Measuring perceived efficacy for coping with posttraumatic stress disorder in the workplace

Abstract

BACKGROUND:

PTSD is associated with high levels of vocational difficulty, and research on relationships between PTSD and vocational adjustment may be relevant to vocational rehabilitation services to achieve optimal outcomes. Veteran perception of ability to cope with stressors in the workplace setting may play a role in rehabilitation outcome.

OBJECTIVE:

This article outlines preliminary steps in the development of the Vocational Efficacy in Trauma Survivors Scale (VETSS), to measure perceived efficacy in managing PTSD symptoms in the workplace. This has potential to expand future options for research in vocational rehabilitation for veterans with PTSD.

METHODS:

Veterans in outpatient treatment for PTSD at a large, mid-western Veterans Affairs Health Care System facility responded to items on the proposed instrument and items on other measures of vocational and psychological functioning to assess the potential validity of items for an instrument to measure vocational self-efficacy among veterans managing PTSD.

RESULTS:

In a sample of 63 working veterans who receive outpatient care for PTSD, exploratory factor analysis identified two viable subscales, one tapping Workplace Coping, and another tapping Self-Disclosure.

CONCLUSIONS:

Preliminary findings indicate that the measure demonstrated acceptable indications of reliability and validity, suggesting promise for future use in vocational rehabilitation research.

Keywords

Veteran vocational rehabilitation social support measurement

1 Introduction

Posttraumatic Stress Disorder (PTSD) is a significant source of vocational disability [1], especially among veterans. Trauma-related vocational disability among veterans has personal, social, and economic costs [2]. While research is mixed, at least some studies indicate that veterans managing PTSD are less likely to be employed than their peers [1 , 4]. There is evidence that individuals managing PTSD experience deteriorating work functioning over time [5], express negative attitudes about work [6], have higher rates of absence from work [7], and experience lower levels of work volition [8]. Vocational rehabilitation services make an important contribution to care, because moving individuals into work roles can help to mitigate combat stress reactions [9]. Outcomes from conventional types of vocational rehabilitation for PTSD have been comparatively poor; PTSD symptoms can be a barrier to seeking employment, and employed individuals managing PTSD tend to function less well at work over time [5, 10]. While Individual Placement and Support (IPS)models result in higher rates of return to work among veterans with PTSD [4], duration of effects is a concern; studies of IPS outcomes indicate that clients work for an average of 24.2 weeks in the year after placement [11].

Changes in work placement rates associated with IPS models [4] are consistent with other studies demonstrating changes in both environmental and intrapersonal resources, even well after trauma exposure, can be associated with changes in vocational functioning. For example, security workers with significant workplace trauma exposure were likely to attribute delayed onset PTSD and vocational disability to increases in workplace stress [4]. Intrapersonal change may also precipitate changes in vocational functioning; there is evidence that employees managing PTSD report better vocational adjustment if they maintain an internal locus of control [8].

According to the social cognitive model of career development [13], vocational self-efficacy is a critical intrapersonal resource predicting vocational outcome expectations, goals, behavior, and attainment [13, 14]. Research on workers managing psychiatric disabilities confirms that those with high vocational self-efficacy are more likely to be employed [15] and report higher levels of work engagement [16]. Important domains of self-efficacy may not be limited to task-related behavior at work; self-efficacy regarding managing social relationships, as well as managing boundaries around disclosing one’s disability are also relevant. Research on workers managing mental health concerns indicates stigma limits job acquisition and wages [17], and disclosure of a mental health concern significantly increases interpersonal stress in the workplace [18]. Veterans managing PTSD not only must perform job tasks, but also actively manage stigma and resulting interpersonal stressors. This suggests efforts to measure relevant vocational self-efficacy should tap two domains: a) perceived efficacy in managing symptoms well enough to complete relevant job tasks, and b) perceived efficacy in managing the interpersonal stresses in the context of a stigmatizing condition.

