The Effects of Mental Health Symptoms and Organizational Climate on Intent to Leave the Military Among Combat Veterans

Transcription

1 MILITARY MEDICINE, 177, 7:773, 2012 The Effects of Mental Health Symptoms and Organizational Climate on Intent to Leave the Military Among Combat Veterans CPT Paul J. Wright, MS USA; Paul Y. Kim, MA; Joshua E. Wilk, PhD; LTC Jeffrey L. Thomas, MS USA ABSTRACT Frequent deployments to Iraq and Afghanistan have placed a strain on military retention. There is a need to determine contributing factors predicting intent to leave the military. The purpose of this study was to determine to what extent soldiers mental health symptoms and perceptions of organizational climate are associated with intent to leave the military. Participants (n = 892) were soldiers of one infantry brigade combat team stationed in the United States, anonymously surveyed approximately 6 months after returning from a combat deployment to Iraq. The survey assessed overall deployment experiences, mental health symptoms, and perceptions of organizational climate. Results showed that soldiers reporting higher perceived organizational support were significantly less likely to report intent to leave and those screening positive for anxiety were significantly more likely to report intent to leave than those not screening positive. Implications of these results for Army clinicians and career counselors are discussed. INTRODUCTION The U.S. Army has encountered personnel retention problems as a result of stress from long and frequent deployments to Iraq and Afghanistan. 1 Military personnel turnover is costly considering investments in recruiting and training of new members and the loss of experience and technical expertise. 2 Meeting retention goals has been challenging to the U.S. Army even after offering large re-enlistment bonuses and expanding GI Bill benefits. 1 Several factors may contribute to intentions to leave the military among Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) soldiers including soldiers mental health symptoms and perceptions of poor organizational climate. Recent studies have shown that veterans of OIF and OEF have high rates of psychological problems following deployment, 3 5 but it is unclear if these problems are associated with intentions to leave the military. Likewise, the impact of organizational climate on military career intentions among postdeployment OIF/OEF soldiers is largely unknown. The purpose of this study is to examine the relative impact of selected mental health problems and organizational climate measures to identify possible drivers of intent to leave the military. to quit serving as mediators. Subsequent models have focused on the influence that organizational factors, such as job security and procedural justice, have on turnover behavior. 8 The underlying premise behind these models is that job dissatisfaction that leads to turnover is cumulative. Recently, researchers have turned their attention toward more immediate, acute events as precipitating factors on job turnover. 9 Traditional turnover theories have not been demonstrated in military populations. 2 However, one theory that military organizations, such as NATO, have adopted is Beach s image theory, 10 which posits that unexpected life events lead to voluntary turnover as opposed to accumulative job dissatisfaction, as posited in other theories. These life events (e.g., illness, marriage, college aspirations) can initiate thoughts of quitting and can be positive (e.g., job offer, birth of a child), neutral (e.g., transfer), or negative (e.g., ineffective leaders, environment, change in policies). Applying Beach s classification of events, we examine the relative impact that a negative event, i.e., the onset of mental health symptoms, may have on soldiers intent to leave military service. Additionally, we examine the effects of organizational climate and whether these effects may buffer the relationship between mental health symptoms and intent to leave. Organizational Retention Models Early models of civilian job turnover emphasized the role of job attitudes and organizational commitment on the decisionmaking processes involved in turnover. 6 Mobley et al 7 proposed that job satisfaction was both a direct and indirect pathway to turnover, with thoughts of quitting and intentions Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD Material has been reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The opinions or assertions contained herein are the private views of the authors, and are not to be construed as official, or as reflecting true views of the Department of the Army or the Department of Defense. Organizational Climate and Intent to Leave the Army In this study, we examine unit cohesion, morale, and perceived organizational support (POS) as key indicators of organizational climate. Unit cohesion develops when soldiers bond together to accomplish a mission. 11 Despite some evidence that unit cohesion is related to increased performance and lower stress appraisals, 11,12 its role in intent to leave the military has been underexamined. 13 When confronting combat trauma and unexpected life events, unit cohesion may decrease the likelihood of a soldier s intent to leave because of shared bonds among unit members striving to achieve a common goal. MILITARY MEDICINE, Vol. 177, July

