Work Evaluation and Work Programs

Denise Haruko Ha, Jill J. Page and Christine M. Wietlisbach

Chapter Outline

History of Occupational Therapy Involvement in Work Programs

The therapeutic use of work has always been a core tenet of occupational therapy since the inception of the profession.³² Work programs have their roots in those with mental illness during the moral treatment movement, which started in Europe in the late 18th and early 19th centuries.⁷⁷ In 1801, Philippe Pinel, one of the founders of moral treatment, first introduced work treatment in the Bicentre Asylum for the Insane. He suggested that “prescribed physical exercises and manual occupations should be employed in all mental hospitals. … Rigorously executed manual labor is the best method of securing good morale. … The return of convalescent patients to their previous interests, to industriousness and perseverance have always been for me the best omen of a final recovery.”⁸⁰ Later in the 1800s, several psychiatric settings instituted productive activity programs.

In 1914, George Barton, one of the founding fathers of the occupational therapy profession who was disabled by tuberculosis and a foot amputation, established the Consolation House in New York.⁸⁹ This program enabled convalescents to use occupations to return to productive living.⁸⁹ Barton stated, “the purpose of work was to divert the mind, exercise the body, and relieve the monotony and boredom of illness.”⁸³

In 1915, Eleanor Clarke Slagle, another founder of the occupational therapy profession, was hired to create a program for persons with mental or physical disabilities to work and become self-sufficient.⁸⁹ The program was located at Hull House, a settlement house in Chicago, and was funded by philanthropic contributions. The participants involved in the program produced goods such as baskets, needlework, toys, rugs, and cabinets while developing manual skills and receiving wages for their work.

The early leaders of occupational therapy identified the importance of work when defining the profession’s focus and purpose. Adolph Meyer, a psychiatrist who emigrated from Germany at the time and was an early proponent of moral treatment, observed that healthy living involved a “blending of work and pleasure.”⁶¹ Dr. Herbert Hall helped establish a medical workshop at Massachusetts General Hospital in Boston, where clients were involved in “work cure.”³⁰ In this workshop, clients produced marketable goods and received a share of the profits. The focus of treatment in these curative workshops was to restore the impaired body part to as normal function as possible, with the goal of returning the client to work.

While this curative workshop movement was transpiring on the East Coast, similar programs were developing elsewhere in the United States. For example, at the Los Angeles County Poor Farm, now recognized as Rancho Los Amigos National Rehabilitation Center in Downey, California, “all inmates were requested to do an amount of work that was commensurate with their physical strength and mental capacity, which was determined by the admitting doctor.”²⁷ Inmates used woodworking machinery to build a large amount of furniture that was used at the farm. Commodes, bedside tables, wheelchair tables, park benches, cabinets, and other items were built in the shops. In later years when there was a true occupational therapy department, patients made Navajo-type rugs, rag or braided rugs, brushes, shawls, pottery, pictures, baskets, and leatherwork (Figure 14-1, A). Patients took special occupational therapy classes “which were designed to enable those who are crippled, blinded or otherwise handicapped to make themselves useful” by producing articles that could be used at the County Farm or sold to employees or the California Crafts and Industries Society in Los Angeles (Figure 14-1, B).²⁷

In the early 1900s, the medical profession did not seem to consider vocational readiness programs to be important. The focus of care for persons with physical illnesses was primarily palliative and involved immobilization and bed rest. This attitude shifted after World War I with the need to rehabilitate the large numbers of injured soldiers to help them become functional and gain employment.

The U.S. Federal Board for Vocational Education (FBVE) was created after adoption of the Vocational Education Act of 1917.⁴² In 1918, the Division of Orthopaedic Surgery in the Medical Department of the Army organized a reconstruction program for disabled soldiers.⁷⁷ One of the founders of occupational therapy, Thomas Kidner, served as an advisor. This program led to the development of reconstruction aides, who were the precursors to occupational and physical therapists. Treatment involved both handicrafts and vocational education. The reconstruction aides used work activities to return the injured soldiers to military duty or civilian life to the highest degree possible.

In 1920, Congress passed the Civilian Rehabilitation Act of 1920 (Smith-Fess Act, Public Law 66-236). This law provided funds for vocational guidance and training, work adjustment, prostheses, and placement services.⁴² If therapy was part of a medical treatment program, the law provided payment for occupational therapy services; however, it did not provide payment for physician services. Physicians either provided free services or received payment through state or volunteer contributions. This limited the use of occupational therapy services in vocational rehabilitation to the states that supplemented federal program funds to support services such as the curative workshops.

The Social Security Act of 1935 defined rehabilitation as “the rendering of a person disabled fit to engage in a remunerative occupation.”⁵³ This was the first attempt to provide vocational rehabilitation to the physically handicapped in the community.

In 1937, industrial therapy, called employment therapy, was born.⁵⁸ The occupational therapist used activities as treatment modalities. It was common for patients to have work assignments in the hospital that matched their experience, aptitude, and interest. Sheltered work environments within the hospital were used, including the hospital laundry, barber shop, and carpenter shop.

The term prevocational started appearing in the literature by the late 1930s. It referred to the use of crafts to develop skills readily transferable to industry.¹⁰¹ Prevocational therapy prepared patients for the work role. Occupational therapists worked as directors, work evaluators, and prevocational therapists in work programs. In the 1940s, prevocational programs and work evaluation were accepted as part of the practice of occupational therapy. Patients in acute care facilities who were physically disabled were transferred to outpatient or rehabilitation prevocational and vocational programs.

World War II brought more opportunities for occupational therapists to become involved in work programs. With the advancement of medicine and pharmacology, many injured soldiers survived their wounds. Federal funding for rehabilitating disabled veterans increased as the government discharged the disabled soldiers. This led to an increase in the development of work programs designed to evaluate and rehabilitate injured veterans.¹⁷

In 1943, the Barden-LaFollette Act (Public Law 78-113) modified the original provisions of the Civilian Rehabilitation Act of 1920.⁴² This new law, called the Vocational Rehabilitation Act, covered many medical services, including occupational therapy and vocational guidance. Services were expanded to those with physical and mental limitations. This law also created the Office of Vocational Rehabilitation, a state and federally funded agency that is still in existence today and provides job training and placement services to people with disabilities. Industrial therapy continued in various settings as a form of vocational rehabilitation.

During the 1950s, many occupational therapists believed that work evaluation belonged to a newly established profession of vocational rehabilitation rather than occupational therapy.⁵⁸ Occupational therapy involvement declined, and vocational counselors, vocational evaluators, and work adjusters were primarily the leaders in this field. There were, however, still a few occupational therapists who remained active in work programming.

A high point in the development of prevocational exploration and training techniques in the field of occupational therapy occurred in 1960.⁴² Rosenberg and Wellerson published an article on development of the TOWER (Testing, Orientation, and Work Evaluation in Rehabilitation) system in New York.⁸⁴ The TOWER system was one of the first work sample programs to use real job samples in a simulated work environment.⁸⁴ In 1959, Lilian S. Wegg gave the Eleanor Clarke Slagle Lecture on “Essentials of Work Evaluation” based on her experiences at the May T. Morrison Center for Rehabilitation in San Francisco. Wegg promoted the need for both sound testing procedures and training programs.¹⁰⁰ Florence S. Cromwell, a president of the American Occupational Therapy Association (AOTA), established norms for disabled populations on certain prevocational tests while evaluating the performance of adults with cerebral palsy at the United Cerebral Palsy Organization.⁴² Cromwell continued to be an important advocate of work-related therapy in the ensuing decades.

Occupational behavioral theory, which emerged in the mid-1960s and early 1970s, offered a return to the profession’s concern for occupation. Mary Reilly, an early proponent of occupational behavior theory and a 1962 Eleanor Clark Slagle lecturer, believed that productive activity as treatment was the unique contribution of occupational therapy.⁴² Occupational behavior theory advocated that persons can achieve healthy living only through a balance between work, rest, and play.