Efficacious beliefs about ability to manage symptoms and relationships in the workplace may be a critical determinant of vocational outcomes for veterans with PTSD [15, 16]. Previous research indicates that for working veterans receiving outpatient PTSD treatment, the ability to effectively garner supportive relationships at work accounts for a substantial portion of variance in vocational adjustment [19]; specifically, access to mentoring and collegial support predicted higher levels of job satisfaction. However, to fully explicate relevant relationships and use findings to more effectively target vocational rehabilitation interventions for optimal outcomes, it would be necessary to develop more specific and effective instruments to measure veterans’ perceptions of their ability to manage symptoms and interpersonal stressors specific to PTSD in the workplace.

In order to better assess vocational self-efficacy among veterans managing PTSD, we examined the properties of 15 items proposed in the evaluation section of “Work Success for Veterans with PTSD and Other Mental Health Challenges: Group and Individual Counseling Manual” [20]. The manual was developed cooperatively by the Veterans Health Administration and the Veterans Benefits Administration to supplement existing vocational rehabilitation services for veterans. The items that formed the foundation for the Vocational Efficacy in Trauma Survivors Scale (VETSS) were designed to specifically tap workplace symptom management and workplace relationship skills taught in a cognitive-behaviorally based vocational skills intervention. Response options were on a 5-point Likert scale, “Not at All True,” “Slightly True,” “Somewhat True,” “Very True,” and “Extremely True.” This study appears to be the first effort to empirically explore the reliability/validity of these items as a potential instrument for research and assessment of vocational self-efficacy among veterans pursuing vocational rehabilitation. This study is designed to provide preliminary reliability and validity data on the VETSS based on coefficient alphas, factor structure, and convergent/discriminant correlations with other relevant constructs. Expected criteria to support further research on these items as a valid psychometric instrument include coefficient alpha values >0.70 [21], evidence of measurement of both symptom management and interpersonal management consistent with the social cognitive model of career development [13], positive correlations with job satisfaction and workplace social support, and negative correlations with PTSD symptoms, anger, absenteeism, and workplace conflict.

2 Methods

2.1 Participants and procedure

Participants were 172 veterans in outpatient specialty PTSD care at the Minneapolis VA Health Care System. The study was approved and monitored by the Institutional Research Board. Clinic clerks invited patients at check in to complete an anonymous survey regarding current symptoms and employment status. An informational cover letter and passive consent form, informing potential participants of risks/benefits and the voluntary nature of their participation in this survey, were included at the beginning of each survey. Veterans completed their surveys in the clinic waiting area; on average, this required 15 minutes of effort from each veteran. Only those veterans who were employed at the time of responding to the survey were included in this study (N = 63).

2.2 Instruments

Job in General (JIG). The JIG [22]is an 18-item adjective checklist designed to assess job satisfaction. In this sample, Cronbach’s alpha for this instrument was0.90, consistent with previous alpha’s ranging from 0.91 to 0.95 [22]. The JIG correlates with other measures of job satisfaction ranged from 0.67–0.80 [22].

Mentoring and Communication Support Scale (MCSS). The Mentoring and Communication Support Scale [23] (MCSS) is a 15-item instrument designed to assess workplace social support. While this instrument can be interpreted in terms of four subscales, only the total score was used for this study. In this sample, Cronbach’s alpha was 0.91. Total scores for this instrument were correlated with job satisfaction and tenure [19]. Higher scores on this instrument indicate less workplace social support; however, the instrument was reverse scored for this analysis, so that higher values reflected higher levels of workplace social support.

PTSD Checklist. The PTSD Checklist – Military version [24] (PCL-M) is a 17-item instrument designed to assess DSM-IV PTSD symptoms. Cronbach’s alpha for this instrument ranged from 0.96 to 0.94 [25, 26]. Alpha for this sample was 0.94. Validity was based on positive correlations with other self-report and structured interview instruments that measured PTSD [27].

Dimensions of Anger Reactions [28, 29] is a brief 7-item instrument designed to assess irritability and anger, especially as encountered in the context of posttraumatic stress disorder. Coefficient alpha was 0.94 in this sample; previous research on the instrument yielded alphas around 0.90 [28, 30]. Validity was established via positive, significant correlations with other self-report anger instruments [30, 31].

Absenteeism was measured using a single item, “In the last 30 days, how many days have you called in sick or missed work?” The number of days the veteran entered was used for analyses.