2 Morale is, a service member s level of motivation and enthusiasm for achieving mission success. 14 Edens et al 13 found that high individual morale was associated with soldiers decisions to remain in the Army. In another study, intent to leave was higher and morale was lower for a deployed group when they deployed much sooner than they had expected. 14 These studies suggest that morale is an influential part of Army career decisions. However, no other studies, to our knowledge, have directly tested the impact of unit morale on intentions to leave the military. POS is the perception that an organization has a willingness to support employees with coaching, mentorship, and rewards. 15 Studies in the civilian literature provide evidence for the role of POS on turnover intentions. For example, in a study of retail employees, those with low POS ratings revealed anger scores resulting in higher turnover intentions. 16 Furthermore, a meta-analysis attributed POS to better job satisfaction, positive mood, commitment, and performance. 15 These benefits associated with high POS are expected to also be associated with decreased intentions to leave one s job. To our knowledge, there are no studies linking POS and intent to leave the military. Mental Health Symptoms and Intent to Leave the Army Poor mental health has consistently been associated with attrition in the military. For example, Army trainees reporting a history of childhood abuse, which is often coupled with mental health problems, were significantly more likely to be discharged before completing training. 17 Furthermore, mental health problems appear to place a stronger influence on leaving the Army than medical problems. 18 A study of outpatient soldiers sampled before OIF/OEF reported that 38% of those diagnosed with a mental health problem, such as a mood or anxiety disorder, left the military after 1 year, compared to 14% of those diagnosed with medical illnesses. 19 Likewise, postdeployment assessments show that those reporting mental health problems, including depression and post-traumatic stress disorder (PTSD), were more likely to leave the Army than those without problems. 20 In another study, Edens et al 13 found that 58% of married soldiers meeting screening criteria for depression, anxiety, or PTSD were more likely to leave the Army in comparison to 33% not meeting the same screening criteria. Stressors that impact psychological well-being have also been linked to intent to leave the military. 21 Researchers assessed U.S. Army Reservist s well-being and intent to leave after activation because of the terrorist s attacks of 9/11. Stressors, such as deactivation uncertainty, workload, and organizational constraints, were negatively correlated with psychological well-being and positively correlated with intent to leave the military. 21 In light of these findings, it is clear that poor mental health, as well as stressors that lead to poor mental health, adversely impacts retention rates in the military. Thus far, studies have investigated the overall effect of poor mental health on attrition, such as a diagnosis on the ICD-9 category , 19 which covers a wide range of possible mental health problems. What is not clear is which specific mental health problem or problems weigh on soldiers leaving the Army. Also unclear from previous research is how poor mental health affects intentions to leave the military, as opposed to actual attrition rates. To our knowledge, no studies have identified the effects of specific mental health problems on soldiers intentions to leave the military. Study Research Questions Using Beach s framework, we propose three hypotheses. First, higher mental health symptoms (i.e., PTSD, depression, and anxiety) will be associated with intent to leave the Army. Second, perceptions of a poor organizational climate as assessed by low unit cohesion, low unit morale, and lack of POS will be associated with intent to leave the Army. Third, perceptions of a strong positive organizational climate will buffer the link between mental health symptoms and intent to leave the Army. METHODS Background and Setting Anonymous survey data were collected under a research protocol approved by the Walter Reed Army Institute of Research Institutional Review Board and was supported by the leadership of the sponsoring unit. Gauging soldiers intent to leave the military was a component of a larger study aimed at measuring overall soldier and family well-being at postdeployment. Participants were members of one infantry brigade combat team stationed in the continental United States. Data from 1,316 soldiers were