Increasing Engagement of Women Veterans in Health Research.

BACKGROUND: Meaningful engagement of patients in health research has the potential to increase research impact and foster patient trust in healthcare. For the past decade, the Veterans Health Administration (VA) has invested in increasing Veteran engagement in research. OBJECTIVE: We sought the perspectives of women Veterans, VA women's health primary care providers (WH-PCPs), and administrators on barriers to and facilitators of health research engagement among women Veterans, the fastest growing subgroup of VA users. DESIGN: Semi-structured qualitative telephone interviews were conducted from October 2016 to April 2018. PARTICIPANTS: Women Veterans (N=31), WH-PCPs (N=22), and administrators (N=6) were enrolled across five VA Women's Health Practice-Based Research Network sites. APPROACH: Interviews were audio-recorded and transcribed. Consensus-based coding was conducted by two expert analysts. KEY RESULTS: All participants endorsed the importance of increasing patient engagement in women's health research. Women Veterans expressed altruistic motives as a personal determinant for research engagement, and interest in driving women's health research forward as a stakeholder or research partner. Challenges to engagement included lack of awareness about opportunities, distrust of research, competing priorities, and confidentiality concerns. Suggestions to increase engagement include utilizing VA's patient-facing portals of the electronic health record for outreach, facilitating "warm hand-offs" between researchers and clinic staff, developing an accessible research registry, and communicating the potential research impact for Veterans. CONCLUSIONS: Participants expressed support for increasing women Veterans' engagement in women's health research and identified feasible ways to foster and implement engagement of women Veterans. Given the unique healthcare needs of women Veterans, engaging them in research could translate to improved care, especially for future generations. Knowledge about how to improve women Veterans' research engagement can inform future VA policy and practice for more meaningful interventions and infrastructure.

Women Veterans' Experiences of Harassment and Perceptions of Veterans Affairs Health Care Settings During a National Anti-Harassment Campaign.

PURPOSE: In 2017, Veterans Health Administration (VA) launched a social marketing and training campaign to address harassment of women veterans at VA health care facilities. We assessed women veterans' experiences of harassment, reported perpetrators of harassment, and perceptions of VA in 2017 (before campaign launch) and 2018 (1 year after campaign implementation). METHODS: We administered surveys to women veterans attending primary care appointments (2017, n = 1,300; 2018, n = 1,711). Participants reported whether they experienced sexual harassment (e.g., catcalls) and gender harassment (e.g., questioning women's veteran status) from patients and/or staff at VA in the past 6 months. They also indicated whether they felt welcome, felt safe, and believed the VA is working to address harassment. We compared variables in 2017 versus 2018 with χ2 analyses, adjusting for facility-level clustering. RESULTS: There were no significant differences in percentages of participants reporting sexual harassment (20% vs. 17%) or gender harassment (11% vs. 11%) in 2017 versus 2018. Men veterans were the most frequently named perpetrators, but participants also reported harassment from staff. Participant beliefs that VA is working to address harassment significantly improved from 2017 to 2018 (52% vs. 57%; p = .05). CONCLUSIONS: One year after campaign launch, women veterans continued to experience harassment while accessing VA health care services. Findings confirm that ongoing efforts to address and monitor both staff- and patient-perpetrated harassment are essential. Results have implications for future anti-harassment intervention design and implementation and highlight additional opportunities for investigation.

Mobilizing embedded research and operations partnerships to address harassment of women Veterans at VA medical facilities.

Key insights: A: Addressing a complex problem like harassment in VA medical facilities requires committed, engaged collaboration at multiple levels of the organization. B: Timely feedback of initial research findings to operations partners enabled rapid and more responsive development of new programs and policies. C: Our research-clinical partnership has enabled us to pursue targeted change from the outset, while incorporating real-time findings from embedded researchers working to develop a comprehensive understanding of the problem.

Promoting learning health system feedback loops: Experience with a VA practice-based research network card study.

