Barriers and Facilitators Related to Work Success for Veterans in Supported Employment: A Nationwide Provider Survey

Veterans with mental illness tend to have poor employment outcomes (1), which are known to pose a substantial threat to well-being and financial stability over time. The Individual Placement and Support (IPS) model of supported employment (SE), an evidence-based practice involving the provision of individualized employment support, has been shown to improve the work success of these veterans (2), although challenges persist. At least one-third of veterans remain unemployed even with the help of SE (3). Given the burgeoning number of veterans experiencing mental illness and disruption in functioning, understanding the barriers that hinder work success and career advancement is crucial.

Prior studies have examined factors related to vocational success among persons with disabilities; however, only one has addressed veterans with mental illness. Approaching the question from the vantage point of veterans, Kukla and colleagues (4) found that motivation and efficacy beliefs, health and cognitive problems, and interpersonal relationships on the job most affected achievement in the civilian workplace. Furthermore, studies of employment success among nonveterans have typically examined barriers and facilitators from the perspective of SE staff. Specifically, a handful of community studies have recognized elements at the client level, such as motivation, fear of work, and self-stigma; factors related to the vocational worker, such as competencies and provision of general support; and factors at the program level that are consistent with the IPS SE model, including rapid job development and follow-along support (5–9).

Efforts have also been made to quantify the association between an array of factors and employment outcomes among nonveterans, with few consistent findings across studies. Cognitive dysfunction and previous work history seemed to be the most consistent predictors of future employment outcomes; however, the strength of these relationships was modest (10–13). Receipt of evidence-based SE demonstrated the strongest relationship with employment success (14).

Although these findings provide some insight regarding factors influencing work among nonveterans who are receiving vocational services in the community, the state of knowledge is incomplete. No published studies have conducted an assessment of the perspectives of SE personnel in the Department of Veteran Affairs (VA) on work barriers and facilitators. VA SE personnel offer unique and important insights, given their daily experience working directly with a range of veterans; they also have key insights regarding the impact of the nature of SE services, core personnel competencies, and employer perspectives on veterans with mental illness. Furthermore, past community studies in this area have been small in scope, carried out in one agency or state with a limited number of staff or related stakeholders. Studies have almost exclusively considered nonveterans with severe mental illness, such as psychotic disorders and bipolar disorders. Veterans with other mental disorders, most notably, posttraumatic stress disorder (PTSD), are increasingly in need of individualized vocational services (15); these veterans often have complex comorbidities, such as general medical ailments, cognitive problems, and substance use disorders (16) that further complicate their vocational pursuits (17).

In addition, veterans of recent conflicts, including Operation Iraqi Freedom, Operation Enduring Freedom, and Operation New Dawn, are tasked with simultaneously managing multiple, complex life transitions, such as adjustments to work and family roles, as they reintegrate into the civilian world after extended periods of combat deployments and active duty involvement (18). Taken together, these circumstances suggest the need to further consider influences that may be distinctly salient to veteran work success.

In recognition of these issues, the VA has placed a high priority on improving the economic security of these vulnerable veterans (19). In response, this study used a mixed-methods approach to investigate barriers and facilitators related to competitive work among veterans with mental disorders through the lens of a nationwide sample of VA SE personnel.

Methods

Sampling

Participants were eligible if they were employed by the VA and were involved in the provision of SE services according to the IPS model, including frontline staff persons, supervisors, managers, and service line chiefs. In the VA, this program is referred to as “evidence-based supported employment” and falls under the umbrella of compensated work therapy (CWT), which includes all work supports and vocational rehabilitation programs for veterans. SE differs from other CWT programs, such as transitional work, in its focus on helping veterans obtain competitive, permanent community jobs (20). VA personnel involved in the provision of other CWT services were excluded. Of 300 SE personnel, 114 (38%) completed the survey.

Procedures

The VA Office of Therapeutic and Supported Employment Services leadership, which oversees the operation of vocational programs across the VA, distributed the link to the online survey via e-mail to all SE staff persons, supervisors, managers, and service line chiefs at all SE sites. After providing written informed consent, participants provided background information and completed the survey. Data were collected in November and December of 2013. All procedures were approved by the Institutional Review Boards at Indiana University and the Richard L. Roudebush VA Medical Center.

Measures

The survey comprised 26 items and was based on an employment survey that was used in a sample of veterans with mental illness (4). For each item, participants were asked to “indicate to what extent they (the factors) play a role in the overall employment success of the veterans with whom you work.” Responses were rated on a Likert scale, with 1 indicating plays no role; 2, a slight role; 3, a moderate role; 4, a large role; and 5, a very large role. Participants responded first to the degree to which each factor acted as a facilitator and then to the degree to which each factor acted as a barrier. Finally, participants responded to the following open-ended questions about additional factors not covered by the survey: “Are there other key factors not previously listed that impact the ability of the veterans with whom you work to obtain jobs?” and “Are there other key factors not previously listed that impact the ability of the veterans with whom you work to keep jobs long term?” In a previous study, the items had good internal consistency (Cronbach’s α=.83) and convergent validity (4).