Work Conflict was measured using a single item, “In the last 3 months, how much conflict with coworkers, bosses, or customers did you have?” Response options were “No conflict,” “A little conflict,” “Some conflict” “A lot of conflict,” or “Not applicable.” Scores ranged from 0–3. “Not applicable” responses were coded as missing data so they would not be misinterpreted in the analysis.

3 Results

The sample population was 93% Caucasian and 84% male, with a mean age of 44. The sample group included 69% full-time employees and 31% part-time employees. The most frequently selected income category was $2001– $3000 per month. The most frequently selected level of education was “Some College.” Means and standard deviations for scores on the measures used in this study can be found in Table 1.

Table 1
Means and Standard Deviation of Comparison Variables

Variable Mean SD

VETSS 30.75 8.52

Workplace Coping 20.05 5.78

Self-disclosure 13.42 4.82

JIG 39.46 11.22

PCL 37.30 14.85

DAR 21.45 7.59

MCSS 43.59 10.69

Absences 3.70 7.15

Conflict 2.56 1.16

Variable	Mean	SD
VETSS	30.75	8.52
Workplace Coping	20.05	5.78
Self-disclosure	13.42	4.82
JIG	39.46	11.22
PCL	37.30	14.85
DAR	21.45	7.59
MCSS	43.59	10.69
Absences	3.70	7.15
Conflict	2.56	1.16

VETSS: Vocational Efficacy in Trauma Survivors Scale, JIG: Job in General, PCL: PTSD Checklist, DAR: Dimensions of Anger Reactions, MCSS: Mentoring and Communication Support Scale.

In an initial exploratory, Promax factor analysis four factors emerged with Eigenvalues of 5.19, 2.37, 1.26, and 1.03. Factor loadings for each item are reported in Table 2. Eight of the items loaded on Factor 1, and the remaining four on Factor 2. Factor 2 items consistently tapped levels of comfort with co-worker relationships and self-disclosure; the Factor 1 items tapped perceived self-efficacy in managing symptoms and relationships (especially supervisory relationships) at work. We subsequently explored the reliability of these factors as two subscales; Factor 1 as “Workplace Coping” and Factor 2 as “Self-disclosure.” Coefficient alpha for Workplace Coping was 0.87, 0.76 for Self-disclosure, and 0.85 for the total scale. While many items on interpersonal coping loaded with items on intrapersonal coping, a subset of interpersonal factors specific to comfort with self-disclosure emerged on a second factor.

Table 2

Means and Standard Deviations of Items

	Mean	SD	Subscale
1. I can successfully manage my stress at work.	2.79	0.85	Workplace Coping
2. I can relax away physical tension at work.	2.12	1.10	Workplace Coping
3. I can cope with conflicts with co-workers.	3.20	1.14	Workplace Coping
4. I can cope with conflicts with bosses.	3.14	1.17	Workplace Coping
5. My irritability and anger causes problems for me at work.	3.15	1.36
6. I have good relationships with my co-workers.	3.41	1.11	Self-Disclosure
7. I have a good relationship with my boss.	3.32	1.25	Workplace Coping
8. My problems with concentration interfere with my performance at work.	3.12	1.34
9. I can’t remember important things at work.	3.05	1.36
10. I can manage my mental health symptoms so that they don ’t interfere with my ability to succeed at work.	2.76	0.97	Workplace Coping
11. I can talk to someone at work who will support me about my mental health symptoms.	2.33	1.60	Self-Disclosure
12. I can maintain a balance between work and the rest of my life.	2.66	1.17	Workplace Coping
13. I get a sense of satisfaction from my job.	2.86	1.25
14. I can handle it when co-workers ask about my war experiences.	2.59	1.29	Self-Disclosure
15. I can handle it when co-workers ask about my mental health symptoms.	2.41	1.67	Self-Disclosure

Bolded items are elements of the validated VETSS.

