ORIGINAL ARTICLE

Factors influencing bladder management in male patients with spinal cord injury: a qualitative study

JP Engkasan1, CJ Ng2 and WY Low3

Study design: Qualitative study using individual in-depth interviews. Objectives: The objective of this study was to explore the factors influencing the choice of bladder management for male patients with spinal cord injury (SCI). Setting: Public hospitals in Malaysia. Methods: Semistructured (one-on-one) interviews of 17 patients with SCI; 7 were in-patients with a recent injury and 10 lived in the community. All had a neurogenic bladder and were on various methods of bladder drainage. Interviews were audio-recorded, transcribed verbatim and analyzed using thematic analyses. Results: The choice of bladder management was influenced by treatment attributes, patients’ physical and psychological attributes, health practitioners’ influences and social attributes. Participants were more likely to choose a treatment option that was perceived to be convenient to execute and helped maintain continence. The influence of potential treatment complications on decision making was more variable. Health professionals’ and peers’ opinions on treatment options had a significant influence on participants’ decision. In addition, patients’ choices depended on their physical ability to carry out the task, the level of family support received and the anticipated level of social activities. Psychological factors such as embarrassment with using urine bags, confidence in self-catheterization and satisfaction with the current method also influenced the choice of bladder management method. Conclusion: The choice of bladder management in people with SCI is influenced by a variety of factors and must be individualized. Health professionals should consider these factors when supporting patients in making decisions about their treatment options. Spinal Cord (2014) 52, 157–162; doi:10.1038/sc.2013.145; published online 26 November 2013

Keywords: decision making; urinary catheterization; peer group; neurogenic bladder; qualitative research

INTRODUCTION

In people with spinal cord injury (SCI), there is an increased risk of urinary tract deterioration, giving rise to significant morbidity and mortality.1 Health professionals often emphasize the clinical importance of appropriate bladder management and stringent surveillance of renal functions to prevent these complications. Despite medical advances, conservative management remains the mainstay of bladder management,2 and the common options are the following: clean intermittent catheterization (CIC), either self or assisted, indwelling catheterization, either transurethrally (IDUC) or suprapubically (SPC), and spontaneous voiding.3

The choice of a bladder management method should take into consideration factors such as patients’ age, functional status, pre- ference, motivation and cost.4,5 Existing clinical practice guidelines list the indications for each treatment option but do not guide the health professionals on how to help patients deliberate the risks and benefits of each of these options.1,6 This is particularly important in decisions where there is clinical equipoise in supporting one treatment option over another.4,7

In Malaysia, the four options mentioned above are widely available in general public hospital. Owing to the lack of resources, urodynamic study is not routinely performed during the initial admission. Most

patients use disposable polyvinyl catheter for CIC. Suprapubic and urethral catheters are changed every 2 to 6 weeks, depending on the type of catheter. Family members are taught how to change suprapubic catheter at home, but for urethral catheter, it is usually carried out in a health facility for fear of urethral injury. The surgeon decides whether suprapubic catheter insertion needs to be carried out under general or local anesthesia.

Previous studies have noted that patients changed their bladder management over time and suggested that incontinence, obesity, autonomic dysreflexia, spasticity, dependency, accessibility and cloth- ing influence are among some contributing factors.3,5 Most were retrospective studies, and to the authors’ knowledge, there is no study that explicitly looked at the decision-making process of people with SCI when choosing a treatment for bladder management. By understanding these factors, health professionals would be in a better position to engage patients in shared decision making. Patients who are actively involved in decision making have better knowledge of treatment options, a more accurate expectation of possible benefits and harms, lower decisional conflicts and make choices that are consistent with their values.8 Therefore, this study aimed to explore factors that influence patients’ decisions when choosing a type of bladder management.

1Department of Rehabilitation Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia; 2Department of Primary Care, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia and 3Dean’s office, Faculty of Medicine, University of Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia Correspondence: Dr JP Engkasan, Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Wilayah Persekutuan 50603, Malaysia. E-mail: [email protected] or [email protected]

Received 17 July 2013; revised 4 October 2013; accepted 20 October 2013; published online 26 November 2013

Spinal Cord (2014) 52, 157–162 & 2014 International Spinal Cord Society All rights reserved 1362-4393/14

www.nature.com/sc

MATERIALS AND METHODS This study used a qualitative methodology to provide an accurate description

and interpretation of the decision-making process from the perspective of

patients with SCI.9

Participants Seventeen participants with SCI were recruited from five hospitals in Malaysia

that offer spinal rehabilitation services (Table 1). A purposeful sampling

technique10 was used to achieve maximum variations in terms of age, level of

disability, method of bladder drainage, duration of injury and stage of decision

making. Inclusion criteria were the following: patients with traumatic SCI

(either paraplegia or tetraplegia with complete or incomplete injury),

neurogenic bladder, Malaysian, male and ability to speak either English or

Malay. We excluded patients who had a cognitive impairment. Patients

attending the outpatient spinal clinics and those admitted for spinal

rehabilitation were screened for eligibility. Except for one participant who

refused to participate owing to logistic difficulties, all 17 who were approached

agreed to participate.

Data collection Between May and December 2012, semistructured interviews were conducted

by two of the researchers (JPE and CJN), using an interview topic guide

(Box 1). Development of the interview guide was based on the conflict theory

of decision-making,11 the author’s (JPE) experience in working with people

who have SCI, opinions of experts in the field of decision making and issues

identified from the literature. Interviews were conducted until data saturation

was reached, that is, ‘a point reached during data collection when no new

themes or issues arise within a category of data’.12 All interviews were audio-

recorded, transcribed verbatim and checked. Memos were used to document

any relevant impressions, spontaneous ideas, evaluations, solutions and

thoughts after each interview and throughout the analyses. The duration of

the interviews ranged from 23 to 75 min.

Analysis The NVivo qualitative software package (version 10; QSR International Pty

Ltd, Doncaster, VIC, Australia) was used to manage the data, which were

analyzed thematically using an approach described by Braun and Clarke.13 The

analysis focused on the reasons why the patients chose or rejected a particular

treatment option or changed their bladder management method. JPE read the

transcripts repeatedly to familiarize herself with the data. Labeling individual

phrases or paragraphs with descriptive codes that reflect the meaning of the

data generated the initial codes. The codes that were conceptually similar were

grouped into categories and were constantly compared within and across

transcripts. The coding framework was revised iteratively until the team agreed

on the final framework, which was then used to code the rest of the transcripts.

The final process involved defining and naming the themes.

Reflections and data trustworthiness JPE is a female rehabilitation physician with 6 years of experience in managing

patients with SCI; as a novice qualitative researcher, this study is part of her

PhD project. CJN and WYL are her PhD supervisors and are experienced

qualitative researchers in the field of medical decision making. A number of

steps were taken to ensure data trustworthiness. In-depth interviews allowed

prolonged engagements with the participants, which enabled the researcher to

gain the participants’ trust and better understand the research field. The

researchers also kept records of all analysis decisions, kept a reflective journal

and maintained the verbatim quotations throughout all stages of analysis.

Emerging codes and categories were constantly critiqued and challenged by

CJN and WYL to reduce potential bias during data interpretation by JPE.

Statement of ethics Both University Malaya Medical Centre Medical Ethics Committee (878.7) and

The Ministry of Health Medical Research Ethics Committee (NMRR-12-91-

10850) approved the study. We certify that all applicable institutional and

government regulation regarding the ethical use of human volunteers were

followed during the course of this research. Written consent was obtained from

all participants.

