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Research directions related to rehabilitation practice: a Delphi study.

Szymanski, Rubin, and Rubin (1988) challenged the rehabilitation counseling profession to reconceptualize its identity, value structure, and mission. They identified several trends as the basis of their argument for change, including major legislative and policy initiatives; the emergence of new or newly recognized disability groups; recognition of the importance of the environment and related intervention strategies; and changing paradigms regarding disability and rehabilitation.

Ten years later, their call for self-evaluation is even more relevant. In spite of the employment provisions of the Americans with Disabilities Act (ADA), labor force participation rates for people with severe disabilities remains unacceptably low (Weaver, 1994). There is considerable dissatisfaction among people with severe disabilities with the state-federal vocational rehabilitation (VR) system (Weaver, 1994). People with mild to moderate disabilities, who are low on the priority list for VR services due to the order of selection criteria, are equally hostile toward the public system. Block grant and voucher systems are examples of whole-sale changes that have been proposed in this decade (e.g., Weaver, 1993; Thomas & Strauser, 1995).

Proprietary rehabilitation systems have had their share of setbacks as well. After two decades of steady and uninterrupted growth, some state worker compensation boards began to modify or remove requirements for mandatory participation in VR (Habeck, 1996). Unfortunately, rehabilitation professionals in the private sector had not been able to demonstrate the efficacy of their intervention through research support and were vulnerable to criticisms that VR services represented little more than an additional cost. At the same time, ADA, Social Security Administration reforms involving disability insurance, and the movement toward managed care and integrated benefit systems have dramatically altered the prospects for private sector VR professionals, restricting or eliminating some areas of practice, while creating entirely new areas of opportunity (Leahy, Chan, Shaw, & Lui, 1997). These changes in both the private and public sectors underscore the importance of having "qualified personnel" deliver necessary services in order to maximize rehabilitation outcomes and protect consumers.

For example, the 1992 Rehabilitation Act Amendments require that state personnel standards be "consistent with any national or state approved or recognized certification, licensing, registration or other comparable requirements." In other words, in the case of rehabilitation counselors, holding a state license (as a professional counselor or VR specialist) and/or the Certified Rehabilitation Counselor (CRC) credential appears to be required for VR counselors. Consistent with that legislative mandate, on February 11, 1997 the Rehabilitation Services Administration issued its final regulations. The regulations make it unequivocal that state personnel standards must be based on national certification standards or state licensure/certification requirements (for disciplines in which such standards exists, as they do in rehabilitation counseling). Credentialing has long been an important consideration in managed disability and health care systems as payers seek to improve both outcome and consumer satisfaction.

While the American health care system and the rehabilitation industry undergo major structural changes, there are currently increased demands for research to demonstrate the efficacy of various professionals and their intervention programs. The purpose of this article is to solicit the opinions of individuals who are leaders in rehabilitation credentialing and certification regarding research priorities that will help rehabilitation counseling and related professions become more responsive in these times of change. Prior to presenting results of the study, a brief history of the three rehabilitation practitioner groups involved in this study is presented.

History of Rehabilitation Credentialing

Rehabilitation can be defined as a comprehensive sequence of services, mutually planned by the consumer and the rehabilitation counselor to maximize employability, independence, integration, and participation of people with disabilities in the workplace and/or the community (Jenkins, Patterson, & Szymanski, 1992). In the ongoing development of various rehabilitation professions, there has been a long-standing interest in responding to demands by people with disabilities and financial providers for higher levels of accountability. For this reason, accountability mechanisms have been established such as accreditation of rehabilitation facilities and education programs, as well as national certification and state licensing programs for rehabilitation professionals. All of these activities involve active participation by relevant professional organizations and consumer groups, and all are believed to be characteristics of established professions which serve the public interest.

