Strategies for enhancing career maintenance self-efficacy of people with multiple sclerosis.

Strategies for Enhancing Career Maintenance Self-Efficacy of People with Multiple Sclerosis(1)

The purpose of this article is to apply a psychosocial theory for human behavior (self-efficacy theory) to the career maintenance problems encountered by people with evere disabilities such as multiple sclerosis (MS). Specifically, their employment retention rates following diagnosis are lower than those reported by people with disabilities in general and, according to experts, lower than would be expected based solely on the severity of the symptoms associated with MS (LaRocca, Kalb, Scheinberg, & Kendall, 1985). Two explanations are offered for the high unemployment rate of people with MS.

The severe and pervasive impact of multiple sclerosis is, of course, one reason for the low rate of post-diagnosis employment. However, factors other than disability-related symptoms result in poor career maintenance outcomes. A self-efficacy theoretical position is used to explain the exceptional problems that people with multiple sclerosis face in attempting to continue working. We propose that the lack of predictability of MS symptoms (Falvo, 1991) and the resulting uncertainty about one's life and future (LaRocca et al., 1985) have a negative impact on one's sense of self-efficacy. Decreased feelings of efficacy result in less frequent proactive behaviors that are required to maintain one's career. A psychosocial training intervention is, therefore, needed to enhance feelings of self-efficacy among people with MS and, thereby, increase the likelihood that they will initiate such career maintenance actions as requesting that their employers review their needs for reasonable accommodations on the job.

Career Maintenance and Multiple Sclerosis

Recent statistics document the assertion that most people with disabilities find it difficult to maintain employment. According to figures cited by Ficke (1992) and Yelin (1991), only 36% of males and 28% of females with work disabilities are in the labor force, compared to 89% and 69% of males and females who do not have work disabilities. Retention of employment among people with MS is lower than the previously cited figures for people with disabilities in general and lower than would be expected even given the presence of a severe physical disability. LaRocca and Hall (1990) reported that more than 90% of people with MS have employment histories, and most (60%) were working at the onset of MS. Unfortunately, only one in four people with MS (25%) is typically able to retain employment (Jackson & Quaal, 1991), and some research suggests that the employment outlook for women with MS is even worse. LaRocca et al. (1985) found that only 14% of women with MS were employed.

The employment rates of 25% and 14% respectively for all people with MS and women with MS are clearly lower than for a comparison group of people with work disabilities. But the surprising fact is that some experts believe that the poor rates of career maintenance reported by people with MS exceed what one might expect even considering the severity of the disability. Consistent with common sense, research indicates that the physiomedical impairments of MS reduce the likelihood that a person who acquires the illness will return to or retain employment (Jackson & Quaal, 1991; Komblith, LaRocca, & Baum, 1986). In concluding their research on the topic, however, LaRocca and Hall (1990, p. 53) noted that "the physical aspects of MS do not come close to fully explaining the high rate of unemployment." They stressed that both the symptoms associated with MS and the unpredictability of those symptoms, that is, exacerbations followed by remissions, have a debilitating psychological effect on people with MS which decreases their capacity to cope with on-the-job barriers to career maintenance.

Symptom Unpredictability and its Impact on Self-Efficacy

In unraveling the complicated relationship between MS and the high unemployment rates associated with it, LaRocca and Hall (1990) proposed that the unpredictable medical symptomatology of MS causes diminished feelings of self-efficacy and self-control. Although exacerbated by failure in key life roles such as employment, diminished feelings of efficacy and control are viewed more as the cause of such failure than as the result.

Research by Devins and Seland (1987) documented the negative impact that severe disabilities such as MS have on self-efficacy. Self-efficacy is defined in Bandura's (1986) terms to include two domains of expectancy, efficacy expectations and outcome expectations. Efficacy expectations reflect the person's belief that he or she possesses the skills required to respond satisfactorily in a given situation. Outcome expectations refer to the likelihood that one will actually perform a certain task based on his or her perceptions of (a) the possibility of a successful outcome and (b) the extent of environmental constraints, social consequences, and other results of task completion.

