supported employment.
Motivation levels of the client are addressed by Hensel et al. (2007), where they recommend that supported employment services should focus on this aspect of the client when they engage with supported employment services.In their research into psychological factors associated with obtaining employment, they concluded that supported employment agencies should consider using motivation levels of the client as an entry criterion when individuals are entering supported employment.In a retrospective chart review, West et al. (2015) concluded that poor work performance, attendance and punctuality problems, conflicts with the supervisor and social and behavioural issues caused people to cease being in supported employment.
Limited evidence and research exists from the perspective of service providers.Lynch (2002) refers to best practice and inclusive policies to facilitate individuals in leading ordinary lives and having real jobs in regular settings with appropriate support.In the Irish context, the Comprehensive Employment Strategy for people with disabilities (Government of Ireland, 2015) was launched with priorities focused on building skills, capacity and independence; providing co-ordinated supports into work; making work pay; promoting job retention; and engaging employers.Encompassed in this strategy is the concept of individual's capacity and not an individual's incapacity.This is in congruence with the World Health Organization (2001) International Classification of Functioning, Disability and Health (ICF), which focus on the level of health and participation for individuals, with a shift from cause of an illness or disability to the impact of it functionally on the individual.
Work has always been a domain of occupational therapy practice, where occupational therapy has a philosophy of seeking to create work for individuals with a lifelong disability (Thurgood and Frank, 2007).College of Occupational Therapists ( 2006) supports this, stating that employment is a key agenda for occupational therapy.
Against this backdrop of limited research, the need to investigate the experience of occupational therapists when referring adults with intellectual disabilities to supported employment services in Ireland was identified.'A consistent finding of reports on the issue of employees with disabilities is that, relative to other equality and diversity issues, there is very little research on the subject either in Ireland or worldwide ' (Alban-Metcalfe, 2004a;Hirst et al., 2004;Murphy et al., 2002cited in National Disability Authority, 2008).This leads to the question of what are the experiences of occupational therapists who refer adults to supported employment services in Ireland?
The aim of this research was to explore the experience of Irish occupational therapists who refer adults with intellectual disabilities to supported employment services.A secondary aim was to discover what factors may assist and what barriers may exist for occupational therapists when working in this area of practice.

Research design
A qualitative approach was used for this study.Within the area being researched, there was minimal published information from the viewpoint of Irish occupational therapists who refer adults with intellectual disabilities to supported employment services.In this research project, the authors wanted to establish the experience of occupational therapists in an aspect of programme delivery.Spencer et al. (2003) purport that qualitative data are useful and appropriate as a method when identifying factors that contribute to programme delivery and as a method to analyse policies and verify outcomes.
The authors' rationale for using a qualitative approach for this research include that it is, as Carpenter and Suto (2008) describe, interpretive, flexible and a method of gaining indepth information on the individual's experience.Semi-structured interviews were used by the author because of the nature of them being what Miller and Crabtree (2004) describe as a method of gathering focused, specific information in partnership with participants with a motive to generate themes.

Sample selection
Only occupational therapists, working in Ireland, who specifically worked with adults with intellectual disability, or had adults with intellectual disabilities on their caseload, were included.Participants were sought through the Association of Occupational Therapists of Ireland (AOTI) Intellectual Disability Advisory Group.

Data collection
In-depth, semi-structured interviews were conducted with four participants, and all interviews were audio-taped and transcribed verbatim.

Data analysis
The results were analysed using thematic analysis (Braun and Clarke, 2006).The first author commenced manual analysis following the completion and transcription of the first interview.Initially, line-by-line coding on the written transcripts was conducted, which advanced onto focused coding, conducted in a manner advised by Charmaz (2004) where the recurring codes that emerged in the line-by-line coding were grouped together into more focused coding.The first author made memos throughout the analyses to assist the development of themes.Concepts that emerged from the coding were continuously compared with all available data and the other themes as they emerged.Concepts that represented similar phenomena were grouped together to create the four emergent themes.

Ethical considerations
Ethical approval was granted by the University of Limerick ethics board to conduct this research and ethical guidelines cited in the University of Limerick Research Ethics Committee (ULREC) Guidelines for completion of Application Form (2008) were adhered to.Participation was voluntary and participants were free to withdraw at anytime, and there are no benefits, financial or otherwise for participants.Confidentiality was strictly adhered to and nothing to identify the participants or where they work is included in this paper.