Certified Rehabilitation Counselor (CRC) Group

Rehabilitation counseling is defined as "a profession that assists individuals with disabilities in adapting to the environment, assists environments in accommodating the needs of the individual, and works toward full participation of persons with disabilities in all aspects of society, especially work" (Szymanski, 1985, p. 3). Research conducted in recent years has established the link between educational attainment and actual rehabilitation counselor performance in state VR agencies. A number of independent researchers have conducted a series of studies (Cook & Bolton, 1992; Szymanski, 1991; Szymanski & Danek, 1992; Szymanski & Parker, 1989a, 1989b) to investigate the relationship of counselor education and experience to client outcomes in Arkansas, Maryland, New York, and Wisconsin. They found that counselors with master's degrees in rehabilitation counseling (or closely related fields) had better outcomes for clients with severe disabilities compared to counselors without such educational preparation. Their findings underscore the importance of mastering, through formal education, the knowledge domains essential to rehabilitation counseling practice. Rehabilitation counseling knowledge and skill standards have also been empirically derived from roles-and-function studies such as Leahy, Szymanski and Linkowski (1993), Leahy, Shapson, and Wright (1987), Rubin et al. (1984), Emener and Rubin (1980), and Muthard and Salamone (1969).

For nearly 40 years, the rehabilitation counseling profession has been conducting field-based research to identify the types of knowledge, skills, and abilities required of the rehabilitation counselor to work effectively with persons with disabilities in achieving employment outcomes. Utilized extensively by the profession, these data provide the foundation for graduate training curricula and standards for certification.

The Certified Rehabilitation Counselor (CRC) credentialing process is the oldest certification mechanism in the counseling or rehabilitation professions in the United States (Leahy & Holt, 1993). The Commission on Rehabilitation Counselor Certification (CRCC) was officially incorporated in January 1974 to conduct certification activities on a nationwide basis. Leahy, Szymanski, and Linkowski (1993) surveyed CRCs to examine the perceived importance of the knowledge areas underlying rehabilitation counseling credentialing. They found 10 common core knowledge areas that are important to the contemporary practice of rehabilitation counseling: Vocational Counseling and Consultation Services; Medical and Psychosocial Aspects of Disability; Individual and Group Counseling; Program Evaluation and Research; Case Management and Service Coordination; Family, Gender, and Multicultural Issues; Foundations of Rehabilitation; Workers' Compensation; Environment and Attitude Barriers; and Assessment.

Since 1974, more than 23,000 qualified professionals have participated in the certification process. There are 14,081 CRCs currently practicing in the United States and in several other countries (Leahy & Holt, 1993). The primary purpose of certification is to provide assurance to consumers of rehabilitation counseling services (service recipients and payers) that providers have met acceptable minimum national standards of professionalism. Therefore, certification standards are considered by the profession to be in the best interest of the consumers of services (Leahy & Holt, 1993; Schmitt, 1995).

Certified Disability Management Specialists (CDMS) Group

Disability management is defined by CDMSC as "the practice of providing preventive and remedial services to minimize the impact and cost of disability and to enhance productivity" (CDMSC, 1996). A more specific definition is provided by Akabas, Gates, and Galvin (1992) as a ".... work place prevention and remediation strategy that seeks to prevent disability from occurring or, lacking that, to intervene early following the onset of disability, using coordinated, cost-conscious, quality rehabilitation service that reflects an organizational commitment to continued employment of those experiencing functional work limitations" (p.2).

The Certified Insurance Rehabilitation Specialist (CIRS) credential was established in 1985 to recognize and certify the knowledge and skills of the practitioners who work in this specialized area of rehabilitation practice. The primary purpose of the certification was to assure that professionals engaged in insurance rehabilitation met acceptable minimum national standards of professionalism (e.g., education, experience, and knowledge). Such standards are considered to be in the best interests of the clients served by CIRSs (Matkin, 1995).

To validate the CIRS examination, the CIRS Commission funded a series of studies in the 1980s and 1990s to identify the work activities and associated knowledge required to perform them (e.g., Matkin, 1995). Specifically, Matkin surveyed 3,500 CIRS applicants during the certification grandfathering period in 1985-1986, and again five years later (1991) at the end of the first certification renewal phase. He found the knowledge requirements for insurance rehabilitation practice during the two time periods to be quite similar, with the 1991 data providing a clearer labeling of work role categories: Case Management and Human Disabilities; Job Placement and Vocational Assessment; Rehabilitation Services and Care; Disability Legislation; and Forensic Rehabilitation. The knowledge requirements associated with these work categories formed the basis of the CIRS national examination.

