Researchers have suggested that the Internet is changing vocational rehabilitation (VR) service delivery and that it can be incorporated into every phase of the rehabilitation process (Hampton & Houser, 2000; Patterson, 2000; Patterson, Knauss, Lawton, Raybould, & Oehlers, 2002; Riemer-Reiss, 2000). Only a few empirical studies have been conducted on this topic as it relates to VR (cf. Johnson, 2004; Patterson, 2002), although there is some evidence that counselors are using the Internet in the rehabilitation process (Patterson et al., 2002). Numerous empirical studies have been conducted in related fields such as vocational and career counseling (cf. Clark, Horan, Tompkins-Bjorkman, Kovalski, & Hackett, 2000; Harris-Bowlsbey, Riley Dikel, & Sampson, 2002; Malone, Miller, & Miller, 2004).
Several studies provide anecdotal evidence for how the Internet can be applied in every phase of the VR process, from customer application and intake to post-employment services and follow-up. Counselors could use the Internet to identify new referral sources and communicate with referral staff (Patterson et al., 2002). The Internet (e-mail and video conferencing) could be used to conduct intake interviews with customers, and later to discuss the results of individuals' assessments with them in terms of vocational potential and program eligibility (Riemer-Reiss, 2000). Instant online access to information and resources regarding, for example, types of disabilities and other related information, assessment, and career guidance, could be useful to counselors during the assessment and employment-planning phase (Patterson, 2000; Patterson et al., 2002).
Counselors and customers could develop the Individualized Plan for Employment (IPE) online (Riemer-Reiss, 2000), and use e-mail (among other methods) to communicate during the rehabilitation process (Patterson et al, 2002). With respect to job development and placement, counselors could use the Internet to identify job vacancies and obtain information about potential employers; to share job leads and related information with customers via e-mail, Internet forums, and electronic mailing lists; and to provide employment support to groups of customers via Internet forums and chat rooms (Patterson et al., 2002; see also Patterson, 2000; Riemer-Reiss, 2000). Counselors and customers could use e-mail (among other methods) to periodically check in or follow up once the individual is employed (Riemer-Reiss, 2000).
Despite the Internet's potential to be used in every phase of the rehabilitation process, researchers (Hampton & Houser, 2000; Patterson, 2000; Riemer-Reiss, 2000) have suggested that the Internet will not replace the counselor. These suggestions are based on the assumption that personal, face-to-face contact with customers is necessary to build an effective counseling relationship and achieve rehabilitation success, and that technology compromises this connection. It should also be noted that these suggestions mostly reflect the perspectives of rehabilitation counselors, giving little consideration to VR customers. Indeed, not much is known about how VR customers experience Internet use in the rehabilitation process, their perspectives on this, and their preferences.
There is evidence that counselors are using the Internet in VR. Patterson (2002), for example, surveyed a convenience sample of 1,034 counselors from 34 state VR agencies about Internet access at work, Internet use in rehabilitation practice, and views on the Internet and the agency's Intranet (e-mail) system. Study results showed that counselors used the Internet mostly to identify potential jobs for customers (75.6%), to look up medical terms and conditions (70.3%), to identify state and local resources (69.4%), to look up occupational requirements or projections (68.8%), and to communicate with customers via e-mail (65. 1%). Counselors were less likely to use the Internet to teach job skills to customers (39.6%) or for their own professional development (39.7%). On average, counselors used the Internet for seven ofthe 13 VR activities listed in the survey.
Findings on counselor perceptions of Internet use in VR and the decision-making process are presented in this paper, as well as findings on the types of Internet applications counselors used, and the types of VR activities they conducted online. Findings are based on a survey of 399 counselors at four state VR agencies that was part of a larger study to investigate technology adoption and the transformation ofthe VR process (Boeltzig, 2010). With this paper, the researcher intends to contribute to existing research on technology adoption and use by VR counselors.