Trustworthiness
The authors adhered to the concept of "reflexivity" cited in Finlay (2006) and reflected on their own thoughts at different stages during the research keeping a reflective diary to supplement what Finlay (2006) describes as an "audit trail".There was multiple coding to produce the highest quality themes possible and within the limited time-span the authors worked on identifying themes to the point of data saturation.

Findings
Following in-depth analysis of the data, the following themes emerged about the experiences of Irish occupational therapists who work with adults with intellectual disabilities who access supported employment: Referrals are received by occupational therapists in contrast to occupational therapists referring adults to supported employment This was highlighted by all the participants who stated the following: Participant 1: "the job coach actually refers the clients to me".
Participant 2: "we would sit down together and look for the most appropriate service for the client and that would include into supported employment so I wouldn't refer them directly myself".

Occupational therapy roles
All participants spoke about the different roles that they play in working with individual's availing of supported employment or transitioning to supported employment.Within this role, the major themes that arose were assessments, task analysis, supporting clients and the development of client skills.
Assessment.All four participants spoke of different assessments that they conduct with individuals who are either considering commencing supported employment or were in supported employment.This was highlighted by Participant 1 who reported: Transport safety assessments were described as another aspect of the role of the occupational therapist: Participant 4: "they (Day service staff) would ask the occupational therapist to come and do a travel safety assessment and that is where I have stepped in".
Task analysis.Another aspect of the occupational therapy role identified was that of task analysis.This was reported to be completed when the client was in a job and occasionally before the client commencing work: Participant 1: "when I would meet the employers I will analyse the task.I would then bring the individual to the task, and we will demonstrate what they have to do and break that task down".
"Supporting the individual" and "developing skills".Participants reported that they spend time supporting the clients and developing skills such as social skills, life skills, work skills and communication skills: Participant 1: "I will put in a number of hours supporting the individual".
Participant 2: "it is to build their skills, build esteem and confidence and everything".
Pragmatics: factors that facilitate and barriers that challenge Factors that assist the process and potential barriers were identified by participants.
One participant reported being inspired by client motivation as highlighted here: Participant 1: "Realistically they want a job, and I think that is an expected normality and all of us, we want to be engaged in something, engaged in something worthwhile and proactive you know and I am just inspired sometimes by their motivation".
Another participant reported on client motivation stating: Participant 3: "They're very motivated and it's their capacity to be able to do something that will stop them more than their motivation".
The level of happiness of clients was identified: Participant 2: "they are just blooming, you can see them once they start, it's just interacting with others and their communication and social skills, all of that, that you strive to do in sessions, that develops just quickly within the working environment".
The good will and support of employers was highlighted: Participant 2: "people with intellectual disability need that extra bit of support with supported employment as well, so it is the good will of the employers as well to take them on".
In contrast to the factors that facilitate, barriers that exist were identified such as low client expectations, and this was also described as an area to develop with clients to raise expectations as exemplified by Participant 1: Participant 1: "I find with intellectual disability their expectations is very limited [. ..] [. ..]. the limitation of their knowledge because that's just the work experience they got, because that's the common work experience, to the likes of Dunnes or big supermarkets and bring boxes from the store and stack shelves.That's the limitations; it's hard for them to think beyond that".
The barrier of transport in a rural areas was highlighted as was the area of information and having the relevant information on services: Participant 3: "transport and things like that cause problems too, because we are reliant on family as well as we don't have, say, public transport".
Participant 2: "Information, it's not, you really have to dig as a therapist to find out which service is which, which takes a lot of time.The information isn't there all the time".
Another barrier identified was of funding and the current economic climate: Participant 1: "Funding is a big issue, always a big issue".
Participant 2: "Funding is a nightmare, no getting away from it".
Participant 4: "economically in the current climate now we are going to be the worst hit people and unless they are very much into a job and have it secured, but if there's other people in the community who can do that job who don't have an intellectual disability, I am very sorry, that is the reality, they will probably be accepted for work".
Participant 1: "It has been extremely difficult (placing clients in work) with the climate at the moment because of the recession in Ireland and the limitation of the jobs and the way a number of employers have been hit financially".
Associated with funding, the area of client's benefits was discussed by participants: Participant 1: "they normally don't do more hours than to affect their benefits. ...so keeping within a certain amount so not to interfere with benefits".
Participant 2: "There are only a certain amount of hours that they are officially allowed to work that won't affect their benefits".
"Future role" When asked about the future role of occupational therapy in the area of supported employment, the following information emerged: Participant 1: "I think as OTs we have to be pro-active and we have to put ourselves forward, that we can do this because I think that our training, we have the best training to make us very competent in assessing an individual's abilities and to analysing the task and breaking the task down, making it something the individual can perform in the work environment so I think we are the best placed people to carry this forward".
Participant 2: "I think there is a huge role.I think it is, an area that will be developed and I think there is a role for OTs working within that area".
When asked about working with different agencies in the future: Participant 2: "I suppose more working together in the future would be beneficial".
Participant 4: "OT see things a bit differently maybe than other services, it's just the way, that is just our profession as well, so I think we could bring lots to groups and developing their skills and getting people ready for supported employment but at the moment there are just so few of us".

