The use of work schedule modification to enhance employment outcomes for persons with severe disability.

Despite growing attention to the employment needs of persons with severe disabilities, modification of work schedules has received limited mention (Hopkins & Johnson, 1988; Kuhlman, 1988; Seaver, 1989) in the rehabilitation literature. In addition, the personal impact of altering work schedules in terms of lifestyle and personal adjustment has been largely ignored. While a variety of modifications have been used to enhance access to employment for workers with disabilities, including technical and structural modifications to the work environment (Amaroli, 1986; Angelo, Hurlburt, & Oddo, 1991; Lysaght & Lloyd, 1993), and modification of work tasks (Feuerstein, 1991), the challenge for rehabilitation workers is to develop innovative means of integrating workers with severe disabilities into competitive work settings in ways that will maximize the worker's productivity, enhance quality of life, and lead to long term success.

One concern which impacts the success of people with severe disabilities in managing a full-time, competitive work schedule is the activity tolerance levels of these workers. Reduced physical stamina may limit tolerance for productive work activity in workers with severe disability (Hopkins & Johnson, 1988; Treishman, 1988). In a survey by Stewart, Chubon, and Ososkie (1988) of rehabilitation professionals and clients, which identified the most critical factors in settling a disability claim, 36% of professionals rated the exertional demands of work as an important factor, while 77.5% of working individuals with disabilities considered this to be important. In fact, after hiring biases of employers, this was the factor most identified by disabled respondents (Stewart et al., 1988). Workers with a variety of chronic medical conditions have identified the need for scheduling flexibility due to fatiguability (Hopkins & Johnston, 1988).

Quality of Life

Productivity of a paid or volunteer nature is acknowledged as an essential feature in achieving quality of life in terms of personal satisfaction following the onset of disability (Crisp, 1990; Kinney & Coyle, 1992; Krause, 1990; Yerxa & Baum, 1986). The role of productivity in achieving a satisfying lifestyle is not exclusive, however. Research indicates that quality of life is enhanced by a balance between work, leisure, and self care (Kinney & Coyle, 1992; Spencer, 1989). People with severe disabilities such as spinal cord injuries may find it difficult to achieve this balance due to the disproportionate amount of time spent on self care activities. In her review of the work patterns of some persons with severe disabilities, Treischmann (1988) observed that many persons interviewed describe returning home from work only to spend their leisure hours resting in order to gain enough energy to return to work the next day.

Hopkins and Johnson (1988) note the positive effects of work schedule modification on worker satisfaction, and the benefits in terms of transportation and flexibility in scheduling medical treatments. Various authors have noted the importance of involving the family in rehabilitation planning (Power, Hershenson, & Fabian, 1991; Dew, Phillips, & Reiss, 1989), highlighting the need to look at employment and its significance in the context of the individual's larger social environment. Modified work schedules may reduce the impact of employment-related stressors on families (i.e., transportation, daily personal care) by providing additional time and flexibility.

Financial Concerns

Financial disincentives to employment may actually make part-time employment more practical than full-time employment for some people. Individuals who qualify for public financial assistance programs may find themselves earning less by working full-time than they do working part-time due to disqualification for certain benefits (Schloss, Wolf, & Schloss, 1987). Private insurance regulations and workers' compensation laws differ across jurisdictions and companies, and awarding of benefits can vary depending on the coverage responsibilities of different carriers, the nature of the accident, and the interpretation of terms such as "reasonable" and "substantially disabled" (Hynes, 1989; Wyrick, 1992). Some policies may, in fact, disqualify workers for benefits based on their ability to do any work at all.

Of the examples of "reasonable accommodation" provided in the Americans with Disabilities Act of 1990 (Equal Opportunity Commission, 1992), the use of flexible or modified work schedules is perhaps the simplest for an employer to implement. Work schedule modification may take the form of reduced hours, flexible shifts, or creative use of break time (Hopkins & Johnson, 1988). Modified work schedules must necessarily be designed through a collaborative process involving both worker and employer, addressing the special concerns of each. Some workers may require flexible work hours which allow time to schedule appointments, to receive attendant care during the day, or to take medications. Many of these are issues which may be of concern to other workers without disabilities, but are more difficult to accommodate due to complicating factors, such as transportation, ease of movement, or dependency on assistance from others. Other, less obvious concerns as previously discussed, such as fatiguability and loss of energy for out-of-work activities may appear less credible to employers, but are of equal significance if long-term retention of employees is a goal.

