Are “place and train” principles suited to support people with severe mental illness into work? A questionnaire-based survey in a public employment service

Individual Placement and Support (IPS) has repeatedly been reported to increase employment rates in patients with severe mental illness. Despite this, IPS is only available to a small minority. Translation from evidence to practice is often slow and hindered by a variety of barriers. Barriers include organizational, contextual and attitudinal factors. Despite evidence, many believe that people with severe mental illness are generally dangerous, in need of rest and at risk of harm from work-related stress. Such stigma fosters negative attitudes that may constitute signicant barriers to employment for people with mental illness. Employees in the Norwegian Labour and Welfare Administration hold important gatekeeping positions in relation to the employment schemes that people with mental illness are offered. The aim of this study was to measure the attitudes of these employees towards the core principles of IPS. Secondly, we examine whether attitudes change for Labour and Welfare Administration employees exposed to IPS practice. Methods A case vignette describing a person with severe mental illness and statements referring to this vignette was developed. The survey was administered to a sample of employees at two different timepoints four years apart. The respondents were asked to indicate their attitudes on a six-point Likert scale between statements in accordance to IPS and statements in accordance with treatment as usual. Independent two tailed samples t-tests were used to analyse differences between responses between employees in municipalities with IPS experience, compared to municipalities without. Multiple linear regressions with attitudes as dependent variable, were used to test if attitudes changed over time, dependent on exposure to IPS. as possible” paired with the divergent statement: “We need adequate time for work preparation and treatment before looking for competitive employment”. Responses were collected on a six-point Likert scale dened by each pair of statements. The respondents were asked to read the case vignette and respond to the statements marking on the Likert scale which best indicated their view. On two of the questions, 2 and 7, a score of six on the scale indicated attitudes in accordance with IPS, whereas a score of six on questions 1,3,4,5,6 and 8, indicated attitudes more in accordance with usual practice. To check conceptual validity, as part of questionnaire development a focus group was conducted with representatives from the local labour and welfare oces which further rened the questionnaire.

to current practices [9]. The e cacy of IPS is well established [10,11] , but despite this, the intervention is not scaled up as standard for people with severe mental illness anywhere in the world [12] IPS is evidence-based, not just regarding e cacy, but also in its focus on service-users' needs and preferences, it is well-de ned and structured, and it differs on several important principles from more traditional forms of vocational rehabilitation. Traditional vocational services typically focus time and resources on training people to develop new skills in segregated and sheltered environments before attempting to help individuals gain employment -often referred to as 'train and place' approaches. In contrast, the primary goal of IPS is to directly nd a job and then to provide continued support to enable the individual to retain that job -a 'place and train' approach. The IPS approach integrates the vocational intervention with an individual's clinical treatment. Another important principle is the emphasis on an individual's own employment goals and preferences, and experience through relevant competitive employment instead of preparation through a step-wise approach [13]. In regard to people with severe mental illness, direct placement into competitive employment might be experienced as challenging among personnel within statutory Labour and Welfare administration organisations. Such organisations are used to following de ned rules and regulations often in accordance with 'train and place' approaches to vocational rehabilitation when it comes to people with scarce employment experience or long term unemployment [14].
The translation and implementation of the IPS evidence based principles into routine settings might be hampered by different barriers at a national, regional and local level [15,16], and these barriers can also change dependent on implementation phase [17]. Within the IPS literature, attitudes of mental health professionals have been an identi ed barrier to effective implementation [15,18,19], but few studies have investigated attitudes among personnel within statutory Labour and Welfare Administration. A meta-ethnographic review including studies from Scandinavia, UK, Australia and Canada, reported that social workers did not feel that IPS tted the welfare systems rules and regulations and were skeptical about the IPS-process towards competitive employment [20]. It has been reported that employees in social security gatekeeping positions, see less bene t and more barriers regarding competitive work than the advisors who work with specialized vocational rehabilitation [21]. In Norway, employees in the statutory Labour and Welfare Administration organisation (NAV) have traditionally been social security gatekeepers but have increasingly also taken over the more specialized vocational advisors' role. Employees in the Labour and Welfare Administration may have both negative and positive attitudes to IPS. On the positive side, they may embrace IPS due to the evidence on e cacy [10]. It is also possible that IPS may be rejected as it challenges current practices and beliefs, potentially threatening current working methods, roles, hierarchies, power structures, and perhaps even jobs. More studies on implementation of supported employment models in the traditional vocational rehabilitation context are warranted [22].
Eventually scepticism towards IPS and its key principles has potential to hamper implementation of IPS [23,24]. In addition, attitudes of professionals in uence jobseekers' beliefs and motivation in nding and managing competitive work [25]. Professionals who favour traditional vocational rehabilitation principles could limit the effectiveness of creating new pathways into work for people with severe mental illness.