Table 3

Factor Loadings

Item	Factor 1 (Workplace Coping)	Factor 2 (Self-Disclosure)	Factor 3	Factor 4
1.	0.80	0.17	0.40	0.37
2.	0.74	0.33	0.38	0.18
3.	0.80	36	0.02	0.02
4.	0.86	0.11	0.34	0.23
5.	0.26	– 0.04	0.28	0.92
6.	0.59	0.63	0.09	0.19
7.	0.64	0.38	0.55	0.37
8.	0.12	– 0.23	0.58	0.36
9.	0.27	0.04	0.74	0.37
10.	0.71	0.40	0.48	0.49
11.	0.16	0.81	0.13	<0.01
12.	0.68	0.33	0.46	0.14
13.	0.40	0.23	0.77	– 0.18
14.	0.22	0.74	0.03	– 0.13
15.	0.34	0.84	– 0.14	– 0.09

The results strongly suggested that four of the items did not load with or correlate well with most of the items on the instrument. These items asked about difficulties with anger, memory, concentration, and job satisfaction. Two of these items did not load on any of the four factors, and the remaining two were the only items that loaded on the third and fourth factors, respectively. For subsequent analyses to validate the VETSS, we removed the items that loaded on no factors, or only on the third or fourth factors, because these items did not appear to contribute to measurement of a construct effectively measured by this scale. Means and standard deviations for items are documented in Table 1.

A correlation matrix, including both subscales and a total score for VETSS, is presented in Table 4. Total score for the VETSS was positively correlated with job satisfaction (r = 0.35, p = 0.007) and workplace social support (0.48, p < 0.001). Workplace Coping was also positively correlated with job satisfaction (r = 0.48, p < 0.001) and workplace social support (r = 0.54, p < 0.001), but Self-Disclosure was weakly correlated only with workplace social support (r = 0.27, p = 0.04). In contrast, total score for the VETSS was negatively correlated with PTSD symptoms (r = – 0.36, p = 0.007), anger (r = – 0.49, p < 0.001), self-reported absence from work for the past 30 days (r = – 0.29, p = 0.035), and self-reported conflict at work (r = – 0.40, p = 0.002). The Workplace Coping subscale mirrored all of these relationships, but the Self-disclosure subscale did not evidence significant correlations with absence from work, or conflict at work.

Table 4

Correlation Matrix

	Workplace Coping	Self-Disclosure	VETSS Total	JIG	PCL	DAR	MCSS	Abs.
Workplace Coping	–
Self-Disclosure	0.52^**	–
VETSS Total	0.86^**	0.88^**	–
JIG	0.48^**	0.07	0.35^**	–
PCL	– 0.35^**	– 0.33^*	– 0.36^**	– 0.29^*	–
DAR	– 0.47^**	– 0.39^**	– 0.49^**	– 0.14	0.65^**	–
MCSS	0.54^**	0.27^*	0.48^**	0.43^**	– 0.15	– 0.17	–
Abs.	– 0.25	– 0.22	– 0.29^*	– 0.37^*	0.04	0.12	– 0.20	–
Conflict	– 0.52^**	– 0.14	– 0.40^**	– 0.28^*	0.21	38^**	– 0.28^*	0.28^*

^*p < 0.05, ^**p < 0.01 Note: VETSS = Vocational Efficacy for Trauma Survivors; JIG = Job in General; PCL = PTSD Checklist; DAR = Dimensions of Anger Reactions; MCSS = Mentoring and Communication Support Scale; Abs = Number of absences at work; Conflict = Workplace Conflict.

3.1 Case example

The following case example demonstrates the way this instrument may be useful in vocational rehabilitation settings:

Rhondel is a 32-year-old, African-American army veteran who served as a mortuary affairs specialist in Operation Iraqi Freedom. Much of her work involved recovering bodies and body parts from blast sites.On return to the U.S., she sought treatment for PTSD, as well as vocational rehabilitation services to assist managing return to civilian work. With rehabilitation services, she obtained a master’s degree in social work, and did very well in her practicum experiences and coursework. Because of stiff competition in her field in her region, she had difficulty obtaining an entry-level position in social work on graduation, so she took a position as a clerk in a local medical center, while hoping to seek promotion from within to a social work position. After applying unsuccessfully for 3 social work positions within the facility, Rhondel met with her rehabilitation counselor to ask for help with interview skills. Rhondel performed well in a mock interview. Her counselor administered the VETSS to obtain additional information on her vocational adjustment. Rhondel’s score on the “Workplace Coping” subscale was 35, which is the instrument ceiling. On the other hand, her score on the “Self-Disclosure” subscale was 8, which is well below average for working Veterans who can manage PTSD. The counselor discussed instrument results with Rhondel, and then she shared that she was very afraid she would never be considered in a mental health position if anyone knew of her history of PTSD. She avoided any informal social interactions with professional peers for fear that might lead to discussions about her service or PTSD symptoms. As a result, she did not have the necessary professional network to effectively seek promotion.