More recently, Leahy, Chan, Taylor, Wood, and Downey (in press) identified seven empirically derived knowledge factors as important for effective private rehabilitation practice. These knowledge factors are: Vocational Assessment and Planning; Case Management and Reporting; Expert Witness Testimony; Employment and Disability Related Legislation and Regulations; Community Resources; Psychosocial and Functional Aspects of Disability; and Job Analysis and Modification. Their research has identified factors which have broadened the roles and functions of practitioners in insurance rehabilitation. Practitioners in their study also conveyed that disability management has become an emerging practice area for private rehabilitation practitioners.

In 1996, the Certified Insurance Rehabilitation Specialists Commission (CIRSC) changed its name to the Certification of Disability Management Specialists Commission (CDMSC), to better reflect the current practice focus of private sector rehabilitation specialists. The associated credential is now known as the Certified Disability Management Specialist (CDMS) designation. Presently, there are 4,593 CDMS practitioners.

Certified Case Managers (CCM) Group

Case management is defined by the Commission for Case Manager Certification (CCMC) as "a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes" (CCMC, 1996). In the late 1980s, case management began to develop its own impetus as a professional practice area. In 1991, 29 organizations involved in the field convened in Dallas at a consensus meeting organized by the Individual Case Management Association. The intent was to agree upon the philosophical basis for case management, a universal definition of case management, and a set of meaningful practice standards. To accomplish this, a National Task Force on Case Management was formed which accepted a proposal from the Certification of Insurance Rehabilitation Specialists Commission (CIRSC). The purpose of this proposal was to develop a certification program for case managers, including eligibility criteria and content areas for a certification examination. On July 1, 1995, the Commission for Case Manager Certification (CCMC) was incorporated as a separate, independent credentialing body which ceased to operate under the auspices of CIRSC. Although the process is only four years old, there are currently 18,516 Certified Case Mangers (CCMs) who have completed the certification requirements.

The Foundation for Rehabilitation Education and Research (Foundation) was established in place of the Board for Rehabilitation Certification in 1993. It is an independent organization sponsored by three separate credentialing bodies: the Commission on Rehabilitation Counselor Certification (CRCC), the Certification of Disability Management Specialists Commission (CDMSC), and the Commission for Case Manager Certification (CCMC). The mission of the Foundation is twofold: to promote and support the credentialing processes of its sponsors through education and research; and to enhance quality of service provided to individuals with disabilities. With technical and administrative support from the Foundation, Leahy (1994) surveyed 14,078 practicing case managers representing multiple professional disciplines (e.g., registered nurses, rehabilitation counselors, and social workers) in a variety of work settings (e.g., independent case management companies, workers' compensation insurers, and managed care companies). His research suggested that case managers do share a common knowledge base required for case management practice comprised of five factors: Coordination and Delivery of Services; Physical and Psychosocial Aspects of Disability; Benefit Systems and Cost Benefit Analysis; Case Management Concepts; and Principles of Community Re-entry.

Purpose of the Study

It is well known that the emergence of managed care and integrated health care systems has enhanced the importance of accountability mechanisms, including accreditation, certification, and licensure. In response, the CRCC, CDMSC, and CCMC have combined to certify more than 30,000 rehabilitation practitioners working in the full spectrum of disability and health care services in both the public and private sectors. All three commissions and the Foundation are continuously engaging in programmatic research to establish the value and relevance of these credentialing processes as an indicator of the ability of certified individuals to provide quality services and produce desired outcomes. The purpose of this article is to report the results of a Delphi study, the objective of which was to obtain a consensus regarding priorities for rehabilitation credentialing and certification research in this era of health care and disability policy reform.

Method

Participants

A total of 23 professionals were selected for this study. They consisted of either board members of the Foundation or commissioners representing the Commission on Rehabilitation Counselor Certification (CRCC), the Certification of Disability Management Specialists Commission (CDMSC), or the Commission for Case Manager Certification (CCMC). These individuals are nominated by a variety of rehabilitation and disability-related organizations. Appointing organizations include the American and National Rehabilitation Counseling Associations (ARCA, NRCA), the Council on Rehabilitation Education (CORE), the National Council on Rehabilitation Education (NCRE), and the Vocational Evaluation and Work Adjustment Association (VEWAA). Thus the researchers assume that this group represents leaders in the field who are knowledgeable of and committed to professionalism in rehabilitation practice. More specifically, the individuals surveyed included those who held professional positions such as Chair of the CRCC, CDMSC, and the CCMC, or Chair of the Research and Examination Committees of these commissions.