Aim
There are two aims of this study: First to examine the attitudes of employees in the Labour and Welfare Administration towards the key principles for IPS. Secondly, we examine whether these attitudes change over time for employees exposed to IPS practice.

Setting
The context of this study was the implementation of IPS in Bodø city in Nordland county in Norway. Nordland County is geographically placed in the northern part of Norway, and Bodo is the capital and largest city in the region, with 50 000 inhabitants. Other municipalities in Nordland county, where IPS was not yet implemented, were included as reference group. Nordland County has 44 municipalities, with 43 of these having their own statutory Labour and Welfare Administration o ces. These o ces represent Norway´s Public Employment Services, functions de ned at EU level: (https://ec.europa.eu/social/main.jsp?catId=105&langId=en) In 2013, there were 450 employees in these o ces, which had increased to 480 employees in 2017. Traditionally there has been little coordination between these labour and welfare o ces and mental health services to support individuals with severe and enduring mental health conditions into work. The traditional way of working has been a step-wise train and place approach [26], similar to the control arm in IPS e cacy trials. Prior to 2013, there was no IPS activity in Nordland County. In 2013, the Labour and Welfare Administration o ce, along with the mental health service in the municipality of Bodø, began implementing IPS and employed three full-time IPS employment specialists. Between 2012 and 2017, all the employees both in health and NAV in Bodø were trained in the principles of IPS, and several local meetings and seminars about work and mental health were organized. The IPS program had three independent IPS delity reviews during this period: rst in September 2013 scoring fair delity, and the second and third scored good delity. The rest of the county did not start implementing IPS before 2017.

Questionnaire
A questionnaire was developed based on the eight key principles of IPS. The questionnaire began with a case vignette about a hypothetical patient "Line" and continued with statements with reference to this vignette (text box 1). Eight paired statements were developed according to the eight key principles for IPS ( Figure 1). For each pair, one statement was in accordance to an IPS principle whilst the other statement opposed it. The statements opposing IPS were generally in line with current practice in the Labour and Welfare Administration, and in accordance with 'train-and-place' approaches to vocational rehabilitation.

Insert Text box
For example, for the IPS principle "Rapid job search" we developed the statement: "Line wants to work now. This means that the job search should start as soon as possible" paired with the divergent statement: "We need adequate time for work preparation and treatment before looking for competitive employment". Responses were collected on a six-point Likert scale de ned by each pair of statements. The respondents were asked to read the case vignette and respond to the statements marking on the Likert scale which best indicated their view. On two of the questions, 2 and 7, a score of six on the scale indicated attitudes in accordance with IPS, whereas a score of six on questions 1,3,4,5,6 and 8, indicated attitudes more in accordance with usual practice. To check conceptual validity, as part of questionnaire development a focus group was conducted with representatives from the local labour and welfare o ces which further re ned the questionnaire.
Insert Figure 1 Design and participants

Statistics
Data were analysed by Stata version 15 [27]. Scores for each of the statements, as well as a sum score for overall attitude towards the IPS principles, were computed. The internal consistency of this scale was analysed by Cronbach's coe cient alpha. The independent samples t-test was used to analyse differences between responses from the geographical area where IPS was implemented and areas without IPS experience. This was executed for the total sumscore and for each of the individual items at two timepoints. Multiple linear regressions with attitudes as the dependent variable were also used to test the hypothesis that attitudes changed over time, dependent on exposure to IPS. The hypothesis for interaction was tested by an interaction term (time by site) where both were coded as dichotomous indicating 2013 versus 2017 and IPS versus no IPS implementation area.
The Cronbach's coe cient alpha based on standardized items for the sum score was 0.616. In Figure 2, responses are illustrated with histograms. The "no IPS group" is visualised as grey bars in the histogram, and employees in the municipality with IPS are visualized as black bars. The con dence intervals are illustrated in Figure 2 and Table 1 (Table 1).

