Year	2018
Project Title	Rehabilitation Research and Training Center on Employment for Persons with Physical Disabilities
Participator	Jasin Wong
Job Title	Post-doctoral fellow
Period	2018.01 ~ 2023.12
Unit	National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR)
Abstract	Background and Significance Employment is a goal for many individuals with an acquired physical disability and can contribute to economic self-sufficiency and quality of life. However, quantitative studies provide conflicting results in identifying predictors of return to work after illness or injury, and qualitative studies are limited. Qualitative analysis of transcripts from  interviews with 12 stroke survivors,136 stratified by job type and extent of return-to-work (RTW), identified 7 RTW barrier and facilitator categories: financial, impairment, interpersonal support, therapy, organizational, job-specific, and psychological issues. These themes extend qualitative studies of individuals’ perceived work potential and VR efforts by identifying employer-, job-, environmental, and personal factors. This work was extended by surveying individuals about their RTW experience at various stages during stroke recovery.137 The survey was developed through interviews of stroke survivors, focus groups, and other key stakeholder input to identify RTW issues. A total of 715 respondents completed the survey; respondents were an average of 54 years old, mostly white, well-educated, urban-dwelling, and employed in skilled occupations. The authors identified several categories of barriers: financial, stroke impairments, organizational, work, psychological issues, interpersonal support, and therapy. Earning an income was a strong facilitator, as were anticipated psychological benefits, attitudes of co-workers, and flexibility in work schedule. Work stress was viewed as the greatest barrier, with fatigue as the second highest barrier to RTW, which persisted over time. Only 24% of the sample received VR counseling, often 6 months or longer after their stroke. The State-Federal VR system invests considerable resources in training, preparing, and placing individuals in competitive employment. VR providers are required to monitor and support clients for 90 days after placement. Clients often encounter challenges in maintaining employment after 90 days, which often results in dependence on SSDI or other government or private insurance. Facilitators and barriers to job retention after 90 days may reflect individual, employer, job, and environmental factors. Employer factors include limited understanding of resources and on-going opportunities to provide job accommodations or adopt assistive technology.138,139 Individual factors include limited capacity to manage cumulative job-related stress, cognitive limitations, exacerbation of symptoms related to disability and illness, including pain,140 and emotional factors. Job demands may not match with workers’ skills, and job demands may change over time due to advancement and/or restructuring of job tasks. Environmental factors include limited coworker and family support, changes in supervisors, and unreliable transportation. A fuller understanding of the experience of VR clients and employers is needed to enhance job retention after 90 days for populations with diverse physical disabilities employed in varied occupations. Environmental factors, which can affect mood, participation, and quality of life, may play a critical role in job retention. As part of our RRTC on Improving Measurement of Medical Rehabilitation Outcomes, we developed measures of environmental factors that influence healthcare outcomes for people with physical disabilities. We conducted an extensive literature review, binned and winnowed items from existing instruments, selected items that cover a broad range of International Classification of Functioning, Disability and Health (ICF) concepts,141 wrote items to fill gaps in content, and completed cognitive testing following the approach of PROMIS developers.142 Ten content-area and outcome measurement experts contributed to instrument development; 200 individuals with stroke, TBI, and SCI participated in focus groups, and 15 participated in cognitive testing.114 Content experts categorized 2,273 environmental factor items in 6 domains: assistive technology; built and natural environment; social environment; services, systems, and policies; access to information and technology; and economic quality of life. We then winnowed this pool to 291 items for cognitive testing and recommended 274 items for pilot data collection.115 A second sample of 604 individuals with disabilities answered these items. Five of the Environmental Factor Item Banks (EFIB) demonstrated good to excellent evidence of reliability and validity, including the built and natural environment;122 social environment;113 services, systems, and policies;143 access to information and technology;118 and economic quality of life.117 The EFIB item banks assess most of the ICF environmental factors chapters, 144 and provide a brief, focused assessment of ICF Environmental Factors that may influence employment. We will evaluate their utility as predictors of job retention. Specific Aims and Hypotheses Aim 1: Identify employer, client, job, and environment-related barriers and facilitators of job retention from the perspective of VR clients with physical disabilities and employers. Hypothesis 1: The barriers and facilitators identified by a diverse group of SRALab VR clients and employers will overlap but extend the previous list of stroke-related issues.137 Aim 2: Pilot test a survey of job retention barriers and facilitators, then develop a quantitative model of job retention that incorporates job retention barriers and facilitators along with environmental factors. Hypothesis 2: Provision of employer accommodations, use of assistive technology, and client self-advocacy skills predict job retention in a sample of former SRALab VR clients. Aim 3: Validate the quantitative model of job retention barriers and facilitators with a national sample of VR clients and employers. Hypothesis 3: Predictors of job retention in a national sample of VR clients with physical disabilities and employers are similar to those identified in the SRALab sample. Aim 4: Develop and prioritize strategies to promote job retention based on survey results. Hypothesis 4: Employers value accommodations that impose minimal cost and business disruption, while employees value flexible approaches to fulfilling job demands.
Language	English