For the purpose of this study, the term "information and communication technology" (ICT) is used to refer to a group of electronic devices as well as the application of those devices for communication and information-sharing. In this study, devices included the Internet, videophones, mobile phones, and smart phones. Examples of Internet applications that were the focus in this research included communication and information-sharing options such as e-mail, electronic mailing lists, instant messaging (IM), Short Message Service (SMS) texting, Internet forums or message boards, video conferencing, web conferencing, websites, web logs (hereafter referred to as blogs), and wikis. The following research questions were addressed in this study:
1 . How do counselors perceive Internet use in vocational rehabilitation?
2. How is the decision to use the Internet in the rehabilitation process made, and what factors do counselors perceive as important in the decision-making?
3 . What types of information and communication technology do counselors use in the rehabilitation process and how often do they use them?
4. For which aspects ofthe rehabilitation process do counselors use the Internet, how often do they use the Internet, and how useful do they find it?
Method
Four state VR agencies (sites) - Maryland, New York, Pennsylvania, and Vermont - agreed to participate in this study. Each state assigned a staff member to be the main contact for the agency and to assist with the implementation of this research.
Participants
The sampling frame consisted of all counselors who worked full-time in VR service delivery for the selected sites (Total N = 948; Maryland: ? = 153; New York: : ? = 340; Pennsylvania: ? = 382; Vermont: ? = 73). Individuals in managerial or administrative positions were excluded, since they were unlikely to be involved in direct VR service delivery, The researcher achieved an overall survey response rate of 42% (Maryland: 73%; New York: 24%; Pennsylvania: 44%; Vermont: 45%; five counselors did not report what state they belonged to), resulting in a final sample of 399 counselors (N= 399).
Instrumentation
A survey instrument was developed that consisted of four parts. Part 1 asked counselors about their views on and experiences with ICT in general. It included 42 survey items, with only one item being open-ended. Closed-ended items asked counselors about their views on and experiences with different types of ICT (listed previously); things that helped them learn how to use ICT; VR office access to different types of ICT; caseload size and composition (types of disabilities and special populations, home and VR office Internet access, digital literacy); their views on Internet use in the VR process; and the number of peers in their VR office who used the Internet for VR service delivery. The open-ended item asked counselors about what prevented them from learning how to use the Internet in general. The last item in Part 1 asked counselors about whether or not they used the Internet in the rehabilitation process. Those who responded positively were instructed to continue to
Part 2; those who responded negatively were asked to skip Part 2 and continue with Part 3. Part 2 ofthe survey focused on counselor experiences in using the Internet in the VR process and included 23 survey items, four of which were open-ended. Closed-ended items asked counselors about the percent of customers on their caseload and the types of customers (types of disabilities and special populations) with whom they used the Internet in the rehabilitation process; the types of rehabilitation activities they conducted online including the frequency of these activities and the usefulness ofthe Internet for these purposes; the types of ICT they used in the VR process including the frequency of using them; and the benefits and limitations of using the Internet in the rehabilitation process. The four open-ended items asked counselors how they make the decision to use the Internet with customers in the VR process; important factors in the decision-making process; challenges to using the Internet in the rehabilitation process; and recommendations for other counselors who might consider using the Internet in VR.
Part 3 asked counselors about their state VR agency's capacity to support ICT-based VR service delivery and included 1 5 survey items, with only two items being open-ended. Closed-ended items asked counselors about their state VR agency's policies and procedures related to ICT; their awareness of ethical guidelines for technology use and distance counseling; types of ICT training and supports provided by their state VR agency including the usefulness of those; and their interest in ICT-related topics for future training. The two open-ended items asked counselors about changes that their state VR agency should make to help counselors better integrate the Internet into VR service delivery and to encourage customers to use the Internet in their rehabilitation experience.