The rehabilitation counselor worked with Rhondel in several counseling sessions to help her improve networking skills, including connecting with peers during informal lunch meetings, establishing a Linked-In account to expand her professional network, and scheduling meetings with several social work administrators to share information about her skills, training, and career goals. She asked if she could volunteer to help in the social work department outside of her clerical hours. After Rhondel developed a stronger professional social network, she was successful in obtaining the next social work opening in the facility.

4 Conclusions and discussion

This study provides preliminary support for the VETSS scale as a measure of vocational self-efficacy among veterans managing PTSD. The VETSS had acceptable internal consistency and a logical factor structure, and correlated as expected with positive (job satisfaction and workplace social support) and negative (PTSD, anger, absenteeism, and workplace conflict) correlates of vocational adjustment. Preliminary evidence for the VETSS supports the utility of further research on the 11-item version to assess perceived self-efficacy in management of PTSD symptoms in the workplace among veterans managing PTSD. Indications of inter-item reliability and convergent validity in this sample appear promising. Note, however, that the sample is relatively small, the data in this study were cross-sectional, and the instrument used to measure PTSD symptoms was based on DSM-IV criteria. The homogenous demographics of the sample do not allow for broad generalizability of the findings. Furthermore, the reliability of the results of a factor analysis in a sample of this size will require validation. The subscales resulting from the factor analysis did not result in many differences in relationships with comparison variables, and the differences that did emerge were due likely to the lower level of reliability in the Self-Disclosure subscale. Our recommendation is that a single-factor interpretation may be the most effective use of this instrument. These findings should be replicated in a larger, more diverse sample before the instrument should be considered a strong basis for social science conclusions.

With limitations acknowledged, vocational self-efficacy has emerged as a critical factor in vocational outcomes in both theoretical [13, 14] and clinical literature [15, 16]. Furthermore, vocational self-efficacy appears to be especially important in outcomes for rehabilitation clients managing psychiatric disabilities [15, 16]. Effective vocational rehabilitation services for veterans managing PTSD is a national priority in the United States of America. Further research into the vocational efficacy in this population is warranted, and requires a valid and reliable outcome measure. Additional empirical exploration of VETSS as an outcome measure would be a useful step toward that research goal.

Conflict of interest

None to report.

Footnotes

Acknowledgments

This work is the result of work supported with resources and the use of facilities at the Minneapolis VA Healthcare System.

The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government. There were no grants involved in this data collection.

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Measuring perceived efficacy for coping with posttraumatic stress disorder in the workplace

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1 Introduction

2 Methods

2.1 Participants and procedure

2.2 Instruments

3 Results

Table 1 Means and Standard Deviation of Comparison Variables Variable Mean SD VETSS 30.75 8.52 Workplace Coping 20.05 5.78 Self-disclosure 13.42 4.82 JIG 39.46 11.22 PCL 37.30 14.85 DAR 21.45 7.59 MCSS 43.59 10.69 Absences 3.70 7.15 Conflict 2.56 1.16

4 Conclusions and discussion

Conflict of interest

Footnotes

Acknowledgments

References

Table 1
Means and Standard Deviation of Comparison Variables

Variable Mean SD

VETSS 30.75 8.52

Workplace Coping 20.05 5.78

Self-disclosure 13.42 4.82

JIG 39.46 11.22

PCL 37.30 14.85

DAR 21.45 7.59

MCSS 43.59 10.69

Absences 3.70 7.15

Conflict 2.56 1.16