RESULTS

The factors influencing a patient’s choice of a bladder management method were classified into broad categories: treatment attributes, patient attributes (physical and psychological), health professionals’ influences and social attributes (Table 2). Illustrative quotes that support the themes are presented in Boxes 2–6.

Table 1 Participants demographics and illness characteristics

No. of participants (n)

Age (years)

Range 19–58

Mean 36.4

Marital status at interview

Married 4

Single 11

Divorced 2

Cause of SCI

Motor vehicle accident 13

Fall 3

Diving injury 1

Chronicity of injury

New SCI (inpatient) 7

Chronic SCI (outpatient) 10

Level of injury

Paraplegia 9

Tetraplegia 8

Method of bladder management at interview

CIC 6

IDUC 5

SPC 4

Spontaneous voiding 2

Stage of decision-making

Undecided 2

Decided but has not implement 1

Implementing decision as inpatient 7

Implementing decision as outpatient 7

Abbreviations: CIC, clean intermittent catheterization; IDUC, indwelling transurethral catheterization; SCI, spinal cord injury; SPC, suprapubic catheterization.

Box 1 Interview topic guide

Understandings of spinal cord injury and bladder problem

Knowledge on bladder management options

Perceptions of bladder management options

The preferred/current treatment and why he chose it

Reasons for changing methods of bladder drainage (when relevant)

Sources of information

Information needs

People involved in making this decision and their roles

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Treatment attributes Treatments that were perceived to be convenient to execute and offer continence appealed to participants. However, the impact of the potential treatment complications on their decision was more variable (Box 2).

Convenience. The participants interpreted the concept of ‘conveni- ence’ differently. What appeared to be a convenient treatment option by a patient might be considered as inconvenient by another. For instance, some participants considered the frequent catheterization in CIC as troublesome and chose IDUC instead. For this group, carrying a urine bag was considered convenient, as the urine bag could store large amounts of urine. On the other hand, those who chose CIC viewed regular catheterization as an act that disciplined them and perceived the urine bag as ‘annoying’ and the presence of tubing restrictive to their mobility. The ability to change a suprapubic catheter at home by family members was considered convenient compared with IDUC, which required travelling to a health facility.

Continence. The ability of a particular treatment option to maintain continence was an important consideration when making a decision.

Patients were more likely to accept occasional incontinence; however, when the continence became more frequent, they would opt for another method of bladder management.

Treatment harm. When making a decision, almost all participants were concerned about renal disease, but the reactions to other complications (urinary tract infections, urethral injury and surgical complications) were more variable. Many considered IDUC, CIC and SPC to be protective against renal disease, whereas sponta- neous voiding was felt to be an unsafe option. Past experience in handling these complications and doctors’ reassurance helped to alleviate these concerns. Participants who refused SPC viewed the procedure as painful, particularly among those who had recent surgeries. Although the patients’ main reasons for avoiding SPC were fear of complications, they were unclear about the nature of complications. There was a misperception that SPC surgery involved the genitalia.

Box 2 Illustrative quotes for treatment attributes

Convenience

‘I never thought of asking other people to do it [CIC]. If I use this IDUC, I only

need to change it once a week instead of every 4 h. It’s troublesome for others to

do it for you. It’s a bit difficult.’ (03_PT_06, tetraplegia, IDUC)

‘My sister changes it [SPC] for me. The nurse taught her before I was

discharged. It’s easy, I don’t have to go to hospital.’ (02_PT_03, tetraplegia,

SPC)

Continence

‘This method [CIC] is good. I can control my urine. If not I will choose the one

with the tube [IDUC].’ (05_PT_04, paraplegia, CIC)

Treatment harm

‘ I felt this one [CIC] there is some friction. It’s a bit intrusive, not too keen on

that. Forced in you know. I don’t like that. It could be injury to my urethra, tear

and all that. So a bit prejudice about this thing. Later on urine might leak out or

lead to other complicationsy I thought if the doctor handle it maybe OK. But if

I go back and I have do it on my own. That’s why I am against CIC.’ (01_PT_01,

paraplegia, IDUC)

‘When you have surgery, there might be complications in the future. As I age, I

am sure there will be complications. That [SPC] will be my last resort.’

(03_PT_02, paraplegia, CIC)

Box 3 Illustrative quotes for patients’ physical attributes

Physical ability

‘Previously, I have problem to move in and out of bed. So I had to do it [CIC] on

the bed. So every 3 to 4 h, I have to call my mom to help me. It was troublesome

for my mom. So I decided to stop CIC and did IDUC. [6 years later]. Now, I take

only a few seconds to transfer from the bed to wheelchair and to the toilet bowl.

My movements are normal now. Now that I am independent, I think I will do

CIC.’ (02_PT_01, paraplegia, changed from CIC to IDUC)

Sexuality and fertility functions

‘I was only thinking about myself. I was not married. So I don’t really care about

these things [sexuality and fertility]. When I chose SPC, it was for my own good.

Sex or fertility was not important. It is only now that these issues cross my

mind.’ (02_PT_02, tetraplegia, SPC)

After the accident, I just forgot about it completely. Nor more urge. Not

interested at all.’ (05_PT_05, paraplegia, spontaneous)

Table 2 Categories, themes and subthemes of factors influencing

decision on method of bladder management

Category Themes Subthemes

Treatment attributes Convenient Frequent catheterization

Care of urine bag

Presence of tubing

Treatment harm Risk of urethral trauma

Risk of urinary tract infec-

tions

Penile discomfort

Pain

Risks of surgical complica-

tions

Risk of renal disease

Continence

Health professionals’

influences

Opinion on treatment

option

Support

Social influences Family support Decisional role

Supporting patient’s choice

Burden of care

Peers’ experiences and

opinion

Observation of peers’

experiences

Sharing of information

Motivation

Social activities

Physical attributes Physical ability Hand function

Body balance

Transfer skills

Sexuality and fertility

functions

Psychological attributes Embarrassment

Confidence

Satisfaction

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Patients’ physical attributes Physical disability. Participants cited impaired hand function, body imbalance and impaired transfer skills as reasons not to choose CIC (Box 3). As they regained these functions over time, their bladder management method preference tended to change.

Sexuality and fertility. Concerns about sexuality and fertility did not emerge spontaneously unless the researchers probed the issues. At the early stage of the injury, having sex and children were not priorities and did not influence the choice of bladder drainage. The importance of these functions became more evident at later stages of their illnesses when they began to think about having a relationship and marriage.

Patients’ psychological attributes Embarrassment. Participants were embarrassed to carry a urine bag and were concerned about the stigma (Box 4). Those who chose this method also shared the same sentiment but coped with it by hiding the urine bag.

Confidence in catheterization. Participants’ decision to use CIC was not only affected by the confidence in performing catheterization

themselves but also whether they trusted their caregiver to perform the task. There was fear that an inexperienced caregiver would inflict pain and injury to them during the catheterization.

Satisfaction. The satisfaction that participants had with their current method reinforced their belief that it was the best choice for them, whereas dissatisfaction made them discontinue the method and seek another treatment option.

Health professionals’ influences Opinions on treatment options. Participants tended to respect and concur with the health professionals’ expert opinions on the treat- ment recommendation, even when they were not fully informed of the treatment options and their risks and benefits (Box 5). At times, patients were instructed by the doctors to choose a particular treatment option without first asking their preference.

At early stages of injury, patients with SCI were overwhelmed with many competing concerns, and bladder management was often not their priority. In addition, most had no prior knowledge about SCI. As a result, they often followed their doctors’ recommendations when making the decision. However, this did not apply when SPC was recommended; other factors such as fear of surgery and peers’ opinions had a greater influence on the participants’ decisions compared with the doctors’ opinions.

