Supported Employment for Veterans With Traumatic Brain Injury: Provider Perspectives.

OBJECTIVE: To identify any pilot and nonpilot site differences regarding current (1) provision of supported employment (SE) to veterans with traumatic brain injury (TBI); (2) staffing and communication between the SE and polytrauma/TBI teams; and (3) provider perceptions on facilitators and barriers to providing, and suggestions for improving, SE. DESIGN: Mixed methods cross-sectional survey study. SETTING: Veterans Health Administration SE programs. PARTICIPANTS: Respondents (N=144) included 54 SE supervisors and 90 vocational rehabilitation specialists. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Web-based surveys of forced-choice and open-ended items included questions on SE team characteristics, communication with polytrauma/TBI teams, and experiences with providing SE to veterans with TBI history. RESULTS: SE was provided to veterans with TBI at 100% of pilot and 59.2% of nonpilot sites (P=.09). However, vocational rehabilitation specialists at pilot sites reported that communication with the polytrauma/TBI team about SE referrals was more frequent than at nonpilot sites (P=.003). In open-ended items, suggestions for improving SE were similar across pilot and nonpilot sites, and included increasing staffing for vocational rehabilitation specialists and case management, enhancing communication and education between SE and polytrauma/TBI teams, and expanding the scope of the SE program so that eligibility is based on employment support need, rather than diagnosis. CONCLUSIONS: These findings may contribute to an evidence base that informs SE research and clinical directions on service provision, resource allocation, team integration efforts, and outreach to veterans with TBI who have employment support needs.

Identifying barriers to culture change: A qualitative analysis of the obstacles to delivering resident-centered care.

A growing number of healthcare organizations have moved from traditional, institutional nursing home models to ones that emphasize culture change, or resident-centered care (RCC). In 2006, the Department of Veterans Affairs (VA) began implementing a number of changes to VA nursing homes, now called Community Living Centers (CLCs), to provide veterans with a more resident-centered and homelike environment. This study aimed to understand the barriers CLC staff face when delivering RCC. Ten CLCs were included on the basis of their performance levels on RCC and quality of care. Semistructured interviews that focused on facility efforts in RCC and quality were conducted with all levels of staff. Interviews were systematically content coded. We found similarities and differences in barriers reported at high- and low-performing sites. Staff across all performance levels cited 5 main categories of barriers to delivering RCC: staffing, resources, acuity of residents, RCC and quality of care conflicts, and regulations. Staff in high-performing sites reported fewer barriers to RCC, although 1 barrier cited was difficulty coordinating RCC across departments. Staff in low-performing sites reported additional categories of barriers related to administrator turnover/lack of guidance, CLC culture/staff morale, and difficulty working with residents and families. As RCC continues to spread, it is important to anticipate the barriers to implementing these practices. Particular focus on regulatory, leadership, organizational, workforce, and process factors may help organizations avoid or reduce barriers to RCC. Given their training and skill set, mental health providers may be uniquely situated to assist staff in overcoming these barriers. (PsycINFO Database Record

What roles do middle managers play in implementation of innovative practices?

BACKGROUND: Middle managers play key roles in hospitals as the bridge between senior leaders and frontline staff. Yet relatively little research has focused on their role in implementing new practices. PURPOSE: The aim of this study was to expand the understanding of middle managers' influence in organizations by looking at their activities through the lens of two complementary conceptual frameworks. METHODOLOGY/APPROACH: We analyzed qualitative data from 17 Veterans Affairs Medical Centers with high and low potential to change organizational practices. We analyzed 98 interviews with staff ranging from senior leaders to frontline staff to identify themes within an a priori framework reflecting middle manager activities. FINDINGS: Analyses yielded 14 emergent themes that allowed us to classify specific expressions of middle manager commitment to implementation of innovative practices (e.g., facilitate improvement innovation, garner staff buy-in). In comparing middle manager behaviors in high and low change potential sites, we found that most emergent themes were present in both groups. However, the activities and interactions described differed between the groups. PRACTICE IMPLICATIONS: Middle managers can use the promising strategies identified by our analyses to guide and improve their effectiveness in implementing new practices. These strategies can also inform senior leaders striving to guide middle managers in those efforts.