Whole Health

Adjognon OL, Cohen-Bearak A, Kaitz J, Bokhour BG, Chatelain L, Charns MP, Mohr DC. Factors affecting the implementation of employee whole health in the veterans health administration: a qualitative evaluation. BMC Health Serv Res. 2023 Jun 8;23(1):600.

BACKGROUND

There is increasing recognition of the need to focus on the health and well-being of healthcare employees given high rates of burnout and turnover. Employee wellness programs are effective at addressing these issues; however, participation in these programs is often a challenge and requires large scale organizational transformation. The Veterans Health Administration (VA) has begun to roll out their own employee wellness program-Employee Whole Health (EWH)-focused on the holistic needs of all employees. This evaluation's goal was to use the Lean Enterprise Transformation (LET) model for organizational transformation to identify key factors-facilitators and barriers-affecting the implementation of VA EWH.

METHODS

This cross-sectional qualitative evaluation based on the action research model reflects on the organizational implementation of EWH. Semi-structured 60-minute phone interviews were conducted in February-April 2021 with 27 key informants (e.g., EWH coordinator, wellness/occupational health staff) knowledgeable about EWH implementation across 10 VA medical centers. Operational partner provided a list of potential participants, eligible because of their involvement in EWH implementation at their site. The interview guide was informed by the LET model. Interviews were recorded and professionally transcribed. Constant comparative review with a combination of a priori coding based on the model and emergent thematic analysis was used to identify themes from transcripts. Matrix analysis and rapid turnaround qualitative methods were used to identify cross-site factors to EWH implementation.

RESULTS

Eight common factors in the conceptual model were found to facilitate and/or hinder EWH implementation efforts: [1] EWH initiatives, [2] multilevel leadership support, [3] alignment, [4] integration, [5] employee engagement, [6] communication, [7] staffing, and [8] culture. An emergent factor was [9] the impact of the COVID-19 pandemic on EWH implementation.

CONCLUSIONS

As VA expands its EWH cultural transformation nationwide, evaluation findings can (a) enable existing programs to address known implementation barriers, and (b) inform new sites to capitalize on known facilitators, anticipate and address barriers, and leverage evaluation recommendations through concerted implementation at the organization, process, and employee levels to jump-start their EWH program implementation.

Bui E, Blackburn AM, Brenner LH, Laifer LM, Park ER, Fricchione GL, Sylvia LG. Military and Veteran Caregivers' Perspectives of Stressors and a Mind-Body Program. Issues Ment Health Nurs. 2018 Oct;39(10):850-857

There are over one million post-9/11 military caregivers in the United States who face a variety of stressors inherent to caring for an incapacitated loved one. Mind-body interventions, such as the Stress Management and Resilience Training Relaxation Response Resiliency Program (SMART-3RP), have been shown to reduce stress and improve overall health and functioning. The present qualitative study aims to explore stressors experienced by military caregivers in their caregiving role and to assess attitudes towards the virtual delivery of the SMART-3RP. We conducted two focus groups with a total of 13 caregivers [M (SD) age = 41.25 (11.49); 92% female], and participants subsequently completed a survey on their caregiving experiences. Focus groups were conducted remotely via Google Hangouts by two doctoral-level clinicians, transcribed verbatim, and coded using inductive thematic analysis. Themes related to stressors of caregiving included: logistical stressors faced by caregivers, demands of the caregiving role, concerns about children, worries about the future, exacerbation of the caregiver's physical/mental health concerns, social dynamics, sacrifices made for their veteran in the caregiving role, and relationship dynamics between the veteran and caregiver. Military caregivers found the SMART-3RP logical and felt as though it could be helpful to them. Caregivers expressed interest in a brief, virtual version of the SMART-3RP. Using the findings from the current study, we are adapting the SMART-3RP to be administered virtually as a podcast-based intervention.

Freeman RC Jr, Sukuan N, Tota NM, Bell SM, Harris AG, Wang HL. Promoting Spiritual Healing by Stress Reduction Through Meditation for Employees at a Veterans Hospital: A CDC Framework-Based Program Evaluation. Workplace Health Saf. 2019 Sep 20:2165079919874795.