Support. The degree of support provided to the patients by the doctors influenced the participants’ treatment choices. Discussing the decision over several sessions and using educational materials helped the patients to make decisions.

Social attributes Peers’ opinions and experiences. Peers with bladder problems had a substantial influence on patients’ decisions and could, at times, over- ride doctors’ recommendations (Box 6). Observing their peers performing a particular bladder drainage method had a significant impact on the participant’s decision. Similarly, being surrounded by peers using a different method of bladder management might lead

Box 4 Illustrative quotes for patients’ psychological attributes

Embarrassment

‘First of all, I think this thing [urine bag] is embarrassing to bring around. I don’t

think I need to tell everybody I have this problem. Even though we are fine with

it, people around us may feel uncomfortable when they see it.’ (03_PT_02,

paraplegia, CIC)

Confidence in catheterization

‘I am not confident to ask other people to do this catheterization. It’s OK if the

doctors do it. To ask my wife to do it, she is not used to it. If I can do it myself, I

know where it hurts. But if other people do it, they might want to get it done

quickly so they probably just shove it in.’ (03_PT_04, tetraplegia, IDUC)

Satisfaction

‘I can feel the difference after I did SPC. It’s better compared to IDUC. It’s less

painful and easier to change. My mother and my sister change the catheter.

Once my SPC site was blocked, I was admitted and I immediately decided to do

it again. There was no hesitation. I never thought of other options.’ (02_PT_02,

tetraplegia, SPC)

Box 5 Illustrative quotes for health professionals’ influences

Opinion on treatment option

‘Basically a patient should follow doctor’s advice. If he said I couldn’t use a bag,

then I will not use the bag. If the doctor says you have choices, then you choose

which is convenient for you.’ (05_PT_05, paraplegia, spontaneous)

‘The hope to walk again was very high. So I didn’t really think about this bladder

problem. When the doctor told me I need to do CIC, I just followed. I didn’t

know the benefits or the risks.’ (02_PT_01, paraplegia, SPC)

‘He [the doctor] did not ask me to think about it. He explained that it is better

for me to use CIC, not IDUC. It was his decision. I just followed. I didn’t mind.’

(05_PT_03, paraplegia, CIC)

Support

‘The first time the doctor told me about it [SPC] I felt pressured. Then he came

back, gave me some diagrams, some motivations, and talked about my mental

and physical health. Slowly I was able to accept it and made the decision to do

it.’ (02_PT_02, tetraplegia, SPC)

Box 6 Illustrative quotes for social influences

Peers’ experiences and opinions

‘He was wearing a catheter bag. Then about a month back they asked him to

take it out and do CIC. So every time every 4 h he has to call the nurse to bring

the catheter. I think it is a bit of a problem. It also turns me off sometimes. After

I saw that guy suffering from doing the CIC, I thought this [IDUC] is the best

method.’ (01_PT_01, paraplegia, IDUC)

‘So far I have not met anybody using this. I need to see for myself a person who

uses this. I want to see how he changes it, the care involved, and the risks and

benefits. Maybe from there I might gain some confidence to make a decision.’

(03_PT_06, tetraplegia, IDUC)

Family support

‘I did not discuss this with them [family]. They don’t know anything about this.

Even if I discussed, I don’t think I will get any answer. I still have to make the

decision. So I made my own decision.’ (03_PT_02, paraplegia, CIC)

‘I didn’t want to consult anyone else, not too comfortable to talk about this thing

with my parents.’ (01_PT_01, paraplegia, IDUC)

Social activities

‘I am choosing this [IDUC] in the understanding that for the next 1 or 2 months

I won’t be going out much, concentrating more on my exercise and for some

kind of recovery.’ (01_PT_01, paraplegia, IDUC)

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them to choose that method. Similarly, the information that participants gathered from their experienced SCI peers served as an impetus to help them decide whether to accept a particular treatment option.

Family support. This study did not find that family support had a direct influence on the patients’ decision-making process. Participants felt that their families were not knowledgeable about their condition, and some felt uncomfortable discussing bladder drainage methods with their family, because it was perceived as something private. However, participants did consider the burden of care their choices might have on their family and choose methods that were the easiest for their families to manage.

Social activities. The level of social activities in which the patient was likely to be engaged is a factor to consider when making decisions about treatment options. Participants would choose an option that they perceived would allow them to participate in their social activities. When the patients were not involved actively in social activities, they were willing to tolerate the disadvantages of a particular treatment option.

DISCUSSION

This qualitative study provides insight into the factors that influence decision making in people with SCI. Through interviews, the participants expressed how the treatment attributes, health profes- sionals’ preferences, and their physical, social and psychological status influenced their decisions.

This study highlights how people with SCI give different emphases to medical complications associated with treatment options, which in turn determine their choice of bladder drainage method. The information provided by health professionals, participants’ preinjury perceptions about disability and bladder problems and previous experience all contribute to the participants’ views regarding these complications. Therefore, it is important for health professionals to explore patients’ perceptions of treatment complications and provide accurate information, especially during the early phases of their illnesses.

Following SCI, survivors are usually confined to an environment with which they are unfamiliar, and this often excludes them from making decisions about their own treatment.14,15 Similar to a previous study, we found that participants trust and rarely question the information they receive from health professionals,16 impelling them to simply agree with what was recommended. Health professionals should be aware of this imbalanced power relationship and make an attempt to create an environment in which patients are able to make informed choices with minimal influence from health professionals. One way to achieve this would be to ensure that patients receive accurate and balanced information about the treatment options and their benefits and risks. In this study, some participants who made decisions based on insufficient information and misperceptions decided to change their method of bladder management at a later time. Such a change normally occurred when the patient experienced adverse effects of the chosen treatment option. This result not only causes psychological distress to the patient but also wastes resources for retraining patients.

Peers’ influences on participants’ decisions in this study echoed the results of previous studies that described peer support as indispen- sable when peers have experience with SCI.17,18 In this study, peer support seemed to influence those who were making decisions about SPC. It is likely that our participants did not receive adequate

information and support when they were asked to consider SPC. A previous study reported that SPC users’ initial negative experiences were due to inadequate preparation and support from health professionals.19

It was rather unexpected that, in this study, there was a lack of involvement of the family in the patients’ decision-making process. SCI is known to cause emotional and physical stress to family members, and many are involved in caregiving responsibilities. Thus, it would be natural to assume that their opinions are valued when making treatment decisions.20 It could be that our participants considered bladder management as something private, which consequently hindered family involvement. More studies are needed to define the role of the family in decision making, across different contexts and cultures.

As evident from this study, the ability of patients to imagine their future activities influenced the choice of bladder drainage. SCI survivors encountered difficulties to move forward and needed time to rediscover their new selves.21 In the case of bladder management, it might be necessary to help them visualize the possible social activities in which they are likely to engage and how different methods of bladder drainage may facilitate or hinder those activities. Once these individuals have chosen a method, it is equally important to educate them on how to manage the entire procedure not only in the community but also at home and in the office. For instance, in CIC, in addition to emphasizing the ability to self-catheterize, the health professionals should counsel patients on how they could independently prepare the catheterization equipment, discard the urine and manage the consequences of leaking, such as changing soiled clothes and linens. Patients who are managed in hospitals are likely to overlook these tasks, as most of these are carried out by hospital aids.