collected from six sessions in June 2009, which was approximately 6 months after returning from a combat deployment. We excluded 137 females and 106 officers because of their small enrollment numbers. An additional 181 soldiers reported that they had never deployed and were excluded from the study. The remaining sample of 892 soldiers reported that their most recent deployment had been to Iraq or Afghanistan and were included in this study. Fifty-five percent of soldiers from the brigade combat team were present during the recruitment sessions. Soldiers not attending the recruitment session were unavailable as a result of leave, sickness, or on temporary duty. Overall, 83% of soldiers attending the recruitment session consented to participate in the study. Demographics (Table I) of this sample are consistent with other studies using a similar sampling approach. 3,5 Procedure Participants completed surveys in garrison, at times and locations convenient to their unit in order to minimize disruption 774 MILITARY MEDICINE, Vol. 177, July 2012

3 TABLE I. Sample Demographics Characteristics (N = 892) Variable n % Rank Junior Enlisted Personnel Noncommissioned Officers Years in the Military = > Age(Years) or Older Education Some High School High School Diploma/GED Some College/Associates Degree Bachelor s Degree Graduate Degree Marital Status Single Married Separated, Divorced or Widowed Battalion Type Combat Arms/Maneuver Combat Support/Service Support Not all percentages add to 100 because of rounding. to unit training and maximize participation. Unit members received a 5-minute recruitment briefing explaining the purpose of the study, the survey, and the consenting procedure. Upon completion of this briefing, researchers answered questions, invited participants to volunteer and give consent to use their responses for research purposes. On average, participants completed the survey in 45 minutes. Instrument The paper-and-pencil survey instrument included assessment of combat exposures and deployment experiences, general and mental health symptoms, health care utilization, and organizational climate factors. 5 Measures PTSD was measured using the 17-item Post-traumatic Checklist, 22,23 a well-validated measure in civilian and military primary care and mental health settings. 24 Participants were asked to respond to how much these items have bothered them in the past month. Sample items include: Suddenly acting or feeling as if a stressful experience was happening again, being super alert, and feeling as if your future somehow will be cut short. Soldiers had to report being bothered moderately by at least one intrusion symptom, three avoidance symptoms, and two hyperarousal symptoms. 25 Items use a 5-point scale with response options from not at all to extremely, with summed scores ranging between 17 and 85 and with 50 as a cutoff score for a positive screen of PTSD. This cutoff score is a widely used and validated approach to apply a more strict definition of PTSD caseness. 3,5,22 Cronbach s a reliability was Depression was measured with the nine-item Patient Health Questionnaire, 26 a well-validated clinical scale for depression based on the Diagnostic and Statistical Manual of Mental Disorders fourth edition 25 criteria. Participants responded to nine items using a 4-point scale with response options from not at all to nearly every day. Participants were asked to respond to how much these items have bothered them in the past month. Sample items include: Little interest or pleasure in doing things, Feeling down, depressed, or hopeless, and Feeling tired or having little energy. Criteria for depression required reporting being bothered at least more than half the days with at least five of the nine depression symptoms. In addition, soldiers had to report either little interest or pleasure in doing things or feeling down, depressed, or hopeless more than half the days in the past month. Soldiers screening positive for depression also had to report that their depression symptoms made it very or extremely difficult to function at work or home or to get along with other people. Cronbach s a reliability was Anxiety was measured with the seven-item Generalized Anxiety Disorder scale, a well-validated clinical scale for anxiety that is widely used in clinical practice and research. 27 Participants were asked how often symptoms have bothered them in the past month. Sample items include: Feeling nervous, Trouble relaxing, and Feeling afraid as if something awful might happen. There were seven items using a 4-point scale with response options from not at all to nearly every day with summed scores ranging between 0 and 21. Soldiers with a score of 10 or higher and reporting that their symptoms made it very or extremely difficult to function at work or home or to get along with other people were classified as screening positive for anxiety. Cronbach s a reliability was Unit cohesion was measured using a three-item scale adapted from Podsakoff and MacKenzie. 