The increasing numbers of industries in the late 1970s and early 1980s introduced a whole new arena for occupational therapists: industrial rehabilitation and work hardening.⁴² Work hardening used actual work tasks in a simulated structured work environment, generally in community-based settings.⁵ Occupational therapists used their knowledge of neuromuscular characteristics, including range of motion (ROM) and endurance, along with task analysis skills and knowledge of the psychosocial aspects of work in evaluating, planning, and implementing a work-hardening program.

In 1989, the Commission on Accreditation of Rehabilitation Facilities (CARF) developed work-hardening standards requiring an interdisciplinary approach.¹⁵ The interdisciplinary team consisted of occupational therapists, physical therapists, psychologists, and vocational specialists.

The Americans With Disabilities Act of 1990 (ADA; Public Law 101-336) was important legislation that opened major markets for occupational therapists.⁴² Occupational therapists were involved in providing both work training for persons with disabilities and assistance to employers in meeting the requirements of the ADA. This legislation continues to have important implications for work practice.²³ (See Chapter 15 for more information on the ADA.)

In 1992, the AOTA defined work as “all productive activities and included life roles such as homemaker, employee, volunteer, student, or hobbyist.”⁴ This document was replaced in 2000 by the statement “Occupational Therapy Services in Facilitating Work Performance.” This statement asserts that “occupational therapists and occupational therapy assistants contribute to the delivery of services for the promotion and management of productive occupations as well as the prevention and treatment of work-related disability.”²

In 2002, the Occupational Safety and Health Administration (OSHA) unveiled a comprehensive approach to ergonomics to reduce the incidence of musculoskeletal disorders (MSDs) in the workplace. Their four-pronged, comprehensive approach includes guidelines, enforcement, outreach and assistance, and a national advisory committee on ergonomics.

Occupational therapists have traditionally consulted and continue to consult with employers and employees on making recommendations about equipment, posture, and body mechanics to prevent injuries. Ergonomic intervention continues to be an area of many opportunities for occupational therapists who have received additional training and education in the area of ergonomics.

Role of the Occupational Therapist in Work Programs

Occupational therapists and occupational therapy assistants play an important role in helping individuals participate in all aspects of work. According to the Occupational Therapy Practice Framework: Domain and Process, second edition, work is an area of occupation that is defined by Mosey as “activities needed for engaging in remunerative employment or volunteer activities,” including the following: “employment interests and pursuits, employment seeking and acquisition, job performance, retirement preparation and adjustment, volunteer exploration, and volunteer participation.”¹ Occupational therapy practitioners provide services to those with limitations in the area of work performance. The occupational therapist focuses on identifying and analyzing the problem and selecting and/or designing appropriate assessments and interventions for solution of the problem. According to the statement “Occupational Therapy Services in Facilitating Work Performance,” “problems in work performance can arise from physical, sensory, cognitive, perceptual, psychological, social, or developmental changes. Therefore, occupational therapy practitioners provide work-related services in a variety of settings, including, but not limited to, acute care and rehabilitation facilities, industrial sites, and office environments, psychiatric treatment centers and in the community.” Two key services are provided in these settings, “evaluation and intervention, which includes consultative, preventive, restorative, and compensatory services.”² This chapter describes the range of work evaluations and interventions in which occupational therapists are involved in assisting people in actively participating in meaningful work roles.

Industrial Rehabilitation

The range of services provided to injured workers and industry is often encompassed by the terms “industrial” or “occupational rehabilitation.” These terms will be used interchangeably in this chapter. Industrial rehabilitation includes functional capacity evaluation (FCE), vocational evaluation, job demands analysis (JDA), worksite evaluation, pre-employment screening, work hardening/conditioning, on-site rehabilitation, modified/transitional employment, education, ergonomics, wellness, and preventive services. Occupational therapists are integral in providing these services, and this area of practice provides a tangible way for therapists to experience the tremendous reward of seeing lives changed through their efforts. The AOTA has developed a Work and Industry Special Interest Section (WISIS) for those who are involved in or wish to know more about this area of specialization.

Functional Capacity Evaluation

An FCE is an objective assessment of an individual’s ability to perform work-related activity.^28,52 These functionally based tests have been used since the early 1970s to assist in making return-to-work decisions and were primarily performed by occupational and physical therapists.³⁸ Today, however, the results of such an evaluation can be used in many different ways and they are performed by a multitude of disciplines. Occupational therapists are remarkably qualified to conduct FCEs because of their education and background in task analysis.^2,3 An FCE can be used to set goals for rehabilitation and readiness for return to work, assess residual work capacity, determine disability status, and screen for physical compatibility before hiring a new employee and case closure.⁷⁵

An FCE usually consists of a review of medical records, an interview, musculoskeletal screening, evaluation of physical performance, formation of recommendations, and generation of a report.⁴⁵ Evaluation of physical performance usually takes the form of assessing the client’s physiology, both cardiovascular and muscular endurance, during the course of strength, static, and dynamic tasks. The report usually contains information regarding the overall level of work, tolerance for work over the course of a day, individual task scores, job match information, level of client participation (cooperative or self-limited), and interventions for consideration.^45,50

A wide variety of FCEs are currently used in practice today, both commercially available systems and evaluations developed by individual therapists or clinics (Box 14-1, Figure 14-2).

FCEs can be (1) all-inclusive when looking at case closure or settlement; (2) job specific when making a match between a person’s abilities and the job description, such as “cashier at XYZ store” or a broader occupational title such as “cashier”; or (3) injury specific, such as an upper extremity evaluation after bilateral carpal tunnel release. Joe, the 26-year-old man with T11 paraplegia, could benefit from a job-specific FCE to determine whether he can meet the physical demands of the alternative job as a laundry attendant.

A well-designed FCE is comprehensive, standardized, practical, objective, reliable, and valid.^45,50,86

A comprehensive FCE will include all of the physical demands of work as defined by the Dictionary of Occupational Titles (DOT) published by the U.S. Department of Labor and last revised in 1991 (Box 14-2).⁹⁷ The main focus of Joe’s FCE will be on the physical demands of work that he can still reasonably do from the wheelchair, such as lifting, sitting, carrying, pushing, pulling, balancing, reaching, handling, fingering, feeling, talking, hearing, and seeing.

It is also important for the individual being tested to understand the correlation between the test items and the functions of the job. The application of meaningful activity can improve individuals’ cooperation during testing and encourage maximum effort. For example, an individual who performs secretarial duties may have difficulty understanding the need to test her ability to climb ladders if she does not actually perform this function during the course of her job.^1,75

An FCE needs to be practical in terms of length of testing, cost, space, and report generation.^50,75

Standardization in FCEs means having a procedure manual, task definitions and instructions, a scoring methodology, and equipment requirements and set-up.^50,52,76 This type of structure helps ensure that individuals are being assessed in a fair and consistent manner and demonstrates the effort to minimize observer bias. Verbal instructions are critical in establishing rapport between the evaluator and the individual being tested. During the initial interview, the tone is set for the course of the evaluation, and the individual’s trust in the evaluator is implicit in maximizing cooperation and effort during the evaluation.⁵⁰ Objectivity is not limited to weights, distances, heights, or some other numeric quantity; subjective measures can be made objective with operational definitions. Objectivity during the course of an FCE does not exclude clinical judgment and decision making, but it does require the measure to be as free as possible of examiner bias.⁸⁶ This includes physical performance, as well as client cooperation during testing. Objectivity is accomplished through standardization of the testing protocol and a structured scoring methodology.

