Ulrika Bejerholm

Time use among people with psychiatric disabilities: implications for practice.

TOPIC This paper reviewed the current literature regarding time use among people with psychiatric disabilities. PURPOSE The purpose was to investigate what characterizes time use, occupational balance and occupational patterns among people with psychiatric disabilities, how time use relates to health in this group, and how time use can be used in research designs and addressed in assessments and interventions. SOURCES The databases CINAHL and PubMed were searched, by combinations of terms such as: time use, time geography, occupational balance, occupational pattern, assessment, intervention, occupational therapy, lifestyle redesign, well-being, and mental health. CONCLUSIONS Time use for people with psychiatric disabilities is often restricted to sleeping, eating, caring for oneself, and performing quiet activities. The target group is at risk of being both over- and under-occupied, and occupational imbalance may be regarded as an expression of the disability, thus shaped by a misfit between the persons capacities and environmental opportunities and demands. Several time-use methods exist for the study of daily occupations in people with psychiatric disabilities, but no intervention based on time use was found. Principles for a time-use based intervention are discussed. However, such an intervention needs to be investigated for relevance and effectiveness in future research.

Profiles of occupational engagement in people with schizophrenia, POES: Development of a new instrument based on time-use diaries

Previous time-use research suggests that it is highly relevant for an occupational therapist to estimate time use and occupational engagement in order to understand some of the determinants of wellbeing for people with schizophrenia. This article describes the development and the testing of the psychometric properties of an instrument, Profiles of Occupational Engagement in people with Schizophrenia (POES), with the aim of helping to interpret and evaluate time-use diaries and thus providing a systematic description of status regarding occupational engagement. The first part of POES involves completion of time-use diaries and the second part, the assessment, is based on nine items that are rated on a four-point ordinal scale. The time-use diaries of 41 people with schizophrenia and the judgements from 12 occupational therapists were used in the study. A test of content validation involved experts from Sweden and the United Kingdom and resulted in two stages of revisions. The strength of agreement between two raters resulted in a mean weighted kappa of 0.70. Internal consistency was calculated for both raters separately and the alpha coefficients were 0.97 and 0.95. This study provides initial support for the content validity, interrater agreement and internal consistency of POES. Based on the judgements of the occupational therapists in this study, POES seems to have good clinical utility. However, further research on the clinical utility as well as the criterion validity of the construct is warranted.

Individual Placement and Support in Sweden—A randomized controlled trial

Abstract Background: Currently there is no evidence on the effectiveness of Individual Placement and Support (IPS) in Sweden. Aims: To determine the effectiveness of IPS on vocational outcomes among people with severe mental illness (SMI) in a Swedish context. A secondary aim was to evaluate a community integration effect. Methods: A randomized controlled trial with a parallel design was used. Mental health outpatients with SMI were randomized to IPS or traditional vocational rehabilitation (TVR) services. The allocation status was assessor-blinded. The primary outcome was competitive employment. All vocational outcomes were collected continuously, and socio-demographic and clinical variables at baseline, 6 and 18 months. The trial is registered with ClinicalTrials.gov: NCT00960024. Results: One hundred and twenty participants were randomized. Eighty seven per cent were assessed after 6 months, and 73% after 18 months. IPS was more effective than TVR in terms of gaining employment at 18-month follow-up (46% vs. 11%; difference 36%, 95% CI 18–54), along with the amount of working hours and weeks, longer job tenure periods and income. Cox regression analysis showed that IPS participants gained employment five times quicker than those in TVR. Ninety per cent of the IPS participants became involved in work, internships or education, i.e. activities integrated in mainstream community settings, while 24% in the TVR group achieved this. Conclusions: IPS is effective in a Swedish context in terms of gaining employment and becoming integrated within the local community. The welfare system presented obstacles for gaining competitive employment directly and it was indicated that internships delayed time to first competitive employment.