Clinical implications This study describes the importance of how the particular treatment, the attributes of patients and health professionals and social factors affect the decision-making process of patients with SCI. Patients also trust the information they receive from health professionals and use it to help them make decisions. It is, therefore, crucial for health professionals to provide sufficient high-quality information and explore what is important to SCI patients when assisting them in making decisions that are congruent with their values. At the time of this study, there were no structured health education programmes on bladder management options at any study sites. Future patient education programmes should include the provisions of accurate and balanced information on the treatment options and their risks and benefits. Health professionals should be trained on how to support patients in decision making using effective communication skills or decision support tools, such as patient decision aids.8 The important role that peers play in the decision-making process suggests that having a platform for patients to connect with their peers is beneficial.

Limitations and strengths This study has a few limitations. First, decision making is a dynamic process that occurs over time. By interviewing participants at a particular stage of illness may not provide a full picture of their decision-making process. Future studies should consider conducting multiple interviews with each participant over time. Other methods of data collection, such as observation and clinical record analysis, might also be helpful. Second, the patients interviewed were from a tertiary hospital with rehabilitation facilities, and thus the findings

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may not be transferrable to those in different settings where the options are not identical. The variations in clinical settings, health- care policies and cultural beliefs on bladder-related diseases and disabilities may also make some of the findings non-transferable.

The strength of this study is it is one of the few studies that capture the experiences of patients with SCI in the decision-making process. The sampling technique enabled us to capture patients at the point of decision making as well as those with experience. This approach provides information at the time of decision making as well as retrospectively.

CONCLUSION

Participants’ encounters with health professionals and interactions with peers have important roles in the decision-making process. Patients’ physical, psychological and social attributes influence their choice of bladder management. Health professionals should consider these factors when supporting patients in making decisions about their treatment options.

DATA ARCHIVING

There were no data to deposit.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ACKNOWLEDGEMENTS We thank the Director of Health Malaysia for permission to publish this paper.

The study was funded by the BKP Grant from University of Malaya, Malaysia

(BKP002-2012A).

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Article

In North America, approximately 20,000 people acquire spinal cord injury (SCI) each year, and approximately 270,000 individuals with SCI live within the United States (Cripps et al., 2011; National Spinal Cord Injury Statistical Center [NSCISC], 2012). In addition to functional impair- ment directly caused by the initial injury, individuals with SCI often experience secondary health conditions, psycho- social adjustment challenges, and limitations related to architectural and attitudinal barriers in the broader work environment (Schoen & Leahy, 2012). Work is critical to the overall health and subjective well-being (SWB) of indi- viduals with SCI, with unemployment and poverty restrict- ing access to high-quality health care and rehabilitative resources (Cao, Krause, Saunders, & Bingham, 2014; Krause & Terza, 2006; Marini, Lee, Chan, Chapin, & Romero, 2008).

Compared with people without disabilities, a signifi- cantly lower proportion of individuals with SCI are employed (Cao et al., 2014; Marini et al., 2008). Longitudinal data indicate that nearly 60% of individuals with SCI are employed prior to injury, but only about 30% are employed following rehabilitation from injury (NSCISC, 2012; Young & Murphy, 2009). Cao et al. (2014) found that over a 10-year period, a substantial proportion of individu- als with SCI are living in poverty, with 21% reporting annual household income less than US$10,000, and 27% reporting annual income between US$10,000 and US$24,999. Conversely, individuals with SCI who reported

an annual household income of US$25,000 or more had higher SWB and fewer problems with health and other life situations than individuals in the lower-income groups (Cao et al., 2014).

In recent years, there has been a growing interest in the field of organizational behavior and industrial/organiza- tional (I/O) psychology in adopting a positive psychology approach when investigating work-related behaviors, atti- tudes, and outcomes in employment settings (Luthans, 2002a). Positive organizational behavior (POB) has its roots in positive psychology and has been defined as “the study and application of positively oriented human resource strengths and psychological capacities” (Luthans, 2002b, p. 59). Organizational behavior and I/O findings indicate that attachment and hope are related to several important vocational variables among the general population (Wandeler, Baeriswyl, & Shavelson, 2011). However, there is a dearth of research applying POB and positive psychol- ogy concepts to improve employment outcomes of people

621036RCBXXX10.1177/0034355215621036Rehabilitation Counseling BulletinBlake et al. research-article2015

1West Virginia University, Morgantown, USA 2University of North Texas, Denton, USA 3University of Wisconsin–Madison, USA

Corresponding Author: John Blake, Assistant Professor, Counseling, Rehabilitation Counseling & Counseling Psychology, West Virginia University, P.O. Box 6122, 504-C Allen Hall, Morgantown, WV 26506-6122, USA. Email: [email protected]

Attachment and Employment Outcomes for People With Spinal Cord Injury: The Intermediary Role of Hope

John Blake, PhD, CRC1, Jessica Brooks, PhD, CRC2, Hannah Greenbaum, MA1, and Fong Chan, PhD, CRC3

Abstract The purpose of this article is to evaluate the mediation effect of hope on the relationship between attachment and full-time employment for people with spinal cord injury (SCI). Quantitative descriptive research design using logistic regression, multiple regression, and correlational techniques were used. Eighty-four persons with SCI were recruited from several SCI advocacy organizations in Canada, the United Kingdom, and the United States. The results show that secure attachment, anxious attachment, and hope were significantly related to employment. Hope was found to be a significant mediator of the relationship between attachment and full-time employment. Results provide support for the use of hope-based interventions by vocational rehabilitation counselors working with individuals with SCI.

Keywords hope, attachment, mediation analysis, spinal cord injury, employment

78 Rehabilitation Counseling Bulletin 60(2)

with disabilities, including people with SCI (Chan, Chan, Ditchman, Phillips, & Chou 2013; Elliott, Witty, Herrick, & Hoffman; 1991; Smedema, Pfaller, Moser, Tu, & Chan, 2013; Wilson et al., 2013). To explore the relevance of attachment and hope for vocational rehabilitation profes- sionals, the goals of this study were to evaluate the relation- ships between attachment, hope, and full-time employment in a sample of individuals with SCI.

Attachment

Experiences of caregiver availability and responsiveness during infancy and early childhood contribute to the devel- opment of adult attachment profiles (Bowlby, 1951, 1969, 1973; Mikulincer & Shaver, 2005). Attachment theory (Bowlby, 1951) posits that intimate bonds between infant and caregiver are essential for positive psychological devel- opment. Adult attachment behavior is the product of inter- nal working social-relational models that are comprised of early caregiver relationship dynamics (Fraley, Vicary, Brumbaugh, & Roisman, 2011). Bowlby (1969, 1973) described attachment in adults as the unconscious need to recreate and maintain interpersonal relationships from childhood. Over the course of the last century, several scholars in developmental and social psychology have hypothesized that attachment is a fundamental human moti- vation to feel a sense of belonging and connection to others (e.g., Ainsworth, Blehar, Waters, & Wall, 1978; Baumeister & Leary, 1995; Freud, 1930; Fromm, 1956; Hazan & Shaver, 1990; Maslow, 1968; Ryan, 1991).

A significant body of research has indicated that adult attachment is linked to work-related outcomes (e.g., Collins & Read, 1990; Feeney & Noller, 1990; Hazan & Shaver, 1987, 1990; Little, Nelson, Wallace, & Johnson, 2011; Richards & Schat, 2011). Hazan and Shaver (1990) found that securely attached adults (50% of study participants) had the highest levels of work satisfaction and overall well- being, that individuals with anxious/ambivalent attach- ments (30% of participants) were less productive at work than those with secure attachments, and that individuals with avoidant attachment (19% of participants) were over- involved with their jobs and used work activity to avoid social interactions. Other studies have indicated that securely attached employees are more willing to engage in career exploration, have higher career self-efficacy, and fewer problems with career commitment (Ketterson & Blustein, 1997; Wolfe & Betz, 2004). Securely attached people also have less dysfunctional thoughts about work problems and more positive relationships with coworkers and employers (Mikulincer & Florian, 1998; Mikulincer & Shaver, 2005; van Ecke, 2007).