Research on self-efficacy clearly supports the proposition that people will initiate actions, attempt particular tasks, and aspire to particular goals if they believe they will be able to perform those actions efficaciously (Fiske & Taylor, 1991). In general, the stronger one's perceived self-efficacy, the more effort and persistence one will exert at a task (Bandura, 1986). In matters of personal health maintenance and self-care, a sense of efficacy promotes adaptive responses which result in restoration of well-being. Rodin (1986) reported that perceived and real control can produce such health benefits as reduction of subjective threat, lower levels of stress, positive changes in symptom labeling, and a willingness to practice better health habits. He also reported that persons with high degrees of perceived self-efficacy tend to seek needed treatment and follow prescribed therapeutic regimens. Low self-efficacy has been linked to prolonged negative mood states (Maslach, 1982), inferior general health and high mortality rates (Peterson, Vaillant, & Seligman, 1985), and on-the-job stress and burnout (Maslach, 1982).

Research clearly documents, therefore, the connection between feelings of self-efficacy and effective coping responses. Given the fact that MS has a negative impact on self-efficacy, it seems plausible that diminished self-efficacy is one reason for the difficulties that people with MS experience in maintaining their careers (Gecas, 1989). They do not believe that they possess the skills required to remove or reduce on-the-job barriers to their productivity (efficacy expectation), nor do they have the confidence that such actions would result in desirable outcomes (outcome expectation). Hence, a need exists for a career maintenance intervention for employed people with MS that enhances their levels of self-efficacy with regard to the identification and removal of on-the-job barriers to satisfactory performance.

A Self-Efficacy/Career Maintenance Intervention

Bandura (1986) indicated that enhancement of self-efficacy requires an intervention that addresses cognitive, social, and behavioral skills. To overcome the impact of low self-efficacy on career maintenance of people with MS, rehabilitation interventions must, therefore, (a) demonstrate how to identify on-the-job barriers to productivity (cognitive skills), (b) inform individuals of their right to a review of those barriers and their accommodation needs by their employers (cognitive skills), (c) encourage people to assert their rights for an accommodation review, and (d) instruct individuals in competent techniques for presenting those barriers and potential solutions to their employers (social and behavioral skills). By coupling procedural knowledge (needs, solutions, and rights) with means for confidently communicating those needs (social competence), a career maintenance intervention could have a desirable effect on self-efficacy as it applies to the task of job retention. A multi-component self-efficacy/career maintenance intervention can be developed from existing psychological principles and rehabilitation technology.

Identification of Accommodation Needs: A Cognitive Approach to Enhancing Self-Efficacy

One method for enhancing career maintenance self-efficacy involves a cognitive strategy which enables the person to learn what his or her accommodations needs are. Based on a structured interview technique using the Work Experience Survey (WES; Roessler, 1991) the procedure involves the individual in specifying barriers to productive performance, considering possible accommodations, and developing an accommodation plan. As a result of participating in the WES structured interview which requires about 45 minutes to complete, participants describe their accommodation needs in four areas: environmental accessibility, performance of essential functions, job mastery, and job satisfaction. In the final section of the WES, they rank order their three most important job-related barriers, suggest reasonable accommodations, and identify possible resources (who can help, how can they help).

Recent research with the WES (Roessler & Rumrill, 1993) supports its validity as a measure of accommodation needs. The total number of accommodation needs (e.g., problems with accessibility and performance of essential functions) reported by employed people with MS (N = 34) correlated negatively with their levels of job satisfaction (r = -.50, p .01) and positively with the number of job mastery problems they reported (r = .36, p .05). Perceived barriers on the job, therefore, are related to two constructs, job mastery and job satisfaction, which research has related to tenure on the job (Dawis & Lofquist, 1984). But, information on accommodation needs alone is insufficient as a cognitive intervention. To enhance the person's outcome expectations with regard to seeking on-the-job accommodations, the rehabilitation professional must provide information regarding support in the environment for making such a request. One important source of such support is Title I of the Americans with Disabilities Act (ADA) which ensures the rights of people with disabilities to reasonable accommodations at work. Hence, the second cognitive-based intervention focuses on information on rights to reasonable accommodations under Title I of the ADA.

