Key factors related to vocational outcome: trends for six disability groups.

This revie!w examined the key factors related to vocational outcome (that is, commencement of, or return to, work after onset of disability) reported in the research literature for six disability groups. Previous reviews of vocational outcome found that most studies differed with respect to sampling procedures, participant characteristics, methodology and variables associated with vocational outcome in, for example, disability groups such as SCI (Crisp, 1990; Trieschmann, 1988), TBI (Crisp, 1992; Sherer, Novack et al., 2002), CP (Crook, Milner, Schultz & Stringer, 2002) and severe mental illness (Tsang, Lain, Ng & Leung, 2000). Since they evaluated the methodological quality of much of the research literature and analyzed the return to work rates for these disability groups, these two aspects will not be the primary interest of this review. Instead, this paper focused upon the dominant themes emerging from those studies that analyzed a range of medical, socio-demographic and psychosocial factors that were related to vocational outcome. It was intended to draw attention to the need for a broader perspective than can be provided by smaller sets of variables to explain or predict vocational outcome. Most attention was paid to the more recent studies with larger samples and sets of predictor variables; and mostly upon the implications for vocational rehabilitation service providers than for researchers.

The goal of this review was to identify the important factors that impact upon the employment of people in six disability groups. It was not assumed that the issues common to persons with particular disabilities could be generalized to persons with other disabilities. These groups were selected because of the likelihood that they would provide different perspectives on vocational outcome, and included persons with: spinal cord injuries (SCI), traumatic brain injuries (TBI), amputations, chronic pain (CP), myocardial infarction/coronary artery bypass grafting (MI/CABG), and severe mental illness, that is, psychosis, bi-polar disorder, long-term major depression or dysthymia.

Method

A selective rather than an exhaustive literature search was conducted to identify articles from prominent rehabilitation and disability journals, published since 1987, which would locate recurring themes. There were several inclusion criteria:

1. Exclusive focus was on one of the six abovementioned disability groups;

2. Research was well-designed, in so far as the authors clearly described the objectives of the research, sample selection, data collection and analysis;

3. Prospective and retrospective studies, utilizing multivariate statistical analyses, consisted of samples with high generalizability and reliability (e.g., 10 or more participants per predictor variable) as recommended by Crook et al. (2002) and Sherer, Novack et al. (2002);

4. Retrospective studies, utilizing univariate statistical analyses, had samples of 50 or more participants;

5. Predictor variables consisted of socio-demographic, psychosocial and clinical variables;

6. The outcome measure was return to work or employment status after onset of disability.

Results

Seventy-five studies were included for review. The number of studies selected for review in each of the six diagnostic groups are listed in Table 1. Although there were differences between and within disability groups, and between the methodologies adopted by researchers, it was possible to identify five key factors related to vocational outcome. The most commonly cited predictor variables are listed in Table 2.

1. Severity of disability

Return to work was most likely to occur when individuals' residual abilities and pre-injury skills were utilized in relatively less physically demanding employment. This trend was evident in most SCI (e.g., DeVivo, Rutt, Stover & Fine, 1987; Hess, Ripley, McKinley & Tewksbury, 2000; Krause, 2003; Krause, Kewman et al., 1999; MacDonald, Nielson & Cameron, 1987; Rohe & Krause, 1998; Young, Alfred, Rintala, Hart & Fuhrer, 1994) and amputation studies (Livingston, Keenan, Kim, Elcavage & Malangoni, 1994; Schoppen et al., 2001; Whyte & Carroll, 2002).

In much of the TBI research, employment status was related to post-traumatic amnesia (PTA) or length of coma (Cattelani Tanzi, Lombardi & Mazzucchi, 2002; Cifu et al., 1997; Fleming, Tooth, Hassell &Chan, 1994; Kreutzer et al., 2003; McMordie, Barker & Paolo, 1990; Ponsford, Olver, Curran, & Ng, 1995; Sherer, Sander et al., 2002); and by early neuropsychological assessment conducted at resolution of PTA, or at one month post-TBI, and not more than 12 months post-TBI (Cifu et al., 1997; Dikmen et al., 1994; Fleming et al., 1999; O'Connell, 2000; Sherer, Sander et al., 2002). While these studies differed in the types of cognitive deficits that most strongly predicted employment, verbal and/or visual memory and attention deficits were most often reported.

