Review of Models of Work Rehabilitation

Another facet of my recent work has been a review of literature, and derived from this, the synthesis of a number of approaches to the conceptual and contextual modelling of work rehabilitation.

The resulting discussion and synthesis, documented here, presents variety of ways of conceptualising and taxonomising the experience and impact of; work, work-ability, and/or work-rehabilitation interventions, and from this engages in a discussion of factors to be considered as we develop our own systems and models for monitoring and providing recommendations on successful vocational rehabilitation interventions and care-pathways.

Building on my tentative attempts to concept model / or model the underlying facets of the JANUS Pathway Generator patient data vector, documented here, and with a view to supporting the project team to identify and build the tools to start to gather, measure and analyse suitable or equivalent data in a Swedish context, it seemed pertinent to situate and compare the JANUS model with other established and evidence-informed models of vocational rehabilitation and health related quality of life / biopsychosocial health. The hope is, that by doing so, it will allow us to abstract a model of the Pathway Generator that is broader than simply the variables adopted in an Icelandic context, and help ensure that the model we implement in Sweden is also grounded in the literature and evidence-base of vocational rehabilitation more broadly.

The process of conceptually modelling different abstractions and interpretations of vocational rehabilitation and it's markers from the literature, and summarising approaches to work capability assessment in a Swedish context specifically, will thereafter serve a number of longer-term purposes for both my own research and the activities of the wider project team. Not least, the identification of 'federated' sources of data, or the development of working partnerships and a richer understanding with which to navigate the politics of such partnerships and interrogate such data.

In the first instance it is hypothesised that this literature review and synthesis will help us develop a unifying conceptual model of the types of data it is possible and pertinent to gather in a work rehabilitation context, and with such an awareness, develop a shared understanding across the team of the context we are working in, and a shared vocabulary through which to express the phenomena we are interested in and may encounter in this context. Simply put, conceptual modelling and the role of design-based visualisation, may assist us in identifying the type of phenomena we can become attentive to in our work context, and data we can derive from these phenomena, and thereafter support us in developing project plans for how we might work together to develop tools and systems for gathering and storing such data and implement them successfully in this context.

It is further hoped, that this literature review will also allow us to situate the various data gathering processes and the philosophies that underpin them, and thereafter more readily critically appraise the types of data we are proposing to gather. With this greater awareness, also providing deeper understanding and shared mental models from which we can design and develop such systems in an accessible and participatory manner and design better and more sensitive interfaces and database systems to support our data gathering and data science processes.

Approach to this work

The primary approach I have taken in this work, and in reviewing the literature, is that of conceptual modelling. Following the identification of a number of key resources and publications from the work rehabilitation and return-to-work literature, these texts have been reviewed for theoretical or concept models pertinent to representing the context and phenomena of health-related quality of life (of which employment is deemed to be part) but also, from the existing literature models that have been proven as viable for assessing and measuring the impact of work rehabilitation more generally.

Concepts and Conceptual Modelling

"Conceptual modelling is described as “the activity for formally describing some aspect of the physical and social world around us for the purposes of understanding and communication” (Mylopoulos, 1992, p. 51).

Conceptual models attempt to capture requirements with the purpose of creating a shared understanding among various people during the design of a project within the boundaries of the application domain or an organization" (Maass and Storey, 2021, p. 2)

This ethos of conceptual modelling can also perhaps be better understood as a form of clustering or abstraction - an attempt to position and aggregate the different observed, encountered or documented phenomena deemed relevant in the process of reviewing various models of work, work capability and work rehabilitation, and attempting thereafter to structure and systemitise them and their underlying relations and logic.

As Kahl et al (2019) explain:

"Much like artistic concepts – for example, different shots in cinema (close-ups, long shots, jump-cuts etc.) – [concepts] are not only ways to look at things, but also ways to make things seen. Concepts enable and facilitate this making-present by way of intensifying elements and characteristics of a given domain"

This work here can be understood therefore as an attempt to see, and make seen a variety of 'frames' and 'lenses' for mapping, modelling, data-gathering and analysing 'vocational rehabilitation' and it's context. Taking inspiration, and experience from how previous approaches to this have been gathered in the literature to then enable us to create our own 'feature space' in the ADAPT project.