Attachment has also been linked to health and disabil- ity outcomes (e.g., Davies, Macfarlane, McBeth, Morriss, & Dickens, 2009; Gick & Sirois, 2010; Huebner, Thomas,

& Berven, 1999; Ponizovsky, Arbitman, Baumgarten- Katz, & Grinshpoon, 2014; Rossi et al., 2005; Wilson et al., 2013). However, little is known about the underly- ing processes that explain the relationships between attachment and rehabilitation outcomes, and related find- ings have been mixed (Lopez, Mauricio, Gormley, Simko, & Berger, 2001). For instance, Wilson et al. (2013) found that secure attachment patterns significantly contributed to subjective happiness in people with SCI. Sela-Kaufman, Rassovsky, Agranov, Levi, and Vakil (2013) found that avoidant attachment style significantly moderates the rela- tionship between injury severity and occupational func- tioning among individuals with traumatic brain injury, with low avoidant attachment (secure attachment) predict- ing higher levels of occupational functioning. Conversely, Yokotani (2011) found that people with autistic spectrum disorders reported better work adjustment when they experience a more avoidant attachment style. Mixed find- ings highlight the need for rehabilitation researchers to evaluate the implications of specific attachment patterns among clients with different disabilities, including SCI.

Hope

Decades after seminal attachment research, Snyder (1994) developed his hope theory. Hope is defined as “a cognitive set that is based on a reciprocally derived sense of success- ful: (a) agency (goal-directed determination) and (b) path- ways (planning of ways to meet goals)” (Snyder et al., 1991, p. 570). Like Scheier and Carver’s (1985) optimism model, Snyder et al.’s (1991) hope theory proposes a cogni- tive set related to outcome expectancies. However, while Scheier and Carver’s (1985) theory posits that outcome expectancies are the primary determinants of goal-directed behavior, with efficacy expectancies as minor contributors, Snyder et al.’s (1991) hope model describes an iterative process between an efficacy expectancy comprised of self- beliefs about goal-achievement ability (agency) and an out- come expectancy comprised of perceptions of available routes to goal achievement (pathways). Therefore, Snyder et al.’s (1991) theory is more closely aligned with Rotter’s (1966) locus of control.

Hope is empirically related to psychological factors such as positive affect (Ciarrochi, Heaven, & Davies, 2007), cop- ing (Chang & DeSimone, 2001), adjustment (Gilman, Dooley, & Florell, 2006), happiness (Alarcon, Bowling, & Khazon, 2013), SWB (Şahin, Aydın, Sarı, Kaya, & Pala, 2012), and meaning of life (Dogra, Basu, & Das, 2011). Unlike attachment profiles, states of hope are transient and amenable to intervention (Cheavens, Feldman, Gum, Michael, & Snyder, 2006; Davidson, Feldman, & Margalit, 2012). Hope-based interventions center on increasing cli- ents’ goal-directed thinking and emphasize the role of adap- tive coping in relation to achieving therapy goals.

Blake et al. 79

A growing body of POB research links hope to work- related outcomes (e.g., Luthans, Avolio, Avey, & Norman, 2007; Luthans, Norman, Avolio, & Avey, 2008; Youssef & Luthans, 2012). Organizational researchers consider hope to be a part of the higher-order construct of psychological capital. Psychological capital refers to an “individual’s pos- itive psychological state of development” and includes resources such as hope, optimism, self-efficacy, and resil- ience (Luthans, Youssef, & Avolio, 2007, p. 3). A recent meta-analysis (Avey, Reichard, Luthans, & Mhatre, 2011) found that psychological capital had a significant impact on job satisfaction, job tenure, organizational commitment, organizational citizenship behaviors, and job performance. Another meta-analysis provided empirical evidence for sig- nificant relationships between the hope subconstructs (i.e., pathways and agency), work performance, and employee well-being (Reichard, Avey, Lopez, & Dollwet, 2013). In an experimental study, Luthans, Avey, and Patera (2008) found that participants in a psychological capital training inter- vention developed more psychological capital than study participants from a comparison group.

Several studies have indicated that hope levels are linked to a range of health and rehabilitation outcomes. Elliott et al. (1991) reported that higher hope individuals with SCI exhibited reduced symptoms of depression and psychoso- cial impairment. Smedema et al. (2013) reported that hope was significantly related to positive rehabilitation con- structs, including self-efficacy, self-esteem, disability acceptance, community participation, and life satisfaction for people with SCI. In a pilot study, Hergenrather, Geishecker, Clark, and Rhodes (2013) found that a hope- based intervention helped improve goal-setting skills, health-promoting behaviors, and employment-seeking behaviors among people with HIV/AIDS. Chan et al. (2013) tested the power of an expanded model of Snyder’s hope theory for prediction of participation in employment and other life activities for people with SCI. The hope subcon- structs (i.e., agency and pathways) were positively related to participation, causality, perceived control, resilience, and SWB. Furthermore, path analytic findings indicated that direct effects of agency and causality, along with indirect effects of pathways, perceived control, and resilience accounted for a significant amount of variance in participa- tion and life satisfaction (Chan et al., 2013).

Attachment, Hope, and Employment

Snyder’s (1994) hope theory incorporates the construct of attachment and describes a dynamic in which attachment style is linked to adult levels of hope. Findings from one recent meta-analysis focused on the relationship between adult attachment and hope are consistent with this hypoth- esis, with results indicating significant bivariate relation- ships between secure attachment and hope (r = .39),

avoidant attachment and hope (r = −.23), and anxious attachment and hope (r = −.22; Blake & Norton, 2014). In addition, several studies have yielded findings, indicating that hope was a significant mediator of relationships between attachment and rehabilitation-relevant outcomes. For example, Zhang et al. (2012) found that hope partially mediated the relationship between attachment and SWB for middle-school students. Shorey, Snyder, Yang, and Lewin (2003) found that hope partially mediated the relationship between attachment and mental health for college students. Simmons, Nelson, and Quick (2003) found that hope explained relationships between secure attachment and employee health, as well as avoidant attachment and poor employee health for home care nurses. However, not all mediation analyses have produced significant effects. Simmons, Gooty, Nelson, and Little (2009) found that at the bivariate level, workers’ attachment and hope were signifi- cantly related, and that attachment and hope significantly correlated with trust in supervisor and worker burnout. Nevertheless, mediation analyses indicated that hope did not explain relationships between attachment and outcome.

Purpose of Study

Rehabilitation literature indicates a need for cohesive posi- tive psychological frameworks to guide evidenced-based practice research in rehabilitation. Several studies have indi- cated that attachment and hope are significant predictors of key health, rehabilitation, and employment-related outcomes. Emerging research has also indicated that hope is related to attachment, and that hope may be a significant mediator of relationships between attachment and health, rehabilitation, and employment-related outcomes. However, there is a lack of research examining the relationships between attachment, hope, and employment participation. As individuals with SCI have a high unemployment rate, there were two main aims of this study: (a) to examine the relationships between attach- ment, hope, and full-time employment for individuals with SCI, and (b) to examine the mediation effect of hope on the relationships between attachment and full-time employment for individuals with SCI.