28 It employed a 5-point Likert scale ranging from strongly disagree to strongly agree. Items were: Members of my unit (a) are cooperative with each other, (b) know that they can depend on each other, and (c) stand up for each other. Cronbach s a reliability was Soldiers were asked to rate the morale of their unit using a 5-point Likert scale with responses ranging from very low to very high. Unit referred to the company, battery, or troop to which a soldier belonged. Although it is more common to use multi-item measures, a single-item measure is acceptable to identify a specific factor and to keep the measure from confounding other variables which could influence outcomes. 29 POS was measured using four items, adapted from Eisenberger et al, 30 using a 5-point (1 5) Likert scale ranging MILITARY MEDICINE, Vol. 177, July

4 TABLE II. Correlation Matrix of Intent to Leave, Mental Health Symptoms, and Organizational Climate M SD Intent to Leave Depression Anxiety PTSD Morale Cohesion POS Intent to Leave N/A N/A Depression N/A N/A 0.11 Anxiety N/A N/A PTSD N/A N/A Morale Cohesion POS All correlations are significant at the p < 0.05 level. Means of intent to leave and mental health symptoms denote proportions of those affirming intent to leave the Army and screening positive for mental health symptoms, respectively. Phi coefficients were used for correlations between intent to leave and mental health symptoms. Correlations between dichotomous variables (intent to leave and mental health symptoms) and organizational climate variables reflect point biserial correlations. from strongly disagree to strongly agree. Participants answered how much they agreed or disagreed with statements about their organization. The items were: My organization (a) strongly considers my goals and values, (b) really cares about my well-being, (c) cares about my opinion, and (d) is willing to help me when I need a special favor. Higher scores represented greater POS. Cronbach s a reliability was Intent to leave the Army was measured with a single item: Which best describes your current career intentions? The response options were (a) definitely stay in until retirement, (b) probably stay in until retirement, (c) definitely stay in beyond present obligation, but not necessarily until retirement, (d) undecided about whether to stay after completion of my current obligation, (e) probably leave upon completion of my current obligation, or (f) definitely leave upon completion of my current obligation. We dichotomized responses into two categories: (a) stay in or undecided and (b) probably/definitely leave after current obligation. This item has been used in previous military research to measure intention to leave the military. 31 Data Analysis Hypotheses were tested using correlational and logistic regression analyses, with each of the independent variables entered simultaneously in the models. The Statistical Package for the Social Sciences (SPSS version 17.0) was used for analyses. RESULTS Demographics The majority of active duty soldiers in our sample (see Table I) reported 5 years or less in the military (62%), 72% were combat arms, and 58% married. Nearly all had a high school degree (over 99%). There were 56% junior enlisted soldiers and 44% noncommissioned officers. The largest age group was 20 to 24 (43%). Table II presents the means, standard deviations (SDs), and correlations for each of the variables of interest. Each item is significantly correlated with each other at the 0.05 level but not so much that variables were multicollinear. As expected, there was a strong positive correlation between depression and anxiety (r = 0.78) as well as for PTSD and anxiety (r = 0.41). Each variable of interest was significantly correlated with intention to leave with the strongest correlation being POS (r = 0.26). Organizational Climate, Mental Health, and Intent to Leave the Military Overall, about one-third of the sample reported intent to leave the military beyond their current obligation (Table III). A higher proportion of those reporting intent to leave the military screened positive for a mental health problem (21%) compared to those reporting intent to stay (11%). Additionally, POS was higher among those intending to stay compared to those intending to leave. TABLE III. Comparison of Soldiers Reporting Intent to Leave and Stay by Mental Health Problem and Unit Climate Variables Intent to Stay Intent to Leave p-value Overall Sample (n = 867) 64.50% 35.50% n/a PTSD Screen Positive (n = 102) 53.90% 46.10% Depression Screen Positive (n = 50) 44.00% 56.00% Anxiety Screen Positive (n = 65) 38.50% 61.50% Any Mental Health Problem (n = 130) 49.20% 50.80% Mean POS (SD) (n = 855) 3.01 (0.97) 2.47 (0.99) Mean Morale (SD) (n = 841) 2.73 (0.99) 2.39 (1.02) Mean Cohesion (SD) (n = 855) 3.31 (0.87) 2.96 (1.01) MILITARY MEDICINE, Vol. 177, July 2012