Procedures and Data Analysis

The Delphi technique was employed in this study to obtain a consensus regarding a research agenda for the Foundation. In Questionnaire A, an open-ended approach was used to solicit input. Participants were asked to list three rehabilitation research questions that they felt were important and relevant for rehabilitation credentialing and certification research. They were also asked to provide a brief rationale for the importance of each research question submitted.

A total of 38 questions was received. A content analysis was performed on the data obtained to minimize redundancy. A revised questionnaire (Questionnaire B) comprised of 28 research questions was developed, arranged in random order, and circulated to the same group of participants. Twenty of the original 23 participants responded to Questionnaire B for a response rate of 87%. This time, they were asked to rate the centrality of each of the 28 questions in relation to the research priorities for the three commissions (i.e., to promote and support the respective credentialing process, and to enhance the quality of services provided to individuals with disabilities), using the following 5-point Likert-type scale:

1 = Should not be at all central

2 = Somewhat central

3 = Moderately central

4 = Very central

5 = Extremely central

Finally, based upon responses to the second questionnaire, a third questionnaire was developed (Questionnaire C). For each item in Questionnaire B, the median centrality score and interquartile range were computed. In completing Questionnaire C, participants were:

* instructed to compare their individual ratings from Questionnaire B with the median score (reflecting the group's position), and

* encouraged to change their original centrality rating if they wished.

The inter-quartile range for each item on Questionnaire B2 was also provided to give participants an idea of the variability of responses. Participants whose responses to Questionnaire C remained extremely discrepant relative to the median response were asked to provide a rationale for their ratings. The intent was to move participants toward a consensus and reduce the variability among responses from Questionnaire B to Questionnaire C. Eighteen of the original 23 participants responded to Questionnaire C, for a response rate of 78%. The tenet underlying the Delphi technique is that the consensus will improve with successive rounds of anonymous group judgment (Hornsby, Smith, & Gupta, 1994). These same researchers found the Delphi technique to be superior to the focus group approach because it allows the greatest degree of anonymity in reaching a group consensus.

Using data from Questionnaire C, the mean and median scores of each item were computed, and the research questions were ranked according to mean score.

Results

The 28 research questions were ranked in order of their importance and were examined more closely by members of the Foundation's Research Committee. These items appeared to reflect three major themes:

* Who are CRCs, CDMSs, and CCMs and how are they similar and different in terms of their roles and functions and the underlying knowledge and skill required to perform those functions?

* What is the effectiveness of services provided by individuals holding the CRC, CCM, and CDMS credentials?

* Where are the CRC, CCM, and CDMS specializations headed and are our educational, accountability, and funding processes prepared to address changes in direction?

Next, items with a mean centrality rating greater than 3.5 were classified according to these three themes. Within each of the three broad categories or themes, the items were then ranked ordered. This information is presented in Table 1. Research questions with centrality ratings of less than 3.5 are presented in Table 2.
Table 1
Research Questions Organized by Major Themes

Item Mean Centrality
No. Research Question Rating

Theme No. 1: Similarities and Differences Among
CRCs, CDMSs, and CCMs

1. What are the underlying knowledge 4.56
 dimensions of the CRC, CDMS, and CCM
 examinations?

6. What items in the CRC, CDMS, and CCM 4.33
 examination item pool are significantly
 related to the service delivery
 effectiveness of rehabilitation
 counselors, disability management
 specialists, and case managers? (Directed
 at establishing the predictive validity
 of certification examinations.)

8. What are the similarities and differences 4.00
 in knowledge domains identified as
 important by the applicants for various
 rehabilitation certifications? How are
 these similarities and differences
 changing over time? (To identify important
 trends in the evolution of knowledge
 competencies for various areas of
 practice--Are the groups becoming more
 alike or more diverse?)

9. What is the relationship between 4.00
 discipline, education, years of practice
 and performance on each certification
 examination? (This will provide
 information to various disciplines
 regarding educational preparation for
 rehabilitation practice roles.)

2. What are the trends in examination scores 3.72
 over time?

3. What are the examinee characteristics over 3.56
 time?

Theme No. 2: Outcome Related Research

5. On what service delivery criteria should 4.56
 the service delivery effectiveness of
 rehabilitation counselors, disability
 management specialists, and case managers
 be assessed? (Directed at establishing the
 predictive validity of certification
 examinations.)