Understanding One's Rights to Reasonable Accommodation: A Second Cognitive Approach to Increasing Self-Efficacy

People with severe disabilities such as MS also need current information on protections and procedures relevant to requesting a review of their accommodation needs by their employers and supervisors. Written materials are available which explain Title I provisions of the ADA, for example, "Enhancing productivity on your job: The 'win-win' approach" (Roessler & Rumrill, 1994). The rehabilitation professional should request that the person read such a pamphlet and then discuss the implications of the information with the person. The pamphlet provides two valuable types of information: (a) information on consumer rights under the ADA for requesting accommodations in the workplace and (b) an explanation of a collaborative or "win-win" approach to discussing accommodation needs with an employer. The booklet explains that the ADA is a comprehensive statute that affords individuals with disabilities anti-discrimination civil rights protections in employment, public services, public accommodations, and communications. In Title I of the Act, employers are required to provide reasonable accommodations so that qualified individuals with disabilities can perform the essential functions of their jobs. Reasonable accommodations may result from a variety of strategies such as modification or provision of equipment, job restructuring or reassignment, modification of the work environment, provision of personal assistance or aides, and rescheduling.

Procedures for requesting such reasonable accommodations are clearly described in the Act and reviewed in the brochure. The employee may initiate a request for an accommodation to which the employer is required to respond. The employer and the employee then collaborate in identifying barriers to the individual's ability to perform essential functions of the position. Using the employee with a disability as a source of information, the employer identifies a variety of accommodations and assesses the extent to which they might represent an economic hardship to the business. The employer implements appropriate accommodation, considering the employee's preference in the case of two or more accommodations deemed equal in cost and effectiveness (Feldblum, 1991, p. 95-96).

When added to the previous cognitive self-efficacy intervention, that is, using the WES to identify barriers and possible accommodations, clarifying the individual's rights under the ADA for an accommodation review with the employer is another important step in restoring the person's sense of career maintenance self-efficacy. In other words, the person now has a detailed understanding of barriers and solutions and legal mechanisms for pursuing those solutions. Knowledge of one's accommodation needs should enhance efficacy expectations in that the person understands what requests to make; knowledge of one's rights should enhance outcome expectations in that the person is aware of environmental support for the behavior of requesting an accommodation review.

The rehabilitation professional must, however, supplement cognitive strategies with other behavioral techniques that will increase the probability of accommodation-seeking behavior. Hence, the counselor should follow-up on the person's experience of completing the WES and reviewing the "Win-Win" brochure with strong encouragement that the person request an accommodation review with his or her employer. A simple verbal prompt is one method for providing such encouragement.

Using a Verbal Prompt to Encourage the Person to Initiate an Accommodation Review

Having completed the WES and reviewed his or her rights to reasonable accommodation under Title I of the ADA, the individual is prepared to implement an accommodation plan with the employer. Research suggests that the probability of plan implementation is increased if the person receives encouragement to do so from a person perceived as being a credible source (Kanfer & Goldstein, 1991). This encouragement can come in the form of a verbal prompt or message as follows: "Now that you know what your barriers and needs are and what your rights are under the ADA, you should contact your supervisor or employer to discuss some steps to help you become even more productive on your job." Kanfer and Goldstein (1991) cited several studies which demonstrate that the verbal prompt increases the frequency of behavior, in this instance, the target behavior of requesting an accommodation review with one's employer. The importance of the prompt is that it results in initiation and maintenance of the behavior long enough for natural reinforcement to occur, that is, for support from the supervisor and employer to develop. Prompts must be direct and conspicuous, particularly in the early stages of the treatment. Hence, after restating the person's right to an accommodation review by the employer, the rehabilitation professional should review the accommodation plan from the WES with the person and prompt the person to request a review by the employer.