BACKGROUND

Employees in the Veterans Affairs (VA) hospital experience psychological stress from caring for vulnerable veteran populations. Evidence suggests that mindfulness meditation decreases stress in health care employees and military personnel. The purpose of this worksite program was to explore the acceptability of a mindfulness meditation program among VA workers.

METHODS

Chaplain residents developed the "Promoting Spiritual Healing by Stress Reduction Through Meditation" (Spiritual Meditation) program for employees in a VA hospital. To evaluate acceptability, a 13-multiple-choice-item survey with an open-ended question was administered after the intervention. Descriptive statistics and qualitative content analysis were performed.

FINDINGS

In 29 participants, 70% to 100% agreed with positive statements for the personal learning experience, program components, teacher quality, time to practice, and place to practice. Two categories emerged from qualitative responses: "positive practical experience of Spiritual Meditation" and "perceived values from Spiritual Meditation."

CONCLUSION/APPLICATION TO PRACTICE

Occupational health nurses are uniquely positioned to lead and collaborate with chaplains to deliver Spiritual Meditation in their workplace setting.

Gragnani CM, Fitzgerald IK, Mullur R. The Use of Experiential Learning Modules to Teach Integrative Medicine Approaches. J Grad Med Educ. 2018 Dec;10(6):688-692. doi: 10.4300/JGME-D-18-00351.1. PMID: 30619530; PMCID: PMC6314377.

BACKGROUND

Complementary, alternative, and integrative medicine (CAIM) are considered important in shifting toward whole person care. Residents remain limited in their understanding of CAIM approaches, preventing effective utilization.

Objective

We created modules to expose residents to available CAIM approaches in a Veterans Administration setting, using conceptual frameworks for experience-based learning.

METHODS

In June 2016, 38 internal medicine residents at the VA Greater Los Angeles Healthcare System were randomized to 45-minute small group sessions. One cohort received an experiential module incorporating 10-minute practices of yoga, biofeedback, and acupressure. The other cohort received a standard lecture focused on CAIM use and outcomes. Participants completed a 6-question quiz to measure their understanding of CAIM use and an 8-question survey to assess their satisfaction of teaching, exposure to CAIM, and anticipated practice change. Referrals to CAIM modalities before and after the learning modules were counted to assess practice change.

RESULTS

All 38 residents completed the study, with 25 residents completing the experiential learning modules and 13 completing the standard lectures. Initial postquiz scores were similar. Five months postintervention, residents who participated in experiential modules were more likely to refer patients to CAIM modalities than those who received standard lectures (3.4 per month versus 0.6 per month, P = .018).

CONCLUSIONS

This study highlights the advantages of experiential learning of CAIM approaches for residents. It reinforces existing literature suggesting that physicians who experience CAIM are more likely to incorporate these approaches into practice.

Haun JN, Ballistrea LM, Melillo C, Standifer M, Kip K, Paykel J, Murphy JL, Fletcher CE, Mitchinson A, Kozak L, Taylor SL, Glynn SM, Bair M. 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. JMIR Res Protoc. 2019 May 13;8(5):e13666.

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.

Lara-Cinisomo S, Fujimoto EM, Santens RL. Feasibility of a Mindfulness-Based Intervention for Caregivers of Veterans: A Pilot Study. J Holist Nurs. 2019 Dec;37(4):322-337.

PURPOSE

This pilot study aimed to assess the feasibility of conducting an 8-week mindfulness-based intervention with caregivers of veterans and to examine the effectiveness of the intervention to improve mindfulness using the Five Facet Mindfulness Questionnaire compared with waitlist controls.

DESIGN

In this randomized controlled trial, 23 caregivers of veterans were assigned to either the intervention or waitlist group.

METHOD

Compliance with mindfulness instruction and attendance was assessed among those in the intervention. Wilcoxon signed-rank tests compared within group pre- and post-intervention scores and Mann-Whitney U tests compared difference scores (post-pre) by group type. Effect sizes were also calculated. Compliance variables were correlated with difference scores in the intervention group only.

