Work Hardening Strategies: Feasibility for Competitive Employment

///Work Hardening Strategies: Feasibility for Competitive Employment
Work Hardening Strategies: Feasibility for Competitive Employment 2017-05-20T18:56:27+00:00

Work Hardening Strategies: Feasibility for Competitive Employment

Leonard N. Matheson, Ph.D.

Introduction

Feasibility for Competitive Employment is an integral component of the basic conceptual model of Work Capacity Evaluation. It applies to all disability groups and, indeed, to all workers at all levels of employment. This concept is readily understood by clients, their families and employers. It provides an excellent means of communication. It also offers a results-oriented approach to rehabilitation, acting as external touchstone against which the individual’s progress can be measured.

Feasibility for Competitive Employment is defined as the client’s acceptability as an employee in the most general sense; what the employer in the competitive labor market expects of any employee. Some of the questions that are asked of the client are

  • Can the client get to work on time?
  • Can the client put in a full workday?
  • Will the client be safe in my workplace?
  • Can the client get along with his supervisors?

Employers consistently require acceptable responses to these issues whether they are considering hiring a clerical worker, a laborer, or a physician. These issues pertain to all employers and employees in the competitive labor market.

Basic Concepts

The Work Capacity Evaluation process begins with a look at the client’s feasibility for competitive employment. The client is considered as an employee in terms of his ability to meet the general requirements that any employer in the competitive labor market has of any employee. Feasibility is evaluated in terms of factors that can be grouped in three major areas:

  1. General Productivity: The client’s ability to perform work tasks with sufficient speed, endurance, quality, and consistency to allow the employer to profit from his/her employment.
  2. Safety in the Workplace: The client’s ability to perform the job tasks within the work environment in a manner which is safe to himself/herself and his/her fellow clients.
  3. Interpersonal Behavior: The client’s ability to get along with his/her fellow clients, accept direction from a supervisor and adjust to different supervisory styles.

The feasibility issues are considered prior to other vocational issues (aptitudes and interests, for instance) because, no matter how well the client performs in these latter areas, he or she will not be acceptable to an employer if not feasible for competitive employment.

The evaluation of feasibility for competitive employment has always been part of the vocational evaluation process. Work Capacity Evaluation uses the formally defined concept of feasibility that is presented here as the primary context within which all Work Capacity Evaluation efforts take place.

The factors which comprise feasibility for competitive employment have been specified only recently. The identification of the specific feasibility factors and their development into the Feasibility Evaluation Checklist (Matheson, 1980) was stimulated by the demands of the Workers’ Compensation rehabilitation system in California. This system requires employers to provide rehabilitation services to an employee who has become disabled due to a work injury in addition to (and separate from) the cash grant that is based upon the permanent disability rating.

The First Clinical Case

In l976, Emilio Rodriguez, a male client at Rancho Los Amigos Hospital in Downey, California, was attempting to return to work. He was involved in an outpatient chronic pain rehabilitation program as a client receiving services which were underwritten by his employer’s Worker’s Compensation insurance carrier.

Mr. Rodriguez had seven children. He was 34 years old. He had been a meat cutter for fourteen years. He had a serious cervical and lower back disk injury and had declined surgical intervention. He had participated in the Rancho Los Amigos Pain Rehabilitation program and had been discharged after receiving maximum benefit. However, he had not yet returned to work. He was subsequently transferred to the Work Capacity Evaluation program where he demonstrated problems with regular attendance, dependable workplace tolerance, and inconsistent levels of productivity. He applied himself diligently but, after weeks of struggling, he continued to be unsuccessful in establishing sufficient pain control to be able to work for more than three hours per day at even a sedentary physical demand level.

Just 18 months prior to this, the state of California had implemented legislation that required that the Workers’ Compensation insurance carrier or self-insured employer provide vocational rehabilitation services as a regular part of the benefits package offered to any worker injured on a job. As with most legislated social service programs, many of the procedural guidelines had yet to be developed at the time that Mr. Rodriguez was under its aegis. At that time, vocational rehabilitation benefits were provided to any injured worker who was unable to return to his usual and customary employment and requested the benefit. These benefits were to be terminated only if a client

  1. Declined to participate;
  2. Was found to be “non-cooperative”;
  3. Returned to work;
  4. Died.

In 1976, guidelines to evaluate the client’s ability to benefit from the provision of these services had not yet been developed by the State of California Division of Industrial Accidents. In spite of his lack of progress, Mr. Rodriguez had not declined to participate, he gave every indication that he was highly motivated to return to work, he had not yet returned to work, nor had he died. He did not fit into any of the four bureaucratic categories that were available to allow his insurance carrier to request that his vocational rehabilitation case be closed. This case focused attention on the need to develop guidelines to evaluate the individual’s ability to

  1. Return to the competitive labor market;
  2. Return to work on a less-than-competitive basis;
  3. Benefit from vocational rehabilitation services.

