VOL: 103, ISSUE: 22, PAGE NO: 32-33
Donna Gannon, BSc, RMN; Nathan Gregory, BSc, MSc, RMN
Donna Gannon is community mental health nurse, north community mental health team; Nathan Gregory is team manager, Gloucestershire recovery in psychosis team, both at Gloucestershire Partnership NHS Trust.Gannon, D., Gregory, N. (2007) Barriers to improving work opportunities for people with severe mental illness. www...
Abstract Gannon, D., Gregory, N. (2007) Barriers to improving work opportunities for people with severe mental illness. www.nursingtimes.net
AIM To explore two areas related to the barriers to employment opportunities for people with severe mental illness (SMI): the mental health service userÂ's perspective; and the efficacy of mental health nurses and community mental health teams.
METHOD Six UK studies were evaluated, with a view to answering two specific questions relating to the service userÂ's perspective and the efficacy of services.
RESULTS An evaluation of these six studies revealed variations in methodology, diversity in sample frameworks and disparities in rigour.
DISCUSSION Findings highlight the complexities of the subject area, with recommendations that a modification to clinical practice and further research are necessary if barriers to employment are to be improved.
CONCLUSION The continuing interest in vocational issues may assist practitioners to offer evidence-based approaches to tackle stigma and discrimination, thereby promoting social inclusion of people with mental health problems.
Evans and Repper (2000) described the benefits of work as follows: 'Work provides a sense of purpose and belonging; an opportunity to contribute to shared goals; a social forum; status and recognition for our efforts and achievements.'
People with mental health difficulties are one of the most disadvantaged groups of people in the labour market (Learning and Skills Council, 2006). Furthermore, clients who experience severe mental illness report a clear need for access to employment and education (Honey, 2004; Bates, 2002), with research finding that work improves self-esteem and wellbeing, particularly benefiting people with significant support needs (McGilloway and Donnelly, 2000).
Studies report a strong link between suicide and unemployment (Lewis and Sloggett, 1998), yet high unemployment rates continue among people with long-term mental health problems. For example, the Labour Force Survey revealed that 24% of people with mental health problems are employed, while only 8% of those who have experienced severe mental illness are in work (Department for Education and Employment, 2003). There are particular difficulties relating to people with a diagnosis of schizophrenia, who experience the most serious levels of employment discrimination (Manning and White, 1995).
In the UK, it is estimated that the economic costs of mental illness are Â£23.1bn in output losses, of which Â£9.4bn is due to non-employment alone (Sainsbury Centre for Mental Health, 2003). While these figures are only a proportion of the overall social and economic costs of mental illness, it provides an illustration of the influences on government policy.
This has resulted in the establishment by the government of a Social Exclusion Unit, now the Social Exclusion Taskforce. One of its roles is enabling people with mental health problems to enter and retain work, and have equal opportunities for social participation and access to services (Social Exclusion Taskforce, 2007).
At a government level, the introduction of the National Service Framework for Mental Health (Department of Health, 1999) requires that the inclusion of employment, training or occupational activity is addressed in care planning for people receiving enhanced provision in the Care Programme Approach.
More recently, the role of the mental health nurse has been reviewed by the chief nursing officer, who identified a need for a focus on employment issues for clients with mental illness (DH, 2006).
Further commissioning guidance has been directed at vocational services for people with severe mental health problems (Department for Work and Pensions, 2006).
This increased focus on employment issues for individuals with mental illness will have direct implications for mental health professionals. Commissioning guidance advocates individual placement support and time-unlimited assistance, with the emphasis on paid employment (Department for Work and Pensions, 2006). It is further suggested that vocational programmes are integrated into the work of mental health services through appointing employment specialist posts within teams.
To examine the evidence base, an electronic database search of Cinahl, Medline, PsycINFO, BNI and the gateway access OVID was conducted. Keywords were Â'vocationÂ', Â'employmentÂ', Â'inclusionÂ' and Â'exclusionÂ', with the addition of Â'mental illnessÂ' to define the subject area. Additional information was gathered from websites including those of the DH, Sainsbury Centre for Mental Health and NICE. The reference sections of the papers collected were searched for other sources.