BACKGROUND: We tested the capacity of the 60-site VA Women's Health Practice-Based Research Network (WH-PBRN), embedded within VA, to employ a multisite card study to collect women Veterans' perspectives about Complementary and Integrative Health (CIH) and to rapidly return findings to participating sites and partnered national policy-makers in support of a Learning Health System (LHS) wherein evidence generation informs ongoing improvement. METHODS: VA primary care clinic clerks and nurses distributed anonymous surveys (patient feedback forms) at clinics for up to two weeks in fiscal year 2017, asking about CIH behavior and preferred delivery methods. We examined the project's feasibility, representativeness, acceptability, and impact via a tracking system, national administrative data, debriefing notes, and three surveys of WH-PBRN Site Leads. RESULTS: Twenty geographically diverse and largely representative VA Medical Centers and 11 Community-Based Outpatient Clinics volunteered to participate. Over six months, N = 1191 women Veterans responded (median 57; range 8-151 per site). In under three months, we returned local findings benchmarked against multisite findings to all participating sites and summary findings to national VA partners. Sites and partners disseminated results to clinical and leadership stakeholders, who then applied results as warranted. CONCLUSIONS: VA effectively mobilized an embedded PBRN to implement a timely, representative, acceptable and impactful operations project. IMPLICATIONS: Card studies by PBRNs within large, national healthcare systems can provide rapid feedback to participating sites and national leaders to guide policies, programs, and practices. LEVEL OF EVIDENCE: Self-selected respondents could have biased results.

Women Veterans' Perspectives on How to Make Veterans Affairs Healthcare Settings More Welcoming to Women.

PURPOSE: Women veterans are a rapidly increasing subset of the Veterans Affairs (VA) patient population but remain a numerical minority. Men veteran-dominated health care settings pose unique considerations for providing care to women veterans in a comfortable and welcoming environment. We analyzed patient suggestions on how to make the VA more welcoming to women. METHODS: We surveyed a convenience sample of women veteran patients who visited 1 of 26 VA locations in August and September of 2017. Women veterans were invited to complete brief anonymous questionnaires that included questions about harassment experiences and feeling welcome at the VA, and an open-ended question about suggestions to make the VA more welcoming to women. We analyzed data from the open-ended question using the constant comparison method. RESULTS: Among respondents (N = 1,303), 85% felt welcome at the VA. Overall, 29% answered the open-ended prompt for a total of 490 distinct responses: 260 comments and 230 suggestions. Comments included praise for the VA (67%) and stories about feeling uncomfortable or harassed in the VA (26%). Suggestions included those related to VA staff (31%), the environment of care (18%), additional resources for women veterans (18%), clinical services for women veterans (15%), changing men veterans' behavior toward women veterans at the VA (5%), and making the treatment of women and men the same (5%). CONCLUSIONS: Although most women veterans felt welcome in the VA, patient-centered suggestions offer opportunities for making the VA more welcoming to women. Soliciting patient suggestions and increasing awareness of how feeling welcome is experienced by patients are first steps to health care settings becoming more inclusive.

Validating nursing competencies using a fair format.

Across the healthcare system, staff development specialists and nurse leaders have been challenged with the development, implementation, and evaluation of processes by which clinical nursing staff demonstrate competence in an efficient and effective manner. The purpose of this article is to describe one approach used in an acute care setting. Staff development specialists and nurse leaders played key roles in assessing, developing, and evaluating a nursing competency validation fair.

Practice-based research networks add value to evidence-based quality improvement.

Background: Evidence-Based Quality Improvement (EBQI) is a systematic, multilevel approach to implementing research evidence into clinical settings. Little is known about EBQI effectiveness in the context of Practice-Based Research Networks (PBRNs), which are themselves designed to foster practice-based change. We evaluated EBQI implementation in a PBRN setting to determine the extent to which the PBRN infrastructure added value. METHODS: We conducted a four-site cluster randomized trial of an EBQI approach to tailoring an evidence-based gender awareness curriculum in the VA Women's Health PBRN (WH-PBRN). After curriculum implementation, site teams identified impacts of the WH-PBRN context on EBQI processes using qualitative methods, including a formal review of project call minutes, post-project debriefing calls, and structured site team input. WH-PBRN site feedback was mapped to the Replicating Effective Programs implementation phases: pre-condition, pre-implementation, implementation, and maintenance/evolution. RESULTS: The pre-condition phase benefited from the existing WH-PBRN research-clinician relationships to facilitate stakeholder engagement and build project buy-in at local sites. During pre-implementation, differences across WH-PBRN sites offered variations in local tailoring of EBQI elements. The WH-PBRN Coordinating Center helped resolve process complexities stemming from local resource differences and the sharing of mid-project adaptations during implementation. Local efforts were amplified in the maintenance phase by WH-PBRN dissemination of findings. Conclusions: The PBRN strengthened multi-site EBQI activities across all implementation phases. Implications: PBRNs contribute to the uptake of evidence into everyday practice, and may serve as an important component of the future implementation of evidence-based initiatives. Level of evidence: V.