As a consequence of this case, the Rancho Los Amigos Hospital Work Capacity Evaluation program staff began to differentiate “feasibility” from “employability.” The term nonfeasible for competitive employment was used for the first time in the report that that summarized Mr. Rodriguez’s status and was the basis on which the Workers’ Compensation insurance carrier was able to discharge its responsibility to provide further vocational rehabilitation benefits. The staff’s initial response to the use of this phrase to describe his status (that is, that he was nonfeasible for competitive employment) left them troubled because they knew that this opinion would lead to cessation of Mr. Rodriguez’s vocational rehabilitation benefits. While it was difficult to take a stand in which they offered an expert opinion that Mr. Rodriguez was not able to be employed because he was nonfeasible for competitive employment, it became clear that a worse fate would result if he continued without some sort of resolution. Consider the circumstances:

  1. Mr. Rodriguez had not been successful although he had participated in a rehabilitation program;
  2. He was not, at this point, able to be employed;
  3. To continue to attempt to return Mr. Rodriguez to the labor market meant to continue to frustrate him and expose him to failure. The repeated failures were expensive physically and emotionally, and, to the insurance carrier, financially.

The Rancho Work Capacity Evaluation staff discovered with this case that the resolution of the client’s status was more important than success in rehabilitation. For example, if the professional staff had not taken a stand to help resolve Mr. Rodriguez’s status, he would not have been able to qualify for Social Security Disability benefits. As it was, he applied for benefits and was turned down. The Rancho Los Amigos Hospital report that he was nonfeasible for competitive employment was subsequently forwarded to the Social Security Administrative Law Judge. In addition, a staff member attended an appeals hearing to explain the concept of feasibility for competitive employment and vouch for Mr. Rodriguez’s motivation to return to work. He was subsequently awarded Social Security Disability benefits.

In Mr. Rodriguez’s case, feasibility for competitive employment worked as a gatekeeper for two different bureaucratic systems. In the Workers’ Compensation System, his nonfeasibility provided the basis upon which vocational rehabilitation benefits were terminated. Within the Social Security Disability system, nonfeasibility for competitive employment provided the basis upon which disability benefits were established.

Development of the Feasibility Evaluation Checklist

As an immediate consequence of the Rodriguez case, the Rancho Work Capacity Evaluation program staff began to more clearly define in operational terms the concept of feasibility for competitive employment and subsequently developed the Feasibility Evaluation Checklist (Matheson, 1980). [Download the Feasibility Evaluation Checklist.]

Over the several months following Mr. Rodriguez’s case, a series of one hundred (100) evaluations within the Workers’ Compensation rehabilitation system were reviewed at Rancho. Of the one hundred clients, fifty-six (56) were believed to be nonfeasible for competitive employment at the conclusion of the evaluation process. Inspection of these subjects’ evaluation reports led to the identification of thirty-eight (38) factors that contributed to the finding of nonfeasibility. A preliminary checklist that included these factors was developed based upon this research. Subsequent research by the author identified twenty-one (21) distinct factors that were found to recur. These are listed in the Feasibility Evaluation Checklist and are delineated below.

Operational Definitions

PRODUCTIVITY: Measured in terms of the client’s demonstrated work product or output. Affected by attendance, workplace tolerance, timeliness, instructability, memory and concentration, all of which impact the client’s ability to provide the employer with an acceptable level of work product.