In CP studies, the extent of participants' self-reported CP together with socio-demographic and psychosocial factors were more significantly related to employment than physical functional impairment (Blyth, March, Nicholas & Cousins, 2003; Gatchel, Polatin & Mayer, 1995; Milhous et al., 1989; Rainville, Sobel, Hartigan & Wright, 1997; Schultz et al., 2002; Suter, 2002). Vocational outcome was also related more to psychosocial than clinical factors in studies of persons with major depressive disorder (Elinson, Houck, Marcus & Hincus, 2004; Sherbourne, Hays & Wells, 1995), bipolar disorder (Hammen, Gitlin & Altshuler, 2000) and other severe mental illnesses (Bond et al., 2001; Mueser et al., 1997; Mowbray, Bybee, Harris & McCrohan, 1995; Russinova, Wewiorski, Lyass, Rogers & Massaro, 2002; Waghorn, Chant & Whiteford, 2002).

For persons with MI/CABG, medical factors were less predictive of employment than their perceptions of their health status, expectations regarding future employability and/or anxiety and depressive symptoms (Boudrez & De Backer, 2000; Maeland & Havik, 1987; Mittag, Kolenda, Nordmann, Bernien & Maurischat, 2001; Myrtek, Kaiser, Rauch & Jansen, 1997; Petrie, Weinman, Sharpe & Buckley, 1996; Schleifer et al., 1989; Soderman, Lisspers & Sundin, 2003).

While much of the research literature has been written from a medical perspective, researchers have placed more emphasis on the socio-demographic, psychosocial and psychological factors that will be discussed below.

2. Socio-demographic factors

Dominant socio-demographic factors in the literature were age, education, race/ethnicity, and litigation/financial compensation.

Age, education.

Being younger and better educated were frequently cited predictors of employment in studies with participants with SCI (DeVivo et al., 1987; Hess et al., 2000; Krause & Anson, 1996; Krause, Kewman et al., 1999; Krause, Sternberg, Maides & Lottes, 1998; Ville & Ravaud, 1996) and TBI (Brooks, McKinlay, Symington, Beattie & Campsie, 1987; Dikmen, et al., 1994; Felmingham, Baguley & Crooks, 2001; Keyser-Marcus et al., 2002; Kreutzer et al., 2003; McMordie et al., 1990; O'Connell, 2000; Ponsford et al., 1995; Rao et al., 1990; Ruff et al., 1993; Sherer, Sander et al., 2002). In general, persons under age 45 and/or with more than 12 years education reported higher rates of employment.

While age and education were less dominant in other disability groups, similar trends were evident in amputation studies (Dunn, 1996; Pezzin, Dillingham & MacKenzie, 2000; Schoppen et al., 2001; Weed et al., 1997) and severe mental illness (Elinson et al., 2004; Russinova et al., 2002; Waghorn et al., 2002). Employment was related to age in several CP studies (Blyth et al., 2003; Ericsson et al., 2002; Haldorsen, Indahl & Ursin, 1998; Milhous et al., 1989; Rainville et al., 1997) but not others (Gatchel et al., 1995; Schultz et al., 2002). This disparity may reflect different sample characteristics; for example, older workers were less likely to return to work when they were involved in compensation systems and/or litigation. Age was not a factor when participants were involved in programs that applied cognitive behavioral strategies (Gatchel et al., 1995; Schultz et al., 2002).

Age and education were not consistently reported as predictors of employment in most MI/CABG studies consisting of samples with mean ages in the 50-60 years range. Stronger predictors of employment across these studies were, instead, anxiety and depressive symptoms and/or perceptions regarding health status (Maeland & Havik, 1987; Myrtek et al., 1997; Petrie et al., 1996; Rost & Smith, 1992; Schleifer et al., 1989).

