The initial step of reasonable accommodation begins with a referral from the treating medical professional, insurer or employer who provided information about the pathology. This was supported by one participant who said:

Healthcare professionals treating employees diagnosed with MDD will refer them to an occupational therapist to facilitate the return-to-work process. In some cases, where the employer or insurer struggles to manage an employee’s incapacity, they may refer the employee to an occupational therapist for further management or assistance with reasonable accommodations.

The second step is an FCE, which includes interviews and employees’ clinical presentation of MDD. These were reported by a participant who remarked:

Another participant elaborated that comparing job requirements with employees’ work capacity is essential, as this is part of a functional capacity assessment. This is supported by a participant’s sentiments that:

Other participants highlighted the need for an occupational therapist to:

The majority of the participants asserted that assessment of the employees with MDD is vital to determine the presence of clinical symptoms of MDD, such as mood problems, cognitive impairments and functional limitations. It is essential to understand the severity of MDD symptoms. This is substantiated by a participant who remarked:

Participants were in agreement that the occupational therapist should conduct a full FCE to determine whether the employee with MDD can return to work. This was expressed by one participant who said:

With regard to the third step, the participants emphasised the importance of having a clear understanding of the employees’ job roles and engaging in discussions with the employer about the nature of the job and its requirements. This can be achieved through a meeting with an employer representative and conducting a job analysis. The participants also highlighted the necessity of a worksite visit, as they agreed that:

Following the fourth step, once the comprehensive assessment is completed, the participants stated that an occupational therapist will need to develop appropriate, reasonable accommodations. The participants advised that the occupational therapist should create reasonable accommodations that are clear and specific, including the types of reasonable accommodations needed and their implementation. They agreed that the occupational therapist must provide relevant and reasonable accommodations. One participant supported this by stating that:

The participants reported that the facilitation of reasonable accommodations for employees living with MDD should be person specific and not general, given the uniqueness of each employee and their workplace. The participants further highlighted that clear and specific reasonable accommodations were necessary for an employee with MDD, as captured by a participant who said:

Some participants provided examples of reasonable accommodations for employees with MDD, including acquiring new equipment and/or adapting the environment, restructuring job functions, a graded return to work, adjusting working time and leave, allowing time off for treatment and providing specialised supervision, training and support. The participants expressed concern that, although the formulated reasonable accommodations could be clear and specific, the implementation thereof might remain a challenge. Implementation of the recommended reasonable accommodations should be ensured by an occupational therapist. This view was articulated by one participant who remarked:

Another participant emphasised the importance of setting a reasonable duration for accommodations. Where the reasonable accommodation lasts longer than a year, permanent reasonable accommodations should be recommended. This was emphasised by a participant who said:

The review is the final stage in the process of reasonable accommodation. It concentrates on ongoing feedback, the employee’s return to normal work or the continuation of reasonable accommodations or relapse. Participants emphasised the importance of the review throughout the process, noting that it can take various forms. They advised that feedback from the occupational therapist to the employer is crucial for identifying any additional reasonable accommodations needed to enable the employee to perform their essential duties. The employer must update the occupational therapist on the success or difficulties of the arrangements put in place. If the suggested reasonable accommodations fail, the process may need to restart. Regular follow-up by the occupational therapist with both the employee and employer regarding progress may be necessary. This sentiment was expressed by a participant saying:

The success of reasonable accommodations can be secured through follow-up and feedback, as emphasised by participants. One participant concurred on the importance of follow-up with the utterance:

The success of reasonable accommodation is measured by returning employees to their full duties. Participants substantiated this notion when one of them commented:

If an employee fails to return to normal duties, it indicates to the occupational therapist that an assessment is needed to determine whether further reasonable accommodation is necessary. The participants warned about the possibility of disappointment due to relapse. They reported that employees with MDD may relapse, which could mean restarting the process from the beginning. This concern was voiced by a participant who said:

It is crucial that occupational therapists remain informed about reasonable accommodations through sufficient knowledge of occupational therapy and capacity building, as advised by participants. Furthermore, occupational therapists require a thorough understanding of occupational therapy principles, including the application of the PEOP model, relevant labour and disability equity laws, and insights into the world of work and the context in which clients operate. This view was supported by a participant who remarked:

The other participants echoed their understanding of the MDD pathology in employees, the level of functioning of employees with MDD and the prognosis related to the condition. The participants indicated that mentoring, advanced training, postgraduate diplomas in vocational rehabilitation, ongoing professional development courses (CPD) forums, webinars and interest groups will enhance occupational therapists’ knowledge. They also noted that occupational therapists might utilise academic resources such as journal articles and the Job Accommodation Network as part of capacity building. This view is supported by a participant who said:

‘They can go on vocational rehabilitation, they can learn it, they can work it with other colleagues under mentoring situations or some sort of advanced training’ (Participant 4).

The participants found that essential skills, such as assertiveness, negotiation, clinical reasoning, listening, interviewing and facilitation, are crucial for occupational therapists who recommend reasonable accommodations. They believed that occupational therapists with clinical experience possess advanced clinical reasoning skills necessary for assisting employees with MDD in obtaining suitable accommodations. This is borne out by a participant who said:

The participants reported that facilitation skills are necessary for occupational therapists to manage employers and other stakeholders. This is supported by a participant who cited:

They further emphasised the importance of managing cases of employees with MDD. During case management, the occupational therapist should manage the expectations of both employee and employer and play the role of a proactive consultant. The significance of case management is supported by a participant who commented:

The participants advised that the employees’ MDD may require proper management to prevent it from backfiring. They also reported that all stakeholders should ensure expectations are clearly managed. This view was expressed by the participants who commented:

The participants emphasised that during consultations with employees suffering from MDD and other stakeholders, occupational therapists must regularly follow-up on the client. This is supported by the participant who said:

Referral is the initial step in the reasonable accommodation process. Swart and Buys (2014) advised that service delivery and payment boundaries should be clearly indicated in the referral. Moreover, the referral letter must include comprehensive details from medical reports, job descriptions and the employee’s work performance (Buys 2015). Providing comprehensive and detailed information in the referral letter can facilitate the preparation for the interview and assessment of the specific employee.