Case Study

The potential value of work schedule modification is demonstrated through the experience of one individual with high level quadriplegia who experienced a change in work schedule while involved in a vocational training program. Bill (not his real name) is a 42-year-old man who was employed for 16 years as a pipefitter and hull inspector at the local dockyard prior to sustaining a spinal cord injury at the C4/C5 level. Bill was married, and had a four-year-old son at the time of his injury.

As part of his vocational retraining plan, Bill entered a full-time computer training program during the period of outpatient rehabilitation. This five-day a week, 52-week structured program was designed to enhance the employability of persons with physical disabilities. Participants completed classroom-based training for a total of 38 weeks (vacation included) and trained in community work placements for two periods totalling 14 weeks. The daily in-class format was structured to simulate a regular work environment. Work hours, breaks, dress, and behavioral expectations approximated industry standards. The day's work routine consisted of a morning lecture, completion of self-paced learning modules, an afternoon life skills group, and individual work time throughout the day for completion of simulated work assignments.

Following four months in the program, Bill's attendance became irregular, punctuated with numerous absences for health reasons. Staff were aware of decreased energy for in-class work, evidenced by an increase in errors, and a less-animated affect. He reported concerns regarding his ability to concentrate in class. Bill and his wife became aware of a decrease in Bill's interest and enthusiasm for participating in daily activities outside of work hours. The primary factor identified as contributing to his declining morale and ability to fully participate in the program was the need to arise at 4:30 each weekday in order to complete, with his wife's assistance, his morning care routine. This resulted in his feeling fatigued each day, and required that he retire at an extremely early hour each evening, thus eliminating most of his available leisure hours. On weekends, he reported resting most of the time to recover from the heavy demands of his weekday schedule.

Despite Bill's concerns regarding his ability to manage his academic workload in a reduced workday, he agreed to attempt a modified workday on a trial basis. The schedule modification occurred in week 32 of the 52 week program, and spanned both classroom and community training phases of the program. Prior to the change in work schedule, Bill had followed the standard training schedule for the training center, which required attendance from 8:30 to 4:30, with a one-hour lunch break, and two additional 15-minute breaks.

Work schedule modifications

Bill's work schedule was modified through a collaborative process between the client and project staff. Schedule modifications included shortening work hours to 5 hours per day, changing the start time (from 8:30 to 11 AM) and altering the break schedule (two 15-minute breaks, with the hour long lunch break eliminated). Bill no longer attended moming lectures, instead listening to select lectures on tape. He was given the opportunity to complete the same workload as the rest of the group, and he completed the same mastery tests. He maintained the modified work schedule throughout the remaining three months of training, during classroom and community-based phases of training.

Review of Bill's situation following the modification in work schedule revealed a number of qualitative changes in lifestyle for both Bill and his family. Bill and his wife described a substantial increase in Bill's personal interest and enthusiasm for both work and leisure activity following work schedule modification. Prior to the change in work schedule, Bill indicated that it was his enthusiasm for the program and his competitive nature that "kept him going." Although he could feel himself becoming exhausted and losing interest as time passed, he stated,

My objective was to finish the course. I thought if I shortened my work day I wouldn't graduate with the rest of my class. Then I realized that all of the stress I was putting my family through just wasn't worth it. Once l finished in the program and started a full time job I knew I wouldn't be able to handle it, and it was no fun living like that.

The change in daily routine also held fundamental importance to the family's roles and habits. Prior to the change in work schedule, the family's morning routine consisted of Bill and his wife arising at 4:30 AM in order for his wife to perform his personal care. This "personal attendant" role was necessitated by the unavailability of nursing care prior to 8:30 AM or in the evenings. In addition to her role as mother of a young child, this role was especially stressful. Their son was required to arise at an earlier hour than in the past in order to accompany his mother as she drove Bill to work/training in the morning. When the work day was rescheduled, it was possible for the family to make alternate arrangements for personal care. The change in arisal time also permitted Bill to spend more time with his family in the evenings, allowing him to resume more normalcy in his parenting and spousal roles. Prior to the modification in work schedule, Bill stated that he would be "beat" when he arrived home from work. His wife stated,

Bill is a teaser, always playing with me and our son. He just wasn't doing this when he was attending the full day.