The most important aspects of an FCE are reliability and validity of the testing protocol. Two types of reliability are deemed to be important in an FCE: interrater and test-retest reliability.⁵² Interrater reliability in an FCE means consistency; if two therapists administer the same test to the same client, will they get the same results?⁴⁵ King and Barrett state that “test-retest reliability or intra-rater reliability refers to the stability of a score derived from one administration of an FCE to another when administered by the same rater.”⁴⁵ Being able to establish reliability is the first step in determining the validity or accuracy of the results.⁸⁶ If there is not agreement between evaluators, it is difficult to determine whose results are correct.⁴⁵ Once reliability has been proved, validity can be assessed. The term validity is used in many ways, often with significance placed on issues surrounding sincerity of effort. In scientific terms, validity means accuracy; in other words, does the FCE provide results that truly describe how the client can perform at work?^50,86

There are several types of validity, with content, criterion (both concurrent and predictive), and construct validity having the most impact on the results of an FCE.^45,50 Content validity is the easiest to establish in an FCE because this measure refers to whether the evaluation tests the physical demands of work, as defined by a panel of experts, by job analysis, or by a recognized document such as the DOT.^50,52,75,97

Criterion validity refers to whether conclusions can be drawn from the measures taken, and in an FCE this refers to whether a person can actually perform at the level demonstrated during testing.^45,50,52 Criterion validity is often determined by comparing the methodology in question with a “gold standard”—another instrument that has been proved to be reliable and valid.^45,50,52 This is difficult to do in an FCE because there are a limited number of available assessments with proven reliability and validity to compare against and because other methods, such as comparing the person’s tested ability with the actual work level, can be seriously flawed.^50,52,56 Criterion validity includes concurrent and predictive validity.

Concurrent validity refers to the ability of a test to measure existing abilities, and in an FCE this would be demonstrated by the test’s ability to determine which clients can perform at a given level and which clients cannot perform at a given level.^45,50,52

Predictive validity is indicated by the test’s capacity to predict future ability and has great value in an FCE by determining who can safely return to work and remain without injury.^45,50,59 The first FCE to be studied for validity and published in peer-reviewed literature was developed by the occupational therapist Susan Smith and has served as an important contribution to the knowledge base.⁹² Without reliability and validity, a referral source cannot know whether the results of the evaluation would vary if the individual were tested by another therapist or whether the results are accurate.^45,50,52

Vocational Evaluations

Work evaluations, or vocational evaluations, are “a comprehensive process that systematically uses work, real or simulated, as the focal point for vocational assessment and exploration to assist individuals in their vocational development.”²⁵ According to CARF, the following factors are addressed in the traditional vocational evaluation model: physical and psychomotor capacities; intellectual capacities; emotional stability; interests, attitudes, and knowledge of occupational information; aptitudes and achievements (vocational and educational); work skills and work tolerances; work habits; work-related capabilities; and job-seeking skills.³⁵ These assessments can last from 3 to 10 consecutive days, depending on the goals of the assessment. Vocational evaluators generally conduct these types of assessments in private vocational agencies; however, some occupational therapists have been involved in conducting these evaluations in public and private medical or nonmedical settings as well. Vocational rehabilitation, worker’s compensation, and long-term disability carriers pay for these services, but most medical plans do not.

Standardized work samples such as the Valpar Component Work Sample System or the Jewish Employment Vocational Services are used to assess specific skills in the areas of data or things (Figure 14-3). Dexterity tests such as the Bennett Hand Tool, Crawford Small Parts, and Purdue Pegboard are used to evaluate motor skills (Figure 14-4).³⁵ When no standardized work samples are available to assess the specific skills needed for a particular occupation, specially designed situational assessments are also used to create real-life work situations that are related to actual work tasks that would be conducted on particular jobs. For example, a person who is interested in working as a floral arranger could have her motor skills evaluated to see whether she has the coordination, energy, and strength and effort to grip and manipulate tools to cut the stems of flowers and plants and arrange them in floral containers. Individuals can also be evaluated in real worksites and perform actual job tasks that one would perform on the job.

There are generally two different types of vocational evaluation: a general vocational evaluation and a specific vocational evaluation. A general vocational evaluation is a comprehensive assessment to evaluate a person’s potential to do any type of work. For an individual who has never worked, does not have a job to return to, or cannot return to the previous job because of a disability, this type of evaluation is beneficial in determining one’s aptitudes, abilities, and interests to explore all reasonable options for work. For example, Henry, the roofer who experienced a traumatic brain injury from a fall while working, could benefit most from a general vocational evaluation to explore other options for employment. A general vocational evaluation could help identify other vocational interests and abilities by exploring a person’s cognitive and motor skills and physical and mental tolerances that could be applied to a different occupation. A specific vocational evaluation assesses a person’s readiness to return to a particular occupation. For a person who has suffered a stroke and wants to return to work as a general office clerk, a specifically tailored vocational evaluation to assess the person’s ability to return to this particular type of work can be done. Clerical work samples and specially designed situational assessments that gauge the person’s ability to multitask, pay attention to detail, file, answer a telephone, and take messages can be incorporated as an integral component of the vocational evaluation.

Job Demands Analysis

Assessing the physical demands of a job by JDA is often beneficial in the rehabilitation process inasmuch as recommendations for initiation or return to work require objective information about both the client’s abilities and the job itself. A well-written job description that includes the essential tasks of the job, physical requirements, cognitive aptitudes, educational requirements, equipment operated, and environmental exposure assists in selecting suitable candidates for employment, setting compensation packages, and making appropriate return-to-work decisions after an injury.⁸

A JDA does not need to be confused with ergonomic evaluations or identification and abatement of hazards. A JDA seeks to define the actual demands of the job, whereas ergonomic evaluations and hazard assessment focus more on work practice and risk for injury secondary to postural or manual material-handling extremes or excesses.⁷ Certainly, these areas can overlap, but it is important to be clear about the differences and the reasons behind the request for information and to use suitable methods for each.⁷

Approaches to a JDA include questionnaires, interviews, observations, and formal measurement.⁷ It is common to interview incumbents or supervisors about the job requirements.⁷⁵ Such an informal approach often leads to narrative descriptions with little functional information and questionable accuracy of demand estimates.^36,62,75 As with other types of assessment, it is important to have an objective process for analyzing the demands of the job. In the context of attempting to make return-to-work decisions based on matching the results of an FCE with the job description, many FCEs include a JDA component.⁵⁰ However, these are often subjective interviews with the client and can lack accuracy regarding the physical demands.

The occupational therapist who was working with Joe contacted the employer and conducted a JDA to obtain a complete picture of the job demands and requirements of the laundry attendant position. The occupational therapist spoke to the supervisor, as well as to other employees while they were performing the actual job at the worksite. Being able to actually observe the job being done in the real work environment allowed the occupational therapist to gather the information needed to adequately assess Joe’s ability to carry out the essential functions of this job.

A standardized classification system is crucial to ensure consistency in terminology and among professionals. The DOT defines the physical demands of work and defines occupations in the United States (Tables 14-1 through 14-3).⁹⁷ It provides definitions of the overall level of work, strength demands, and frequencies of the physical demands.^97,98 Many countries around the world also refer to the DOT as their primary reference for generic occupational descriptions.

The DOT was last revised in 1991, and in the early 1990s the U.S. government made the decision to not revise the DOT again but instead create a new format for classifying occupations.²⁶ The intent was to create a more generic classification system or framework for defining work. The American Institutes of Research (AIR) was awarded a contract by the Utah Department of Employment Security on behalf of the U.S. Department of Labor, and they developed O*NET, an online, searchable database for information about occupations. Although the format includes an enormous amount of data, its definitions can make it difficult for rehabilitation professionals to use in a qualitative fashion.⁷⁴ O*NET, however, is not intended to take the place of the DOT but rather to provide a more structured approach for “career exploration.”⁷⁴ It is recommended that both the DOT and O*NET be consulted when obtaining occupational information.²⁶

In terms of recent legislation that has an impact on employment law, both the ADA and the Equal Employment Opportunities Commission (EEOC) define essential tasks as being the reason that the job exists.^6,7 The ADA further defines essential tasks as those that are highly specialized (i.e., the reason that the incumbent was hired to perform the job) and that there are a limited number of people available at the job site to perform the tasks.⁶ During the course of a JDA it is important to distinguish between tasks that are essential and those that are not. This can be challenging because it is a nontraditional way for both the employee and the employer to look at the job. It is important that both hiring and return-to-work decisions be based on job descriptions that define the essential tasks to be congruent with both the ADA and EEOC language.