14. What is the relationship between client 4.39
 outcomes (e.g., employment) and the
 certification status (e.g., CRC) of the
 rehabilitation professional providing
 services in various rehabilitation
 settings? (In other words, do those
 with a CRC, CDMS, or CCM achieve more
 positive outcomes than those who do not
 have the requisite education and
 experience to apply for certification?)

10. What is the relationship between 4.28
 performance on the certification
 examination and effectiveness of clinical
 decision-making in rehabilitation
 practice? (Recognizing that this question
 requires data collection beyond what is
 currently available, the goal is to
 create the link between knowledge and
 clinical performance and outcomes. Are
 there other ways to test minimum clinical
 knowledge beyond a basic paper and pencil
 test and what is the cost/benefit of
 doing so?)

17. How do employers benefit by hiring 4.00
 certified rehabilitation professionals?
 (Cost-effectiveness of service delivery by
 certified rehabilitation professionals
 needs to be established.)

18. What benefits do people with disabilities 4.00
 accrue from services rendered by certified
 rehabilitation professionals?

16. What rehabilitation approaches, under what 3.94
 condition, with what types of client
 problems, appears to be most effective in
 the attainment of desired outcomes? What
 are the most appropriate outcome
 measurement/criteria for rehabilitation?
 (This line of inquiry would assist the
 profession in establishing empirically
 based standards of practice.)

15. What is the relationship between consumer 3.61
 satisfaction with services provided in
 various rehabilitation settings and the
 certification status of the providers?

Theme No. 3: Future Trends

25. Is the CORE curriculum meeting the 4.28
 expected needs of the employers? Are
 rehabilitation counselor education
 program curricula sufficiently current?

27. Where is our field going? -- counseling, 4.28
 disability management, case management?

24. In what ways are the Rehabilitation 4.22
 Counselor Certification Examination
 contents and the CORE standards relevant
 to the current and future practice of
 rehabilitation counseling?

12. What impact has managed care had on the 4.11
 need and use of rehabilitation counseling,
 disability management and case management?
 If any, how are they different?

11. What are the effects of licensed 4.00
 professional counselor laws on
 rehabilitation counselor certification?

22. What ethical guidelines are needed to 3.83
 address issues raised by managed care and
 other challenges?

Item
No. Research Question Rank

Theme No. 1: Similarities and Differences Among
CRCs, CDMSs, and CCMs

1. What are the underlying knowledge 1
 dimensions of the CRC, CDMS, and CCM
 examinations?

6. What items in the CRC, CDMS, and CCM 4
 examination item pool are significantly
 related to the service delivery
 effectiveness of rehabilitation
 counselors, disability management
 specialists, and case managers? (Directed
 at establishing the predictive validity
 of certification examinations.)

8. What are the similarities and differences 10
 in knowledge domains identified as
 important by the applicants for various
 rehabilitation certifications? How are
 these similarities and differences
 changing over time? (To identify important
 trends in the evolution of knowledge
 competencies for various areas of
 practice--Are the groups becoming more
 alike or more diverse?)

9. What is the relationship between 11
 discipline, education, years of practice
 and performance on each certification
 examination? (This will provide
 information to various disciplines
 regarding educational preparation for
 rehabilitation practice roles.)

2. What are the trends in examination scores 17
 over time?

3. What are the examinee characteristics over 19
 time?

Theme No. 2: Outcome Related Research

5. On what service delivery criteria should 2
 the service delivery effectiveness of
 rehabilitation counselors, disability
 management specialists, and case managers
 be assessed? (Directed at establishing the
 predictive validity of certification
 examinations.)

14. What is the relationship between client 3
 outcomes (e.g., employment) and the
 certification status (e.g., CRC) of the
 rehabilitation professional providing
 services in various rehabilitation
 settings? (In other words, do those
 with a CRC, CDMS, or CCM achieve more
 positive outcomes than those who do not
 have the requisite education and
 experience to apply for certification?)

10. What is the relationship between 5
 performance on the certification
 examination and effectiveness of clinical
 decision-making in rehabilitation
 practice? (Recognizing that this question
 requires data collection beyond what is
 currently available, the goal is to
 create the link between knowledge and
 clinical performance and outcomes. Are
 there other ways to test minimum clinical
 knowledge beyond a basic paper and pencil
 test and what is the cost/benefit of
 doing so?)

