Perceptions of providers and administrators in the Veterans Health Administration regarding complementary and alternative medicine.

BACKGROUND: The integration of complementary and alternative medicine (CAM) therapies into a large organization such as the Veterans Health Administration (VHA) requires cultural change and deliberate planning to ensure feasibility and buy-in from staff and patients. At present, there is limited knowledge of VHA patient care providers' and administrators' viewpoints regarding CAM therapies and their implementation. OBJECTIVES: Our purpose was to qualitatively examine knowledge, attitudes, perceived value and perceived barriers, and/or facilitators to CAM program implementation among VHA providers and administrators at a large VHA facility. RESEARCH DESIGN: We are reporting the qualitative interview portion of a mixed-methods study. SUBJECTS: Twenty-eight participants (patient care providers or administrators) were purposely chosen to represent a spectrum of positions and services. Participants' experience with and exposure to CAM therapies varied. MEASURES: Individual interviews were conducted using a semi-structured format and were digitally recorded, transcribed, and coded for themes. RESULTS: Recurrent themes included: a range of knowledge about CAM; benefits for patients and staff; and factors that can be facilitators or barriers including evidence-based practice or perceived lack thereof, prevailing culture, leadership at all levels, and lack of position descriptions for CAM therapists. Participants rated massage, meditation, acupuncture, and yoga as priorities for promotion across the VHA. CONCLUSIONS: Despite perceived challenges, providers and administrators recognized the value of CAM and potential for expansion of CAM within the VHA. Interview results could inform the process of incorporating CAM into a plan for meeting VHA Strategic Goal One of personalized, proactive, patient-driven health care across the VHA.

Integrating Massage Therapy Into the Health Care of Female Veterans.

Background: Female veterans experience higher rates of chronic pain, depression, and anxiety than do male veterans. Gynecologic examinations and procedures can be stressful, painful, and anxiety provoking. Research has shown that massage can help reduce pain and anxiety. The purpose of this study was to examine the relationship between massage and well-being in female veterans. Methods: A pre- and postvisit study design was used. In advance of their clinic visit, female veterans were asked by clinic staff whether they would like a relaxation massage in conjunction with their visit. Effleurage massages were administered by licensed volunteer massage therapists in a private space and performed on the back, neck, hands/arms, legs/feet. Patients rated their pain intensity, pain unpleasantness, anxiety, shortness of breath, relaxation, and inner peace pre- and postmassage on 0 to 10 scales. Demographics and data were abstracted from the medical records. Results: Results are based on the first massage received by 96 individuals: A majority of participants were aged ≤ 40 years (53%) and were White women (68%). Most (70%) were scheduled for an invasive procedure (eg, pelvic examination, biopsy). Seventy-nine percent had a history of chronic pain; 65% had a diagnosis of depression. Mean scores for pain intensity decreased by 1.9 points, pain unpleasantness by 2.0, and anxiety by 2.4. Relaxation increased by 4.3 points and sense of inner peace by 3.5 points. These changes were all statistically significant (P < .001). Conclusions: Results from this pilot study suggest massage therapy may be an effective, inexpensive, and safe treatment for pain and/or anxiety in female veterans attending a gynecology appointment. Further research should assess the effects of massage therapy in female veterans with chronic pain and coexistent mental health conditions.

A systematic exploration of differences in contextual factors related to implementing the MOVE! weight management program in VA: a mixed methods study.