Jobs are composed of the tasks that are performed, the physical demands that make up the tasks, and the frequency with which the physical demands are performed, including weights handled, forces exerted, and distances both ambulated and reached.⁷ The frequency of each physical demand must be weighted appropriately for the given duration of each task because there is often a significant difference in the amount of time spent on each task during the workday. For example, the job of “loader” in ABC warehouse is composed of two tasks: (1) loading crates with boxes and (2) wrapping the crate with packing tape when loaded. The loader completes 48 cycles of loading and taping in an 8-hour shift, with loading the crate taking approximately 80% of the work shift. The boxes weigh 10 lb each. To correctly assess the overall level of work, the amount of weight lifted must be determined, as well as the frequency of the manual materials handling.

Task 1 is composed of the physical demands of lifting, carrying, stooping, walking, reaching, handling, and standing. Task 2 is composed of walking, reaching, handling, fingering, and standing. To correctly sum the amount of the physical demands for the job of loader, one must determine how much time is spent on each physical demand within each task and then account for the proportion of the time that the task is performed during the workday. This type of assessment can be performed manually, as well as with the application of various software protocols available in the marketplace.

Whatever methods are selected, clinicians should strive to provide an accurate picture of the job and its requirements, with an emphasis on functional demands for easier application in the rehabilitation continuum.

Work Hardening/Work Conditioning

The idea of using work for rehabilitation is at the very core of occupational therapy. In the 1970s, the idea of occupational rehabilitation developed from the necessity of improving strategies to control work-related injuries.^19,44,51,73 Work hardening was first illustrated conceptually by Leonard Matheson, a psychologist at Rancho Los Amigos who worked very closely with Linda Dempster, an occupational therapist, in developing his material.^44,51,73 The goal was then and still remains rehabilitation of injured workers, maximization of their function, and returning them to work as quickly and safely as possible. The delivery system for this type of rehabilitation has evolved over time from a lengthy hospital-based program, to structured interdisciplinary programs in outpatient settings, to the more progressive partnership between outpatient intervention and transitional work, as well as to rehabilitation occurring at the workplace in company-sponsored clinics. In the 1980s, CARF developed guidelines for work-hardening programs and offered certification for a fee through adherence to their guidelines and periodic surveys.^19,44,51,73 In 1991, a committee from the American Physical Therapy Association (APTA) developed another set of principles for clinics that wanted to follow recognized standards but did not desire to undertake the CARF accreditation process.^19,44,51

Work hardening refers to formal, multidisciplinary programs for rehabilitating an injured worker.^19,44,51,73 The disciplines represented on the team can often include occupational and physical therapists and assistants, psychologists, vocational evaluators and counselors, licensed professional counselors, addiction counselors, exercise physiologists, and dieticians.^19,44,51 The programs typically range from 4 to 8 weeks and consist of an entry and exit evaluation (usually an FCE or a derivative thereof), a job site evaluation, graded activity, both work simulation and strength and cardiovascular conditioning, education, and individualized goal setting and program modification, with the goal of return to work at either full or modified duty.^19,44,51 Actual equipment from the job is preferred during the work simulation to maximize cooperation of the worker and more closely replicate the actual demands of the job.⁴⁴ Work conditioning is more often defined as physical conditioning alone, which covers strength, aerobic fitness, flexibility, coordination, and endurance and generally involves a single discipline.^19,42,44 Both approaches involve evaluation of the worker to establish a baseline from which to plan treatment and measure progress.

Motivational issues are a constant concern and are often thought to be at the forefront of unsuccessful return to work.⁹¹ Maladaptive behavior regarding return to work can develop in an injured worker as a result of depression, financial issues, family pressures, and feelings of being manipulated by the “system.”⁹¹ This can lead to employer mistrust, interest in litigation, and a need to exaggerate symptoms. Fraud on the part of the injured worker is also an issue.⁹¹ Employer indifference is a concern and can have a remarkable impact on a worker’s attitude toward returning to the job.⁹¹ Surveys of attitudes among employers have indicated that activity on the part of the employer can affect costs; as many as 90% of respondents indicated that how well the employee perceived that he or she was treated at the time of the injury was associated with decreased costs as a result of the injury.⁹¹

Think about Lorna, the upholsterer who is experiencing hand problems, and the difficulties that she is experiencing at work. An occupational therapist could evaluate her symptoms and her job description and make suggestions to the employer about modifying her job demands so that she can continue to work during treatment. This demonstrates to Lorna that her well-being matters and can help her have a positive outcome with treatment.

Ensuring a positive outcome for the injured worker requires early intervention and a customized plan of treatment to address the various areas affected by the injury, including both physical and psychosocial.⁹¹ Incorporation of a multidisciplinary team allows the patient to have the benefit of many areas of expertise working toward his or her common good. Intervening and initiating the rehabilitation program as soon as possible following the injury dramatically increase the chance for successful return to work. Based on a study of 5620 worker’s compensation beneficiaries, there was a 47% return-to-work rate in workers referred to rehabilitation within the first 3 months after injury, with a cost savings of 71%. When referred during months 4 through 6, the rates dropped to 33% for return to work and 61% for cost savings. For those referred beyond 12 months after injury, only 18% returned to work and cost savings dropped to 51%.⁹¹

Transitional work and modified duty programs involve a combination or a progression of acute rehabilitation and return to work at a level consistent with the individual’s current ability, with the goal of returning to work at full duty or maximizing the individual’s work capacity. An example of transitional duty would have a worker performing work-conditioning activities under supervision in an outpatient clinic from 8 to 10 a.m., going to the worksite and performing the less physically demanding portions of his job from 11 a.m. to 1 p.m., breaking for lunch, and then returning to the “lighter” duties of the job for the duration of the shift. More regular duty activities are added under supervision as the worker’s skill and strength improve, with eventual return to full duty. This type of structure provides a much better environment for the worker to be involved in the work culture and allows coworkers and supervisors to participate in job modification and overall recovery of the injured worker.⁹¹ Modified duty follows a similar path but typically does not include the clinical portion of the day. There are challenges to return to work at less than full duty, however, with some employers not wanting workers to return to the site unless they are at “100%.” It is imperative to demonstrate the benefit to the company and the employee, both economically and psychologically, of early transitional return to the long-term success of returning the employee to the workforce.

Industrial rehabilitation programs will continue to change as the tides of economy, industry needs, and legislation move forward. Occupational therapists are key in directing the changes that lie ahead.