It was evident that a number of studies originated outside the UK. For example a Cochrane review of vocational rehabilitation for people with severe mental illness (Crowther et al, 2001) was determined from randomised controlled trial criteria drawn from studies in the US.
In our study, articles within a five-year period of the review are included. An initial critique of UK studies allowed the precise direction of this review to be clarified, with the aim of answering the following two questions:
- What are the barriers to improving employment opportunities for people with severe mental illness in the UK from the service userÂ's perspective?
- How effective are community mental health nurses and community mental health teams in facilitating employment for clients with severe mental illness?
Following a systematic search, six studies were selected for critical review and in-depth analysis. To address the first question, three qualitative research papers were examined.
The limited amount of research on the service user perspective of barriers to employment is highlighted by Marwaha and Johnson (2005) in their qualitative descriptive study. In this paper, the authors aimed to encapsulate a fuller understanding of the issues that affect individual maintenance of employment, including views on service provision. Although the methodology of this paper appears comprehensive, the sample of 15 participants arguably limited the ability to detect relationships and differences.
In comparison, the factors associated with job retention were investigated by Secker and Membrey (2003) from the perspective of employment project clients. This qualitative study focused on participants with severe mental illness and was concerned specifically with experiences of maintaining open employment or aspects that caused employment to discontinue. However, there are reservations about the reliability and validity of this study as the authors did not refer to socio-demographic details, and this draws into question whether the sample represents the target population.
An earlier qualitative investigation by Secker et al (2001) similarly focused on participantsÂ' views of employment, training and education. Although the study is limited due to a focus on one inner-city area, it does provide a clear geographic setting for the interpretation of data. Compared to other studies, the authors dealt with a much larger sample, with 156 people seen individually and a further 120 participants involved in focus groups. What is also significant in this study is that interviews were carried out by service users who received an hourly rate of pay.
It is evident that these three studies provide a distinct variation in descriptors of methodology despite similar aims, objectives and target population. While this can cause uncertainty regarding the rigour of data collection, each study does identify clear inclusion and exclusion criteria with the use of different researchers to aid the elimination of bias. However, the research offers marked similarities from individual participant accounts in areas such as stigma, loss of confidence and lack of priority given to employment by mental health workers.
The research provides an objective acknowledgement of the difficulties faced by participants with regards to the benefits system (Read and Baker, 1996). It also highlights similarities in the workplace needs of people with mental health difficulties compared to the general population (Cox, 1993). Although this leads to recommendations made purely to employers, there is no focus on other areas including mental health service provision despite the implications for clinical practice (Hek et al, 1996).
The second question - Â'How effective are community mental health nurses and community mental health teams in facilitating employment for people with severe mental illness?Â' - considers a randomised controlled trial and two further studies using a qualitative approach.
Seebohm and Secker (2003) explored the factors that help team commitment to vocational work as well as aspects that create barriers. The authors used a qualitative approach in order to explore participant experience, with the target population consisting of care co-ordinators, vocational specialists and other staff involved in the provision of employment resources. Although the paper includes comprehensive descriptors of socio-demographic aspects and the variations in vocational approaches, the multifaceted nature of this study calls for caution regarding the conclusions drawn from its findings. Furthermore, the inclusion of assertive outreach teams, although improving external validity, changes the focus from community mental health teams, requiring care in the interpretation of data.
OÂ'Brien et al (2003) examined community mental health team approaches to vocational services in their randomised controlled trial. The authors aimed to test whether community mental health team changes in approach to vocational rehabilitation alone would improve employment outcomes without the introduction of staff specifically trained to offer support in this area. There are concerns regarding power analysis in this study and the 12-month period of investigation may limit findings. However, there is a strong rationale for the research aims that take into account research outcomes from employment models in the US, yet acknowledge the financial burden that would result from this model being adopted in the UK.