FINDINGS

Of the 23 participants, 11 were assigned to the intervention; 100% of participants were retained. There was significant improvement from pre- to post-intervention in four of the five facets of mindfulness (p < .05) in the intervention group. Significant between-group differences (p < .05) were also observed in two of the five facets. Effect sizes ranged from small (.44) to large (.89). No significant improvement was observed in the waitlist control group.

CONCLUSIONS

A mindfulness-based intervention is feasible and acceptable to improve mindfulness in caregivers of veterans.

Leary S, Weingart K, Topp R, Bormann J. The Effect of Mantram Repetition on Burnout and Stress Among VA Staff. Workplace Health Saf. 2018 Mar;66(3):120-128.

In this study, the authors determined the effect of a structured Internet-delivered Mantram Repetition Program (MRP) on burnout and stress of conscience (SOC), stress related to ambiguity from ethical or moral conflicts among health care workers (HCWs) within the Veteran Affairs (VA) Healthcare System. A secondary purpose was to determine whether practicing meditation prior to the study combined with MRP affected burnout or SOC. The MRP teaches the mindful practices of repeating a mantram, slowing down, and one-pointed attention for managing stress. Thirty-nine HCW volunteers who provided direct patient care completed the Internet-delivered MRP. The outcomes of burnout (i.e., exhaustion, cynicism, and professional efficacy) and SOC (i.e., frequency of stressful events and troubled conscience about those events) were measured at baseline (T1), postintervention (T2), and 3-months postintervention (T3). Repeated measures ANOVA indicated that exhaustion significantly ( p < .05) declined between T1 and T3; professional efficacy and cynicism did not change during the study. The same statistical model also indicated the frequency of stressful events significantly declined between T1 and T2 and troubled conscience declined between T1 and T3. Secondary analysis demonstrated that individuals who did not practice meditation at baseline ( n = 16, 41%) significantly decreased exhaustion, frequency of stressful events, and troubled conscience between T1 and T3, and improved professional efficacy between T1 and T2. Individuals who practiced meditation at baseline ( n = 23, 59%) did not demonstrate significant change on any study outcomes. An MRP intervention may reduce burnout and SOC in those individuals who are naïve to practicing meditation.

Reddy KP, Schult TM, Whitehead AM, Bokhour BG. Veterans Health Administration's Whole Health System of Care: Supporting the Health, Well-Being, and Resiliency of Employees. Glob Adv Health Med. 2021 May 30;10:21649561211022698. doi: 10.1177/21649561211022698. PMID: 34104580; PMCID: PMC8168167.

ABSTRACT

The Veterans Health Administration (VHA) is implementing a Whole Health System (WHS) of care that empowers and equips Veterans to take charge of their health and well-being and live their lives to the fullest, and increasingly leaders recognize the need and value in implementing a similar approach to support the health and well-being of employees. The purpose of this paper is to do the following: 1) provide an overview of the WHS of care in VHA and applicability in addressing employee resiliency; 2) provide a brief history of employee well-being efforts in VHA to date; 3) share new priorities from VHA leadership as they relate to Employee Whole Health strategy and implementation; and 4) provide a summary of the impacts of WHS of care delivery on employees. The WHS of care utilizes all therapeutic, evidence-based approaches to support self-care goals and personal health planning. Extending these approaches to employees builds upon 10 years of foundational work supporting employee health and well-being in VHA. In 2017, one facility in each of the 18 Veterans Integrated Service Networks (VISNs) in VHA was selected to participate in piloting the WHS of care with subsequent evaluation by VA's Center for Evaluating Patient-Centered Care (EPCC). Early outcomes, from an employee perspective, suggest involvement in the delivery of the WHS of care and personal use of the whole health approach have a meaningful impact on the well-being of employees and how they experience the workplace. During the COVID-19 pandemic, VHA has continued to support employees through virtual resources to support well-being and resiliency. VHA's shift to this patient-centered model is supporting not only Veteran care but also employee health and well-being at a time when increased support is needed.

Richards LK, Bui E, Charney M, Hayes KC, Baier AL, Rauch PK, Allard M, Simon NM. Treating Veterans and Military Families: Evidence Based Practices and Training Needs Among Community Clinicians. Community Ment Health J. 2017 Feb;53(2):215-223.