In Part 4 of the survey, the researcher collected demographic information about the counselors. Only one of the 12 survey items in Part 4 was open-ended, offering counselors an option to provide additional comments. To increase validity of the survey instrurpent, it was sent to the site contacts and five rehabilitation counselors for review and feedback. In addition, the instrument was piloted with five students enrolled in a graduate rehabilitation-counseling program. Students completed a hard-copy version of the survey and reported the time it took them to do so. The researcher then asked students debriefing questions about particular survey items, probing further into the basis for their responses. This technique has been referred to as "verbal probing" or "cognitive probing" (Willis, 2004).
Procedures
The primary survey mode was the Internet. The survey was offered in other modes (mail and telephone) as well to increase the survey response but also to encourage those counselors who do not have access to the Internet, or choose not to use the Internet, to respond to this survey and share their views and experiences. The web software SurveyGizmo was used to develop an accessible online survey. The survey was implemented between February and April 2009. One week before the launch, the site contacts sent an invitation together with a study information sheet by e-mail to all counselors. Once the survey had been launched, the site contacts disseminated the survey website location to the counselors by email. This e-mail also offered counselors the option to complete a paper or telephone survey. However, there was not one counselor request for a paper or telephone survey.
Data Analysis
The survey responses were downloaded from the SurveyGizmo website as an electronic file and then imported into the statistical software program Stata, Version 1 1 . The data file was inspected and cleaned prior to statistical analysis. Descriptive statistics were used to analyze closed-ended survey responses; text or qualitative analysis was used to analyze open-ended survey responses.
Results
Characteristics of Counselors
The majority of counselors were women (73% of 390) and were white (83% of 380). Almost all reported not being Hispanic or Latino (99% of 368). Counselors ranged in age from 25 to 70, the mean age being 46 years. One third (33% of 387) reported having a disability. The majority of counselors (81% of 394) had master's degrees, followed by those with bachelor's degrees (18%); 1% of counselors reported having a doctorate. Slightly less than half (47% of 394) had been in the profession for 10 years or more. More than one third (37% of 395) had been with the current state VR agency for 10 years or more. Counselors' average caseload size was 130 customers.
All 399 counselors who participated in the survey considered themselves Internet users. Only 1 1 counselors (2 from Maryland, 1 from New York, 7 from Pennsylvania, and 1 from Vermont) reported not using the Internet for VR service delivery. Survey results showed that the majority of counselors (239, or 65% of 366) used the Internet with more than one quarter of customers on their caseload. The majority of counselors reported that more than one quarter of customers on their caseload had home Internet access and were digitally literate (knew how to use computers and the Internet and felt comfortable using them) (see Table 1).
Counselor Perceptions of Internet Use in VR
The majority of counselors reported that developing a counseling relationship via the Internet is possible (76% of 396 agreed or strongly agreed), compared to 24% who disagreed, strongly disagreed, or remained neutral. Counselor responses to the statement about the Internet's compatibility with the rehabilitation process were similarly distributed (80% of 397 agreed or strongly agreed; 20% disagreed, strongly disagreed, or remained neutral). About two thirds of the counselors (64% of 396) agreed or strongly agreed that the Internet is compatible with the philosophy and the principles of the rehabilitation process, with the rest of the counselors disagreeing or remaining neutral on this subject.
The majority of counselors reported that Internet use in VR not only fits their work style (82% of 395 agreed or strongly agreed) but also the way they would like to work (77% of 396 agreed or strongly agreed). The Decision to Use the Internet in VR Counselors were asked how the decision to use the Internet with customers in the rehabilitation process is made and what roles the counselor and the customer play in this process. Based on openended responses from 307 counselors, the researcher identified a variety of ways - both formal and informal - in which this decision is made. Sixty counselors would, as part of the initial intake meeting, discuss with customers whether they had access to computers and the Internet at home or elsewhere, whether they used them, and how comfortable they felt using these applications.
Counselors also discussed with customers how to keep in contact in between meetings and what communication methods to use given customer access, preferences, and convenience. Based on this discussion, counselors and customers would decide together how to best communicate. Sixty-three counselors described situations in which customers would initiate Internet use (mostly e-mail) in the rehabilitation process and 36 reported that they were the initiators (see Boeltzig, 2010, for more detail).