Worksite Evaluations

Worksite evaluations are on-the-job assessments to determine whether an individual can return to work after onset of a disability or whether a person can benefit from reasonable accommodations to maintain employment.^41,95 For example, a man who worked at a manufacturing company as a machine operator incurs a stroke and the employer is willing to take him back as long as he can meet the physical and cognitive demands of the job. An occupational therapist can go to the worksite to evaluate the person’s ability to safely and adequately operate the machinery and carry out the essential functions of the job. Consider another example. A person who previously worked as an office clerk without any difficulty is now experiencing extreme fatigue, pain, and muscle weakness with repetitive tasks as a result of post-polio syndrome. This person could benefit from a worksite evaluation to identify reasonable accommodations to allow her to continue working at this job while minimizing her symptoms. Several factors are assessed at the worksite with the worker present: the essential functions of the job, the functional assets and limitations of the worker, and the physical environment of the workplace.⁵⁵

A worksite evaluation is usually conducted after a job analysis has been done. Larger companies may already have information on job analyses done on specific jobs. If a job analysis has not been done, the occupational therapist can conduct a job analysis if the employer is willing, or a job description could be obtained from the employer before going out to the worksite. If there is no written job description, a phone call to the supervisor/manager of the worker should be made to obtain verbal information regarding the essential functions of the job and the physical and cognitive requirements for the job. After this information is obtained, the occupational therapist schedules a time with the employer and the worker to meet at the worksite. This is exactly what happened with Joe as he prepared to switch from the job of janitor to laundry attendant at the hotel and spa. After the occupational therapist conducted the job analysis, Joe met with both the occupational therapist and the employer at the worksite for the worksite evaluation.

When the occupational therapist meets the employer and worker at the worksite, the occupational therapist assesses the work, the worker, and the workplace.⁴⁷ The evaluation begins with an analysis of the essential functions that may require accommodation.⁹⁵ The occupational therapist should have an idea of what these functions are based on the information obtained before going to the worksite. The desired outcome of the work tasks should be emphasized, not just the process of performing the essential function.⁹⁵ The occupational therapist should find out certain details, such as how the outcome will be affected if a particular task is done incorrectly, in a different sequence, or omitted; whether there are quotas, standards, or time constraints that must be met⁷⁹; and whether the frequency with which a task is done will affect the outcome.

Activity analysis is a useful tool for evaluating a person at the worksite.¹¹ It can be used to address all areas, including motor, sensory, cognitive, perceptual, emotional and behavioral, cultural, and social. When assessing a person’s ability to carry out the essential functions of the job, the occupational therapist has expertise in breaking down the tasks and determining the parts of the task with which the worker is having difficulty or may have difficulty over the course of a workday. The occupational therapist can suggest accommodations to allow the worker to carry out the essential functions of the job.

The final step in the worksite evaluation is to assess the work environment. The environment outside the immediate work area should be evaluated (parking if driving or access to public transportation; access into the building, break room, and restroom), as well as the workstation itself. All work areas that the worker may use need to be investigated to identify obstacles and solutions to increase accessibility. The location and placement of machines, supplies, and equipment that the worker needs to access should be assessed, as well as other environmental factors such as lighting, temperature, and noise level.

Taking photographs or video recordings at the worksite can be very useful; however, permission must be obtained from the employer as well as the worker to do so. The occupational therapist should also bring a tape measure to measure the height of work surfaces, width of doorways, and other factors, depending on the person’s needs. Drawing a layout of the work area to scale on graph paper is also very helpful, especially when the worker is in a wheelchair. Critical measurements can be recorded on the diagram.

The outcome of the worksite evaluation is to determine whether the person can safely and adequately carry out the essential functions of the job with or without any reasonable accommodations. Ergonomic principles (addressed in the following section) should be considered and applied when recommending reasonable accommodations. The process of identifying reasonable accommodations requires cooperation between the person with the disability, the employer, and the occupational therapist.⁷⁹ Each person has valuable insights and information to contribute to the process of identifying the best accommodations. The Job Accommodation Network (JAN) is a service provided by the Office of Disability Employment Policy (ODEP) of the U.S. Department of Labor’s and is the best resource for assisting employers and disabled workers in making reasonable accommodations (http://askjan.org).⁸⁷ Their Website points out that most job accommodations are not usually expensive. According to the JAN, more than half of all accommodations cost nothing. The JAN offers one-on-one guidance on workplace accommodations, the ADA, and self-employment options for people with disabilities. JAN consultants can be contacted both over the phone and online. JAN’s toll-free number is (800)526-7324. The occupational therapist analyzes the need for modification of the equipment that the worker is using or modification of the workplace to help the person perform with greater efficiency, effectiveness, and safety.⁵

After the worksite evaluation is completed, a report is prepared and sent to the qualified employee, the referring party, and the employer. The problem areas that relate to the essential job functions should be listed clearly, as well as the accommodations necessary to solve them. If training is necessary to use a recommended accommodation, sources for the training should be identified. If commercially available equipment is recommended, exact model numbers, local sources, and approximate expenses should be provided.⁹⁵ If custom equipment needs to be fabricated, sources, cost estimates, and the amount of time required to fabricate the equipment should be included as well. The report should summarize the findings of the evaluation and the accommodations that were recommended.

After Joe’s worksite evaluation, it was determined that he could safely and dependably carry out the essential functions of the job from his wheelchair. Just one accommodation was recommended and implemented. Since it gets very hot in the laundry room and Joe is sensitive to the heat, the employer agreed to purchase additional fans to ventilate the room better, as well as allow the door to the laundry room to be propped open. The employer agreed to schedule Joe’s shift in the evening or early morning when it was cooler to avoid having to work in the heat of the day.

The occupational therapy practitioner thus evaluates the worker, the work, the workplace, and the relationship among them. Therapeutic intervention is used when deficits in performance are found. The occupational therapist can modify the way that the worker performs the work or modify the work environment to allow the worker to perform optimally.

Ergonomics

All aspects of the domain of occupational therapy must be in harmony for people to fully engage in the occupation of work. The activity demands of the job and the context in which the job is performed must fit with the employee’s abilities and physical/psychosocial makeup. Any mismatch between the activity demands of the job and context, individual client factors, and performance patterns will interfere with successful execution of the appropriate performance skills required to do the job.

Occupational therapists use the science of ergonomics to assist clients in fully engaging in the occupation of work. Ergonomics addresses human performance and well-being in relation to one’s job, equipment, tools, and environment. The goal of ergonomics is to improve the health, safety, and efficiency of both the worker and the workplace.⁶⁷ The term ergonomics is derived from the Greek words ergos, meaning “work,” and nomos, meaning “laws”—hence the laws of work.²⁰ The Polish educator and scientist Wojciech Jastrzebowski (1799-1882) introduced the term ergonomics in the literature about 150 years ago.¹⁹ However, the concept of ergonomics—that there is some connection between physical well-being and the type of work performed—is as old as humanity: “From the very first tool of the Stone Age, humans have tried to find better ways of working, taking advantage of human talents and making up for human shortcomings.”⁵⁶

The idea behind ergonomics is that every worker brings his or her own unique set of performance skills, performance patterns, and client factors to the workplace. Many times work settings and work processes are designed to satisfy space and budget limitations and the demands of productivity and aesthetics. When these designs fail to take into account the people who will be using the work setting and process, injury and inefficiency can result. Finding a way to match individual employees’ strengths and limitations with the context and activity demands of a job can improve both worker safety and workplace productivity.

The principles of ergonomics help address a variety of work-related issues. Common issues include workplace and work process design, work-related stress, the disabled and aging workforces, tool and equipment design, architectural design, and accessibility. Ergonomic intervention can be applied proactively, preventing problems before they occur, or reactively, adjusting the worker-job-context “fit” when problems do occur. Many occupational therapists use ergonomic principles as part of their comprehensive rehabilitation or wellness and prevention client-centered programs. A few occupational therapists specialize in ergonomics and become professional ergonomists.

With regard to ergonomic services, the occupational therapist’s client base may include the individual worker, workers in the context of employee groups, and/or the employer itself. The environment for an occupational therapist providing ergonomic services is generally at the client’s place of work. These occupational therapists must become skilled in navigating what can be an unfamiliar business world with its unique lingo, social norms, and traditions. However, an occupational therapist providing ergonomic services shares a similar focus with occupational therapists in all areas of practice, that is, a focus on marketing and sale of the product (in ergonomics—wellness), cost-effectiveness, definable outcomes, and client satisfaction.

