1Introduction

The U.S. has deployed more than 2.7 million Americans to Iraq and Afghanistan since 2001, and over half of these have been deployed more than once (Hautzinger et al., 2015). Due to medical advancements, as well as the improvement of protective gear, over 90% of injured OEF/OIF military personnel have survived injuries that in prior conflicts would have been fatal (Lew et al., 2007; Hoge et al., 2006; IOM, 2013). Approximately 1,700 military service members have experienced trauma related amputation since 2002 due to combat exposure in Afghanistan and Iraq (Fischer, 2015). The majority of these involve lower extremity but may also include upper extremity and/or multiple limb amputations at rates higher than the civilian population (Krueger, Wenke, & Ficke, 2012).

OEF/OIF Veterans are also experiencing high rates of post-traumatic stress disorder (PTSD), depression, and substance abuse (Seal, 2007; Dursa, Reinhard, Barth, & Schneiderman, 2014). Additionally, a military culture to “man up” during difficulty contributes to the psychological functioning of service members, with residual effects experienced by Veterans. Furthermore, Veterans are committing suicide at higher rates than any other previous conflict (Tarabay, 2010). The complex interplay of these injuries and mental health conditions will likely have a prolonged impact upon the psychosocial, medical, and vocational experiences of OEF/OIF veterans, their families, and the communities in which they will live (Frain, Bishop, & Bethel, 2010).

A report from the Office of Internal Medicine (2013) cites the alleviation of health, economic, and social issues among Veterans as a significant and urgent need. Resilience and overall well-being have been identified by the U.S. Department of Defense (DoD) as a skill development need for military personnel and Veterans. Well-being Theory is framed within positive psychology and focuses upon the science of flourishing to include positive emotions, engagement, relationships, meaning and achievement (Seligman & Csikszentmihalyi, 2000). One aspect of flourishing is an individual’s resilience capacity (Huppert & So, 2013). Resilience is commonly described as the ability of an individual to “steer through and bounce back” from challenging life events, including trauma. Resilience is comprised of several abilities: emotion regulation, impulse control, empathy, optimism, causal analysis, self-efficacy, and social support seeking (Reivich & Shatte, 2002). Research demonstrates that resilience can be learned (Reivich & Shatte, 2002; Luthans et al., 2006).

Two convergent lines in the extant literature suggest that resilience is key to successful repatriation of our combat soldiers. First, the essence of the concept of resilience is overcoming challenges – both the kind of acute trauma that occurs in battle situations as well as the chronic challenges experienced by returning combat Veterans. Second, there is evidence that resilient individuals are less likely to incur PTSD and similar mental health conditions (Wisco et al., 2014; Tsai, Harpaz-Rotem, Pietrzak, & Southwick, 2012; Bonanno, 2004; Feder et al., 2009). The findings of a study of OEF/OIF Veterans suggests that interventions designed to bolster resilience and post-deployment support may help protect against traumatic stress and depressive symptoms, and improve psychosocial functioning in Veterans (Pietrzak et al., 2010). In particular, Veterans who experience disability may benefit from the development of resilience skills to promote adaptive responses to the challenges presented (Hawley et al., 2016). However, the exploration of resilience among Veterans who experience amputation is limited to date.

Another aspect relevant to flourishing is employment. Individuals who have career wellbeing are more than twice as likely to be doing well in their lives overall (Gallup, 2010). Employment also facilitates social and community connections. Clark, Deiner, Gergellis & Lucas (2008) found that the long term impact of sustained unemployment (more than 1 year) may be the only major life event from which people do not fully recover within five years, this holds particularly true for men. Employment is a primary feature of our self-identity and self-efficacy. Employment in which individuals are actively engaged has been found to improve not only mental, but physical health as well as performance outcomes (Agrawal & Harter, 2009; Harter, Canedy, & Stone, 2008; Luthans, Norman, Avolio, & Avey, 2008; Luthans, Youssef-Morgan, 2017). Thus, psychological capital, including resilience, is a key feature of individual health as well as positive organizational behavior.

The purpose of this study is to explore the resilience of OEF/OIF Veterans with amputation, particularly as it relates to individual characteristics and employment. The following research questions are addressed in this study:

2Methodology

The researchers completed both VCU and Veterans Administration IRB approval processes. Upon approval from both institutions, the researchers implemented data collection procedures, as follows.

3Results

A total of 165 Veterans responded for a response rate of 23%. Of these, 73.7% (n=121) were completed and returned via U.S. Postal Service and 26.7% (n=44) were completed via the online format. Although this is less than the desired 30% for standard survey research, it is actually more reflective of a typical online survey response (Dillman, et al., 2013). Coupled with the probability that some Veterans may also be experiencing research fatigue, these aspects may account for the lower response rate. Of these respondents, 91.5% reported that their amputation was service connected. The majority experienced Lower Extremity amputation with 45.3% below the knee and 37.6% above the knee (n=97). Interestingly 48 individuals did not respond to this item, therefore 117 participants were used for this analysis. Many Veterans who experience amputation also experience secondary or co-occurring conditions as a result of their injury. Table 1 reports co-occurring conditions.

In terms of employment status, 151 (92.1%) did not return to active duty with 118 (79.2%) stating that they could not do so due to their disability. When responding to a binary item (employed/unemployed), 61 (39.3%) reported being employed, with 51 indicating full time employment. The largest employment sector of this sample were individuals (N=20) working in the Government. Ninety-eight (60.1%) indicated that they were unemployed. Parsing this further, of the unemployed category, 35% identified as being unemployed, with approximately 26% identifying as being retired.

The 10-item CD-RISC mean score for this sample of Veterans who experience amputation was 28.2, within mean score ranges identified in earlier research of traumatized populations (20 to 31). See Table 2.

Age, race, amputation group (above or below knee, bilateral etc.), and education were not found to be related to resilience at the 0.05 level. Variables with significance include employment (P=0.008); pain (Great vs Moderate P=<0.001) (Great vs Slight P=0.002); Difficulties participating in social/community activities (Great vs Moderate & Great vs Slight P=<0.001); perception of overall situation as an amputee (Average vs Good P=<0.001) (Average vs Poor P=<0.001); (Good vs Poor P=<0.001), and duration of prosthetic use (equal to or less than 7 hours vs greater than 7 hours P=0.007).

Interestingly, and counter to prior resilience research on Veterans (Pietrzak & Southwick, 2011), Veterans who are Single (29.5) reported a slightly higher level of resilience than those who are Married/Partnered (28.4). However, this difference did not meet statistical significance. With a much higher mean than those who are Widowed, Divorced or Separated who reported the lowest level (25.8). See Table 3 for a summary of demographics, characteristics and additional survey questions.