BACKGROUND: In January 2006, Veterans Affairs (VA) disseminated the MOVE!® Weight Management Program to VA medical centers to address the high prevalence of overweight/obesity. In its second year, MOVE! implementation varied widely across facilities. The objective of this study was to understand contextual factors that facilitated or impeded implementation of MOVE! in VA medical centers in the second year after its dissemination. METHODS: We used an embedded mixed methods cross-sectional study design. Qualitative and quantitative data were collected simultaneously with the primary purpose to explore contextual factors most likely to influence MOVE! implementation effectiveness at five purposively selected facilities. Facilities were selected to maximize variation with respect to participation in MOVE! by candidate Veterans. Semi-structured phone interviews were conducted with 24 staff across the five facilities. Quantitative responses were elicited followed by open-ended questions. The quantitative measures were adapted from a published implementation model. Qualitative analysis was conducted using rigorous content analysis methods. RESULTS: Qualitative and quantitative data converged to strengthen findings that point to several recommendations. Management support can help increase visibility of the program, commit needed resources, and communicate the importance of implementation efforts. Establishing a receptive implementation climate can be accomplished by emphasizing the important role that weight management may have in reducing incidence and severity of obesity-related chronic conditions. Coalescing highly functioning multi-disciplinary teams was an essential step for more effective implementation of MOVE!. In some situations, local champions can overcome challenging barriers in facilities that lack sufficient management support. CONCLUSIONS: Key organizational factors at local VA medical centers were strongly associated with MOVE! implementation. Results pointed to recommendations that can help accelerate large-scale dissemination of complex weight management programs.

Nurse practitioners as primary care providers within the VA.

We examined the perceptions of nurse practitioners (NPs) and physicians regarding NPs' roles as primary care providers within the Department of Veterans Affairs, thus suggesting possible reasons for the variation of NPs use. NPs and physicians from 7 Veterans Affairs hospitals were surveyed regarding perceptions and concerns about NPs' responsibilities. Quality of care was verified through outpatient services, laboratory results, and medications prescribed for 104,226 hypertensive or diabetic patients. Clinical findings suggest primary care for diabetic and hypertensive patients was comparable. Survey findings suggest physicians tended to underestimate what NPs do on their own for acute patients. Both groups expressed some concerns about expectations for NPs. To successfully integrate NPs into the primary care environment, health systems need to pay increased attention to differences in role perceptions among primary care providers.

A quick measure to guide allocation of chaplains' time with hospitalized veterans.

Assessing veterans' desire to see a chaplain can be difficult. Due to alleged personal weakness associated with seeing a chaplain while on active duty, veterans may still be reluctant to admit a need. Additionally chaplains may be challenged with multiple time demands. We devised and correlated with known instruments a single item containing four graded responses. One correlation was strong, suggesting the question's potential for serving as a useful tool for allocation of chaplains' time.

A Mobile and Web-Based Self-Directed Complementary and Integrative Health Program for Veterans and Their Partners (Mission Reconnect): Protocol for a Mixed-Methods Randomized Controlled Trial.

BACKGROUND: Complementary and integrative health (CIH) is a viable solution to PTSD and chronic pain. Many veterans believe CIH can be performed only by licensed professionals in a health care setting. Health information technology can bring effective CIH to veterans and their partners. OBJECTIVE: This paper describes the rationale, design, and methods of the Mission Reconnect protocol to deliver mobile and Web-based complementary and integrative health programs to veterans and their partners (eg, spouse, significant other, caregiver, or family member). METHODS: This three-site, 4-year mixed-methods randomized controlled trial uses a wait-list control to determine the effects of mobile and Web-based CIH programs for veterans and their partners, or dyads. The study will use two arms (ie, treatment intervention arm and wait-list control arm) in a clinical sample of veterans with comorbid pain and posttraumatic stress disorder, and their partners. The study will evaluate the effectiveness and perceived value of the Mission Reconnect program in relation to physical and psychological symptoms, global health, and social outcomes. RESULTS: Funding for the study began in November 2018, and we are currently in the process of recruitment screening and data randomization for the study. Primary data collection will begin in May 2019 and continue through May 2021. Projected participants per site will be 76 partners/dyads, for a total of 456 study participants. Anticipated study results will be published in November 2022. CONCLUSIONS: This work highlights innovative delivery of CIH to veterans and their partners for treatment of posttraumatic stress disorder and chronic pain. TRIAL REGISTRATION: ClinicalTrials.gov NCT03593772; https://clinicaltrials.gov/ct2/show/NCT03593772 (Archived by WebCite at http://www.webcitation.org/77Q2giwtw). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/13666.