Although documented to be effective and probably sufficient for many people with disabilities, a verbal prompt may not be intensive enough as an intervention for some individuals. Some people may respond better to behavioral approaches such as modeling and role playing. Hence, the rehabilitation professional may wish to involve some individuals in instruction on asserting their rights in the most effective manner possible. Social competence approaches in psychology provide guidelines for structuring the behavioral practice elements of a career maintenance self-efficacy intervention.

Social Competence Training: A Behavioral Approach to Enhancing Self-Efficacy

Bandura (1986) stressed that self-efficacy is the product of reciprocal relationships among cognitive, environmental, and behavioral factors. Changes in one of the reciprocals such as cognitive factors will promote changes in the others which often has a cumulative effect on the person's perceptions of self-efficacy in specific situations. Behavioral skill training is, therefore, an important element of a self-efficacy intervention. The focus of the training is on providing the person with the behavioral skills needed to satisfy the task requirements of the environmental situation in question. In this case, the environmental situation involves an employee presenting and discussing his or her accommodation needs with an employer. It is important that the person make this presentation in a socially competent manner. People can increase their effectiveness in requesting accommodations via behavioral instruction.

Cipani (1988, p. 124) defined social competence as a "function of the specific interpersonal situation. It is a social judgment about the general quality of an individual's performance in a given situation." He identified social assertion, interviewing skills, and conversational ability as three major components of social competence. This tripartite model provides an excellent framework for the behavioral instruction phase of the career maintenance/ self-efficacy intervention.

The behavioral phase of learning how to present accommodation requests in a competent manner follows the traditional social skills training format of (a) instruction, (b) modeling, (c) rehearsal, and (d) feedback. The person is, first, instructed with respect to recommended ways to communicate with the employer. Some typical instructions are as follows: dress in work appropriate clothes, arrive on time for the meeting, thank your employer for meeting with you, begin by introducing the purpose of the meeting, use appropriate body language, maintain eye contact without staring, use non-adversarial terms in presenting your needs, and focus on ways that your enhanced productivity will benefit your employer. These and other social competence guidelines are found in the previously described brochure, "Enhancing productivity on your job" (Roessler & Rumrill, 1994). Playing the role of an employee presenting an accommodations request, the instructor then models the social competence performances. The participant plays the role of the employer. The roles are reversed and the employee role-plays the behavioral skills, with the rehabilitation professional providing feedback on both the content and style of the person's presentation.

Throughout the training, the rehabilitation professional may provide feedback on other skills in the social competence model such as interviewing and conversational abilities. Many pre-employment interviewing skills generalize to career maintenance situations such as positive self-statements and expressed intent to succeed on the job. Conversational skills are also appropriate such as positive feedback statements, asking relevant questions, self-disclosure, and maintaining conversations by showing interest and asking follow-up questions.

The social competence training concludes with another prompt that the employee present his or her accommodation needs in a face-to-face meeting with the employer. Of course, it is also necessary for the rehabilitation professional to intervene in the environment to increase employer readiness to participate in the accommodation process. The employer represents the environmental component of the self-efficacy reciprocal.

Kornblith et al. (1986) stressed the importance of the employer, noting that one of the best predictors of job retention was employer willingness to make job modifications. Research in Belgium (Ketelaer, 1993) supported Kornblith's et al. (1986) observations. Environmental factors influencing the success that employees with MS had in retaining their jobs included an understanding reaction by the employer at the time of the diagnosis, the implementation of adaptations in the work place and work environment, and the employer's knowledge of different types of job accommodation strategies. Rehabilitation professionals should arrange for employer education programs that provide information on (a) Title I provisions and protections, (b) job accommodation strategies, (c) resources such as the Job Accommodation Network, and (d) the low cost and effectiveness of accommodations. Rehabilitation personnel can also increase their capabilities to advise employers on the selection and utilization of reasonable accommodations in the workplace.