RCs need to be responsive to the needs of older clients and those whose onset of disability occurs relatively late in life (e.g., over age 50 years); and who may, for example, experience greater cultural barriers in returning to work after late onset of disability. RCs can encourage older persons with disabilities to utilize, transfer or develop their vocational skills; to market their age (maturity) and experience as a positive to prospective employers; to reappraise the traditional retirement age of 65 years; and to target employers whose customers' ages may be similar to their own age.

RCs need to identify clients' aptitude for re-education and training when they cannot return to their pre-injury job, and help them to identify realistic training options (Krause, 2003). Practical on-the-job training may suit persons with low aptitude for re-education and training (Krause, Kewman et al., 1999). For clients with severe mental illness, supported employment may be preferred to pre-vocational training. The former has achieved higher rates of long-term employment and has been valued for its immediacy (there was no extended preparation); it was tailored to clients' interests and abilities; it was continuous and based on real work experiences; it provided time-unlimited support; and viewed work itself as therapeutic (Bond et al., 2001; Crowther, Marshall, Bond & Huxley, 2001).

Race ethnicity

Higher rates of employment for white than nonwhite or racial/ethnic minorities were reported by several SCI (DeVivo et al., 1987; Hess et al., 2000; Krause, Kewman et al., 1999; Krause & Anson, 1996, 1997; Krause, Sternberg et al., 1998; Putzke, Hicken & Richards, 2002; Young et al., 1994) and TBI studies (Kreutzer et al., 2003; Rosenthal et al., 1996), one study of amputees (Pezzin et al., 2000) and of persons with severe mental illness (Cook, 2003). While race/ethnicity variables were not usually included in CR amputation, severe mental illness and MI/CABG studies, a strong access and equity theme was evident in the SCI and TBI literature. Race and ethnicity were viewed as socio-demographic "marker" variables for identifying those at risk of depression and being "hidden" from service providers (Krause et al., 2000, p. 1108). While race per se does not directly influence employment status, particular attention has been paid to ensuring equal access to rehabilitation services and employers for persons in racial/ethnic minorities (see, for example, Putzke et al., 2002). It is now generally agreed that RCs need to (a) be sensitive to the possible differences in cultures held by, for example, vocational rehabilitation agencies that value independence and person-centred planning as opposed to a client's culture that values interdependence with family and ethnic community; and (b) need to listen to how their clients with varied ethnic/cultural backgrounds perceive their disabilities and employment goals and barriers.

Litigation/financial compensation

In several CP studies, workers' compensation and personal injury insurance (Gatchel et al., 1995; Rainville et al., 1997), longer duration of time for receiving compensation (Milhous et al., 1989), and being involved in litigation via common law action while receiving workers' compensation (Suter, 2002) were associated with poorer employment outcomes and greater pain related problems. There were several exceptions to this trend. In studies with participants who were compensated within socialized medical insurance programs in Sweden and Norway, there was evidence of less psychopathology (Ericsson et al., 2002) and higher rates of employment (Haldorsen et al., 1998). Overall, these results suggest that persons with CP involved in compensation and litigation present more significant challenges to RCs.

In contrast to most CP studies undertaken with participants being treated in specialist pain clinics, Blyth et al. (2002) drew upon a large random sample of urban community-dwelling CP participants situated in Australia. Among those employed, working with pain was more common than lost work days due to pain. Further, employment status was not related to litigation. Blyth et al. found, however, that litigants reported more pain-related disability (i.e., interference with usual daily activities), medication use and health services use than non-litigants. They suggested "the possibility of an interaction between having a compensation claim and the response of the health system contributing to disability" (p.46). In other words, the compensation and health systems had an adverse effect on self-reported pain insofar as they encouraged their clientele to seek their services, whereas they should have been more adaptation-oriented than pathology-oriented (Rainville et al., 1997; Schultz et al., 2002). Further research is needed to understand the impact of the compensation process upon vocational outcome.