Assessment should concentrate on ‘finding out what the client wants and needs to do; determining what the client can do and has done; and identifying supports and barriers to health, well-being, and participation’ (AOTA 2020). Assessments in the form of FCE should include an interview, evaluation of MDD clinical presentation and aspects of the occupational therapy domain. Swart et al. (2024) add that an interview guide covering the client’s educational background, work history, psychiatric history, other medical history, current treatment and functional status should be developed before the occupational therapist contacts the employee. During the interview, an occupational therapist must observe and identify MDD symptoms such as emotional problems, cognitive impairments and functional limitations. The selection of appropriate assessment tools to perform an FCE should be guided by the referral letter, interview and observations of MDD symptoms. The findings indicated that FCE aids occupational therapists in making return-to-work decisions and identifying potential reasonable accommodations to recommend.

Worksite visits are important during the reasonable accommodation process as it provides an opportunity for the occupational therapists to meet with the employer and conduct a job analysis. This study suggests that a job analysis can provide occupational therapists with information about job demands and insight into the workplace culture. Worksite visits help to understand possible reasonable accommodations and positions that may need realignment, as well as to acquire a comprehensive view of the job description (Swart et al. 2024). In South Africa, EEA (1998) makes provision for reasonable accommodation. Promotion of Equality and Prevention of Unfair Discrimination Act (PEPUDA) (2000) states that reasonably accommodating people with disabilities will ensure their social transformation. Promotion of Equality and Prevention of Unfair Discrimination Act (2000) provides recourse for refusal of reasonable accommodation under EEA (1998). Ramano and Buys (2018) claim that the results of FCE may help in developing modifications to the employee’s workstation or workplace. Occupational therapists can negotiate and implement reasonable accommodations for individuals with MDD. Importantly, occupational therapists should ensure that they recommend clear and specific accommodations tailored to each employer and their specific job, as this approach will enhance the successful implementation of these accommodations.

Generic reasonable accommodations are ineffective; therefore, it is prudent to tailor clear and specific reasonable accommodations that are individualised to each employee and their particular job. This aligns with Gold et al. (2012), who indicated that developed reasonable accommodations, firmly matched to employees’ specific job functions, will assist them in justifying their case. The ambiguity of the reasonable accommodation negotiation makes it difficult for the employer and employee to provide and receive reasonable accommodation (Hossain et al. 2021). Rangarajan et al. (2020) who focused on workplace reasonable accommodation for professionals with severe mental illness, warned that reasonable accommodation is not ‘one size fits all’ but should be tailored to the individual. Stergiou-Kita et al. (2016) further established that vague reasonable accommodations are ineffective and are seen as a ‘want’ rather than a ‘reasonable and justifiable need’. Types of reasonable accommodations for employees with MDD are listed in Table 2 as proposed by the participants of this study.

Bastien and Corbière (2019), Bolo et al. (2013), McDowell and Fossey (2015) and Rangarajan et al. (2020) agree on reasonable accommodations listed in Table 2, such as flexible work schedules, reduced hours, modified training and supervision, task modifications, job changes or altered job duties or descriptions, environmental adjustments or physical accommodations and reduced work hours. However, the study by McDowell and Fossey (2015) highlights that from the employee’s perspective, changes to work schedules are the most difficult accommodations to negotiate. Providing reasonable accommodation does not only benefit the employee but the company likewise, as it ensures work productivity (MacDonald-Wilson, Fabian & Dong 2025).

The review is significant, and it completes the dynamic process of reasonableness. Furthermore, the review encompasses circulatory follow-up feedback, the return to normal work, the continuation of reasonable accommodation and relapse. The review of occupational therapy interventions and services is instrumental in ensuring quality and maintaining relevance to their intended purpose. Changes in the intervention plan are guided by a continuous process of review and re-evaluation. The review steps involve reassessing the plan and its implementation in terms of achieving outcomes, making necessary adjustments and deciding whether to continue, discharge or refer to other practitioners. Occupational therapists should provide feedback to the employer regarding the reasonable accommodations that are to be implemented, while the employer must also provide feedback to the occupational therapist on the employee’s performance, including successes and challenges with the reasonable accommodations. The process may need to restart if any difficulties are encountered during the implementation of reasonable accommodations. Continuous follow-up between the occupational therapist, employer and employee is essential, whether by telephone, in person or via email. Follow-up could be conducted weekly initially, then gradually reduced to monthly as the employee improves. Buys (2015) advises that follow-up should be done with both the employee and employer and that it ‘closes the case’. The importance of ongoing follow-up feedback is to sustain progress and ensure the success of reasonable accommodations. The primary goal of reasonable accommodation is to return employees to their normal work functions. If the employee does not improve, reasonable accommodation continues and necessary adjustments are re-evaluated accordingly. Following re-evaluation, intervention may resume if ongoing service is required, and modifications to the intervention plan may occur. Occupational therapists should note that some employees may relapse, requiring the process of reasonable accommodations (Figure 1) to be restarted. Schlicker et al. (2018) add that there is a possibility of relapse and recurrence even after treatment is completed. Challenges at work may trigger a relapse of depression.