17. How do employers benefit by hiring 13
 certified rehabilitation professionals?
 (Cost-effectiveness of service delivery by
 certified rehabilitation professionals
 needs to be established.)

18. What benefits do people with disabilities 14
 accrue from services rendered by certified
 rehabilitation professionals?

16. What rehabilitation approaches, under what 15
 condition, with what types of client
 problems, appears to be most effective in
 the attainment of desired outcomes? What
 are the most appropriate outcome
 measurement/criteria for rehabilitation?
 (This line of inquiry would assist the
 profession in establishing empirically
 based standards of practice.)

15. What is the relationship between consumer 18
 satisfaction with services provided in
 various rehabilitation settings and the
 certification status of the providers?

Theme No. 3: Future Trends

25. Is the CORE curriculum meeting the 6
 expected needs of the employers? Are
 rehabilitation counselor education
 program curricula sufficiently current?

27. Where is our field going? -- counseling, 7
 disability management, case management?

24. In what ways are the Rehabilitation 8
 Counselor Certification Examination
 contents and the CORE standards relevant
 to the current and future practice of
 rehabilitation counseling?

12. What impact has managed care had on the 9
 need and use of rehabilitation counseling,
 disability management and case management?
 If any, how are they different?

11. What are the effects of licensed 12
 professional counselor laws on
 rehabilitation counselor certification?

22. What ethical guidelines are needed to 16
 address issues raised by managed care and
 other challenges?




Table 2 Research Questions with Low Centrality Ratings (Mean ratings [is less than] 3.5)
Item Mean Centrality
No. Research Question Rating

4. How did examinees with disabilities and 3.33
 examinees from diverse ethnic backgrounds
 perform (as compared to the majority
 group) on the examination?

26. What will be the major funding sources 3.28
 for vocational and medical rehabilitation
 services in the next decade?

7. Is there a significant relationship
 between the amount of focus placed on
 multicultural issues in rehabilitation
 education programs and the effectiveness
 of their graduates in service delivery to
 clients from minority populations?
 (Addresses a distributive justice issue
 in RCE curricula.)

19. What are supervisory skill tasks and 3.17
 levels of the certified rehabilitation
 professionals, especially as related to
 service delivery and benefit to clients
 and employers?

23. What is the relationship of the Scope of 3.17
 Practice statement to the Rehabilitation
 Counselor Certification Examination? (The
 statement has been accepted by CRCC,
 CORE, and other professional counseling
 organizations. Is the statement relevant
 to the examination?)

20. Are "counseling skills" for nurses and 3.11
 "medical knowledge" for rehabilitation
 counselors two areas of skill deficit
 among practicing case managers?

28. What are the primary disabilities 3.11
 anticipated on our caseloads in the next
 decade?

13. What impact has the Americans with 3.00
 Disabilities Act had on the provision of
 rehabilitation counseling services?

21. Why should an "Approved Supervisor" 2.56
 structure be explored as part of the case
 manager certification process?

Item
No. Research Question Rank

4. How did examinees with disabilities and 20
 examinees from diverse ethnic backgrounds
 perform (as compared to the majority
 group) on the examination?

26. What will be the major funding sources 21
 for vocational and medical rehabilitation
 services in the next decade?

7. Is there a significant relationship
 between the amount of focus placed on
 multicultural issues in rehabilitation
 education programs and the effectiveness
 of their graduates in service delivery to
 clients from minority populations?
 (Addresses a distributive justice issue
 in RCE curricula.)

19. What are supervisory skill tasks and 23
 levels of the certified rehabilitation
 professionals, especially as related to
 service delivery and benefit to clients
 and employers?

23. What is the relationship of the Scope of 24
 Practice statement to the Rehabilitation
 Counselor Certification Examination? (The
 statement has been accepted by CRCC,
 CORE, and other professional counseling
 organizations. Is the statement relevant
 to the examination?)

20. Are "counseling skills" for nurses and 25
 "medical knowledge" for rehabilitation
 counselors two areas of skill deficit
 among practicing case managers?