Terminology

Prior to reviewing the different theoretical models in the literature, it is perhaps pertinent to refer to Schultz's (2007) model of the paradigms that often underpin different models and understandings of the vocational rehabilitation space.

Work Ability Modelling in a Swedish Context

The following sections, whilst when taken together by no means provide a comprehensive review of all the models of vocational rehabilitation in a Swedish context, instead represent the starting point for a repository of knowledge about how work ability can be modelled, measured, impaired and (re)habilitated according to a number of different researchers familiar with, or working within, a Swedish occupational/vocational health context.

Ludvigsson's Model

Ludvigsson's model is a high-level abstracted model, useful for introducing a straight-forward three part concentric hierarchy of the differing dimensions of work ability. This appears to follow some sort of Piagian object-oriented, social-constructivist formulation (discussed more below). But as such presents one of the more general models, and a gentle introduction to the most common facets of individually-oriented work-ability assessment. Namely, that work is a physical activity (i.e. involves abilities of navigating and manipulating the physical environment). Something that itself requires mental or cognitive abilities, or can be impaired by a hostile or unsupportive environment, and/or disability to such mental or physical abilities. And finally, that work is something transacted through, and demanding of a variety of social competencies or capabilities and a social environment that is responsive to, and enabling of these.

Such a three part taxonomy can be recognised as drawing from similar models also used in human development studies with the exception of the authors decision not to differentiate emotional functions or responses from other cognitive processes.

The Role of Emotion and Affect

The role of emotion in human behaviour, and the return-to-work / vocational rehabilitation context is worthy of discussion, and perhaps demands an explicit post or piece of work in it's own right. The reification, or 'overmining' of emotion (in Graham Harman's sense of the term - see Kimbell (2013, p. 7)) as "just another cognitive process" in Ludvigsson's model, is indicative of the potentially dehumanising, 'dispassionate' and bureaucratic approach to data gathering and assessment both in practice and in academic research in this area.

One could also refer to the Schultz Model (discussed previously) to situate the lack of experiential measures or interest in the regulating role of emotion in individual's return to work / occupational health / vocational rehabilitation assessment as indicative of more 'forensic' or alternatively 'biomedical' approaches.

Tengland's Model

Another prevalently cited model, and source for discussion of the concept of "work ability / arbetsförmåga" in a Swedish policy and practice context is that of Tengland (2006).

Discussion and Abstraction of Tengland's Model

The extrinsic notions of the "work environment" and the "nature of work" are conceptualised in various different ways throughout the literature. Tengland's model also draws distinction between the intrinsic 'motivation', 'competence' and 'volition' of the individual but does so implicitly. By redrawing Tengland's model with the addition of this higher level abstraction, it usefully illustrates the two differing 'locus of control' addressed in Tengland's model.

The idea of 'health' as a facet of the individual is not uncontroversial however, recent social models of health, and social models of disability, would situate 'health' as an interaction, or product, of the individual and their environment. This is perhaps a topic for further discussion as part of the modelling of health related quality of life, or in modelling markers of rehabilitation - which particular philosophical 'stance' we, as modellers wish to take. See Knauf and Schultz or Schultz discussed previously, for a broader framework within which to situate such more philosophical discussions.

Westerholm and Bostedt's Model

Another model established in the Swedish literature is that of Westerholm and Bostedt. They to adopt this intrinsic and extrinsic distinction.

Sandqvist's Model

Swedish Labour Market Policy (2009) Model of Factors Affecting an Individual's Ability to Work

Work capability was also defined in the most recent Swedish government policy documentation (SOU 2009:89) governing long-term sickness and work rehabilitation legislation.

Melin's Li-Sat Model

Work Capability Modelling in an International Context

I will now shortly discuss a number of identified theoretical models from a variety of international contexts - which, in the philosophical sense, and in this context, is understood to be models of "things" - principally phenomena. The hope was and is, in reviewing these, that these might provide a more generalisable way of situating or creating a "feature space" in which to develop shared models of the work capability / occupational / vocational rehabilitation context.