Data Analyses

A convergent parallel mixed-methods design was used (21), in which complementary qualitative and quantitative data were collected and synthesized, providing an in-depth understanding of work barriers and facilitators among veterans with mental illness.

Quantitative analyses were conducted with SPSS 20. Descriptive statistics were generated to characterize background characteristics of SE personnel, barriers and facilitators related to work, and rank ordering of elements that affected work outcomes.

Qualitative analyses of open-ended questions were conducted using a conventional content analysis (22). First, three coders read the responses and independently identified themes by using an inductive approach (23). Coders then met, discussed emerging themes, converted themes into codes, and resolved discrepancies. During the coding process, the coders wrote memos, resulting in continued revision of codes and a final a set of focused codes identifying the major themes of the responses. Focused coding was then used to code the remainder of the responses.

Results

Quantitative Findings

Description of participants.

Of the 114 SE participants, 84 were frontline staff; ten had a combined position, providing direct services and supervising staff; 13 were supervisors or managers; three were directors; and two were service line chiefs (data on position descriptions were missing for two participants). Participants represented 78 different SE programs across all 21 Veterans Integrated Service Networks. Participants had worked in the vocational rehabilitation field for 10.3±8.7 years. Frontline staff had a mean caseload size of 26.4±23.2 veterans; mean caseloads consisted primarily of veterans with severe mental illness (15.0±10.0) rather than veterans with PTSD (7.3±11.2).

Employment facilitators and barriers.

As shown in Table 1, the highest rated facilitators of competitive work success were veteran motivation, a good match between the veteran and the job, the assistance of VA SE services, and the veteran’s self-confidence related to work. As shown in Table 2, the highest rated barriers to competitive work success were veteran related: substance use, psychological stress, mental health, cognitive functioning, and general medical health. Mean scores were generally higher for facilitators (range 2.9–4.6) than for barriers (range 2.2–3.9).

Qualitative Findings

Participants’ comments on additional factors influencing competitive work are summarized in Table 3. Thirteen codes signifying important themes influencing competitive work were identified. The most prominent themes were resources at the level of the veteran and SE program (39 responses), staffing (38 responses), and the role of the employer (28 responses).

Resources.

A prominent theme that arose was veterans’ lack of available transportation. For example, one participant commented, “If a veteran lives in a rural area where there is no public transportation, it is difficult to get to work. The price of paying for a taxi sometimes costs more than the income.” In a related vein, many participants suggested that there was a need for SE programs to make bus passes available and to use other means to help arrange transportation. Furthermore, several staff and supervisors mentioned a need for computer labs to bolster veterans’ skills in this area; for instance, one supervisor noted, “I feel that some computer training would help veterans since so many applications are completed online and they need so much help.” Another frequently mentioned theme in the category of resources was program-level resources, particularly a shortage of transportation for staff. One participant stated, “We need adequate tools. Two cars for five [staff] in SE doesn’t work.”

Staffing.

Three secondary themes emerged in the area of staffing. First, staff competencies and approach to SE services were frequently mentioned as highly influential in work success. For instance, one participant commented on the importance of “motivation and experience of assigned job developer[s].” Other participants emphasized the staff person’s “relationship with the employers,” “ability to create natural supports on the job,” and key role in providing individualized follow-along support to bolster job maintenance. A supervisor commented on the role of SE staff in “keeping support available and getting veterans to talk about concerns and problems that are occurring daily as well as positive things that are occurring.” Further, a staff person remarked on the multifaceted and complex nature involved with the provision of SE services, stating, “A caseload of 25 can be extremely challenging at times. . . . There will be months where the SE counselor will be job developing for a few earnest and motivated veterans, while attending to crisis intervention and related job maintenance support that can be time consuming. . . . SE counselors are also ‘sales people’ in one regard.” An additional competency of the SE staff person highlighted was the development of rapport and working alliance with veterans, for instance, “veterans seeing true empathy and advocacy from their vocational counselors.” Another participant commented on the benefits of “support and building confidence that they [veterans] can be successful . . . positive reinforcement to help them see what they have achieved . . . taking small steps and rewarding those accomplishments.”

Another secondary theme arose pertaining to the need for additional training in the tenets of SE. For instance, one staff person commented on the need for training specifically in the area of job development: “We need ideas for effective advertising, marketing, and sponsorship with major employers. This should ensure successful communication with gatekeepers.” With regard to persons overseeing SE programs at the site level, a participant noted, “I would like to see more training geared for the supervisor or CWT program manager. This may help each site to enhance its program.” Similarly, a need for more supervision was also highlighted: “We need closer coordination with VA central office or Veterans Integrated Service Networks mentors to ensure follow-up training and support.”

Numerous suggestions were made regarding staffing structure, particularly a need for more staff to serve a larger number of veterans. In addition, a number of staff and supervisors commented on a need for staff whose sole assignment is job development, in recognition of the unique skills and competencies required to effectively develop jobs. A supervisor stated, “The one thing that would be helpful is for the VA to specifically hire job developers with a business background whose sole job is to develop employer relationships.” A few participants also recognized a need for staff specifically focused on “job coaching” or assisting veterans who have greater needs to learn job duties.