Method

Participants

Eighty-four participants were recruited from the member- ships of SCI advocacy organizations, including the Canadian Paraplegic Association (CPA), National Spinal Cord Injury Association (NSCIA), Paralyzed Veterans of America (PVA), Spinal Cord Injury Network (SCIN)— United Kingdom, and affiliated organizations. Participant eligibility was determined by self-report of (a) presence of a SCI, (b) age between 18 and 64 years, and (c) sixth-grade

80 Rehabilitation Counseling Bulletin 60(2)

or above reading level. Data were collected via an anony- mous, online survey, which participants accessed through the advocacy organizations’ websites newsletters. Therefore, participant response rate cannot be calculated. One hundred fifty-five surveys were attempted and 105 were completed. Eighty-eight completed surveys met inclu- sion criteria for the current study. Two cases were elimi- nated for missing data, and two cases were eliminated for participant response errors (N = 84). Participants ranged from 21 to 64 years of age (M = 47.05, SD = 10.72). Sample participants reflected a higher proportion of women than is estimated for individuals with SCI in the United States, with 26 female and 57 male participants (31% and 67.9%, respectively). One participant did not mark a response for gender. Participants were asked to select all applicable racial/ethnic identities. Most participants identified as Caucasian (88.1%), 6% were Black or African American, 3.6% were Asian American, and 2.4% were Native American. Two participants (2.4%) self-described as “other race,” and one participant did not report racial/ethnic iden- tity. Participants were asked to select all applicable employ- ment status descriptors. Twenty-three participants reported full-time employment (27.4%). Nine participants reported part-time employment (10.7%) and 11 were volunteers (13.1%). Forty-eight reported being unemployed (57.2%). Nearly all participants reported completing high school (97.7%), and the majority of participants had completed some post-secondary education (85.5%). Participants reported more partial injuries (56%) than complete injuries (44%). Thirty-eight participants had cervical-level injuries, 32 had thoracic-level injuries, and 14 had lumbar injuries. Table 1 includes descriptive data on key demographic variables.

Measures

Full-time employment status was coded as a binary out- come from collected demographic data. Participants who reported full-time employment were coded as employed full time. Participants who reported that they were not employed full time were coded as not unemployed full time.

The Attachment Style Questionnaire (ASQ; Feeney, Noller, & Hanrahan, 1994) was used to measure attachment. The ASQ is a self-report measure comprised of 40 items and yields separate scale scores for secure, avoidant, and anxious attach- ment. Respondents rate their level of agreement according to a Likert-type scale from 1 (totally disagree) to 6 (totally agree). Scale scores are consistent with the secure, avoidant, and anxious-ambivalent attachment domains reported by Hazan and Shaver (1987). Scales include items such as “Overall I am a worthwhile person.” ASQ validity is sup- ported by intercorrelations among the three subscales. The Secure and Avoidant subscales were negatively correlated (r = −.49); the Secure and Anxious subscales were negatively

correlated (r = −.29); and the Avoidant and Anxious subscales were positively correlated (r = .35). Reported test–retest reli- abilities over 10 weeks were between .74 and .80. Cronbach’s alphas ranged from .83 to .85 (Feeney et al., 1994). In the present study, Cronbach’s alpha was computed to be .75 for the Secure subscale, .83 for the Anxious subscale, and .81 for the Avoidant subscale.

The Trait Hope Scale (THS; Snyder et al., 1991) was developed as a 12-item instrument that yields scores on total hope, pathways thoughts, and agency thoughts. Four distractor items were omitted for the current study; there- fore, participants responded to eight THS items. Respondents indicated level of agreement with item statements accord- ing to a Likert-type scale from 1 = definitely false to 4 = definitely true. Example items include “I can think of many ways to get out of a jam” and “I meet the goals I set for myself.” Reported Cronbach’s alphas ranged from .74 to .84 for total hope (Snyder et al., 1991). Construct validity is

Table 1. Participant Demographic and SCI Characteristic (N = 84).

Variable n (%) M (SD)

Age 47.05 (10.72) Age at injury 32.8 (12.49) Gender Male 57 (67.9) Female 26 (31.0) Race/ethnicity White 74 (88.1) African American 5 (6.0) Asian American 2 (3.6) Native American 2 (2.4) Other race 2 (2.4) Highest level of education Some high school 1 (1.2) Graduated from high school 10 (11.9) Some college 30 (35.7) Graduated from college 25 (29.8) Some graduate school 3 (3.6) Completed graduate school 14 (16.7) Employment status Full-time employment 23 (27.4) Part-time employment 9 (10.7) Volunteer 11 (13.1) Unemployed 48 (57.2) SCI level Cervical (neck) 38 (45.2) Thoracic (upper back) 32 (38.1) Lumbar (lower back) 14 (16.7) SCI completeness Partial 47 (56.0) Complete 37 (44.0)

Note. SCI = spinal cord injury.

Blake et al. 81

supported by predictable relationships with similar instru- ments such as Scheier and Carver’s (1985) Life Orientation Test and Rosenberg’s (1965) Self-Esteem Scale (Snyder et al., 1991). In the current study, Cronbach’s alpha for the THS was computed to be .84.

Data Analysis

All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS 23.0). A simple impu- tation method using regression was used to estimate missing data. The imputation method computes estimations based on the values of other related item variables in the same measure to replace missing data. This method is preferred over case deletion, as it will not decrease the sample size (i.e., statistical power loss) or affect the sample representativeness. According to Fox-Wasylyshyn and El-Masri (2005), simple imputation and multiple imputation methods will yield simi- lar results when the missing data are less than 5%.

Descriptive statistics were computed to provide informa- tion about the demographic characteristics of the sample pop- ulation and for the predictor, mediator, and outcome variables. Three mediation analyses were performed using multiple regression and logistic regression to investigate hope (M) as a potential mediator of the relationships between (a) secure attachment (X

1 ) and full-time employment (Y), (b) anxious

attachment (X 2 ) and full-time employment, and (c) avoidant

attachment (X 3 ) and full-time employment. We used the boot-

strap testing approach recommended by Hayes (2013) to test our mediation hypotheses. Hayes and his colleagues (Hayes, 2009, 2013; Preacher & Hayes, 2008; Rucker, Preacher, Tormala, & Petty, 2011) indicated that because of limitations of the Baron and Kenny (1986) assumptions for mediation analysis, tests of mediation should now be based on an esti- mate of the indirect effect, and interpretation of the results should be focused on the size and sign of the indirect effect. In addition, we evaluated the significance of the individual paths (X → M) and (M → Y) to provide supplementary information for the models. The SPSS INDIRECT macro written by Preacher and Hayes (2008) was used to estimate the total, direct, and indirect effects of attachment on full-time employ- ment through hope. It should be noted that because the out- come variable (full-time employment) is a dichotomous variable, the SPSS INDIRECT macro calculated estimates for direct and total effects, and the path from the proposed media- tor to the outcome variable using logistic regression (Preacher & Hayes, 2008).

Results

Descriptive Statistics

The overall employment rate for participants was low (38.1%) compared with the general population (74.2%), but

slightly higher than current estimates for the broader popu- lation of people with SCI (32.3%; Houtenville, Brucker, & Lauer, 2014). The current study is focused on effects of attachment and hope for full-time, paid employment. Participants who reported full-time, paid employment were coded as employed full time. Participants who did not report full-time, paid employment were coded as not employed full time. Twenty-three participants (27.4%) were employed full time. Regarding attachment, participants with SCI in the present study had moderately secure attachment (M = 4.34, SD = 0.72) and low-moderate levels of avoidant (M = 3.10, SD = 0.64) and anxious attachment (M = 2.98, SD = 0.74). The average hope rating of 3.13 (SD = 0.48) indicates that participants had moderately high levels of hope and overall agency and pathways thinking. Table 2 includes means and standard deviations for questionnaire subscales.