3. Psychosocial factors

Psychosocial factors here refer to coping strategies, participation in social activities (as opposed to social handicap), interpersonal relationships, social support, and perceptions of control in relation to self and others regarding various social roles at work, home and the wider community. Social support and adaptive coping strategies that diminished the impact of discrete stressful life events and/or chronic stressors were related to psychological well-being of persons with, for example, SCI (Frank et al., 1987), TBI (Moore, Stambrook & Peters, 1989), CP (Jensen, Turner, & Romano, 2001). These factors have more often been related to psychological well-being rather than to vocational outcome. Nevertheless, several SCI and TBI studies have related employment status with social support (McShane & Karp, 1993; Rintala, Young, Hart & Fuhrer, 1994) and coping strategies (Curran, Ponsford & Crowe, 2000; Hanson, Buckelew, Hewett & O'Neal, 1993).

Perception of control (e.g., individuals' expectations that events in their lives will be the result of chance or powerful others) was related to employment status in one CP study (Haldorsen et al., 1998) but not another involving persons with SCI (McShane & Karp, 1993). Participants in the latter study were followed-up three or more years after onset of injury compared to the former, a 12 month follow-up study. Perception of control may apply mainly to new situations; that is, may be related to employment status shortly after onset of disability or return to work. Several CP (Schultz et al., 2002) and MI/CABG studies (Boudrez & De Backer, 2000; Maeland Havik, 1987; Mittag et al., 2001; Petrie et al., 1996) highlighted the importance of fostering positive expectations regarding return to work during the acute phase of illness or impairment.

Studies involving participants with severe mental illness have frequently reported on the significance of psychosocial factors in relation to vocational outcomes; for example, satisfaction with vocational services (Bond et al., 2001; Mueser et al., 1997; Waghorn et al., 2002), active rather than avoidance coping strategies (Sherbourne et al., 1995), support from family (Cook, 2003; Hammen et al., 2000; Mowbray et al., 1995; Sherbourne et al., 1995) and involvement in social networks (Shankar & Collyer, 2003) and self-help groups (Cook, 2003). The absence of relations with co-workers outside the workplace, observed by Cook (2003), reinforced the importance of family support and self-help groups.

RCs need to be attuned to these issues including their clients' evaluations of their social support networks that may include RCs themselves. It is commonly assumed that relationship building involving trust, and expressing empathy and genuine concern for the client, represents the bedrock on which clients are assisted by RCs (Mullins, Roessler, Schriner,

Brown & Bellini, 1997).

4. Psychological factors

Depression as a measure of subjective well-being has dominated the rehabilitation literature. Higher rates of depressive symptoms and lower rates of employment than for the general population were reported for persons with SCI, limited education and minority ethnic status (Kemp, Krause & Adkins, 1999; Krause, Coker et al., 1999; Krause, Kemp & Coker, 1999). In TBI studies, higher rates of depressive symptoms than for the general population were reported (Glenn, O'Neil-Pirozzi, Goldstein, Burke & Jacob, 2001; Kreutzer, Seel & Gourley, 2001). Depressive or distress symptoms were also among several significant predictors of employment status when persons with TBI were surveyed 12 or more months after onset of TBI (Cattelani et al., 2002; Cifu et al., 1997; Felmingham et al., 2001; Ruff et al., 1993; Ryan, Sautters, Capps, Meneese & Barth, 1992). Employment status correlated with improvement in physical and mental health among persons with major depressive symptoms (Sherbourne et al., 1995). Lower rates of return to work were reported for persons with both MI/CABG and depressive symptoms (Boudrez & De Backer, 2000; Maeland & Havik, 1987; Mittag et al., 2001; Rost & Smith, 1992; Schleifer et al., 1989; Soderman et al., 2003).