An intensive care unit quality improvement collaborative in nine Department of Veterans Affairs hospitals: reducing ventilator-associated pneumonia and catheter-related bloodstream infection rates.

BACKGROUND: Measured adherence to evidence-based best practice in the intensive care unit (ICU) setting, as in all of health care, remains unacceptably low. In 2005 to 2006, the VA Midwest Health Care Network used a quality improvement collaborative (QIC) model to improve adherence with ICU best practices in widely varying ICU and hospital settings in nine Department of Veterans Affairs (VA) hospitals. METHODS: Interdisciplinary performance improvement teams at each of the participating sites implemented evidence-based ventilator and central line insertion bundles, interdisciplinary team rounds, and use of a daily patient ICU bedside checklist. RESULTS: Adherence with all five elements of the ventilator bundle improved from 50% in the first three months to 82% in the final three months of the intervention. Mean ventilator-associated pneumonia (VAP) rates decreased by 41% over the same time frame. Use of a central line insertion checklist to monitor adherence with the central line bundle increased from 58% in the first three months to 74% in the final three months of the intervention. Mean catheter-related bloodstream infection (CRBSI) rates decreased by 48% over the same time frame. Following completion of the collaborative, eight of the nine sites continued to report on adherence with the ventilator and central line bundles, the practice of interdisciplinary team rounds, and the use of an ICU patient checklist. The incidence of VAP and CRBSI in these eight sites declined in the 12-month period following the collaborative's completion, compared with the previous 12-month period. DISCUSSION: Implementing the ventilator and central line bundles was associated with a reduction in rates of VAPs and CRBSIs.

Providers' and Administrators' Perceptions of Complementary and Integrative Health Practices Across the Veterans Health Administration.

OBJECTIVES: Use of complementary and integrative health (CIH) therapies is being promoted by the Veterans Health Administration (VA), but promotion may not equate to adoption. The purpose of this study was to explore whether perceptions regarding CIH at one VA medical center (VAMC) were similar to perceptions from a sample of other VAMCs. DESIGN: This article reports a subset of qualitative findings from a mixed-methods study. SETTING/PARTICIPANTS: Sites were recruited through a VA-wide CIH listserver. On the basis of site description (e.g., therapies offered, interest in CIH), sustained site interest, and geographic location, recorded interviews of 22 persons were conducted at 6 sites across the country. OUTCOME MEASURES: Interviewees were asked the same questions as the single-site VAMC study respondents. RESULTS: Variable access to CIH services across the VA created the need for workarounds. Multiple barriers (e.g., limited space and challenging credentialing) and facilitators (e.g., strong champion and high veteran demand) were cited. Respondents described nonpharmacologic pain control, the usefulness in treating mental health and/or post-traumatic stress disorder issues, and improvement of staff morale as additional reasons to promote CIH. Findings confirmed those from the earlier single-site VAMC phase of the study. Even the highest-performing sites reported struggling to meet veterans' demands for delivery of CIH. CONCLUSIONS: Almost half of active-duty military personnel report the use of at least one type of CIH therapy. As active-duty personnel transition to veteran status, both their physical and mental healthcare needs can potentially benefit from CIH therapies. The VA must actively support local enthusiastic CIH proponents and receive congressional support if it is to actually meet its stated goal of providing personalized, proactive, patient-driven healthcare through the promotion of comprehensive CIH services to veterans.

Satisfaction of impaired health care professionals with mandatory treatment and monitoring.