5 TABLE IV. The Effects of Mental Health Symptoms and Organizational Climate on Intent to Leave Model Unadjusted for Combat and Demographics Model Adjusted for Combat and Demographics 95% Confidence Interval p Adjusted Odds Ratio Standard Error Wald 95% Confidence Interval p b Adjusted Odds Ratio Standard Error Wald b PTSD Major Depression Generalized Anxiety Unit Cohesion Unit Morale Perceived Organizational Support Combat Exposure Rank Marital Status c 2 p c 2 p Fit Tests R 2 for first model: Cox & Snell: Nagelkerke: R 2 for second model: Cox & Snell: Nagelkerke: Table IV presents the results of logistic regression analyses between the organizational climate variables, mental health symptoms, and intent to leave the military, controlling for combat exposure, rank, and marital status. As noted above, the correlation between POS and intent to leave was the strongest between each of the variables of interest. This association persisted after entering the controls into the model. There was an inverse relationship between POS and intent to leave the military; soldiers reporting higher POS were significantly less likely to report intent to leave. Additionally, those screening positive for anxiety were three times more likely to report intent to leave than those not screening positive. Neither unit morale nor unit cohesion was significantly associated with intent to leave the military. At subclinical levels for anxiety, depression, and PTSD, we find that those reporting intent to leave the military also report elevated levels of symptomology compared to those intending to stay. Among those not screening positive for anxiety, mean anxiety scores were significantly higher among those reporting intent to leave (3.39) than those reporting intent to stay (2.64, p < 0.05). For soldiers not screening positive for depression, mean Patient Health Questionnaire scores for those intending to leave were significantly higher (1.03) than those intending to stay (0.74, p < 0.05). Similarly, mean Post-traumatic Checklist scores were higher for those reporting intent to leave (27.47) than those reporting intent to stay (25.01, p < 0.05) among those not screening positive for PTSD. The interactions between mental health symptoms and organizational climate variables were also analyzed to test for buffering effects of organizational climate on the relationship between mental health symptoms and intent to leave. None of the interactions produced significant associations with career intentions (results not shown). Additionally, to test the possibility that the effects of PTSD and depression are being reflected through anxiety since each are significantly correlated with one another, an additional model was examined that included interaction terms comprising of depression and anxiety as well as PTSD and anxiety. Neither interactions yielded significant associations with intent to leave. The independent effects of anxiety and POS, however, remained significant (results not shown). DISCUSSION This article examined the association of mental health and organizational climate with intent to leave the Army using Beach s theory of turnover as a framework for predicting expected relationships. Under this framework, unexpected negative events, such as the presence of mental health problems, are posited as factors influencing voluntary turnover. We found support for two of our hypotheses, which indicate that poor mental health and poor POS are associated with increased intent to leave. As expected, soldiers who reported mental health symptoms had a higher intent to leave the Army than those without MILITARY MEDICINE, Vol. 177, July

6 mental health symptoms. Specifically, those with higher reported anxiety symptoms reported significantly higher rates of intent to leave. We also find elevated levels of symptoms at the subclinical level among those reporting intent to leave. Results of our study demonstrate the adverse impact of anxiety on military careers. In fact, soldiers reporting generalized anxiety were more than three times more likely to leave the Army than those not reporting anxiety. Further analyses that account for the interaction between anxiety and depression, as well as anxiety and PTSD, confirm the independent effects of anxiety on intent to leave, despite it being correlated with both depression and PTSD. These results have implications for Army Career Counselors and mental health treatment facilities. Army Career Counselors primary job is to retain qualified personnel. These findings could aid career Counselors in designing programs aimed at soldiers with anxiety issues who are more likely to have intentions to leave. Interventions that emphasize the benefits of health care for soldiers with doubts about whether to remain in the military could provide them with reassurance as they suggest discussing soldier s concerns with their mental health care provider before making career decisions. Military mental health providers typically assess and aid soldiers for a variety of mental health problems including PTSD, depression, and alcohol problems. Although anxiety is not the most prevalent symptom veterans report, our results highlight anxiety as a major factor that drives soldiers intentions to leave. Thus, mental health providers should be aware of the role anxiety plays in soldier s thoughts about discontinuing military service. Additionally, based on these results, it is plausible (although not causally demonstrated) that a significant portion of soldiers who have chosen to transition out of the Army may have done so because of problems with anxiety. 