Little is known about the capacity of community providers to provide military informed evidence based services for posttraumatic stress disorder (PTSD). We conducted a regional, web-based survey of 352 community mental health care providers that sought to identify clinical practices, training needs, and predictors of evidence based treatment (EBT) use for PTSD. Overall, 49 % of providers indicated they seldom or never use a validated PTSD screening instrument. Familiarity with EBTs, specifically prolonged exposure (PE; χ2(4) = 14.68, p < .01) and cognitive processing therapy (CPT; χ2(4) = 4.55, p < .05), differed by provider type. Of providers who received training in PE or CPT (N = 121), 75 % reported using treatment in their practice, which was associated with having received clinical supervision (χ2 (1) = 20.16, p < .001). Widely disseminated trainings in empirically supported PTSD assessment and treatment, and implementation of case supervision in community settings are needed.

Serpa, J.G., Atwood, K., Shamblen, S.R. et al. Training Mindfulness Facilitators: Evaluating the VA CALM Program at the Veterans Health Administration. Mindfulness 13, 1662–1670 (2022). https://doi.org/10.1007/s12671-022-01905-8

OBJECTIVES

As the demand for Mindfulness-Based Interventions (MBIs) expands, there is a growing need for training healthcare professionals to deliver these interventions. To meet this demand, VA CALM (Veterans Affairs – Compassionate Awareness Learning Module) was developed and evaluated.

METHODS

Participants (n = 74, female = 73%) were a national sample of VA clinicians including psychologists (48%), social workers (33%), physicians (10%), nurses (5%), and other clinicians (4%) who joined the year-long training program delivered via hybrid learning platforms including live video and in-person instruction. The evaluation was a single-arm, repeated measures design comparing outcomes at baseline, at the halfway point of training, and immediately post-training. Outcomes from standardized measures included burnout, competence, mindfulness, self-compassion, and stress. Participant self-efficacy was also assessed.

RESULTS

Random intercept regressions were performed examining linear and quadratic time contrasts as predictors of study outcome change trajectories. The pattern of change was largely linear, where there were statistically significant and large magnitude (r > .50) increases at each observation period for burnout (r =  − 0.52), competence with one-on-one interventions (r = 0.68) and groups (r = 0.76), mindfulness (r = 0.61), perceived stress (r =  − 0.51), self-compassion (r = 0.58), and self-efficacy (r = 0.83). The linear model indicates changes in study outcomes were cumulative over the course of the training.

CONCLUSIONS

VA CALM is an effective training program for mindfulness facilitators and appears to confer additional participant benefits, even when participants have significant experience with mindfulness.

Van Kirk ML. Employee Wellness Pilot Program. Workplace Health Saf. 2021 May;69(5):192-197. doi: 10.1177/2165079920976522. Epub 2020 Dec 24. PMID: 33357044.

BACKGROUND

Mental health professionals caring for the veteran population are at increased risk for compassion fatigue, burnout, and secondary traumatic stress based on the nature of their work. While mental health professionals may experience positive outcomes from providing compassionate care to veterans, compassion fatigue can lead to instability of the workforce.

METHODS

A pilot employee wellness program was implemented over a 9-week period, offering a different wellness module weekly during the employee lunch hour. Demographic data were collected pre-program, and mental health employees were surveyed pre- and post-program using an intent to stay scale and the Professional Quality of Life Scale version 5 (ProQOL-5) to measure compassion satisfaction, burn out, and secondary traumatic stress.

FINDINGS

Pre-program participants (N = 42) reported significant differences in intent to stay in their current position for the next year compared to the post-program group (N = 15). Pre-program participants reported no intent to leave their current position, apply for internal or external positions, or retire in the following year. However, post-program participants reported intent to leave their current positions, apply to internal or external positions, or retire. Pre- and post-program compassion satisfaction scores increased and burnout and secondary traumatic stress scores decreased; these scores were not significantly different between groups.

Conclusions/Applications to Practice

While no significant differences were found between ProQOL-5 subscale scores, the change in participants’ scores may indicate some change, potentially as a result of the intervention. This pilot program offered a creative solution to organizations with limited resources to combat occupation-related compassion fatigue.