Beyond the positive effects noted in terms of quality of life, there is evidence which points to improved work performance. On a subjective level, both Bill and the project staff noted improvement's in Bill's attention to detail, work rate, and overall quality of work following work schedule modification. Although he was no longer able to attend lectures, and had less time to complete assignments, he continued to complete as much or more work than his classmates, and consistently achieved higher scores on proficiency tests. Bill stated that he felt he performed better working for 5 1/2 hours with a short break than for 8 hours with an hour long break at noon. Narrative comments from worksite supervisors both prior to and following work schedule modification indicated that Bill's work skills were "exceptional", and that he was able to meet and exceed all work demands.

Long-term implications

The long term outcomes with respect to productivity roles have been extremely positive. Bill successfully completed the training program, and has successfully held employment with his former employer for in excess of 24 months. He has continued to work reduced hours, with a schedule that accommodates both the employer's requirements, and his own work preferences and needs. Performance reviews by supervisory staff indicate that he is an exemplary employee who is highly valued as a member of the work team. Work attendance has been extremely reliable, with only two health-related absences in the past year. Prior to acceptance in the training program, Bill had indicated to medical personnel that he would likely pursue home-based employment of some sort, as he did not feel that community-based employment would be practical or achievable. Although home-based employment is an important option for many people with severe disability, Bill notes several positive benefits of community-based employment, even on a modified basis. His employment at the dockyard provides him with an important link to the employment world, and helps to keep his skills current through regular contact with others in his field.

Bill successfully negotiated a partial cost recovery plan with his insurer, which allows him to retain his benefits, paying back one-half of his earned income to the insurance company. The opportunity for purposeful involvement and to experience the daily challenges and rewards that are part of employment have helped Bill to achieve a sense of self efficacy, and to maintain the role of "provider" in his family. The nature of his modified work schedule also leaves him with sufficient energy to participate in the qualitative aspects of family life.

Discussion

Work and productivity hold special significance for persons with severe disabilities injuries whose ability to master their environments are constantly challenged by physical realities. In fact, given the dramatic changes which may occur in self concept and sense of efficacy in persons following the onset of severe disability, the ability to compete in the employment world and to be self-supporting may assume a critical role in psycho-social adjustment.

It is apparent that the need to achieve a balance between work and leisure roles is important for all members of the family, and that resumption of a work role by a family member with a severe disability may have a significant impact on the roles and responsibilities of other family members. Research indicates that living with a partner or spouse with a spinal cord injury, for example, is extremely stressful, and can have major consequences in terms of physical and mental health (Kester, Rothblum, Lobato, & Milhous, 1988). Consideration of the impact of a work schedule on all family members is critical to success of the employment situation.

Bill's success in training and employment was dependent on a number of factors, including a high skill level, appropriate technology, and a flexible employer. Other factors which contributed to a successful transition to employment were support provided during the initial weeks in the workplace, advocacy, his personal skills in negotiating a different work routine, and support of the insurer. Personal characteristics which were significant included his own willingness to cope with an altered relationship with his peers, and flexibility in negotiating work duties. Workers of different skill levels, and with different disability and social concerns will find success in a totally different work schedule design.

As in any compromise situation, there are negative factors associated with return to work on a modified basis which bear mention. These concerns, such as reduced peer contact, less time for socialization on the job, and the inability to be present for all meetings and special events, are the typical disadvantages associated with part-time employment for any worker, and are generally outweighed by the many advantages of a modified work week. Rehabilitation clients may also wish to consider issues related to reduced income, potential loss of disability benefits, and a possible reduction in employment options when seeking work on a modified basis. The latter two issues are becoming less problematic with time, however, as employers and insurers alike become familiar with the many advantages associated with pant-time employment of worker's with disabilities.

For many workers with severe disability, reduced work hours may not be a practical or desirable option. For those who do not have the support of a disability benefit or a second income, financial concerns may make this form of modified work impossible. Others may choose to work without any modifications in order to demonstrate their ability to meet the work standards of any employee, making lifestyle compromises if necessary. It seems essential, however, that alternatives be made available such that individuals can assess their own priorities, abilities, and tolerances, and make suitable choices.