Discussion
Referrals are received by occupational therapists in contrast to occupational therapists referring adults to supported employment Interestingly, the participants reported that they actually received referrals rather than refer people to supported employment.It would be beneficial to explore this phenomenon further to ascertain if other occupational therapists are referring individuals with intellectual disability to supported employment services.Especially, as evidence from other countries such as the USA indicate that there may be what Casper and Carloni (2007) claim to be an underutilisation of supported employment services.Siperstein et al. (2013) warn that "the employment outlook for adults with intellectual disability will continue to be bleak until new ways are found to meaningfully incorporate this population in the labor force" (Siperstein et al., 2013, p. 157).Watson (2006) suggests that in relation to employment in its broadest sense, occupational therapists currently play a marginal role in this area.Kelsall (2009) supports this suggestion when claiming that few occupational therapy services are taking the challenge and investing their specialist skills in the area of employment (Kelsall, 2009, p. 120).Additionally, it would be useful to explore why occupational therapists are not referring adults with intellectual disabilities to supported employment.

Occupational therapy roles
The role that occupational therapists play in assessment was highlighted in the data collected from all participants.Participants indicated that they used a range of assessments, and these were important to get a functional profile of the person in supported employment or about to enter into supported employment.Law and Baum (2005) assert that occupational therapists use assessments and measurements to improve decisions regarding clients.When reporting on case studies of job support by occupational therapists for people with developmental disabilities, Arikawa et al. (2013) highlighted occupational therapists help by assessing the occupational performance of the individual and the work environment.The present findings from the participants concur with this aspect of occupational therapy practice where occupational performance and the work environment are assessed.
The importance of task analysis to support clients in, or entering, supported employment was highlighted by the participants.It was described as a current role for occupational therapists working in this area of practice.According to O'Brien (2013), activity analysis is central to occupational therapy practice.Braveman (2006) states that occupational therapists are well aware of the importance of the fit between the individual and their environment, with research by Fillary and Pernice (2006) recommending that employment support staff provide "a desirable person/work match" (Fillary and Pernice, 2006, p. 36).Additionally, Crepeau and Boyt Schell (2009) state that occupational therapists "are concerned with the specific situation of the client and therefore must understand the specific occupations the person wants or needs to do" (Crepeau and Boyt Schell, 2009, p. 360).
Skill development for clients was identified as a role by the participants, as was providing support for clients.Research shows that occupational therapists play an important role in the development of client skills.Vila et al. (2007) reported that training and monitoring of the individual in supported employment contributed to the support of these individuals.Fillary and Pernice (2006) recommended that people in supported employment were given effective on job support.Test (2004) further recommended that individuals with disabilities could be taught self-determination skills to prepare them for work situations.The evidence highlighted suggests that what the participants are currently doing is congruent to practice within supported employment.
Pragmatics: factors that facilitate and barriers that challenge Client motivation was an area highlighted by the participants.In relation to the theme of client motivation, research shows that individual characteristics such as motivation are factors in determining the possibility of individuals with intellectual disability finding employment or not (McConkey and Mezza, 2001;Rose et al., 2005).
The sub-theme of limited expectations for clients is in congruence with Kelsall (2009), who stated that many people with intellectual disability have limited opportunity to gain experience in employment opportunities.Kelsall (2009) further indicated that occupational therapists have a role in facilitating individuals with intellectual disability to explore employment opportunities.This role may be to raise client expectations to provide clients with a wider range of vocational exploration because as Townsend et al. (2007) highlight "with support from occupational therapists, clients visions of possibility may energise them to imagine a life that may not be expected of them and they may have not expected" (Townsend et al., 2007, p. 102).
Inadequate transport was highlighted by participants as a challenge.Research conducted by Conley and Taylor (2003) highlighted inadequate transport as a barrier for individuals to access supported employment.The Disability Federation of Ireland (DFI) (2015) assert in their submission to the Department of Social Protection in Ireland that transport has always been a major barrier to the participation in work for people with disabilities.They further assert that "inadequate public transport, and unaffordability or non-viability of personal transport prevent people taking up employment opportunities" [Disability Federation of Ireland (DFI), 2015, p. 5].
Funding and the economic climate in Ireland were highlighted as barriers in supported employment.This is also considered internationally.In a study on the slowing momentum of supported employment services in the USA, Cimera (2006) highlighted the impact that lack of funding may place on the services provided.
Financial disincentives within the benefits system for people with a learning disability were described by Kelsall (2009).Furthermore, Bond et al. (2008) assert that there may be a fear amongst some individuals who access supported employment that they may lose health insurance, and the number of hours worked per week may be influenced by rules relating to disability payments and medical aid eligibility.This was also a theme that emerged from the participants.Provision of reliable, accessible benefits advice was advised by Wistow andSchneider (2006), with Schneider (2007) reporting a lack of confidence amongst professionals working in supported employment in dealing with benefits issues.