Much like with the review of Swedish models of this context conducted previously, the intention is, that through review and synthesis of such models it will become possible to develop broader conceptual models that allow us to model the bio-psychological social and systemic environment users need to navigate, and which public sector services perpetuate and support. From such models, we will be able to construct a "shared feature" space.

Canadian Occupation Performance Measure Model

The models introduced previously from the Swedish literature echo similar conceptions of individuals functional capabilities in work contexts to those referenced in the Canadian Occupation Performance Measure Manual, which states:

"The person is seen as possessing physical, affective, and cognitive components, central to which is the essential core of being, 'the spiritual' element. The environment is comprised of physical, social, cultural, and institutional elements." (Law et al, 2020, p. 5 - emphasis added)

Law et al, unlike Ludvigsson et al, do differentiate the emotional (affective) from the cognitive, and also denote that the concepts physical, and social can also be used to articulate aspects of the environment as well as functions or capabilities of the individual.

This model represents a much more holistic model of rehabilitation than many of the others reviewed so far, with it's focus on lifestyle factors and recreation as much as more productivity oriented outcomes.

Kielhofner's Model of Human Occupation

Another prominent model that might assist with modelling work capabilities is that of Kielhofner's Model of Human Occupation (MOHO). This model itself was foundational to the Sandqvist model reviewed earlier, and much like the COPM models provides a more holistic 'lifestyle' oriented framework within which to consider the phenomena of interest, and of potential measurement in relation to successful vocational rehabiliation.

Beskæftigelses Indikator Projektet (BIP) Model of Vocational Rehabilitation

Part of the Pathway Generator project involves working to support the implementation of BIP in Central Östergötland and across Sweden more generally.

This work also represents a chance to explore practitioners views on digitisation, and data gathering, and exploring the use of design-based approaches in supporting the implementation of new data models and new approaches for evaluating the effectiveness of interventions in an occupational/vocational rehabilitation context.

In much the same manner as conducted earlier for the JANUS data, at it's most simple - and in the form that it is presented by it's authors in their own Swedish language introduction to BIP (Væksthuset, 2019), it is possible to visualise the BIP data model in the following manner:

The BIP Data Model in this form is a distillation of, and evolution from, a much more comprehensive literature review (Væksthuset og New Insight; 2012) that aimed to systematically review the different factors that affect occupational and vocational rehabilitation.

My work recently, has revisited some of this earlier literature in an attempt to understand the genealogy of the current BIP Model, and with that, potentially identify specific facets from the BIP and JANUS Models that overlap.

Unlike many of the other models reviewed, the authors behind BIP also synthesised an explicitly negative model of job readiness, in otherwords the factors that negatively affect an individuals ability to find and sustain employment.

This negative, or 'deficit' model (above) can be considered in contrast to the original model of 'labour market readiness' proposed in the same publication (below).

This original model of the factors affecting labour market readiness, has, been further refined to the current BIP data model (below).

SCÖ's Simplified BIP Model

In the course of it's own implementation of BIP, SCÖ has adopted a simplified version of BIP for ease of implementation. It is presently unclear, at least to me, the precise origins of this more succinct version, although it is easy to imagine this has been driven by a need to simplify the process of gathering data - as well I gather - being reinforced by updated work in Denmark (Væksthuset, 2019) that has narrowed the range of variables that have proven statistically significant in predicting an individuals' successful vocational rehabilitation.

Attempting to abstract these variables, by attempting to aggregate these variables along the lines of some of the social constructivist models previously described, one could summarise the BIP models as:

There is much more one could, and probably should be said about the BIP conceptual model more generally, not least the fact that the model contains both "job-coach" and "user" evaluated measures in one integrated model i.e. combines self-report and objective assessment. But, the key observation here is of a model that has become much less specific - i.e. addresses five much more general themes that relate to an individuals' work ability compared to the original model proposed by the authors in 2012. Whilst this is clearly, in it's increased generality, going to be easier for individuals to respond to, and 'job-coaches' to potentially administer, and, further, easier to apply across a wide range of different interventions or evaluation activities - it is perhaps moving further away from specific and replicable approaches to assessing an individual's ability to work.

At present it is unclear what questions the administrators use to address these specific health, opportunity, capability, collaboration and everyday categories. Nor is it clear how standardised the implementation process of this simplified version is. On what scale are these measures assessed for example? How is the unreliability of self-assessment handled in this process etc.?