28. What are the primary disabilities 26
 anticipated on our caseloads in the next
 decade?

13. What impact has the Americans with 27
 Disabilities Act had on the provision of
 rehabilitation counseling services?

21. Why should an "Approved Supervisor" 28
 structure be explored as part of the case
 manager certification process?




Although the items were subjectively classified into the categories given, the participants gave more valency to the nine "future trend" items (M=3.79) and the nine "professional similarities and differences" items (M=3.75) than the ten "effectiveness" items (M=3.37). Interestingly, multicultural concerns do not receive high centrality ratings, at least from this group of participants. Finally, the Delphi technique appeared to have the intended effect of building consensus as evidenced by the reduction in the variability of ratings from Questionnaire B to Questionnaire C. The average reduction in variability was .12 SD per item. The variability of some items, particularly those with respect to future trends, was lowered by as much as .59 SD (item 27) and .33 SD (item 22).

Discussion

Participants appear concerned about the future of all rehabilitation specializations. In particular, there is concern about changes in work settings, professional activities, funding streams, client populations, ethical challenges, regulations, and legislation. In disciplines with established educational standards, there is concern regarding the responsiveness and flexibility of educational accrediting bodies. Historically, directions in rehabilitation have been determined by major shifts in legislation, primarily at the federal level. Recently, directions appear more affected by changes in reimbursement policies and practices, which also have a substantial impact upon which (if any) services will be rendered to people in need.

Participants are equally concerned regarding the similarities among and differences between rehabilitation specializations. While the nature and scope of each has been thoroughly studied and documented, questions remain about the relative importance of these differences versus an underlying, core body of knowledge and responsibilities common to all rehabilitation endeavors. Certainly most CRCs are trained as counselors or rehabilitation counselors, whereas most CCMs are trained as nurses. CDMSs represent both groups. Is it possible that the common pursuit of rehabilitation objectives could lead to a generic rehabilitation professional over time, with differences being more a matter of emphasis?

Consistent with the history and traditions of rehabilitation, participants expressed the continuing need to demonstrate and document the cost and benefits of services rendered by qualified professionals in all three specializations. This realistic focus on accountability to people with disabilities and financial providers, the ongoing search for what works best for whom and under what conditions, and the overall preoccupation with outcome will likely serve rehabilitationists well when compared to other human services professions.

The potential ramifications of answering these questions are staggering. For example, if clinical competence could be predicted from examination results (item #6, #10), recruitment and selection practices in all sectors of rehabilitation endeavor might change. Alternately, if underlying knowledge domains in the various specializations are indeed merging (item #1, #8), perhaps certification should focus upon a generic rehabilitation credential which could be pursued by members of many more professional disciplines than typically make application today. Suppose that educational standards were discovered to be obsolete and irrelevant to current and future practice patterns (item #25, #24)? Would we find our educators responsive?

Although the focus of this study was on research directions in relation to rehabilitation credentials, many of the questions generated have direct implications for the rehabilitation field in general. Examples include the differentiation of professional specializations, and relevance of professional preparation; future career opportunities and directions; effectiveness of rehabilitation interventions; measurement of outcomes produced; and the like. Also, there are certain research questions which are suggested by these findings that did not emerge as specific items per se. For example, should these credentials and their differences be more clearly articulated to consumers and the public in general? Can the nature or extent of education, nature of academic major, and/or years of experience predict performance on the examinations?

How are the low centrality ratings to be interpreted? Are participants comfortable with the current status of the specializations with respect to issues of multicultural competency, access to future funding, professional supervision, and ADA? Are these less important, or are they somehow more imposing, more complex, and thus, less achievable?

Certainly it would be desirable to repeat this process directly with the leadership of relevant professional organizations (e.g., ARCA, NRCA, CORE, NCRE, VEWAA, etc.) as well as consumer groups representing persons with disabilities. It would be extremely interesting and relevant to compare and contrast the research priorities of all stakeholders before government funding sources (such as the National Institute for Disability and Rehabilitation Research) or research foundations finalize their national research agendas. In the interim, for individual researchers, each item offers a potential research question which has been determined to have value by the participants described herein.

ACKNOWLEDGEMENTS

Funding for this research was supported by the Foundation for Rehabilitation Education and Research, Rolling Meadows, Illinois.

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Stanford E. Rubin, Professor, Rehabilitation Institute, Southern Illinois University at Carbondale, Carbondale, IL 62901.
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Author:Kamnetz, Brian
Publication:The Journal of Rehabilitation
Date:Jan 1, 1998
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