OBJECTIVE: To measure the satisfaction of impaired health professionals with treatment and monitoring programs in Michigan and Indiana. METHOD: Mailed surveys assessed overall program satisfaction, usefulness of various aspects of monitoring, and several miscellaneous items. Persons active in the Michigan (n = 620) and Indiana (n = 267) programs in July 2002 were included. Anonymous responses were received from 263 (43%) of Michigan and 120 (45%) of Indiana participants. RESULTS: Means on the 1 to 5 satisfaction subscale were 3.6 (SD = .94) for Michigan and 4.1 (SD = .86) for Indiana. Means on the 1 to 4 monitoring subscale were 2.7 (SD = .62) for Michigan and 2.7 (SD = .57) for Indiana. 40% of Michigan respondents and 53% of Indiana respondents lacked insurance coverage for program costs. 39% of Michigan and 35% of Indiana respondents reported substance abuse or mental health difficulties prior to their professional career.

Veterans' health and access to care in the year after September 11, 2001.

OBJECTIVE: The goal was to explore veterans' perceptions of their health care in the year after September 11, 2001. METHODS: A random sample of outpatients seen at a Manhattan (New York City) or Midwestern Veterans Affairs facility between September 12, 2001, and September 30, 2002, received a mailed questionnaire. Regression assessed the effects of site, demographic features, military service, and symptoms of post-traumatic stress disorder (PTSD) on health status, care-seeking, and satisfaction with health care among 490 patients. RESULTS: Veterans from New York City reported better health and more satisfaction that their providers listened to them. Patients with more PTSD symptoms reported poorer health, more September 11-related symptoms, and less satisfaction with care and were more likely to seek care outside the Veterans Affairs system. CONCLUSIONS: Proximity to the September 11 terrorist attacks had little relationship to patients' perceptions of their health and health care, whereas PTSD symptoms had a pervasive effect. Patients with PTSD symptoms may require outreach programs to assist them in dealing with catastrophic events, regardless of their proximity to the events.

Health care providers' perceptions of spirituality while caring for veterans.

To determine health care providers' views on spirituality, its role in the health of patients, and barriers to discussing spiritual issues with patients, the author convened five focus groups at two Veterans Administration Medical Centers. Participants were nurses, physicians, social workers, psychologists, and chaplains. Common themes included (a) the lack of education for professionals regarding how to address patients' spiritual needs; and (b) systems-related issues, including communication systems that do not function well, how spiritual needs are addressed on admission, support or lack thereof by hospital administrators, and lack of support for the spiritual needs of staff. The aging and illnesses of many current veterans plus the escalated potential of war highlight the importance of addressing veterans' spiritual needs.

Integrating massage therapy within the palliative care of veterans with advanced illnesses: an outcome study.

AIMS: To describe the integration of massage therapy into a palliative care service and to examine the relationship between massage and symptoms in patients with advanced illnesses. METHODS: Between April 1, 2009, and July 31, 2010, 153 patients received massage at the VA Ann Arbor Health Care System. Data on pain, anxiety, dyspnea, relaxation, and inner peace were collected pre and post massage. Diagnoses, chronic pain, and social support were also abstracted. Analysis of covariance was used to examine changes over time. RESULTS: All short-term changes in symptoms showed improvement and all were statistically significant. Pain intensity decreased by 1.65 (0-10 scale, P < .001), anxiety decreased by 1.52 (0-10 scale, P < .001), patients' sense of relaxation increased by 2.92 (0-10 scale, P < .001), and inner peace improved by 1.80 (0-10 scale, P < .001). CONCLUSION: Massage is a useful tool for improving symptom management and reducing suffering in palliative care patients.

Developing and testing a tool to measure nurse/physician communication in the intensive care unit.