Binge Eating among Women Veterans in Primary Care: Comorbidities and Treatment Priorities.

BACKGROUND: Little is known about the clinical profile and treatment priorities of women with binge eating disorder (BED), a diagnosis new to the fifth edition of Diagnostic and Statistical Manual of Mental Disorders. We identified comorbidities and patients' treatment priorities, because these may inform implementation of clinical services. METHODS: Data were collected from women veteran primary care patients. Analyses compared those who screened positive for BED (BED+), and those without any binge eating symptoms (BED-). RESULTS: Frequencies of comorbid medical and psychological disorders were high in the BED+ group. The BED+ group's self-identified most common treatment priorities were mood concerns (72.2%), weight loss (66.7%), and body image/food issues (50%). Among those with obesity, a greater proportion of the BED+ group indicated body image/food issues was their top treatment priority (12.9% vs. 2.8%; p < .01), suggesting that these patients may be more apt to seek treatment beyond weight management for their problematic eating patterns. CONCLUSIONS: Women primary care patients with BED demonstrate high medical and psychological complexity; their subjective treatment priorities often match objective needs. These findings may inform the development of targeted BED screening practices for women with obesity in primary care settings, and the eventual adoption of patient-centered BED treatment resources.

Effectiveness of an Evidence-Based Quality Improvement Approach to Cultural Competence Training: The Veterans Affairs' "Caring for Women Veterans" Program.

INTRODUCTION: Although providing culturally sensitive health care is vitally important, there is little consensus regarding the most effective strategy for implementing cultural competence trainings in the health care setting. Evidence-based quality improvement (EBQI), which involves adapting evidence-based practices to meet local needs, may improve uptake and effectiveness of a variety of health care innovations. Yet, to our knowledge, EBQI has not yet been applied to cultural competence training. To evaluate whether EBQI could enhance the impact of an evidence-based training intended to improve veterans affairs health care staff gender sensitivity and knowledge (Caring for Women Veterans; CWV), we compared the reach and effectiveness of EBQI delivery versus standard web-based implementation strategies of CWV and assessed barriers and facilitators to EBQI implementation. METHODS: Workgroups at four diverse veterans affairs health care sites were randomized to either an EBQI or standard web-based implementation condition (SI). All EBQI sites selected a group-based implementation strategy. Employees (N = 84) completed pretraining and posttraining assessments of gender sensitivity and knowledge, and focus groups/interviews were conducted with leadership and staff before and after implementation. RESULTS: Reach of CWV was greater in the EBQI condition versus the SI condition. Whereas both gender sensitivity and knowledge improved in the EBQI condition, only gender sensitivity improved in the SI condition. Qualitative analyses revealed that the EBQI approach was well received, although a number of barriers were identified. DISCUSSION: Findings suggest that EBQI can enhance the uptake and effectiveness of employee trainings. However, the decision to pursue EBQI must be informed by a consideration of available resources.

Patient-centered mental health care for female veterans.