Occupational therapists are not the only professionals suited to specialize in the field of ergonomics. Ergonomics professionals come from a variety of backgrounds. It is not unusual to see ergonomists who have been academically trained in industrial hygiene, engineering, safety, business administration, human resources, medicine, physical/occupational rehabilitation, psychology, architecture, epidemiology, or computer science.¹⁸ For the occupational therapist, the road to becoming a professional ergonomist can take many paths. Box 14-3 outlines a variety of methods for acquiring advanced knowledge and certification in the field of ergonomics.

For occupational therapists interested in the field of ergonomics, the holistic nature of occupational therapy training is an asset. The occupational therapist immediately understands that the goal of ergonomic intervention, or achieving a perfect fit between an individual worker and his or her job and context, is never simplistic. In the domain of occupational therapy, the worker component is composed of performance skills, performance patterns, and client factors (Box 14-4). The job component is composed of activity demands, both of the job tasks and of tools/equipment. Engaging in the occupation of work occurs in a variety of contexts, including the environment and organization, as well as the worker’s personal, cultural, social, and spiritual contexts.

Observing independent aspects of the domain offers the observer limited insight. Rather, it is the interactions between the various aspects of the domain that reveal the whole picture. This way of looking at worker performance via the interactions of all aspects of the domain of occupational therapy is known as system theory. Rannell Dahl, MS, OTR, explains that the “components of work systems are workers, job tasks, tools and equipment, work environments, and organizational structure, and the interactions among these components.”¹⁸ Dahl offers an excellent schematic of this concept of the ergonomics work system (Figure 14-5).

In his groundbreaking text Conceptual Aspects of Human Factors, David Meister explained that in human factors (ergonomics), the system concept is the belief that human performance in work can be meaningfully conceptualized only in terms of organized wholes. He emphasized the fundamental Gestalt ideas that “the whole is more than the sum of its parts, that the parts cannot be understood if isolated from the whole, and that the parts are dynamically interrelated or interdependent.”⁵⁹ Occupational therapists understand that one can conceive of worker performance only in terms of the interaction between performance skills, performance patterns, context, activity demands, and client factors. The Occupational Therapy Practice Framework: Domain and Process supports this concept: “Engagement in occupation as the focus of occupational therapy intervention involves addressing both subjective (emotional and psychological) and objective (physically observable) aspects of performance. Occupational therapy practitioners understand engagement from this dual and holistic perspective and address all aspects of performance when providing interventions” (p. 628).¹

Occupational therapist Jeffrey Crabtree adds that it is “the subjective meaning of the interactions in the human-work-machine-environment model [that] is central to occupational therapy and ergonomics.”¹⁶

The system theory does not discount the importance of the adequacy of independent aspects of the domain of occupational therapy. The quality of the work system can suffer if there are deficiencies or deviations in performance skills, performance patterns, context, activity demands, or individual client factors. Dahl explains that each component of the ergonomics work system (see Figure 14-5) “has its own set of characteristics that affect the performance of the work system”¹⁸ as a whole. It is here that ergonomic assessment and intervention seek to make a difference in the quality of our clients’ engagement in the occupation of work. The ergonomic practitioner modifies and strengthens certain aspects of the system with the goal of enhancing the overall quality of the work system interactions (i.e., improving the fit between the worker and his or her job).

Although it is beyond the scope of this chapter to comprehensively review the complete array of ergonomic design considerations, the following is a discussion of selected ergonomic design principles. There are, however, a multitude of resources for occupational therapists interested in learning more about the science of ergonomics. The authors of this chapter direct you to the references listed at the end of the chapter. Additionally, readers may be interested in the ergonomics information available through OSHA (www.osha.gov) and NIOSH (www.cdc.gov/niosh/).

When discussing ergonomic design it is important to understand that it is the relationship between the worker and work equipment, tools, or processes that is the problem, not any particular characteristic on either side. This can be confusing to an employer who orders expensive ergonomic tools and equipment for his or her workers and is disappointed when the workers continue to suffer work-related injuries and illnesses. The specialists in ergonomics must explain to their clients that a tool or piece of equipment is never in itself ergonomic; rather, it is the fit between a particular piece of equipment, tool, or process and the intended user of that equipment, tool, or process that creates a proper ergonomic situation.

Injury Prevention Programs

For decades, the majority of occupational therapy practice has been in the area of rehabilitation. Occupational therapists are unquestionably skilled in facilitating client independence during and/or following an injury, illness, or disease. Though not an entirely new concept, we are now recognizing occupational therapy’s potential to facilitate and perpetuate independence before or even in avoidance of these events. As we move into the 21st century, increasing numbers of occupational therapists are broadening their practices to include wellness and prevention.

Support for this movement is ubiquitous. The 1994-1996 landmark University of Southern California’s Well Elderly Study supports occupational therapy’s preventive intervention role in enhancing physical and mental health, occupational functioning, and life satisfaction.⁴⁰ The Occupational Therapy Practice Framework: Domain and Process, second edition, provides further support and lists health promotion, performance maintenance, and disability prevention as occupational therapy intervention approaches that facilitate “participation in life through engagement in occupations.”¹ Finally, in 2004, AOTA President Carolyn Baum, PhD, OTR/L, FAOTA, identified several prevention-related businesses as “hot” occupational therapy emerging practice areas.⁵⁷

With regard to occupational therapy and work, prevention can take on three forms: primary prevention, secondary prevention, and tertiary prevention. Primary prevention efforts help protect healthy workers against a targeted condition before the condition occurs. Interventions are directed to an entire workforce to prevent a specific work-related medical problem. Secondary prevention emphasizes early identification of and intervention for asymptomatic workers who have risk factors for the development of work-related medical problems, as well as identification and treatment of workers with mild medical symptoms in the early reversible stages of injury. The goal is to identify risk factors so that they can be minimized or eliminated and to reverse any medical problems that might be developing. Tertiary prevention occurs after a worker suffers nonreversible injury, illness, or disease. Interventions include treatment of the medical problem, attempts to restore maximum function in the workplace, and prevention of injury, illness, or disease-related complications. The goal is to return the affected worker to gainful employment within the confines of the medical problem and to prevent further injury. Once a permanent work-related injury occurs, primary and secondary prevention measures have failed. However, early risk factor detection and intervention through secondary prevention may have minimized the severity of the permanent injury.^85,99

Most occupational therapists are familiar with the process of tertiary prevention of work-related medical problems. Typically, the occupational therapist becomes involved after a worker suffers an injury and it becomes the therapist’s job to help the client regain maximum function in the workplace and prevent further injury. Occupational therapists are also commonly involved in secondary prevention efforts. Workers are referred with mild work-related medical conditions and intervention is planned to reverse the symptoms. When these clients get ready to return to work, the occupational therapist may assist the client in identification and modification of risk factors to reduce the risk for reinjury. Worksite evaluation and ergonomic intervention are generally part of the process for successfully re-engaging these workers.

Worksite evaluation and ergonomic intervention can also be part of a comprehensive primary prevention program designed to prevent work-related injury, illness, and disease.

Helping employers improve worker fitness, job comfort, and workplace safety reduces work-related medical problems. It can also lead to improved employee morale and increased productivity.³⁹ Occupational therapists, acting as consultants, can assist corporate clients in establishing injury prevention programs. This is one way that occupational therapists can incorporate the concepts of wellness and health promotion into their daily practices.

Occupational therapist Michael Melnick wrote that “the success or failure of a prevention program has less to do with specific activities implemented and more to do with the methods of implementation.”⁶⁰ Melnick outlines the four characteristics that are common among successful injury prevention programs: ongoing management support, supervisor “buy in,” employee participation, and ongoing support and reinforcement.⁶⁰ Melnick explains that successful prevention programs are grounded in the consultant’s ability to instill in the corporate client a culture of safety and wellness. The focus should be on the process of implementing safety and wellness activities and not on the activities themselves.