Role of the employer.

The final primary theme was related to the impact of employers on the success of veterans in the workplace. Specifically, concerns were raised regarding the role of employer stigma in reducing the likelihood of hiring veterans. Participants noted the importance of “educating business owners . . . [since] many think a person with mental illness issues will impact their service” and “showing [employers] that people with these challenges can be productive and loyal employees.” Another participant commented, “I had employers requesting training to understand what it means to hire an employee with severe mental illness and the types of accommodations needed.” A staff person also commented on “employers’ willingness to work with [veterans] and buy into the SE model” as a prominent factor involved in maintaining employment.

Furthermore, several participants commented on the importance of forming strong “relationships” and “partnerships” with employers to increase the likelihood of work success. Highlighting an example in daily practice, one participant stated, “If an employer is not aware that the veteran is in SE . . . [he or she] may not contact the [staff person] when there is a problem on the job. It is important that the [staff person] has an opportunity to intervene if there is a problem to sustain employment.”

Discussion

A nationwide sample of frontline SE staff, supervisors, and upper-level managers provided a rich picture of factors affecting work success among veterans with mental illness. The five highest-rated barriers were veteran related, including substance use and a range of health factors, whereas highly rated facilitators emphasized the importance of services, including SE and mental health services. These findings highlight the burden of complex comorbidities on vocational functioning among veterans and underscore the necessity of integrating SE services with mental health, a core component of the evidence-based SE model (24). High degrees of integration of vocational services and mental health treatment have been linked with significantly enhanced employment rates (25), although barriers associated with mental health integration within VA SE have been documented (26), suggesting a need for further efforts in this area.

Substance use was perceived as the most substantial barrier to work success, in contrast to past studies, including both subjective examinations and randomized controlled trials of SE, that have not found an impact of substance use on employment (4,13). These inconsistencies between study findings may be partially explained by the limitations of self-report methodology and attribution bias. Specifically, in addition to substance use, many of the barriers ranked highest or reported most often were veteran related or externally related, whereas several of the top-rated facilitators concerned actions of SE personnel. In part, these findings may reflect self-serving bias, in which positive employment outcomes are attributed to the actions of SE staff (facilitators) and negative employment outcomes are attributed to veteran-related or external variables (barriers).

Whereas attribution bias may have influenced some findings, participants also identified internal attributes of veterans as major facilitators, including veterans’ motivation and work-related confidence. These findings are corroborated by extant literature and suggest that interventions augmenting SE, such as motivational interviewing and cognitive-behavioral therapy, may bolster vocational functioning (27–29), particularly during the job search phase (30).

The qualitative findings added depth to the quantitative findings, providing detail and nuance regarding the impact of service provision, staffing, resources at the veteran and program levels, and employers on veteran work success. Specifically, participants emphasized that SE service provision is multifaceted and involves a heterogeneous set of skills, abilities, and tasks (31), with higher confidence in some, such as forming relationships with veterans, compared with others, particularly being a “sales person” and successfully developing jobs. Accordingly, staff and supervisors noted a need for additional training, particularly in job development, which existing research supports as the most critical component of SE services (32). In addition, several SE personnel acknowledged the benefits of allocating staff solely for job development to increase the number of available jobs. Consistent with these qualitative findings, a strong match between the veteran and the job was a highly-rated facilitator, aligned with the existing literature linking a better job fit with longer job tenure among nonveterans who received SE services (33).

The task of forming relationships with employers is considered central to the process of job development (34) and a key contributor to work success. These findings indicate that guiding employers through the process of providing appropriate accommodations for veterans is a critical role for SE staff. Furthermore, previous research has illustrated the complex relationship among perceptions of behavior by people with mental illness—for example, dangerousness—public stigma, and decisions surrounding the employment of this group (35). SE personnel should strive to educate employers about mental illness and highlight the successes of these veterans at work in the context of strong rapport; this is of utmost importance to combat stigma and ensure long-lasting job placements.

Conclusions

This study offers an in-depth understanding of the range of factors that have an impact on the work success of veterans with mental illness. Consistent with a recovery-oriented stance, SE staff regarded facilitators as having more influence than barriers on work success. Fortunately, many of these barriers are malleable and can be improved, for example, by increased access to resources (such as computer training and transportation), targeted staff training, strong integration with VA mental health services, and vigorous efforts to form relationships with employers.

Although this study adds to our understanding of the factors most prominent to work success, it had limitations. As discussed, the study was based on self-report; linking objective data on work outcomes with perceptions of barriers to work success will provide additional information, triangulate the current findings, and offer guidance regarding the allocation of limited resources toward alleviating the most significant barriers. In addition, key internal processes, such as self-confidence and motivation, may be best described by veterans themselves; thus, future research and clinical consideration of these important elements should be person centered. Third, although a unique aspect of this study was the heterogeneity of veterans served in SE, many SE personnel served relatively fewer veterans with PTSD compared with veterans with severe mental illness, per VA regulation. SE services tailored for veterans with PTSD are still in their infancy (36); further research is needed to more fully capture the distinct service needs of these veterans as they work toward fruitful careers.