32 Our second hypothesis was that perceptions of a poor organizational climate would be associated with intent to leave the Army. Of the three organizational climate factors we examined (i.e., cohesion, morale, and POS), our hypothesis was supported only for POS. Higher ratings of POS were associated with a 26% decrease in the likelihood of leaving the Army. These findings suggest that military organizations that are able to foster a positive work environment could have success in retaining soldiers for the war fighting effort. Behaviors such as coaching, mentoring, offering rewards, and showing a sense of belonging to the unit promote a positive climate and are helpful in coping with work stressors. 33 Unit commanders can ensure, to their best effort, a positive organizational climate by demonstrating an active interest in soldiers well-being, goals, and values. By doing so, leaders may decrease the likelihood of voluntary turnover because of poor organizational climate. Our third hypothesis was that perceptions of a strong positive organizational climate would buffer the link between mental health symptoms and intent to leave the Army. Although organizational factors are helpful in reducing mental health problems, we did not find evidence of a buffering effect for any of the organizational climate variables on the relationship between mental health symptoms and intent to leave the Army. Although morale and cohesion have an impact on increasing organizational effectiveness, they are not strong enough factors to buffer the negative effects of anxiety. Our findings indicate that POS and anxiety operate independently as predictors of intent to leave. There are limitations to this study, including the use of selfreport data, issues with generalizability, and measurement issues. First, the data described here were self-report data from a cross-sectional study. Therefore, there are caveats in interpreting the results given that self-report data can be prone to self-presentational or response-set biases. Likewise, because the data were collected at a single time-point, the causal impact of POS and anxiety on intent to leave the military cannot be inferred. Second, the sample was derived from one brigade combat team, which makes it difficult to generalize results to the whole army or veteran s community. Most participants in our study were from combat arms units (e.g. infantry). Combat arms soldiers have a higher rate of intent to leave than noncombat arms soldiers. 34 Third, we used a single item to measure career intention. However, this item has been used in previous research. 35,36 With an indefinite end to combat operations, problems with sustaining the quantity and quality of Army personnel become increasingly urgent. Indeed, recent analyses find historically low continuation rates among soldiers, prompting costly increases in re-enlistment bonuses. Additionally, in order to meet recruitment goals, enlistment qualifications were lowered, which carry further risks for future performance and retention. 37 We offer several suggestions for future research. First, considering the limitations of our study, future studies should include larger and more diverse samples, such as noncombat soldiers and samples from multiple brigade combat teams. Second, research should explore other possible determinants of intent to leave the military such as bonuses, family separation, and combat exposure. Additional areas could include life events as posited in Beach s theory (e.g., illness, college aspirations, job offer, birth of a child, transfer, leadership, and changes in policies). Third, given our findings that anxiety symptoms function as an intractable influence on intent to leave, at least in relation to organizational climate variables, future research should be aimed at identifying potential factors that may serve to moderate the impact of anxiety on intent to leave. It could be that the nature of soldier anxiety lies outside the domain of the Army as an organization, and instead, is related more closely to family or career concerns. It is also possible that soldiers who report anxiety symptoms are not receiving treatment. In this case, lack of access to care may be the true driver of intent to leave rather than the symptoms themselves. Future studies should investigate these other domains and their possible buffering effects on anxiety and intent to leave. 778 MILITARY MEDICINE, Vol. 177, July 2012

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