Important Factors in the Decision to Use the Internet in VR
Counselors were asked what factors they perceived as important in making the decision to use the Internet in VR. Based on open-ended responses from 313 counselors, the researcher identified a variety of factors (see Table 2), the most frequently reported factors are briefly mentioned next. Eighty-four counselors reported that customer access to computers and the Internet determined technology use in the VR process. About one third (100) identified customers' ability to use technology as an important factor, although counselors varied in what they meant by "ability" (e.g., using technology appropriately, confidently, and consistently; understanding the benefits and limitations of using technology in the rehabilitation process).
Customers' comfort level with using the Internet for communication (including providing personal information online) was reported by 37 counselors as being an important factor in the decision about Internet use in VR. Thirty-seven counselors used the Internet if they thought it allowed for more efficient information retrieval and more effective customer communication. Types of Internet Applications Used and Frequency of Use Almost all counselors used e-mail (99% of 383) and websites (95% of 384) in the rehabilitation process, and about two thirds also used electronic mailing lists (65% of 381). This is not surprising given that these types of ICT have come to be ubiquitous in everyday life. Video conferencing (41% of 380) and web conferencing (37% of 379), Internet forums (32% of 380), and blogs/wikis (30% of 379) were used much less. Use of IM was reported by one quarter of respondents (380). Overall, only a few counselors used more advanced Internet applications in VR. The largest number of counselors reported using e-mail and websites very frequently, that is, more than 2 1 times per week (see Table 3).
While a majority of counselors reported using electronic mailing lists, they did so quite infrequently (once per week). The remaining Internet applications were rarely used. Types, Frequency, and Usefulness of Online Rehabilitation Activities Almost all of the counselors (99% of 386) used the Internet to look up information (e.g., medical terms or conditions, medications and side effects, occupational requirements or projections). The majority reported using the Internet to identify a variety of resources: state, local, and community resources (95% of 385); education and training programs for customers (93% of 384); and potential jobs for customers (93% of 385). Ninety-two percent (of 383) reported sharing employment information with customers. Most counselors (87% of 387) used the Internet as one of several methods for communicating with some of their customers. Forty-one percent (of 383) used the Internet (most likely the agency's Internet-based case-management system) for developing employment plans. Part of implementing a customer's employment plan is to teach job-seeking skills. Slightly less than fifty percent of participating counselors (47% of 385) used the Internet as a method for this activity. Counselors used the Internet much less for activities such as customer intake (27% of 385), customer assessment (23% of 384), and group activities such as group counseling, job clubs, and support groups (11% of 384).
All except 40 counselors looked up information on the Internet at least twice per week (see Table 4). The largest numbers of counselors used the Internet between two and 10 times per week for identifying resources, specifically education and training programs for customers, as well as state, local, and community resources. Ofthe counselors who reported using the Internet for customer communication, the largest number used the Internet between two and 10 times per week. Almost all counselors who used the Internet for the previously listed VR activities found it very useful or useful. This finding is not surprising given that all 399 counselors who responded to this survey identified themselves as Internet users and all except 1 1 reported using Internet applications in the rehabilitation process.
Since counselors are not required by their state VR agencies to use the Internet, one can assume that they use this technology, because they find it useful. It is interesting that although the majority of counselors (93% of 385) used the Internet to identify potential jobs for customers, only 59% (of 353) found it very useful for this purpose. Similarly, 92% (of 383) counselors reported using the Internet for sharing employment information with customers, but only 58% (of 334) found the Internet very useful for this purpose. Discussion In this paper, the researcher provided descriptive evidence that counselors use the Internet for every aspect of the rehabilitation process, thus confirming previous researchers' anecdotal descriptions (Hampton & Houser, 2000; Patterson, 2000; Patterson, et al., 2002; Riemer-Reiss, 2000). Indeed, most counselors in this study reported that the rehabilitation process was compatible with Internet-based service delivery, and that this corresponded with their personal work style and preferred way of working. Study results showed that counselors mostly used the Internet to look up information, identify resources including potential jobs for customers, and communicate with customers, and that they used the Internet frequently for these purposes.