Depressive or distress symptoms were greater for persons with CP who were involved with compensation or litigation (Gatchel et al., 1995; Milhous et al., 1989; Rainville et al., 1997; Suter, 2000); and were significantly related to pain-related disability (Blyth et al., 2003; Ericcson et al., 2002; Gatchel et al., 1995; Milhous et al., 1989; Suter, 2002). In contrast, Schultz et al. (2002) argued that anxiety and depression variables were less predictive of return to work than cognitive variables (e.g., not feeling threatened with job loss, expecting recovery, perceiving fair treatment by compensation system) in a workers' compensation system that was adaptation-oriented rather than pathology-oriented.

Many studies did place depression in a socio-cultural or psychosocial context rather than a clinical one. RCs may assist clients to address issues related to psychosocial adjustment to disability; for example, developing coping strategies for job seeking, obtaining and maintaining employment in demanding workplaces (Roessler, 2002). It is therefore recommended that RCs embrace a biopsychosocial model of vocational rehabilitation (Crook et al., 2002; Schultz et al., 2002) or a "person-environment" framework that reflects their legislative mandate (Mullins et al., 1997).

There is one major caveat to most of these studies. Very few studies measured depression with contemporary diagnostic criteria, notably, the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994). In most of the studies with non-psychiatric participants, researchers measured depression via a self-report depression scale and did not always distinguish diagnosable depression from negative affect, anxiety or distress symptoms that may be related to transitory or specific life events. Frequently utilized scales such as the Beck Depression Inventory and the Center for Epidemiological Studies Depression Scale did not distinguish between symptoms (e.g., psychomotor disturbance, changes in sleep and appetite) predictive of major depression and those similarly affecting persons with SCI (Elliott & Frank, 1996), other impairments and chronic illness (Vahle, Andresen & Hagglund, 2000). As a general rule, individuals should not be categorized as "depressed" on the basis of self-report measures alone (Elliott & Frank, 1996; Kreutzer et al., 2001; Vahle et al., 2000).

5. Enduring employment status

A recent trend has been for researchers to focus upon long-term vocational outcome rather than simply focus on employment status at one point in time. Prospective studies have adopted longer periods of follow-up. Studies of persons with severe mental illness employed follow-up at 18 months (Bond et al., 2001; Hammen et al., 2000; Mueser et al., 1997) and at two years (Hammen et al., 2000; Sherbourne et al., 1995). One CP study followed-up two years after completion of litigation (Suter, 2002); and three SCI studies, at nine years (Krause, 1997), 11 years (Krause, 1996) and 20 years (Krause, 1998). Perhaps the value of these studies has been best described by Krause, Sternberg et al. (1998) who observed that prospective studies identified "three distinctive types of participants: those who find and maintain employment, those who become unemployed but cannot maintain employment, and those never to return to work ..." (p.622).

In the TBI literature, early post-injury cognitive functioning has been linked to long-term employment outcomes, as discussed above. But, few TBI studies have tracked employment status over several time periods, the occupations and industries that persons with disabilities performed well in, and the role of family, friends, co-workers and service providers may have played in helping them to maintain work (Keyser-Marcus et al., 2002). Only recently have longitudinal TBI studies focused upon the relationship between socio-demographic and psychosocial factors and fluctuations in employment status at different time periods over three (Sander, Kreutzer, Rosenthal, Delmonico & Young, 1996), four (Kreutzer et al., 2003) or five years post-injury (Keyser-Marcus et al., 2002).

The link between employment and quality of life and subjective well-being has been a recurrent theme throughout the research literature. Exceptions to this trend have been reported in several SCI and amputation studies. In his longitudinal studies, Krause (1997, 1998) found that an increase in employment coincided with diminished well-being. He suggested that positive changes in legislation in the USA may have raised unrealistic expectations that have not been fulfilled, and that subjective well-being may be more influenced by situational factors that have created social barriers even for those who obtained employment. Among amputees, dissatisfaction with employment was attributed to the lack of appropriate workplace modifications, and lack of opportunities for promotion (Schoppen et al., 2001); to the presence of severe phantom or residual limb pain (Ide et al., 2002; Whyte & Carroll, 2002) or severe abdominal injuries (Pezzin et al., 2000); and to physical limitations related to ageing among those who had resumed work post-amputation but later stopped working (Schoppen et al., 2001).