Future role of occupational therapists in supported employment
The participants identified future roles for occupational therapists in the area of supported employment.Current theory such as that of Townsend et al. (2007) support this."Occupational Therapists are encouraged to generate the courage and supports to enable individual and social change, thereby advancing opportunities for client empowerment and participation in society" (Townsend et al., 2007, p. 103).This idea is further developed by Finlayson and Braveman (2006), who stated occupational therapists were challenged to offer the best and most effective interventions possible.
In occupational therapy practice, Pettigrew (2010) asserted that there are many exciting emerging areas of practice on the horizon.Occupational therapy has the potential to play a greater role in the area of supported employment.Occupational therapists contribute to closing the gap between the impairment of individuals with developmental disabilities and the complex demands of supported employment (Siporin and Lysack, 2004).King and Olson (2009) further support this by claiming that occupational therapists are ideally positioned to include motor skill function, cognitive function, social skills, activities of daily living and adaptive equipment as part of treatment programmes in the area of supported employment.
It is important that occupational therapists continue to work in and develop this area of practice.However, in relation to employment in its broadest sense, Watson (2006) suggests that occupational therapists currently play a marginal role in this area.Kelsall (2009) supports this suggestion claiming that "few occupational therapy services are taking the challenge and investing their specialist skills in this area" (Kelsall, 2009, p. 120), highlighting the role that occupational therapists could take in this area of practice.
A review of relevant Irish policy identified four pillars which will underpin services for people with disabilities in Ireland into the future: the rights of people with disabilities; the delivery of person-centred services; the mainstreaming of service provision; and service quality (Finnerty, 2013).Consequently, occupational therapists are ideally placed to support these aspects of service delivery.

Limitations of study
The authors acknowledge that it would be more advantageous to have a larger number of participants to have a greater representation of occupational therapists' views on this particular area of practice.Currently, there is no official database of occupational therapists in Ireland working in the area of intellectual disability; therefore, recruitment of participants was difficult.The limited time-span for completion of this research was also considered when considering limitations of the study.

Conclusion
This study demonstrated that researching occupational therapists' experiences provide an important perspective on supported employment services in Ireland.This research set out to explore the experience of Irish occupational therapists who refer adults with intellectual disabilities to supported employment services.A key finding from the participants was that they received referrals for individuals instead of referring individuals to supported employment.They appeared to work in an inter-agency collaborative method where they worked closely with job coaches, staff of day services and clients.However, it would be advantageous to further investigate whether other occupational therapists in Ireland are referring individuals to supported employment and establish the reasons that occupational therapists may or may not be referring individuals.
The areas that the participants reported to have most involvement in were the areas of assessment, client support, client skill development and task analysis.These areas are traditionally part of the occupational therapy process, and as literature suggests, this is one of the unique aspects of the profession of occupational therapy.
Various pragmatics around the area of occupational therapists working with individuals with intellectual disabilities in supported employment were highlighted.Client motivation and the good will of employers were identified as facilitators, while barriers identified included funding, transport and limited client expectations.All participants felt that there was a future role for occupational therapists working in this area.Possible roles may include raising expectations of individuals with intellectual disability within the area of work and vocational exploration and supporting social inclusion, thus enabling participation.
However, therapist's workloads and a lack of resources and funding may impact on the service they provide, and they may have to prioritise other areas of intellectual disability service provision, such as equipment provision or sensory integration over supported employment.
Participant 1: (receive referral for) "assessment because I undertake pre-vocational assessments and I use standardized assessments.I use the Jacobs Pre-Vocational assessment, I use the Cognitive Assessment of Minnesota and I use the AMPS".Participant 3: "You would be asked to do an assessment on somebody's skills.In fact, I recently did the Assessment of Motor and Process Skills".