OBJECTIVES: The purpose of this study, conducted in 3 intensive care units (ICUs) at 1 Department of Veterans Affairs Medical Center, was to develop tools and procedures to measure nurse/physician communication in future studies. METHODS: We used mixed methods in a multistaged approach. Qualitative data came from 4 observations of patient care rounds and 8 interviews with nurses and physicians. Quantitative data came from anonymous surveys distributed to nurses in all 3 ICUs (n = 66). We administered the Safety Organizing Scale to measure nurses' self-reported behaviors that enable a safety culture. Analysis of variance was the main statistical test. RESULTS: Qualitative data were used to create an observation data collection tool and a working protocol, to measure nurse/physician communication in a future study. Analysis of variance revealed significant differences between the 3 units (f = 4.57, P = 0.02). There also were significant differences on 4 of 9 items of the Safety Organizing Scale. Using mixed methods, we gained multiple perspectives that helped us to clarify and validate the context and content of communication. Quantitative analysis showed significant differences between the 3 ICUs in nurses' perceptions of a safety culture. According to qualitative analyses, nurses from the unit which reported the weakest safety culture also were the least satisfied in their communication with physicians. Qualitative analyses corroborated quantitative findings and demonstrated the importance of contextual influences on nurse/physician communication. CONCLUSIONS: Through the tools and protocol we created, more realistic strategies to promote effective communication between nurses and physicians may be developed and tested in future studies.

Improving eye care for veterans with diabetes: an example of using the QUERI steps to move from evidence to implementation: QUERI Series.

BACKGROUND: Despite being a critical part of improving healthcare quality, little is known about how best to move important research findings into clinical practice. To address this issue, the Department of Veterans Affairs (VA) developed the Quality Enhancement Research Initiative (QUERI), which provides a framework, a supportive structure, and resources to promote the more rapid implementation of evidence into practice. METHODS: This paper uses a practical example to demonstrate the use of the six-step QUERI process, which was developed as part of QUERI and provides a systematic approach for moving along the research to practice pipeline. Specifically, we describe a series of projects using the six-step framework to illustrate how this process guided work by the Diabetes Mellitus QUERI (DM-QUERI) Center to assess and improve eye care for veterans with diabetes. RESULTS: Within a relatively short time, DM-QUERI identified a high-priority issue, developed evidence to support a change in the diabetes eye screening performance measure, and identified a gap in quality of care. A prototype scheduling system to address gaps in screening and follow-up also was tested as part of an implementation project. We did not succeed in developing a fully functional pro-active scheduling system. This work did, however, provide important information to help us further understand patients' risk status, gaps in follow-up at participating eye clinics, specific considerations for additional implementation work in the area of proactive scheduling, and contributed to a change in the prevailing diabetes eye care performance measure. CONCLUSION: Work by DM-QUERI to promote changes in the delivery of eye care services for veterans with diabetes demonstrates the value of the QUERI process in facilitating the more rapid implementation of evidence into practice. However, our experience with using the QUERI process also highlights certain challenges, including those related to the hybrid nature of the research-operations partnership as a mechanism for promoting rapid, system-wide implementation of important research findings. In addition, this paper suggests a number of important considerations for future implementation work, both in the area of pro-active scheduling interventions, as well as for implementation science in general.

Nurse practitioners' and physicians' views of NPs as providers of primary care to veterans.

PURPOSE: To describe NPs' and MDs' perceptions of the role of NPs, the degree of collegiality between professions, and NPs' feeling of acceptance, three relationship components that may affect the acceptance of NPs as providers of primary care. DESIGN AND METHODS: A descriptive study including both closed- and open-ended questions plus several Likert-type questions conducted June-August 2004. Our sample included all primary care NPs (87) and MDs (162) within a Midwestern Veterans Health Administration (VHA) region. Data were collected from 153 providers. FINDINGS: NPs saw their role as one of autonomous practice with physician back-up as needed, while MD respondents envisioned a role akin to a physician extender. Most of the physician respondents did not think NPs could provide adequate primary care to veterans who tend to have many comorbid conditions. Yet both groups considered their relationships to be collegial and most NPs felt accepted by physicians. MDs particularly valued NPs' teaching and interpersonal skills leading to greater patient satisfaction. CONCLUSIONS: To facilitate the teamwork of NPs and MDs while improving utilization of NPs as primary care providers, VHA officials should routinely clarify roles, monitor quality of care of both MDs and NPs, and provide feedback to all concerned.