It is unlikely that Bill would be working competitively today if a modified work schedule had not been negotiated. Evidence gathered with respect to his initial period of full time program participation demonstrates that major components of his life in terms of roles, daily performance, and in his self image were adversely affected by the demands of a full time schedule. As Bill's wife observed,

"For anyone whose stamina is not as high as it used to be, a full work day is really hard and will eventually take its toll. The exhaustion can lead to depression and ultimately affect self esteem."

In the situation reviewed here, the outcome was a win-win situation for all players: employee, employer, and insurer. Inflexibility on the pan of the employer may have meant the loss of a valuable contributor to the work team. Inflexibility on the part of the insurer would have resulted in greater compensation costs. The impact in personal terms for the worker is far greater. The most valuable role for rehabilitation specialists may be to assist clients in finding the appropriate place for work in their lives as part of a whole constellation of life issues. This may require a reexamination of the terms by which we measure success in rehabilitation.

References

Amaroli, R. C. (1986, Fall). Hiring the handicapped: Overcoming physical and psychological barriers in the job market. Journal of American Insurance, 13-19.

Angelo, J., Hurlburt, M., & Oddo, C. (1991). The function of the computer workstation for the physically disabled worker. Work, 1(4), 22-28.

Crisp, R. (1990). Long term vocational adjustment after spinal cord injury: Implications for occupational therapists. Australian Occupational Therapy Journal, 37, 173-177.

Dew, D. W., Phillips, B., & Reiss, D. (1989). Assessment and early planning with the family in vocational rehabilitation. Journal of Rehabilitation, 55, 41-44.

Equal Opportunities Commission (1992). A technical assistance manual on the employment provisions (Title 1) of the Americans with Disabilities Act of 1990. Washington, DC: U.S. Government Printing Office.

Feuerstein, M. (1991). A multidisciplinary approach to prevention, evaluation, and management of work disability. Journal of Occupational Rehabilitation, 1, 5-12.

Hopkins, K., & Johnson, W. (1988). Opportunity 2000 - Creating affirmative action strategies for a changing workforce. Employment Standards Administration, U.S. Department of Labor.

Hynes, D. (1988). Working effectively with insurance case managers. In Whiteneck, G., Lammertse, D. P., Manley, S., & Menter, R. (Eds.). The management of high quadriplegia. New York: Demos Publications.

Kester, B. L., Rothblum, E. D., Lobato, D., & Milhous, R. L. (1988). Spouse adjustment to spinal cord injury: Long-term medical and psychosocial factors. Rehabilitation Counselling Bulletin, 32, 4-21.

Kinney, W. B., & Coyle, C. P. (1992). Predicting life satisfaction among adults with physical disabilities. Archives of Physical Medicine and Rehabilitation, 73, 863-869.

Krause, J. S. (1990). The relationship between productivity and adjustment to spinal cord injury. Rehabilitation Counselling Bulletin, 33, 188-199.

Kuhlman, G. A. (1988). Follow-up of a word processing training and employment program for homebound persons with disabilities. Journal of Rehabilitation, 54, 55-59.

Lysaght, R. M., & Lloyd, M. H. (1993). Adaptive computer education - more than "high tech." Canadian Journal of Occupational Therapy, 60, 90-97.

Power, P. W., Hershenson, D. B., & Fabian, E. S. (1991). Meeting the documented needs of client's families: an opportunity for rehabilitation counselors. Journal of Rehabilitation, 57, 11-16.

Schloss, P. J., Wolf, C. W., & Schloss, C. N. (1987). Financial implications of half- and full-time employment for persons with disabilities. Exceptional Children, 54, 272-276.

Seaver, M. E. (1989). Employing persons with disabilities. American Occupational Health Nurse Journal, 37, 513-517.

Spencer, E. A. (1989). Toward a balance of work and play: Promotion of health and wellness. Occupational Therapy in Health Care, 5, 87-99.

Stewart, W. W., Chubon, R. A., & Ososkie, J.N. (1988). Understanding vocational disability: A critical issue in the adjudication of disability related problems. Journal of Rehabilitation, .54, 29-32.

Trieschmann, R. B. (1988). Spinal Cord Injuries: Psychological, Social, and Vocational Rehabilitation. New York: Demos Publications.

Wyrick, J .M. (1992). Worker's compensation regulations: Implications for documentation. Work, 2(3), 69-72.

Yerxa, E. J., & Baum, S. (1986). Engagement in daily occupations and life satisfaction among people with spinal cord injuries. Occupational Therapy Journal of Research, 6, 271-283.