There is more work required to understand the BIP administration process - work that is ongoing within the project team - and to integrate these different abstractions, and finally to ensure that the data that is gathered using them is consistent in the different contexts of use.

The ICF Model

Another part of my work has explored whether, as perhaps the closest thing to a globally defined standard measuring and assessing both health, and activities specific to vocational rehabilitation, the ICF (International Classification of Functionality) could perhaps represent a more standardised model for data-gathering in this area.

At the very least, utilising the ICF and mapping the existing frameworks and models we are using on this project to them could help us in standardising our own measures, and then identifying suitable standardised data gathering protocols for further populating datasets on this project.

The first challenge in embracing the ICF Taxonomy, has been to navigate it, and to do so in both English and Swedish. One of the first pieces of work that has been completed to address this challenge was the production of a JSON file containing all the ICF codes in both languages.

Ekberg et al (2015) discuss the ICF in relation to work rehabilitation, and from this it is possible to visualise the ICF as follows:

Subsequent to constructing this visualisation, a basic tool for navigating the different trees in the ICF Hierarchy has also been developed - The ICF Navigator.

There is much more work to be done to make this scheme as navigable and accessible as possible, but the provision at the link above of a mechanism for both exploring the ICF Taxonomy, and searching the taxonomy for specific codes, is hopefully a step in the right direction in terms of making the ICF scheme more usable and useful for our purposes on this project.

The dearth of decent interactive ICF navigation tools is - one suspects - at a practice level at least, a significant barrier, to their successful adoption. This project, and this work, could make a contribution here, especially in the rehabilitation space - and specifically in terms of making the ICF Core Set for Rehabilitation more useful, usable and accessible.

The ICF Core Function Set For Rehabilitation

"The ICF Core Set consists of a carefully selected short list of ICF categories that makes the hundreds of categories contained in the ICF practical and useable. A Core Set is designed to be applicable to a specific health condition, health-related event, or a specific setting; it can describe the most salient aspects of the disability experience with the health condition or setting" (Escorpizo et al, in Schultz and Gatchel, 2016)

That said, The ICF Core Set for Rehabilitation is still a relatively complex hierarchy of both highly abstract, and much more specific 'functions'. Hopefully the ICF Core Set for Rehabilitation Navigator and the accompanying visualisation is a starting point, and at the very least can act as a prototype system to make the ICF Core Set for Rehabilitation easier to understand and use.

This can hopefully include exploration and discussion amongst the project group about how we might implement or adopt such a scheme, as well as how we might better standardise how we understand, deliver and measure the impact different aspects of vocational rehabilitation across different international contexts.

Again, this tool requires much further testing and refinement, but hopefully provides a starting point for us all as a project team to be able to understand and navigate these codes, and potentially to start some work mapping our existing data models within these scheme. In a Swedish occupational health context Norrby and Linddahl (2020) provides some precedent for this. A digital version of their "DWA - Dialogue About Work Ability" questionnaire can be found in the repository that accompanies this work DWA.

Discussion of the TPG Model in relation to the ICF Core Rehabilitation Set

Discussion of the BIP Model in relation to the ICF Core Rehabilitation Set

Summary of the Identified Dichotomies and Models

Following the review of the literature outlined above and the identification of various overlapping and distinct conceptual models of work, work capability, vocational and occupational rehabilitation and biopsychosocial health. It is possible to synthesise a number of conceptual continuums along which the phenomena we are working with could be situated, as part of future participatory workshops and user-experience testing. The identification of these potentially contradictory or complementary 'logics' in how the literature and individuals in practice might understand the context we are working with, could be helpful in order to iron out misunderstandings and build better consensus and shared mental models. But also to open up discussions about what data is more relevant or helpful to gather.