In contrast, Bertram and Stickley (2005) produced a study that does not directly address employment issues but offers valuable insight into mental health staff attitudes towards social inclusion and consequent barriers that may exist. However, as the researcher was employed within the setting in which the research took place, concerns could be raised regarding the level of observer bias in the data.
Although there were marked variations in approach from all three studies, each one offered the potential to examine the efficacy of mental health staff and teams in relation to issues of employment and barriers that may exist. For example, OÂ'Brien et al (2003) stated that their results indicate staff training alone cannot improve employment status for individuals with severe mental illness, while Seebohm and Secker (2003) identified interprofessional relationships and vocational specialists as key to improving employment opportunities.
The findings from all three studies raise issues regarding the attitudes and dilemmas of mental health workers in balancing issues of risk and care. Each study further refers to barriers within the role of the mental health worker in response to elements of control that conflict with duty of care.
In particular, Seebohm and Secker (2003) specifically identified that negative attitudes to employment strategies are associated with mental health workers who possess a medical model perspective. A particular strength of Seebohm and SeckerÂ's (2003) investigation is that it provides an insight into the number of professionals and agencies involved in vocational services. This subsequently raises issues of inter-professional working and how levels of efficacy in this area will have direct bearing on employment opportunities for clients with mental illness.
OÂ'Brien et al (2003) recommended that vocational services offer time-unlimited support with specialist input; these findings concur with the conclusions drawn from the Department for Work and Pensions (2006). This is also supported by Bertram and Stickley (2005), who believe that an increase in socially inclusive policies may shift focus from principles that seek to protect the public. Seebohm and Secker (2003) recommended changes in mental health staff attitudes and the provision of resources to improve vocational opportunities for clients.
Although this review has provided increased awareness in relation to the two research questions identified, it further highlights the degree of complexities that need to be considered regarding implementation of vocational policies in the UK.
Current vocational services are varied in style with no overall responsibility for provision (Crowther and Marshall, 2001) and additionally, styles of inter- professional and multi-agency liaison also contrast from one area to another (Secker et al, 2002). When these factors are considered in conjunction with workplace stress, effect of employment on benefits and employers who are fearful of mental illness (Perkins and Rinaldi, 2002), the barriers to employment can appear immense.
The findings of research in this review about the views of people with mental illness add to previous conclusions that indicate the importance of work. Consequently, there is some encouragement that research into vocational approaches appears to be gaining momentum in the UK. Studies that range from occupational therapists providing the lead in vocational services (Davis and Rinaldi, 2004), to improving outcomes for young people with SMI and first-episode psychosis (Harvey et al, 2006; Rinaldi et al, 2004) may have implications for the implementation of vocational strategies.
Indications from the review of community nurses and team efficacy in this area suggest that vocational approaches require a specific focus. While the studies reviewed did exhibit weaknesses, this view is supported by Boardman et al (2003), who said that the dominance of the medical model has led professionals to overlook the importance of employment. Although this necessitates considered acknowledgment, it is also important to recognise that provision of holistic care requires the mental health worker to cover a wide range of areas such as accommodation, finances and carer support; employment is therefore an additional area of complexity (Grove, 1999).
It could be contended that the initiatives proposed within commissioning guidance for vocational services will develop this area, thereby helping service users and mental health workers. The findings of this review may also add credibility to these proposals as they present similar results as studies conducted in the US, although the UK studies were small in scale. However, this needs to be set against the current climate of deficits within the NHS and the impact this will have on new initiatives.
While the effects of budget deficits remain to be seen, people with mental illness will continue to need ongoing focus on employment issues. There is no doubt that this will present challenges to individual practitioners who not only need to maintain a responsibility to include employment in care planning but also wish to provide opportunities to improve social inclusion by promoting hope. Furthermore, the need for attention to interprofessional and multi-agency collaboration is vital to aid the service userÂ's potential.
Therefore, the continuing interest in vocational issues coupled with reliable research may well assist practitioners to offer evidence-based approaches to tackle stigma and discrimination, thereby promoting the social inclusion of people with mental health difficulties.
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