Correlation Analysis

Bivariate correlations between all variables investigated in the study are reported in Table 2.

Secure attachment was found to be positively associated with hope (r = .35, p < .001) and full-time employment (r = .23, p < .05). In contrast, anxious attachment and avoid- ant attachment were inversely related to hope (r = −.39 and r = −.35, p < .001, respectively) and full-time employment (r = −.29, p < .01 and r = −.20, n.s., respectively). Hope was positively associated with full-time employment (r = .36, p < .001). Secure attachment was negatively related to avoidant attachment (r = −.66, p < .001) and anxious attachment (r = −.44, p < .001), while the two insecure domains were positively correlated (r = .53, p < .001).

Mediation Analysis

Three simple mediation analyses were computed to evalu- ate hope as a mediator of the relationship between secure attachment and employment, anxious attachment and full- time employment, and avoidant attachment and full-time employment. The SPSS INDIRECT macro written by

Table 2. Bivariate Correlations, Means, and Standard Deviations (N = 84).

Variable 1 2 3 4 5

1. Secure attachment 1 2. Anxious attachment −.44** 1 3. Avoidant attachment −.66** .53** 1 4. Hope 35** −.39** −.35** 1 5. Full-time employment .23* −.29** −.20 .36** 1 M 4.34 3.10 2.98 3.12 — SD 0.72 0.64 0.74 0.47 —

*p < .05. **p < .01.

82 Rehabilitation Counseling Bulletin 60(2)

Preacher and Hayes (2008) was used to estimate the total, direct, and indirect effects of attachment on full-time employment through hope. As an example, the following are the equations for the secure attachment analysis:

Log odds full-time employment

constant secure attachmen

( ) = +c tt error.( )+

(1)

Hope constant secure attachment error.= + ( )+a (2)

Log odds full-time employment

constant secure attachmen

( ) = +c’ tt hope error.( )+ ( )+b

(3)

Total effect Direct effect Indirect effectc c a b( ) = ( )+ ( )×’ .

Indirect effect Total effect Direct effecta b c×( ) = ( )− ( )c’ .

Because full-time employment is a dichotomous vari- able, coefficients in Equations 1 and 3 were estimated in INDIRECT using logistic regression, whereas ordinary- least-squares (OLS) regression was used for the coefficients in Equation 2. The Nagelkerke R2 for the secure attachment model was computed to be .21, indicating a moderate effect size. A graphical representation of this simple mediation model and information for the unstandardized path coeffi- cients (a, b, c, and c′) are presented in Figure 1.

As can be observed in Figure 1, the odds of being employed full time were higher among individuals with relatively high levels of secure attachment (path c = .57). Secure attachment was positively associated with hope (path a = .34). Finally, hope was positively associated with the odds of full-time employment (path b = .90). The direct effect of secure attach- ment (path c′ = .30) was not statistically significant. Most rel- evant to the mediation hypothesis was the estimate of the indirect effect of secure attachment on full-time employment, computed as the product of the OLS regression coefficient estimating hope from secure attachment (path a in Figure 1) and the logistic regression coefficient estimating full-time employment from hope controlling for secure attachment (path b in Figure 1). If the bias-corrected bootstrap confidence interval (CI) for the product of these paths (ab) does not include 0, it will provide evidence of a significant indirect effect of secure attachment on employment through hope (Hayes, 2009; Preacher & Hayes, 2008). Using the INDIRECT procedure with 5,000 bootstrap samples revealed a significant indirect effect of secure attachment on full-time employment through hope (point estimate = .33, 95% CI = [.09, .80]).

The Nagelkerke R2 for the anxious attachment model was computed to be .21. A graphical representation of this simple mediation model and information regarding the unstandardized path coefficients (a, b, c, and c′) are pre- sented in Figure 2.

As can be observed in Figure 2, the odds of full-time employment were lower among individuals with relatively higher levels of anxious attachment (path c = −.71). Anxious attachment was negatively associated with hope (path a = −.38). Finally, hope was positively associated with the odds of employment (path b = .85). The direct effect of anxious attachment (path c′ = −.42) was not statistically significant. Using the INDIRECT procedure with 5,000 bootstrap sam- ples revealed a significant indirect effect of anxious attach- ment on full-time employment through hope (point estimate = −.34, 95% CI = [−.74, −.08]).

The Nagelkerke R2 for the avoidant attachment model was computed to be .20. A graphical representation of this simple mediation model and information regarding the unstandardized path coefficients (a, b, c, and c′) are pre- sented in Figure 3.

As can be observed in Figure 3, the association between full-time employment and avoidant attachment was not

Figure 1. Path coefficients for simple mediation analysis on employment status (N = 84). Note. Dotted lines denote the effect of secure attachment on employment status when hope is not included as a mediator. b, c, and c′ are unstandardized logistic regression coefficients, a is an unstandardized ordinary-least-squares (OLS) regression coefficient. †p = .34. *p < .05. **p < .01.

Figure 2. Path coefficients for simple mediation analysis on employment status (N = 84). Note. Dotted lines denote the effect of anxious attachment on employment status when hope is not included as a mediator. b, c, and c′ are unstandardized logistic regression coefficients, a is an unstandardized ordinary-least-squares (OLS) regression coefficient. †p = .15. *p < .05. **p < .01.

Blake et al. 83

statistically significant (path c = −.49). Avoidant attachment was negatively associated with hope (path a = −.37). Finally, hope was positively associated with the odds of employ- ment (path b = .93). The direct effect of avoidant attachment (path c′ = −.23) was not statistically significant. Using the INDIRECT procedure with 5,000 bootstrap samples revealed a significant indirect effect of avoidant attachment on full-time employment through hope (point estimate = −.36, 95% CI = [−.78, −.08]).

Discussion

The employment rate for people with SCI (32.3%) is lower than the employment rate for the general population (74.2%; Houtenville et al., 2014). In addition, the employment rate for vocational rehabilitation (VR) consumers with SCI (54%) is lower than the overall employment rate for VR consumers (60%; Marini et al., 2008). Results from our study contribute to a growing body of empirical evidence supporting positive psychology as a useful framework for shaping work-related behaviors, attitudes, and employment outcomes. Bivariate analysis and tests of indirect effect indicated that attachment and hope were significantly related, that attachment and hope were predictive of full- time employment, and that hope was a significant mediator of the relationship between attachment and full-time employment. Therefore, our findings provide empirical support for Snyder’s (1994) model of hope, and a dynamic in which attachment predicted hope, and that together, attachment and hope were predictive of full-time employ- ment for people with SCI.

Bivariate relationships between individual attachment domains and hope were consistent with expectations based on previous research. Anxious attachment had a slightly more robust bivariate relationship with hope than secure or avoidant attachment. Bivariate results on attachment and

employment were mostly consistent with pre-study expec- tations. Secure attachment and anxious attachment were significantly related to full-time employment, whereas avoidant attachment was not. For comparison, Simmons et al. (2003) found a significant negative relationship between avoidant attachment behavior at work and health, and Sela-Kaufman et al. (2013) found that lower levels on avoidant attachment predicted higher levels of occupational functioning. Therefore, while results from Simmons et al. (2003) and Sela-Kaufman et al. (2013) suggest that elevated avoidant attachment may impair healthy workplace adapta- tion, results from the current study did not indicate that elevated avoidant attachment directly impaired participants’ abilities to secure and maintain full-time employment. This is consistent with Hazan and Shaver’s (1990) findings that people with an avoidant attachment style often assign high levels of meaning to work, and van Ecke’s (2007) finding of a strong relationship between avoidant attachment and external conflict, suggesting that people with avoidant attachment may prefer to work very hard to avoid dealing with external conflicts.