The 'The Capabilities to Work' vs 'Benefits of Work'; 'Work as Therapy' Approach

As Drebing et al explain:

"Participation in employment can have important clinical benefits that rival the benefits of many common clinical interventions. These benefits are wide ranging, and while not achieved by every participant, are generally experienced by most participants across most work settings and diagnostic groups. These include the benefits of physical activity; learning and cognitive activity; social contact and engagement; enhanced opportunities to play valued social roles, including a valued family role as “provider”; a valued societal role as a “worker”; a broader sense of purpose and meaning; opportunities to use and develop skills; opportunities for distraction from clinical symptoms such as anxiety; and the indirect benefits of earning income, such as paid leisure time and employer-supported healthcare benefits. These benefits are rarely the primary goal" (Drebing et al, 2012, p. 2 - emphasis added).

Such a conceptualisation of both the functional capabilities required of individuals in order to work and the clinical benefits to individuals of work, highlight a distinction in the type of data that might be relevant, and necessary to gather as part of the evaluation of occupational health or vocational rehabilitation.

The 'Personal System' vs The 'Environmental/Social System'

The conceptualisation of intrinsic aspects of the individual from that of the environment are also consistent with what Antonovsky contrasts as the “personal system” in juxtaposition to the "social system":

the “personal system” (including socio-demographic, self-concept, health status, and functioning factors). In other words, these are the social-structural, cultural, psychological, and physical characteristics of the external and internal environments of the person which shape the stressors and resources, the life experiences, we confront" (Antonovsky, 1987, p. 4)

Antonovsky lists these personal factors in contrast to what he terms the the "'environmental system' (including physical, policy, supra-personal, and social climate factors) (ibid, p. 4)".

This distinction of the 'intrinsic' - 'personal system' features of the human individual, from the 'extrinsic' - 'environmental system' features of the environment, deserves further elaboration and explication.

One model from the Swedish vocational rehabilitation literature that conceptualises more of these specific 'environmental system' factors - as they relate to work is that of Tengland. This model explicitly highlights that of "work environment" and the "nature of work" itself as features that need to be included in assessment of work capability:

A definition of 'competence' and a further articulation of the tension between the intrinsic capacity or potential of an individual vs. the extrinsic opportunity of the individual can be provided by Elliot et al:

Capacity vs Opportunity

"Competence, or the capacity to perform, is the first factor that Blumberg and Pringle (1982) identified as a critical ingredient for effective job performance in their three-dimensional interactive model. Competence refers to the physical and cognitive capabilities, including knowledge, skills, and abilities that enable workers to perform their tasks effectively. However, even highly competent software engineers cannot perform effectively without a computer. Indeed, the opportunity to perform, which refers to the help or hindrance of uncontrollable events and actors in one's environment (e.g., working conditions, equipment, social support, and organizational policies), is Blumberg and Pringle's second determinant of workers' effective performance." (Elliot, Dweck and Yeager, 2017, p. 43)

The third component of Blumberg and Pringle's Model is "Willingness".

An alternative conceptualisation of the competence vs opportunity, or intrinsic vs extrinsic dichotomy is that of 'job-demands' vs '(individual) resources':

Demands vs Resources

"Job resources refer to various physical, psychosocial, and organizational factors that provide support to individuals as they perform their tasks (Demerouti et al., 2001). Like demands, resources have different natures (emotional, cognitive, or physical). They are evidenced in the form of social support, job control, and skill discretion, among others. These resources help individuals perform their tasks, and by the same token, they help reduce job demands (Karasek, 1979) by making the work more interesting or by contributing to individual development and well-being (Bakker & Demerouti, 2007; Schaufeli & Bakker, 2004). However, as suggested by Crawford et al. (2010; see also Lee & Ashforth, 1996), lack of job resources can lead to stress reactions." (Gagne, 2014, p. 234)

Skills, Rules, Knowledge

Other Paradigms For Integrating Design-based Approaches and Work Capability Assessment

Exploring the the 'Information Architecture' of Work Capability

Object-oriented Approaches

Human Factors, Ergonomics and Usability Approaches

The object-oriented, Piagian systems approach adopted in much of the vocational rehabilitation literature, i.e. that previously discussed as perceiving the world as a system composed of physical, psychological, social phenomena or health as constituted of physical, psychological and social components - share much in common with a usability approach to design and human factors.