Construct validity of a newly developed instrument: Profile of Occupational Engagement in people with Schizophrenia, POES

It is highly relevant to estimate to what extent a person with schizophrenia engages in occupations and participates in different life situations in order to understand the determinants of well-being in this group of people. This study aimed at examining the construct validity of the instrument Profile of Occupational Engagement in persons with Schizophrenia, POES. Global Assessment of Functioning, GAF, and a scale measuring Satisfaction with daily occupations and Activity level were chosen as standards against which POES was validated. As hypothesized, moderate associations were found between POES and GAF (0.73), Activity level (0.70), and Satisfaction with daily occupations (0.50). Regarding the separate items of POES, the items that concerned the range of occupations performed had the strongest association with Activity level, and the items that concerned ongoing occupations, i.e. Routines and Extent of performing meaningful occupations, correlated most strongly with Satisfaction with daily occupations. Thus, the strongest associations were found for the expected items. Altogether, POES seems to possess satisfactory construct validity and be a construct in its own right, as indicated by correlations of expected size and direction with the selected instruments and for expected items.

Empowerment in supported employment research and practice: Is it relevant?:

Background: This cross-sectional study is aimed at describing and investigating empowerment and its relationships with level of engagement in daily activities and community life, experienced stigma, psychopathology, and quality of life among people with mental illness entering supported employment. Method: The following scales were administered to 120 persons: Empowerment Scale, Profiles of Occupational Engagement Scale, Manchester Short Assessment of Quality of Life Scale, Rejection Experience Scale and Brief Psychiatric and Rating Scale. Results: Higher scores of empowerment were associated with fewer symptoms and experienced stigma, a higher level of engagement in daily activities and community life, better quality of life and having work rehabilitation. Self-efficacy and self-esteem were in particular significantly correlated to depressive symptoms. Descriptive statistics enveloped the group of participants that said ‘Yes I want to work’ with a somewhat high mean score for empowerment, level of engagement and quality of life, but a low mean score with regard to both symptoms and experienced stigma. Conclusions: This study advocates the importance of evaluating empowerment in supported employment research and practice. The findings suggest the importance of taking into account not only monetary aspects of having a job but also social and psychological aspects such as empowerment, reduction in experienced stigma and community integration.

Occupational Balance in People With Schizophrenia

The aim of this study was to illuminate the concept of occupational balance and to study its relation to occupational engagement as assessed by the Profiles of Occupational Engagement in people with Schizophrenia (POES), health related factors, and quality of life among 72 persons with schizophrenia. Three constructs: being under-occupied, being over-occupied, and having occupational balance, were developed to help assess occupational balance. The inter-reliability testing of occupational balance resulted in good agreement on average. The descriptive statistics showed that 32 participants were deemed to be under-occupied, 35 participants had occupational balance, while five participants were over-occupied. Significant statistical differences were found between the subgroups of being under-occupied and having occupational balance regarding negative symptoms, sense of coherence and quality of life. In clinical practice, the assessment of occupational balance could help occupational therapists to optimize the design of time-use interventions.

Barriers in implementation of evidence-based practice: Supported employment in Swedish context

PURPOSE The aim of this paper is to identify initial barriers influencing implementation of supported employment (SE). SE, according to the individual placement and support (IPS) approach, has been recognised as an evidence-based method to help people with severe mental illness to find regular employment. DESIGN/METHODOLOGY/APPROACH A systematic implementation evaluation of the first randomised controlled SE (IPS) trial in Sweden was conducted in August 2008 and August 2009. Data were collected on a regular basis from SE employment specialists, process heads, clients and representatives from mental health care units and vocational services (social insurance and public employment offices) using interviews, non-participant observations and document analysis. FINDINGS SE employment specialists reported that existing regulations for social insurance and employment regulations presented major obstacles to implementation. Difficulties were reported in cooperation with handling officers at the vocational services. Scepticism towards persons with mental illness was common and employers expected to receive subsidies if they hired a person with mental illness. SE participants expressed fear of losing their social benefits. ORIGINALITY/VALUE The results illuminate a collision between an innovative evidence-based practice and the existing systems for social benefits and work rehabilitation.