The present study evaluated the indirect effect of each individual attachment domain on full-time employment through hope for sample participants with SCI. Each of three tested models accounted for significant variance in full-time employment, and significant indirect effects were found for each attachment domain on employment through hope. In the context of previous research suggesting that people with avoidant attachment assign a high level of meaning to work to avoid social relationships (Hazan & Shaver, 1990), our finding that avoidant attachment had a lesser negative effect on full-time employment than anxious attachment is specifically interesting. In the present study, the relationship between avoidant attachment and employ- ment was not significant; however, the indirect effect of avoidant attachment on employment through hope was sig- nificant. It is likely that the negative impact of avoidant attachment on employment is prominent only in conjunc- tion with low levels of hope.

Implications for Rehabilitation Practice

Nearly one half of adults in the general population are inse- curely attached, and insecure attachment may be higher among people with disabilities (Hazan & Shaver, 1987; Howe, 2006; Mikulincer & Orbach, 1995). Attachment pro- files are largely established during infancy and early child- hood; however, attachment-related behavior can be modified (Wilson et al., 2013). Results from our study indicate that hope-based interventions may provide effective components of rehabilitation strategies geared toward improving attach- ment-predicted job-seeking behavior and outcomes.

Each tested model accounted for a relatively small pro- portion of variance in full-time employment; therefore, our

Figure 3. Path coefficients for simple mediation analysis on employment status (N = 84). Note. Dotted lines denote the effect of avoidant attachment on employment status when hope is not included as a mediator. b, c, and c′ are unstandardized logistic regression coefficients, a is an unstandardized ordinary-least-squares (OLS) regression coefficient. †p = .47. ††p = .08. **p < .01.

84 Rehabilitation Counseling Bulletin 60(2)

findings indicate that counselors should also focus on related variables that were not investigated in the study. Attachment profiles are linked to the relative optimism of individuals’ time perspectives. Secure attachment is associ- ated with a positive time perspective, which in turn is linked to increased capabilities, autonomy, and self-determination. Conversely, insecure attachment is associated with a nega- tive time perspective, which in turn is linked to impaired autonomy, competence, and self-determination. Therefore, rehabilitation counselors should endeavor to maintain and enhance positive time perspective for individuals with secure attachment, and ameliorate negative time perspec- tive and engender positive time perspective for individuals with insecure attachment (Laghi, D’Alessio, Pallini, & Baiocco, 2009). In addition, because high levels of anxious and/or avoidant attachment are associated with increased distress and depression, problems with relatedness, deficits in social skills and social support, and maladaptive perfec- tionism, individuals with insecure attachment may benefit from supportive counseling (Gnilka, Ashby, & Noble, 2013; Huprich, Rosen, & Kiss, 2013). Finally, employed individu- als with avoidant attachment may be vulnerable to unhealthy workplace adaptation and may benefit from counseling to address factors that underlie workaholic behavior.

The central tenets of hope theory comprise an accessible, action-oriented model. Hope-based assessment, conceptu- alization techniques, and interventions provide a pragmatic approach for working with consumers in rehabilitation set- tings (Coduti & Schoen, 2014; Snyder, Lehman, Kluck, & Monsson, 2006). The THS (Snyder et al., 1991) is a brief instrument that can be readily administered, scored, and interpreted in a rehabilitation setting. THS results indicate individuals’ hope profiles, which can be used to inform case conceptualization and intervention selection.

Individuals with high pathways/low agency are adept at generating routing thoughts; however, they often experi- ence frustration and anxiety because goal pursuit processes are hampered by impaired motivation. To increase capacity for agency, counselors should assess and explicitly rein- force incremental goal pursuit progress and help consumers develop skills for self-assessment and reinforcement. Agency is also enhanced through positive self-talk, reflec- tion on past positive outcomes, and framing prior negative outcomes as blocked goals rather than failures. Finally, suf- ficient self-care—including adequate exercise and sleep— is essential for the development of motivational energy (Snyder, 2002; Snyder et al., 2006).

Individuals with high agency/low pathways are profi- cient at generating motivational energy but have difficulty maintaining focus on pursuit of specific goals, and therefore often experience agitation and confusion about how to reach goals. Counselors working to assist low pathways individuals should focus on cognitive skills required to (a) generate and visualize goal paths, and (b) identify alternate

routes when primary goal paths are blocked. Guided lines of inquiry are useful for addressing specific obstacles dur- ing early stages of counseling and as a training intervention for increasing individuals’ internal capacity for pathway. Finally, counselors can help consumers internalize the role of pathways through explicitly and consistently framing the goal pursuit process in hope framework vernacular (Snyder, 2002; Snyder et al., 2006).

Individuals with low agency/low pathways experience a halting, inoperable goal pursuit process and may benefit from increased direction. In addition to working toward increased agency and pathways, counselors working with low total hope individuals should focus on (a) increased goal-directed thinking, (b) development of requisite coping skills for goal attainment, and (c) selection of specific goals and subgoals that are meaningful, incremental, measure- able, and ideally suited to individuals’ capacity for chal- lenge. Across hope profiles, successful implementation of the model hinges on exploring existing hope-related strengths and enhancing individuals’ internalized concepts of the goal-achievement process (Snyder, 2002; Snyder et al., 2006).

Limitations and Future Research

Several limitations inherent this study should be consid- ered in the interpretation of study findings. The present study used a convenience sample comprised of self- selected individuals who provided anonymous responses to an online, self-report survey. Self-report measures are susceptible to social desirability bias and response bias. Data were collected at a single point in time for each par- ticipant (i.e., cross-sectional). Therefore, causal direction in the model and in interpretation of results was primarily informed by theory. Most participants had an association with an SCI community organization (e.g., NSCIA, PVA). It is likely that individuals who participate in community organizations differ from the broader population of indi- viduals with SCI. Participants were relatively well edu- cated and reflected higher socioeconomic status. Most participants were White, and individuals from other racial/ ethnic backgrounds were underrepresented. This study did not investigate factors that may compound vulnerabilities experienced by individuals with SCI such as racial/ethnic minority group membership, socioeconomic status, or rural identity. Future research focused on sociocultural vulnerabilities could provide important information about detrimental effects of marginalization (Fyffe, Botticello, & Myaskovsky, 2013). We did not investigate post- employment factors such as workplace culture or worker adjustment. Research focused on relationships between the presently investigated constructs (i.e., attachment and hope) and post-employment factors could provide useful information about the process of work adjustment for

Blake et al. 85

individuals with SCI. Similarly, studies that operationalize medical and other contextual factors that influence employment would provide valuable information.

Research investigating the validity of attachment and hope measures for individuals with SCI and for the broader population of people with disabilities would contribute to the utility of the measures. Future research could assess the pre- dictive power of the investigated constructs for members of other disability groups. Longitudinal studies and randomized control trials (RCTs) focused on assessing effects of hope- based interventions would add value to the current findings.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Preparation of this manuscript was supported in part by the National Institute on Disability Rehabilitation Research through Grant #H133B13001 to Virginia Commonwealth University, Rehabilitation Research and Training Center on Employment of People with Physical Disabilities. The opinions expressed herein do not necessarily reflect the endorsement or position of the U.S. Department of Education.

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