As Jordan (2002) explains:

"the problem with usability-based approaches—they tend to encourage the view that users are merely cognitive and physical components of a system consisting of the user, the product and the environment of use. The premise on which these approaches are based appears to be that the product must be designed such that the cognitive and physical demands placed on the users are minimised—that the demands do not exceed the person's processing capacity." (Jordan, 2002, p.7)

One could substitute the word product for the word work in this last citation, to understand the critique I am introducing here, both of design and designed systems that merely consider their context of use to be simply constituted of people, places and things (Penin, 2018) but also of work rehabilitation systems that attempt to deconstitute their context and understanding of the concept of work to merely that of a practice composed of physical, cognitive and social/organisational factors.

"Usability-based approaches then encourage a limited view of the person using the product. This is—by implication if not by intention—dehumanising" (Jordan, 2002, p.7)

Löwgren and Stolterman (2012, p. 17) building on the work of Jordan, outlined above specify, the addition of "value-oriented pleasures"

"physical, social, cognitive/emotional, and value-oriented pleasures."

Jafari, Nathan and Hargraves (2015) explain further that there are a number of ways that design, and designers enact values, or that these value-oriented pleasures can be derived, from the world of work, or any other designed artefact or system:

This is significant then, building on the earlier discussion about the role and measurement of emotion and affect with regards to work and work rehabilitation, for the modelling and measuring of the role that participation in work and working-life plays in allowing people to variously acquire artefacts that project values (such as home-ownership or owning a car for eg.), or how embodying and enacting a particular job role, or training towards a particular job role, can, in turn, allow individuals to project and enact particular identities, or project certain ideals or aspirant qualities and social status. As Jafari et al's model further hypothesises, even individuals feeling like they have a choice in their chosen work, or in the process of finding or regaining employment is fundamental in terms of how one is able to enact ones' values, and the pleasure one derives from such activities.

One can see some slight overlap here with the BIP Model's attempt to assess individuals 'attitudes to finding work' - but the contribution here, of looking at these design-research models of values, and digging deeper into this in the potential of exploring deeper into the user experience of the process of finding work, or rehabiliting for work and attempting to explore and better measure of evaluate the impact on the underlying 'value-aspirations' an individual associates with gaining employment or having a job.

Systems Approach

The earlier extrapolated conceptions of a hierarchy of "work experience" or a hierarchy of "functional capabilities" also mirrors conceptual and theoretical frameworks for modelling 'experience' common in the design world, for example Resmini and Rosati's (2017) Framework of Information Seeking Behaviour:

Resmini and Rosati's (2017) Framework of Information Seeking Behaviour

"Spiritual (religion, philosophy, quest for meaning), Aesthetic (arts and literature), Cognitive/conative/affective (psychology), Social and historical (social sciences), Anthropological (physical and cultural) Biological (genetics and ethology), Chemical, physical, geological, astronomical"

(Resmini and Rosati, 2017, p. 14)

Krippendorff's (1997) Trajectory of Artificiality

Engels Hierarchy of Natural Systems Approach

Constructivism and Situated Approaches

Activity Theory

"“Activity theory is a powerful and clarifying descriptive tool rather than a strongly predictive theory. The object of activity theory is to understand the unity of consciousness and activity. Activity theory incorporates strong notions of intentionality, history, mediation, collaboration and development in constructing consciousness. Activity theorists argue that consciousness is not a set of discrete disembodied cognitive acts (decision making, classification, remembering…) and certainly it is not the brain; rather consciousness is located in everyday practice: you are what you do. And what you do is firmly and inextricably embedded in the social matrix of which every person is an organic part. This social matrix is composed of people and artifacts. Artifacts may be physical tools or sign systems such as human language. Understanding the interpenetration of the individual, other people and artifacts in everyday activity is the challenge activity theory has set for itself.” (Nardi, “Activity Theory and Human-Computer Interaction,” p. 7) in McCullough, 2005, p. 248)

Piagian 'Human Development Approach'

"A core premise of constructivism is that cognitive processes (including thinking and learning) are situated (located) in physical and social contexts (Anderson, Reder, & Simon, 1996; Cobb & Bowers, 1999; Greeno et al., 1998). Situated cognition (or situated learning) involves relations between a person and a situation; cognitive processes do not reside solely in one's mind (Greeno, 1989)." (Schunk, 2015, p. 16)

STS?

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