These findings are consistent with those of other researchers, such as Patterson's (2002) survey of 1,034 rehabilitation counselors from 34 state VR agencies. The percentage of counselors reporting Internet use has increased since Patterson's study. This makes sense given the increasing penetration of the Internet into daily life and the workplace. For example, almost all counselors in this study (99%) reported using the Internet to look up information, compared to 70.3% of counselors in Patterson's study who used the Internet to look up medical terms and conditions and 68.8% who looked up occupational requirements and projections via the Internet. Results of this study showed that 95% of counselors used the Internet to identify state, local, and community resources, compared to 69.4% of counselors in Patterson's study. Similar increases were found with respect to counselor Internet use for identifying potential jobs for customers (93%, versus 75.6% in Patterson's study) and for customer communication (87%, versus 65.1%).
Like Patterson, the researcher in this study found that a much smaller percentage of counselors used the Internet for teaching customers job-seeking skills (47%, versus 39.6% in Patterson's study) than for the purposes listed previously. The use of the Internet for job clubs, group counseling, and support groups remains limited, since only a small percentage (11%) of counselors in this study used the Internet for this purpose. Study results showed that most counselors found the Internet useful or very useful for these VR activities. That said, just because counselors use the Internet for these VR activities does not mean that they think the Internet is the most useful method. For example, 93% of counselors reported using the Internet to identify potential jobs for customers, but only 59% found the Internet very useful for this purpose. Similarly, 92% of counselors used the Internet to share employment information with customers, but only 58% found the Internet very useful. This suggests that other methods of employment support, such as networking and customized employment (tailored to each individual's unique needs), might be more appropriate and/or effective in assisting individuals with disabilities, especially those with more significant disabilities, to obtain employment (cf. Luecking, 2008; Owens & Young, 2008).
An interesting finding emerged with respect to Internet use for customer intake, assessment, and employment-planning, which might be related to state VR agencies' case-management systems. Only a small percentage of counselors, mostly from Maryland and Pennsylvania, used the Internet for these purposes. Maryland and Pennsylvania state VR agencies, compared to New York and Vermont, had more sophisticated Internet-based case-management systems that perhaps made the intake and assessment process easier (e.g., less paperwork) and allowed for more efficient case processing (e.g., direct data entry saves time). More research on how these systems can be incorporated into the rehabilitation process is needed. In addition to VR activities, the researcher in this study also investigated what types of ICT counselors used and how often they used them.
Almost all counselors used e-mail and websites and did so very frequently; about two thirds also used electronic mailing lists, although much less frequently than e-mail and websites. This is not surprising given that these types of ICT have become ubiquitous in everyday life. Fewer counselors made use of more advanced types of ICT, such as Internet forums, IM, video conferencing, web conferencing, and blogs/wikis. Several factors might explain these low adoption/usage rates. Some counselors might not be aware of these Internet applications, or they are aware but might not perceive them as relevant to/useful for VR. Their state VR agency might limit ICT use to counselors specializing in certain populations or disabilities. For example, Pennsylvania only granted counselors serving the Deaf (but not its general counselors) permission to use IM in the VR process. In addition, using advanced ICTs for VR service delivery creates challenges and ethical issues that the rehabilitation counseling field has only started to address. Lack of knowledge of, or comfort with, using ICTs in VR, especially those that are more advanced, could prevent some counselors from capitalizing on these electronic resources. Researchers who investigate ICT access and use by counselors in VR do not always examine the situation of customers (e.g., Patterson, 2002).
In this study, the researcher addressed this issue by asking counselors to evaluate their customers at an aggregate level with respect to Internet access at home or through the VR office, as well as customers' digital literacy skills. The researcher found that a large part of the VR customer base served by the participating counselors had Internet access and was fairly computer-literate. Customers were more likely to have Internet access at home than through the VR office. It should be noted that, at the time of this research, only Vermont provided customers with Internet access at all local VR offices. Another issue that the researcher in this study addressed was how counselors decide to use the Internet in the VR process.