Attitudes towards mental illness among health care students at Swedish universities – A follow-up study after completed clinical placement

The aim of the study was to examine the changes in attitudes towards mental illness after theoretical education and clinical placement among students from university programmes preparing for different kinds of health professions. Three different questionnaires were used, measuring the level of familiarity with mental illness and attitudes towards mental illness in general and towards specific mental illnesses. The data were collected on two occasions, before the theoretical course and after the completed clinical placement. The result showed that the attitudes toward mental illness in general had changed in a less stigmatising direction after the clinical placement. On the other hand, attitudes toward specific mental illnesses did not show any major changes. A conclusion is that the clinical placement included in the university programmes to some extent could affect attitudes in a de-stigmatizing direction, possibly because of the interaction with persons suffering from mental illness and experienced supervisors.

The effect of IPS on participants' engagement, quality of life, empowerment, and motivation: a randomized controlled trial

Abstract Objective: To investigate the effectiveness of Individual Placement and Support (IPS) with regard to non-vocational outcomes among individuals with severe mental illness. Methods: A randomized controlled trial was carried out, comparing IPS with traditional vocational rehabilitation. The Empowerment Scale, the Worker Role Interview, the Profile of Occupational Engagement, and the Manchester Short Assessment of Quality of Life were administered to 120 clients, at baseline, six, and 18 months. Results: IPS participants showed higher scores in quality of life (p = 0.002), empowerment (p = 0.047), and work motivation (p = 0.033) at 18 months. Within the IPS group, a significant change in QOL was shown at six (p = 0.002) and 18 months (p = 0.000), and in occupational engagement (p = 0.003; p = 0.012). Conclusions: IPS can be part of a recovery process as individuals may increase their life satisfaction and time spent in daily occupations and community life.

Psychometric testing of a self-report measure of engagement in productive occupations.

Background Occupational therapists working with clients in productive occupations explicitly or implicitly assess their clients’ occupational engagement. Purpose To investigate the psychometric properties of the Profiles of Occupational Engagement in People with Severe Mental Illness: Productive Occupations (POES-P) in terms of internal consistency, initial construct validation, and floor and ceiling effects. Method Participants (n = 93) from six day centres completed the data collection. Correlations between the POES-P and instruments measuring similar and dissimilar attributes, such as satisfaction, psychosocial functioning, and unmet needs, were studied. Findings A moderate relationship was found between the POES-P and occupational satisfaction (r s = 0.43) and a weak one with psychosocial functioning (r s = 0.22). The association with researcher-assessed participant engagement was slightly higher (r s = 0.37), and the relationship with unmet needs was nonsignificant (r s = –0.15). Internal consistency of the POES-P (alpha = 0.85) was good, but the distribution of responses indicated a ceiling effect. Implications The POES-P seems promising for assessing engagement in work-like occupations but would benefit from further development. Description Les ergothérapeutes intervenant auprès des clients à l’aide d’occupations productives évaluent la participation occupationnelle de leurs clients de manière explicite ou implicite. But Examiner les propriétés psychométriques du Profiles of Occupational Engagement in People with Severe Mental Illness: Productive Occupations (POES-P) en fonction de la cohérence interne, la validité structurale initiale et les effets plancher et plafond. Méthodologie Des participants (n = 93) de six centres de jour ont participé à la cueillette de données. Les corrélations entre le POES-P et des instruments mesurant des attributs semblables et différents, comme la satisfaction, le fonctionnement psychosocial et les besoins non satisfaits ont été analysées. Résultats Une relation modérée a été observée entre le POES-P et la satisfaction occupationnelle (r s = 0,43) et une relation faible a été constatée entre le POES-P et le fonctionnement psychosocial (r s = 0,22). L’association entre le POES-P et la participation occupationnelle des participants évaluée par le chercheur était un peu plus élevée (r s = 0,37) et la relation avec les besoins non-satisfaits n’était pas significative (r s = –0,15). La cohérence interne du POES-P (alpha = 0,85) était bonne, mais la distribution des réponses indiquait un effet plafond. Conséquences Le POES-P semble prometteur pour évaluer la participation à des occupations s’apparentant au travail, mais il serait avantageux de développer davantage cet instrument de mesure.