  • Quantity of Productivity and Quality of Productivity are bivalent factors. That is, they are always considered in terms of each other. Quantity has to do with the client’s dependable demonstrated output. This is a measure of sustainable output and is affected by the client’s speed and sustained activity tolerance. Quality has to do with the client’s dependable demonstrated output of acceptable units. This is a measure of the client’s sustainable speed of production while maintaining an acceptable error rate.
  • Attendance has to do with the client’s demonstrated consistency in reporting to the place of work on the assigned work days.
  • Workplace Tolerance has to do with the client’s demonstrated capacity to remain in the workplace on a dependable basis.
  • Timeliness has to do with the client’s demonstrated consistency in reporting to the place of work on time, returning from breaks on time and leaving the workplace at the appointed time.
  • Instructability has to do with the client’s demonstrated ability to perceive, understand, and follow work instructions.
  • Memory has to do with client’s demonstrated ability to remember task instructions, work structure and safety rules.
  • Concentration has to do with the client’s demonstrated ability to focus attention on the task to which he or she is assigned.

SAFETY: A function of the client’s attitude toward safety rules, habits of safety behavior, and sensory capacity. It is measured in terms of the client’s ability to adhere to safety rules, use proper body mechanics and protective behavior, and to generally interact with the work environment in a safe manner.

  • Adherence to Safety Rules has to do with the client’s demonstrated ability to adhere to industry safety rules and implies that safety rules in the Work Capacity Evaluation center are provided to the client.
  • The next factor, Use of Proper Body Mechanics, has to do with the client’s demonstrated consistency in the application of proper body mechanics to job tasks.
  • Workplace Safety is considered in terms of four perceptual factors: audition, vision, sensation and balance. The first three have to do with the ability of the client to perceive stimuli to a sufficient degree to avoid injury. Balance has to do with the ability of the client to avoid injury due to falling.
  • The last factor with the safety section has to do with the client’s consistent Use of Protective Behavior and his/her demonstration of the use of common sense in protecting himself or herself
    and other workers from danger.

INTERPERSONAL BEHAVIOR: A function of the client’s ability to interact successfully with supervisors and fellow workers and to adjust to changes in job tasks.

  • The first factor within the Interpersonal Behavior section has to do with the client’s Response to Supervision. This is a multidimensional factor which considers the client’s ability to accept direction from supervisors, to adjust to different supervisors or supervisory styles, and to follow through with accepted directions.
  • The next factor has to do with the client’s Response to Fellow Workers. The client’s demonstrated ability to work in concert with other workers addressing the same task is the focus of our evaluation here.
  • The client’s Response to Change is evaluated in terms of his or her demonstrated
    ability to adjust to changes in work routine, assignments and conditions.
  • The last factor in the checklist has to do with the client’s General Worker Attitude. In this case consider the client’s demonstrated dedication to work and his or her role as a worker.

Administration of the FEC

Use of the Feasibility Evaluation Checklist requires that every factor that is evaluated and found to be at less than a competitive employment level must also be evaluated in terms of the client’s potential for improvement. This is because the evaluation of feasibility for employment is so important in the vocational rehabilitation process that any factor that contributes to a finding of nonfeasibility must also be assessed in terms of its potential for remediation. Assessment of potential for improvement is often quite difficult. It will usually require that the evaluator look to other members of the rehabilitation team for assistance. In spite of its difficulty, however, it must be undertaken. Absence of the evaluator’s assessment of the nonfeasible client’s potential severely limits the usefulness of the feasibility evaluation. Conversely, the availability of this information to the rehabilitation team provides guidance to the team in an area in which the evaluator has unique expertise.

The Feasibility Evaluation Checklist is used as a report card to communicate the client’s status and progress to the client and other members of the rehabilitation team. The Checklist provides a compilation of those factors which have been found to be important. It should be used to guide the collection and communication of this very important information. Each Work Capacity Evaluation program that uses the Checklist will address these factors in its own manner, depending upon the tools and techniques it has available. Through the use of the Checklist, feasibility will be continually assessed, as it must because feasibility is the “outermost window,” the primary context within which all other work capacity evaluation tasks take place.