In general, maintaining contact with clients throughout a program, and monitoring their return to work are regarded by RCs as key elements of service delivery (Mullins et al., 1997; Roessler, 2002). Vocational rehabilitation may, however, be perceived as relatively time-limited for some client groups; for example, clients with long-term support or treatment needs provided by other agencies. Vocational rehabilitation may be best utilized as one part of an array of community-based services and supports for persons with severe mental illness whose symptoms fluctuate over time (Ormel & Von Korff, 2000).

Limitations

Few researchers reported on access to vocational services as a predictor of vocational outcome. Several researchers suggested that their target population had limited access to vocational rehabilitation; for example,, amputees were identified as a diagnostic group that lacked access to vocational services (especially in the United Kingdom: see Fisher, Hanspal & Marks, 2003; Whyte & Carroll, 2002) or who were not encouraged to participate in vocational rehabilitation (Livingston et al., 1994). Another area of much needed research is the extent to which vocational rehabilitation services are integrated with other clinical or community-based services. It can be expected that services vary within and between countries with different legislative guidelines (Mullins et al., 1997; Waghorn & King, 1999).

Many researchers valued early predictive models of vocational outcome; and advocated research that identified, shortly after onset of disability, those rehabilitation clients who were at risk of long-term unemployment (Crook et al., 2002; Sherer, Novack et al., 2002). Such models of vocational outcome need to include the combined effects of natural history and rehabilitation programs. The efficacy of the latter was often assumed and not adequately assessed, and was rarely acknowledged by researchers cited in this review (except, for example, Bond et al., 2001; Cook, 2003; Dikmen et al., 1994; Myrtek et al., 1997; Waghorn et al., 2002).

Further research is needed to better understand what factors influence long-term employment stability. Topics in need of research include ageing and increasing physical impairment or chronic illness in mid-life, financial disincentives to employment, career development, organisational risk factors for stress, and employer attitudes in regard to recruitment and human resource management.

Conclusion

This review presented a broad perspective from 75 empirical studies published since 1987 and identified variables related to employment outcome for six disability groups. These groups included persons with spinal cord injuries, traumatic brain injuries, amputations, chronic pain, myocardial infarction/coronary artery bypass grafting and psychiatric diagnoses such as psychosis, bi-polar disorder, long-term major depression or dysthymia. Severity of disability continued to be an important factor, and enduring employment status has recently emerged as an area of interest to researchers. However, the key predictors of vocational outcome were socio-demographic, psychosocial and psychological factors. A similar review of factors that predict successful vocational outcomes in other disability groups is recommended.

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Ross Crisp

Australia

Ron Crisp, Ph.D, MAPsS, Rehabilitation Consultant, Psychologist, CRS Australia, P.O.Box 1172, Croydon, Vic. 3136 Australia. Email: [e-mail].

Table 1
Six diagnostic groups and number (N) of studies reviewed

                                                               N

Spinal cord injuries (SCI)                                    21
Traumatic brain injuries (TBI)                                19
Amputation                                                     8
Chronic pain (CP)                                              9
Myocardial infarction / coronary artery bypass grafting
  (MI/CABG)                                                    8
Severe mental illness, i.e., psychosis, bi-polar disorder,
  long-term major depression or dysthymia                     10

Table 2
Most commonly cited predictor variables
and number (N) of studies reviewed

                                                               N

Severity of disability                                        38
Socio-demographic factors
  Age                                                         31
  Education                                                   23
  Race/ethnicity                                              14
  Litigation                                                   6
Psychosocialfactors                                           19
Psychological factors                                         16
Enduring employment status                                    11