Study results suggested a variety of ways - both formal and informal - in which this decision is made, including the roles of counselors and customers in this process. As a partner in the rehabilitation process, the customer is expected to participate actively and to exercise informed choice at every step along the way. This approach is enshrined in the Rehabilitation Act of 1973, as amended [Title I, Part A, Section 100 (a) (3) (C)], which mandates that state VR agencies provide for customer participation and informed choice throughout their rehabilitation experience. More research on how counselors can engage and empower customers in the decision-making process on Internet use in VR is needed. Study Limitations Limitations that must be noted include the different methods used by the sites to disseminate the survey. Maryland's site contact e-mailed counselors individually, New York and Vermont used their staff e-mail distribution lists, and Pennsylvania shared the survey information with the administrators ofthe district offices who sent it directly to their counselors. While survey participation was voluntary, Maryland chose to emphasize in their correspondence to counselors that the agency expected full counselor participation in the study. This may have contributed to the high Maryland response rate.
The level of leadership involved in disseminating the survey to counselors may have been another contributing factor. In three of the four states, the initial survey dissemination included a personal endorsement by the state VR director, which seemed to positively affect counselor response. The fourth state used a personal endorsement by the state VR director after the first few counselors had responded to the survey to stimulate counselor response. Differences in sites' timing of disseminating the survey, as well as staffing changes, may also have contributed to the variation in response rates. A second limitation is that, despite the availability of the survey in mail or telephone form, all 399 counselors who responded (a) used the Internet to take the survey, (b) identified themselves as Internet users, and (c) all but 1 1 counselors reported using ICT in VR.
Note that the researcher primarily used the Internet for surveying counselors and that there was not one counselor request for a mail or telephone survey. This clearly has implications for the survey findings in that they are primarily based on a sample of counselors who had Internet access, who used the Internet in VR, and who perhaps felt more comfortable with technology than those who felt uneasy using the Internet and elected not to respond. Limitations associated with Internet-based survey research, such as differences in respondent access to and use of the Internet, may result in sampling bias - an issue that has been discussed in detail elsewhere (cf. Coomber, 1997). Additionally, little is known about how using the Internet as the primary mode for surveying counselors, compared to mail for example, may have impacted survey non-response (cf. Groves, Fowler, Couper, Lepkowski, Singer, & Tourangeau, 2004).
Implications and Directions for Future Research There is a limited knowledge base on Internet use in VR, highlighting an urgent need for empirical research - both qualitative and quantitative. With this study, the researcher started to address the existing knowledge gap, but also uncovered many other areas in need of investigation. Other researchers might consider exploring how different types of ICT are used for different aspects of the VR process - including challenges to use, reasons for non-use, and strategies to guard against Internet misuse - taking into account the continuous emergence of Internet technology. More research is needed on the decision-making process that leads counselors to use or not use the Internet in the rehabilitation process, including effective strategies for engaging and empowering customers in this process, as well as factors that facilitate or hinder customer and counselor decision-making. Partnering with the training directors of state VR agencies, the regional Technical Assistance and Continuing Education (TACE) Centers, and professional rehabilitation-counseling associations (such as the National Rehabilitation Counseling Association) might be one avenue for incorporating research findings into in-service training and professional development.
Similarly, researchers might consider working with graduate rehabilitation-counseling programs to incorporate information about effective and innovative strategies for Internet use in VR into curricula and other preservice activities. The researcher in this study focused primarily on counselor perspectives on and experiences with using the Internet in VR. Similar research needs to be conducted on how customers view and experience Internet use in the rehabilitation process, including the decision-making process; what their (technology) preferences are in terms of accessing rehabilitation services and communicating with counselors; and to what extent these views, experiences, and preferences match or do not match those of counselors. This information will be useful for state VR agencies in their decisions to invest in technology and new service-delivery models.
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