One common reason that an occupational therapist might be asked to consult with an industrial client is to control the severity and incidence of WMSDs. WMSDs are a class of soft injuries affecting the muscles, tendons, and nerves. Other names for WMSDs are cumulative trauma disorders, overuse syndromes, and repetitive strain disorders. WMSDs come on slowly and develop over time. They are thought to be the result of repeated microtrauma to a body and occur when the body is denied the opportunity to adequately rest and repair itself. Common diagnoses within the class of WMSDs include carpal tunnel syndrome, de Quervain tendinitis, lateral epicondylitis, and some types of back injuries.⁸¹

According to the Bureau of Labor Statistics, WMSDs accounted for 29% of all workplace injuries requiring time away from work in 2007 (reference page info: retrieved from the Bureau of Labor Statistics—www.bls.gov/opub/ted/2008/dec/wk1/art02.htm-on September 27, 2010). Employers pay more than $45 billion annually in worker’s compensation and other expenses associated with these disorders.⁴ These statistics indicate that WMSDs are at a crisis level in the workplace. However, the financial losses to industry and the economy pale in comparison to the physical and emotional pain and suffering endured by today’s injured workers.

Lorna and several of her coworkers were experiencing WMSDs. Their employer agreed to implement an in-house ergonomics program and injury prevention program at the recommendation of the occupational therapy consultant. An ergonomic team was developed that consisted of the company’s chief financial officer, the stapling station supervisor, the employee health nurse, the safety manager, the occupational therapist consultant, and three employees who worked in the stapling station, including Lorna.

There are a multitude of resources available for prevention consultants interested in helping corporate clients develop effective programs for evaluating and addressing musculoskeletal concerns in the workplace. OSHA and NIOSH are excellent starting points. Box 14-6 offers information on these two government entities and provides a partial listing of their ergonomic and injury prevention resource materials.

It is important to remember that every corporate client is unique and that the consultant’s recommendations must work within the corporate culture, goals, and budget constraints. Melnick also reminds us that we must help our corporate clients recognize that “injury prevention consultants do not reduce injuries. This would occur only if the consultant stepped in and performed each worker’s job. Rather, prevention consultants help companies reduce their losses by guiding them through various activities.”⁶⁰

As a guiding framework, however, the injury prevention consultant will want to incorporate the following elements into the corporate plan:

The essential elements of musculoskeletal injury prevention programs listed above are based on recommendations from both OSHA and NIOSH.^14,68–71 In the 1990s and early 2000s, these two entities developed guidelines and recommendations for public and private sector organizations seeking to establish in-house musculoskeletal injury prevention programs. These informational documents are available through OSHA and NIOSH and are an invaluable resource for occupational therapists wanting to offer prevention consulting services to address WMSDs.

Pre-Employment Testing

A frequent use of functional testing includes assessing a person’s ability to meet certain physical requirements before being hired for a job.⁷⁸ Some pre-employment testing may consist of isometric strength testing, ROM testing, or actual measurement of a person’s ability to perform selected tasks from the job description. Pre-employment screening can be an integral part of a company’s comprehensive injury prevention and management strategy.⁷⁸ Because of their training in task analysis and holistic approach, occupational therapists are excellent candidates for assisting companies in expanding plans to more effectively manage employee injuries.

When a company is looking at the overall impact of an employee injury on the bottom line, it goes much further than simply the cost associated with the injury itself. It extends beyond the medical costs to include the employee’s compensation, benefit package payments, training of replacement personnel, replacement personnel wages, and overtime payment for existing personnel if they are needed for coverage. This does not include the indirect costs of diminished productivity during the period when coverage is being arranged. The total impact can be quite staggering. The cost of developing an employment screening process is significant; however, the cost savings to the company can be dramatic.⁷⁸

The EEOC’s Uniform Guidelines on Employee Selection Procedures sets forth guidelines for the structure and function of human resource departments within companies and businesses. The guidelines also address how an organization can select and manage employees and places strong emphasis on the necessity of policies and procedures being job related.^24,78 The EEOC also mandates that an employer’s selection process not have adverse impact on any group of people and must not discriminate on the basis of race, color, religion, sex, or national origin, as established by Title VII of the Civil Rights Act of 1964.^24,78 Meeting these criteria requires that the selection procedures demonstrate validation, be of business necessity, and be a bona fide occupational requirement.^24,78 To be compliant with the ADA, pre-employment screening must be based on an accurate job description, test only the essential functions (although not every function need be assessed), and have high face validity (often referred to as content validity—tests what you really want to know) or closely mirror the aspects of the job that is being tested.^6,78 Dynamic testing (actually replicating physical tasks from the job) is recommended and can be conducted on-site at the company or off-site and needs to use equipment from the job as it is available.⁷⁸ It is vital that companies take the time to thoroughly develop their screening process to be able to defend why the screening was considered necessary, maintain awareness and vigilance in the development phase of good test design, and be prepared to explain and demonstrate the applicability of the screening to the job in question.⁷⁸

Pre-employment testing can also occur at several points in the hiring process; however, many health care providers and legal experts recommend conducting such testing after an offer of employment has been extended.^31,54 With post-offer screening (POS), the most advantageous progression is to interview the applicant and determine whether the person is an acceptable candidate for employment.⁷⁸ A conditional offer is extended to the applicant based on the applicant’s ability to meet a variety of conditions, such as passing a drug screen, acceptable background check, and physical testing. A problem with pre-offer testing is that Title 29 of the Code of Federal Regulations specifically states that medical examination is permissible “after making an offer of employment to a job applicant.”¹³ Monitoring blood pressure or the heart rate or inquiring about past medical history is considered to be part of a medical examination and is precluded in pre-offer testing.⁷⁸

Anything that a therapist does in the way of evaluating an applicant might be deemed medical simply because an occupational therapist is a medical professional. It is also important to look critically at any testing that is considered to be general strength testing because it has been found to be a poor predictor of potential for injury.^21,65,78 Normative databases are of little use in making hiring decisions, too, since according to both the ADA and the EEOC, it does not matter whether the applicant falls into the 5th percentile or the 95th percentile; the only thing of importance is whether the applicant can perform the tasks of the job.^6,24

If the applicant passes the screening, he or she is hired and begins working. If the applicant does not pass, the employer must assess whether the applicant has a disability as defined under the ADA (see Chapter 15).⁶ If the applicant does, the employer must determine whether reasonable accommodation can be offered to the applicant so that that the individual may be able to perform the job. Reasonable accommodation means providing accommodation in such a way that the employer is not placed under undue financial strain for the accommodation to be implemented. If the company can and does offer accommodation to the applicant, the hiring process is completed and the employment begins. If the company cannot offer reasonable accommodation or if the applicant does not have a disability yet fails the screening, the employer can choose to rescind the offer of employment, examine opportunities for alternative placement elsewhere in the company, or offer remediation of some type and allow the applicant to retest if certain criteria are met.⁷⁸ For example, if a nondisabled applicant does not pass the lifting portion of a POS and otherwise meets the employment criteria, the company might elect to allow the applicant 2 weeks to improve strength with the goal of returning for a retest screen in an attempt to pass the lifting portion.

Suppose Henry (the roofer in the case study) had difficulty balancing on one leg as a result of an early childhood accident but that this balance problem was not something that was readily apparent. If a POS were conducted on Henry before being hired at the roofing company and balance was a component of testing for working as a roofer, his difficulty could have been detected and Henry could have been denied the job or offered alternative placement. Either way Henry would have been protected from a fall that would radically change his life.