Discussion
This survey among employees in the statutory Labour and Welfare administration organisation suggest attitudes in strong favour of the key principles in a 'place and train' approach. The positive attitudes are statistically stronger in the municipality with training and practical IPS-experience, compared to the municipalities without. All municipalities show statistically signi cant decrease in positive attitude towards these principles after 4 years, with the strongest decrease in the area without IPS-experience. However, the scores are still positive as de ned by the scale. There is no statistical difference between the two groups for how attitudes changed dependent of time and experience of IPS.
If this study is capturing the true attitudes of statutory labour and welfare administration employees, there is little reason to believe that employees holds strong beliefs in the traditional principles following a "train and place" approach that they are expected to follow in their daily work. The ndings suggest that competitive employment is seen as possible and realistic for people with severe mental illness. This is reassuring as such attitudes should prevail from professionals who hold the task of helping unemployed and disadvantaged people back into the labour market. Still, the sector mainly employs a prevocational training approach, and the focus on direct placement into competitive employment without prevocational training or through a stepwise training approach in sheltered working environments is new. The positive attitude might also suggest that statutory Labour and Welfare administration personnel think that there are employment opportunities for a range of workers with maybe little or no current work experience within a labour market which is highly unionised with good job security. The unemployment rate has been low in this region over a long period, and there is also growth in employment possibilities, although lower than the median growth in the rest of Norway during the same period. The growth is highest for people with higher education.
The shift towards a more evidence based 'place and train' IPS approach has evolved over years in Norway from adaptions of IPS in early intervention psychosis programs [28] to national initiatives and funding of a randomized controlled trial of IPS to test the e cacy of the intervention in a Norwegian context [29]. Whilst the randomized controlled trial was commissioned in a collaboration between the Directorate of Labour and Welfare and the Directorate of Health, none of the research areas within the trial were geographically close to the 44 municipalities within this study. In Norway, the Directorate of Labour and Welfare has been an advocate for IPS, which might have contributed to explain the positive attitudes in favour of this approach among statutory Labour and Welfare administration personnel. The decline in positive attitude over time is signi cant but small, and suggests that the initial favourable perspective has been adjusted a bit over time, although still positive.
The item on the role of personal bene t counselling had responses less in favour of IPS than the average of the other items. Norway is a generous and comprehensive welfare state and has an active labour market policy. Welfare states with a resource perspective like this, might affect norms and values [30]. The latent functions of work like having colleagues, social support, the achievements of personal goals, time structure and quality of life might be considered as potentially more important motivators for whether people want a job or not. Previous research has shown that discussion around nances might promote engagement in vocational rehabilitation [13,31].
There are several limitations of this study. There is no IPS attitude checklist available, and the version applied in this study was developed by us ad-hoc for this project. The Cronbach´s Alpha was 0.616, indicating this may not be a univariate latent construct with high internal consistency. There seems to be a ceiling-effect in the responses, which were more in favour of IPS than the current practice the respondents were expected to follow in their daily work. This may be due to a faking-good bias or a compliance bias, as the respondents may be aware that the researchers are involved in IPS. It may also indicate that the respondents are convinced that IPS is a preferred working method over the practice they are currently expected to follow. This is a cross-sectional survey executed at two timepoints in the same target population, and it is consequently not possible to exclude the possibility that the attitudes measured in this study were different between the IPS municipality representing the biggest Labour and Welfare Administration o ce in the area, and the other areas of Nordland County also prior to the implementation of IPS. This is a convenience sample, and it is not clear how the ndings would generalize to staff in this sector in other places. That said, there were no signi cant differences in responses between regions within the county except between the IPS municipality and the other areas combined, indicating generalizability to staff in this sector in similar contexts. The strong advocacy from the Labour and Welfare directorate in Norway of supported employment and IPS might have caused some compliance bias and fakinggood bias. The vignette may also in uence responses. A vignette with a more severe diagnosis or lower function level would most likely have reduced the support for the IPS principles, hence also reduced potential ceiling-effect. A vignette with addiction may, for example, on average be perceived as more blameworthy and dangerous and would in uence the willingness to assist with job seeking and job keeping [32].
To increase the likely success of implementing a new evidence based practice like IPS, it is important to understand local factors that may impact on implementation [15] like the audience for change and organisational factors [33,34]. The translation of evidence into practice requires not only changes at an individual and local level, but also at a national level [16]. The ndings from this study and, the only other international study we are aware of looking at the attitudes of statutory labour and welfare administration personnel [21] suggest that attitudes within in this organisation would not hinder implementation, nor would the policies.

Page 7/11
This study shows that the Attitudes of statutory Labour and Welfare employees will not be a substantial barrier for implementation of IPS, but should be addressed as speci c possibly barriers early in the implementation. A scaling up of IPS in Norway will require explicit support from relevant authorities and probably also adaption of rules and regulations to support close collaboration between health and NAV. Previous reports have commented on problems with mainstreaming supported employment services after an initial period of success in Nordic countries [26], and the same challenges might arise now if further steps fail to be taken. Scaling up IPS in Norway will require a system for training, supervision and technical support to achieve good delity and sustainability over time [35]. The positive attitudes shown in this study underline that employees in the statutory labour and welfare administration o ces support service redesign of pathways into competitive employment for people with severe and enduring mental illness. Ethics approval and consent to participate

Abbreviations
The study conforms to the principles outlined in the Declaration of Helsinki.