OBJECTIVE: Mental health services for women vary widely across the Veterans Health Administration (VHA) system, without consensus on the need for, or organization of, specialized services for women. Understanding women's needs and priorities is essential to guide the implementation of patient-centered behavioral health services. METHODS: In a cross-sectional, multisite survey of female veterans using primary care, potential stakeholders were identified for VHA mental health services by assessing perceived or observed need for mental health services. These stakeholders (N=484) ranked priorities for mental health care among a wide range of possible services. The investigators then quantified the importance of having designated women's mental health services for each of the mental health services that emerged as key priorities. RESULTS: Treatment for depression, pain management, coping with chronic general medical conditions, sleep problems, weight management, and posttraumatic stress disorder (PTSD) emerged as women's key priorities. Having mental health services specialized for women was rated as extremely important to substantial proportions of women for each of the six prioritized services. Preference for primary care colocation was strongly associated with higher importance ratings for designated women's mental health services. For specific types of services, race, ethnicity, sexual orientation, PTSD symptoms, and psychiatric comorbidity were also associated with higher importance ratings for designated women's services. CONCLUSIONS: Female veterans are a diverse population whose needs and preferences for mental health services vary along demographic and clinical factors. These stakeholder perspectives can help prioritize structural and clinical aspects of designated women's mental health care in the VHA.

Lessons from Initiating the First Veterans Health Administration (VA) Women's Health Practice-based Research Network (WH-PBRN) Study.

BACKGROUND: The Veterans Health Administration (VA) Women's Health Practice-Based Research Network (WH-PBRN) was created to foster innovations for the health care of women veterans. The inaugural study by the WH-PBRN was designed to identify women veterans' own priorities and preferences for mental health services and to inform refinements to WH-PBRN operational procedures. Addressing the latter, this article reports lessons learned from the inaugural study. METHODS: WH-PBRN site coordinators at the 4 participating sites convened weekly with the study coordinator and the WH-PBRN program manager to address logistical issues and identify lessons learned. Findings were categorized into a matrix of challenges and facilitators related to key study elements. RESULTS: Challenges to the conduct of PBRN-based research included tracking of regulatory documents; cross-site variability in some regulatory processes; and troubleshooting logistics of clinic-based recruitment. Facilitators included a central institutional review board, strong relationships between WH-PBRN research teams and women's health clinic teams, and the perception that women want to help other women veterans. CONCLUSION: Our experience with the inaugural WH-PBRN study demonstrated the feasibility of establishing productive relationships between local clinicians and researchers, and of recruiting a special population (women veterans) in diverse sites within an integrated health care system. This identified strengths of a PBRN approach.

Screening for domestic violence.

Nurses have a unique opportunity to develop, implement, and evaluate the outcomes of routine assessments and interventions.

Seeking Safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomatology.

AIMS: To determine whether substituting Seeking Safety (SS), a manualized therapy for comorbid substance use disorders (SUD) and post-traumatic stress disorder (PTSD) for part of treatment-as-usual (TAU) improves substance use outcomes. DESIGN: Randomized controlled effectiveness trial. SETTINGS: Out-patient Veterans Administration Health Care System SUD clinic. PARTICIPANTS: Ninety-eight male military Veterans with a SUD and co-occurring PTSD symptomatology. MEASUREMENTS: Drug and alcohol use and PTSD severity, measured on the first day of treatment, and 3 (i.e. the planned end of SS sessions) and 6 months following the baseline assessment. Treatment attendance and patient satisfaction were measured following treatment (3-month follow-up). Active coping was measured at treatment intake and following treatment. FINDINGS: SS compared to TAU was associated with better drug use outcomes (P < 0.05), but alcohol use and PTSD severity decreased equally under both treatments (P's < 0.01). SS versus TAU was associated with increased treatment attendance, client satisfaction and active coping (all P's < 0.01). However, neither these factors nor decreases in PTSD severity mediated the effect of treatment on drug use. CONCLUSIONS: The manualized treatment approach for substance use disorder, Seeking Safety, is well received and associated with better drug use outcomes than 'treatment as usual' in male veterans with post-traumatic stress disorder. However, the mechanism of its effect is unclear.

Building bridges...and strengthening nursing.

In light of current nursing employment trends, nurses and employment specialists in one rural northern Iowa healthcare organization are collaborating to retain and recruit nurses. The purpose of this article is to describe how these individuals worked toward a comprehensive, cohesive approach to the development, implementation, and evaluation of learning opportunities that support these efforts. Staff development educators played key roles in developing program purposes, descriptions, curriculum, and outcome measures.