A company does not have to test applicants for every job. Typically, it is suggested that a company survey all of its injuries and determine where the majority of injuries are occurring and if they are occurring within the first 6 months of hiring. If so, this company is a good candidate for implementing a physical screen as part of the hiring process. Once it is determined which jobs are going to be selected for testing, the physical demands of the job must be evaluated. This can be done by survey, questionnaire, or observation (either direct or video).⁷ The job description must include information that is functional in terms of physical demands, describe the essential tasks of the job, and be presented in such language that one can test for an individual’s ability to perform them.⁷ In the case of a company requesting that existing job descriptions be used for development of the screen, it is extremely important to document that the company provided the job descriptions and that the therapist does not assume any liability for errors in their accuracy.

Physical demand items can then be selected for testing during screening based on either the difficulty or the frequency of the item. It is not necessary to test all of the physical demands for each job. For instance, a job might include carrying 10 lb a distance of 10 feet twice a day and lifting 40 lb from pallet height to waist height 200 times per day. Testing the ability to lift 40 lb would be a better selection for testing, for if the applicant is able to lift 40 lb from pallet height to waist height, it is likely that he or she will also be able to carry 10 lb a distance of 10 feet. It is important to select a method of testing the tasks that is reliable and valid and demonstrates job applicability, whether choosing from a standardized battery of physical demand tests or developing job-specific tasks to improve the applicant’s understanding of the relevance of the task and defensibility of hiring decisions.^24,78

After tasks are selected, implementation can begin. It is suggested that a statistically significant sample of incumbents be tested to ensure that the correct demands have been selected and that the minimum requirements for each demand have been set appropriately. Once pilot testing is complete, the screening can be administered consistently to all applicants for a given job. It is also recommended that the screening process be monitored to ensure that fair and nondiscriminatory selection of applicants is occurring and that modifications in the screening process can occur as needed.⁷⁸

Transition Services from School to Work

Occupational therapy practitioners can make a valuable contribution to students with disabilities who are transitioning from school to the community. The 1997 amendments to the Individuals with Disabilities Education Act (IDEA) of 1990 specified that transition planning is to be part of the Individualized Education Program (IEP). Representatives from community agencies that provide post-school services, such as state-sponsored vocational rehabilitation, must join the education team. Related services such as occupational therapy are formal contributors to the transition planning for students who need these type of services.⁹⁴ Transition services are defined by the IDEA as “a coordinated set of activities for a student designed within an outcome-oriented process, which promotes movement from school to post-school activities, includes postsecondary education, vocational training, integrated employment (including supported employment), continuing and adult education, adult services, independent living, or community participation.”⁹³ Occupational therapy’s unique focus on occupational performance can be a strong asset to the transition team.

The three main roles that an occupational therapist will participate in are transition-related evaluation, service planning, and service implementation. The occupational therapist contributes vital information about students’ performance abilities and needs in any of the transition domains: domestic, vocational, school, recreational, and community.

Work Readiness Programs

Many times, people who have survived a major accident or illness cannot return to their prior employment and need to explore other options for employment. For example, Henry can no longer carry out the job demands of a roofer. Henry may really want to return to some type of meaningful work but needs guidance and direction to explore what his present abilities and work skills are so that he can set some realistic vocational goals.

A work readiness program is designed to help individuals who desire to work identify vocational options that match their interests, skills, and abilities. At Rancho Los Amigos National Rehabilitation Center in Downey, California, an occupational therapist developed and implemented an ongoing work readiness program as part of the Occupational Therapy Vocational Services. This is a 6-week program that meets three times a week for 2 hours. It consists primarily of group sessions with a few individual sessions. Topics addressed include the following: work habits, goals, interests, work skills, vocational exploration, job hunting strategies, and community resources. Instruction, group discussion, and hands-on exploration of work skills via standardized work samples and situational assessments are used to help people explore their readiness to work and discover their potential for pursuing training for a different occupation. Each person’s program is individualized to address specific goals and interests. For example, Henry may be interested in working with a computer. He would be given the opportunity to do different work-related tasks using a computer so that he could see whether he has an aptitude for this type of work. If Henry was not familiar with the types of jobs that a person could do with a computer, he would learn how to do vocational research by using various reference books in the library or on the Internet.

A work readiness program can help people identify specific goals to pursue and develop a plan to help them work toward their goals. This program can help a person prepare for returning to work, but it does not provide a job for the participant. At the completion of the program, if a person demonstrates readiness to work, he or she can be referred to the State Department of Rehabilitation for assistance in job training and job placement. After completing a work readiness program, the occupational therapist can provide valuable information on a person’s skills, aptitudes, and interests to assist the rehabilitation counselor in developing a feasible plan for the worker. While Henry was attending the work readiness program, he identified the goal of becoming a computer support technician. Based on the vocational testing and research that he did during the program, this was determined to be a reasonable goal for him to pursue. He was referred to the State Department of Rehabilitation for job training and job placement in his new career.

Community-Based Services

Historically, work-related programs took place within medical model clinics, such as rehabilitation programs or settings designed for work intervention, as opposed to the site where the worker actually performed his or her role.⁹⁰ Today, work programs are increasingly being located in the community in which the participant resides or within the work setting itself.⁹⁰ This trend toward increased community practice is probably due to changes in the field of occupational therapy and external forces influencing the practice. Current thinking in occupational therapy recognizes that “occupational dysfunction is multidimensional, resulting from the interplay of biological, psychological, and ecological factors.”⁹⁰ Decreasing reimbursement in medical model settings has resulted in occupational therapists exploring other options for reimbursement in the community.

Funding for most community-based programs is derived from grants or contracts through local, state, or federal governments, as well as foundations. Grants are funds that are awarded for a specific purpose and a specific period, usually for research or a service project, “based on a submission of a creative original proposal.”⁹⁰ Contracts also provide funding for research or service projects; however, the funding agency defines the scope of the project and requests bids from competing organizations in the community. The majority of funding for community-based programs comes from foundations; “foundations are operated by philanthropic families, corporations, or community agencies that have reserved significant amounts of money for the purpose of supporting charitable organizations and programs to address specific community needs.”⁹⁰ Many associations and civic groups, such as the United Way, American Head Injury Foundation, Kiwanis Club, and others, provide funding for community projects related to specific areas of interest. It is important to note that community-based programs should develop a broad financial base with multiple funding sources for programs to “survive and thrive” in the long run.

Future Trends

The population of older workers is increasing, whereas the population of younger workers between 25 and 44 is decreasing.⁸⁸ According to the Bureau of Labor Statistics, between 1977 and 2007, employment of workers 65 and older increased 101% as compared with 59% for total employment (16 and older).⁹ It is predicted that there will be a shortage of younger workers to replace the baby boomers when they retire, thereby creating a gap in the labor market. One proposal to fill this gap would be to employ more people with disabilities.⁸⁸ Occupational therapists can work with human resource managers to educate and provide resources for workplace accommodations. The Society for Human Resource Management has recently partnered with the Office of Disability Employment Policy (ODEP).⁸⁸ This collaboration reveals that human resource professionals are seeking support and services for hiring and accommodating workers with disabilities.

Baby boomers represent one of the largest percentage of the working population.⁸⁸ As they age, employers may need to be sensitive to workers in whom multiple disabilities develop that have an impact on their job performance. Changes in the workplace offer new opportunities for occupational therapists to help aging workers stay employed with their functional limitations. As older workers retire, occupational therapists can help individuals plan for their retirement and explore ways to remain active in the community by participation in leisure pursuits or volunteer activities. Occupational therapists can help older individuals identify their strengths and abilities and provide community resources to allow meaningful participation in valued occupations.

Summary

This chapter provides an overview of the varying types of work programs in which occupational therapists are currently practicing, as well as identifies and discusses areas for further involvement. There are tremendous opportunities for occupational therapists and certified occupational therapy assistants to expand their role and involvement in hospitals, schools, industrial settings, and the community in general in the area of work practice. Occupational therapy practitioners are challenged to take a proactive approach in advocating the need for and benefit of these types of work-related programs in all communities to help restore the worker role in many people’s lives.

References