Evaluation of a Career Maintenance/Self-Efficacy Intervention

To determine whether the career maintenance/self-efficacy intervention has had the proposed effect, two criteria must be examined: (a) the person's level of career self-efficacy and (b) the extent to which the individual initiates the behaviors required to involve the employer in a discussion of reasonable accommodations. Following Bandura and Schunk's (1981) recommendations, we have developed a situational self-efficacy scale, the Career Self-Efficacy Measure, which consists of seven questions asking respondents to indicate how confident they feel about performing specific tasks of the accommodation request process. Anchored on a 10-point scale (1 = not sure, 10 = very sure), sample items enable people with disabilities to indicate how certain they are that they can identify needed employment accommodations, request that their employers review their on-the-job accommodation needs, discuss their needs with their employers in a face-to-face meeting, and negotiate with their employers about implementing reasonable accommodations. When administered to 51 employed people with MS, the scale had high internal consistency (coefficient alpha = .93).

The behavioral impact of the career/self-efficacy intervention may be assessed via a structured interview, the Accommodations Questionnaire, that is administered over the telephone with the employed person with MS. The questionnaire contains 14 items, some with several parts, that address such behavioral criteria as (a) the number of accommodation review meetings requested, (b) the number of accommodations requested in the meeting, and (c) the number of accommodations implemented at the worksite. A career/self-efficacy intervention should increase such behavioral outcomes as the number of meetings requested with the employer and the number of accommodations discussed and received. In a pilot-test with a small sample of employed people with MS (N = 45), researchers compared the impact of three interventions on accommodation seeking behavior, acceptance of disability, and career self-efficacy (Rumrill, Roessler, & Denny, 1993). The three approaches included a control group of employees with MS (n = 15), a group of employees with MS who completed the WES and received a verbal prompt from the WES administrator over the telephone (n = 15), and a group of employees with MS who received the cognitive and behavioral self-efficacy intervention as described in this article (n = 15). Two repeated measures MANOVAs (self-reported attitudes and accommodations activity) revealed that the overall effects of the treatment were not statistically significant. However, it should be mentioned that, although the differences did not reach statistical significance, they were in the order predmcted by the investigators for all of the behavioral variables and for the measure of career self-efficacy. Further research is needed with a larger sample of employed people with MS who have participated in a more intense version of the self-efficacy intervention. Future evaluations should include efforts to educate the participants' employers about the low cost and effectiveness of job accommodations, to inform employers of their responsibilities under Title I of the ADA, and to prepare employers for the accommodation review meetings with employees. In other words, researchers should intervene not only with the cognitive and behavioral reciprocals of self-efficacy but also with the environmental reciprocal.

Conclusion

The purpose of this article is to propose a theoretical explanation for and a response to the diminished self-efficacy that is a common response to severe disabilities such as multiple sclerosis. Self-efficacy is isolated as an important variable because it appears to explain why people with MS have great difficulty maintaining their careers. Their employment outcomes are not only worse than those of the general population of people with disabilities but also worse than would be expected based solely on the severity of the condition. We propose that the latter outcome is a function of the unpredictability of MS symptoms which undermines the individual's belief that he or she can (a) perform adequately on the job, (b) overcome barriers in the workplace, and (c) solicit the employer's assistance in barrier removal.

Combining a variety of cognitive, social, and behavioral skills, a career maintenance/self-efficacy intervention is described that interrupts the process of believing that one cannot respond efficaciously to the impact of MS on one' s employment situation. By identifying their accommodation needs and solutions, understanding their legal rights to reasonable accommodations, being encouraged to act on those needs, and developing the social competence skills needed for presentation of appropriate career maintenance needs to their employers, people with MS should become more skilled in and confident about requesting an accommodation review with their employers. But the environmental reciprocal of career self-efficacy, namely employer readiness to discuss workplace barriers and desired accommodations, is critical as well and must be a part of any effort to enhance the career maintenance self-efficacy of employed people with multiple sclerosis.

1 This paper was funded, in part, by a Health Services Research Grant from the National Multiple Sclerosis Society. Contact the authors for information regarding the Career maintenance/self-efficacy intervention (University of Arkansas, Research and Training Center in Vocational Rehabilitation, 346 N. West Avenue, Fayetteville, AR 72701).

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Richard Roessler, Ph.D., CRC, Arkansas Research & Training Center in Vocational Rehabilitation, 346 N. West Avenue, University of Arkansas, Fayetteville, AR 72701.