Applications of Vocational Feasibility

The evaluation of feasibility for employment makes three important contributions to the rehabilitation process:

  1. As a gatekeeper to triage clients as they enter the vocational rehabilitation process, helping to triage the clients in terms of three categories:
    1. Individuals who are identified as being able to benefit from vocational rehabilitation services directed at competitive employment will receive those services;
    2. Individuals who are identified as being unable to benefit from vocational rehabilitation services directed at competitive employment will be denied those services and will be identified as being “nonfeasible for competitive employment”;
    3. Individuals in this latter group who are identified as having the potential to benefit from vocational rehabilitation services will receive prevocational service that has feasibility for competitive employment as its eventual goal. Clients in this latter group who have been identified as not possessing the potential to develop feasibility for competitive employment receive prevocational services that are designed to optimize rehabilitation potential in other areas, perhaps to prepare for employment at a less than competitive level;
  2. To certify that the individual who is feasible for employment possesses those basic attributes which are necessary for employment at that level of competition somewhere in the labor market. Any subsequent unsuccessful attempts to secure employment are interpreted in this light and may reflect other important factors, such as the client’s level of motivation or important trends in the local labor market. Each of these factors is separate from the issue of feasibility and can be dealt with on that basis.
  3. To maintain safety in the Work Capacity Evaluation program. Experience has shown that when work demands exceed work tolerances for an appreciable length of time, the worker will become nonfeasible. The Work Capacity Evaluation process is conducted within the context of feasibility because this context insures a safe evaluation that results in
    valid recommendations.

The evaluation of feasibility can actually begin in the sub-acute hospital setting. A client who may eventually return to work can benefit by early adoption of feasibility as a framework for treatment. As an example, feasibility can be used by the social worker and physician who are working with the head-injured teenage client to develop timeliness. The client who continues to be late for appointments or to miss appointments altogether can simply consider such behavior as hospital-relevant. Of course, this type of behavior extends far beyond the hospital environment. It has consequences that are critical in the work environment. The concept of feasibility as an external touchstone allows the hospital staff to bring part of the reality of the client’s eventual context of living into the hospital environment to be used as part of the rehabilitation process. Remember that vocational rehabilitation begins as soon as pathology is identified and should not be left to the vocational counselor to implement. The interpretation of the client’s behavior in terms of the acceptability of the client as an employee can begin to orient the client (and his family) towards eventual return to work as a goal. There may be no better opportunity to begin to learn appropriate employer-relevant behavior than in the supportive atmosphere of the hospital or rehabilitation center.

Feasibility can also be a very effective communications link between the client and the treating professional, superior to the traditional communication link that is termed symptoms. Typically, health care practitioners interpret the client’s behavior in terms of his or her symptoms. The client communicates to us through the use of symptom reports. While the use of symptomatology as a communications link between client and health care practitioner has stood the test of time, an alternative approach is to consider the client’s behavior in terms of feasibility. Feasibility can actually be superior to symptomatology as a communications link for four reasons:

  1. Feasibility is the context of the employer. The factors that we consider within feasibility are those factors that are easily understood by any employer. Similarly, the client who has been an employee understands very quickly the measures that are being used to conduct the evaluation.
  2. Feasibility is multi-dimensional. We are able to consider specific feasibility issues and develop specific strategies to remediate the feasibility problems.
  3. Feasibility is verifiable. Feasibility can be validated through cross reference to observable behaviors. While agreed upon standards of feasibility can be developed, symptomatology is not verifiable. It is very difficult to develop agreed upon standards for symptomatology.
  4. Feasibility has a positive orientation to results. As we consider the client in terms of his or her feasibility, we assist him/her to achieve improved attendance, workplace tolerance, and productivity. By comparison, when we consider the client in terms of symptomatology, we usually focus upon something to avoid, such as pain, dizziness or shortness of breath. We teach people that it is important to avoid these experiences even though many of these experiences are not avoidable. Unfortunately, learned avoidance behavior is easily generalized and produces a conservatism that tends to limit the person in the exercise of his options which, in turn, limits his chances of success in rehabilitation. In direct contrast, a focus upon output and productivity are readily reinforced in the external environment and contribute to the growth of the person and his perception of his options. Additionally, while pain behavior and the client’s reports of symptomatology can be difficult to extinguish, competing behaviors that are productivity-oriented can be strongly reinforced. This will result in a loss of the client’s focus on symptoms with a subsequent refocus on productivity. Feasibility, once it is established and carried through to employment, is usually strongly reinforced.

Over the years since the development of this assessment procedure, the feasibility for competitive employment standard has been applied in tens of thousands of cases in California. It has become codified in the policy and procedures of the state bureaucracy, has been the focus of case law resulting from opinions handed down by the State Supreme Court (cf. LaBoeuf, 1984), and is now part of the lexicon of Industrial Rehabilitation throughout the United States and Canada.