Creating Whole Person Health Care Systems: Understanding Employee Perceptions of VAs Whole Health Cultural Transformation

Introduction

Creating whole person health care systems that attend to the well-being of patients is a growing priority across the United States. ^{1 –3} These systems seek to establish a culture that fosters health and well-being beyond the biomedical absence of disease. ^{1,4 –6} The U.S. Veterans Health Administration (VHA) Whole Health (WH) System (WHS) represents one such transformation. ^4,5 This system combines a WH approach that empowers and equips people to take charge of their health and well-being through care that is personalized, proactive, and patient-driven with the delivery of programs/services that promote self-care and support well-being. ^5,7

At its core is a person-centered WH approach where health care workers partner with Veterans to identify what brings each person a sense of meaning, aspiration, and purpose to support their unique vision for their health. ^4,6,7 Distinct from traditional biomedical and problem-focused care, this approach involves getting to know each Veteran holistically, collaboratively developing personalized health plans with them, and linking them to WH-aligned services (i.e., WH coaching; complementary and integrative health [CIH] therapies) to support their well-being, life goals, and aspirations. ^{5,7 –10} For example, a WH approach for a patient with diabetes may begin by identifying the patient's personal goals (rather than disease metrics such as HbA1C) and understanding how diabetes may affect their ability to achieve well-being as they define it, leading to a care plan that would support personal health goals in addition to addressing disease metrics. By using a person-centered approach, health care workers learn about each person's values, goals, and preferences to support their individual definitions of well-being, promote resilience, and restore health. ^{6 –8,11}

Integrating a WH approach into care is predicated on health care workers reconceptualizing their roles beyond find-it-fix-it medicine. ¹ WH is different from other health promotion approaches that prioritize biomedical definitions of health (e.g., diabetes management, smoking cessation) and require skills to carry out person-centered interactions that elicit patients' perspectives and goals. As such, health care workers need to buy-in to WH as a new way of delivering care. ^4,5,7 Simultaneously, advancing this cultural shift obligates health care systems to establish services to support patients' well-being goals, implement new administrative processes and policies, train employees in person-centered communication skills, and encourage practice change. ^4,9,12 Therefore, VA is disseminating WH concepts to all employees to support this system-wide transformation.

VHA committed substantial resources to pilot WH in 18 VA Medical Centers (Flagship sites), partially in response to the Comprehensive Addiction and Recovery Act ¹³ to address the pain and opioid crisis among Veterans. ⁴ Resources were used to develop infrastructure to support integration of a WH approach into practice, create new staff positions, implement WH-aligned services, and train/expose employees to WH concepts. ¹⁴ While the experiences of employees leading to WH implementation have previously been described, ¹⁴ as have employee perceptions of WH-aligned services, ¹⁵ perceptions of a WH approach among employees broadly have not previously been characterized.

To fill this gap, we examined employee perceptions of WH at five Flagship VA Medical Centers (VAMCs). This work was an extension of our evaluation of VHA's WHS to inform the Office of Patient-Centered Care and Cultural Transformation (OPCC&CT) as they led WHS implementation in the context of a learning health system. ^4,14 As such, this work was determined to be quality improvement by the VA Boston and VA Bedford Healthcare Systems institutional review boards and was exempted from oversight.

Materials and Methods

Results

Across all sites, 1873 employees (1073 clinical and 800 nonclinical) responded to the survey, for an average response rate of 12.2%. 51.5% of respondents worked in the main hospital, 57.4% were clinical staff, and 68.7% were mostly female. Clinical respondents most commonly practiced in primary care (15.8%), mental health (16.0%), or other clinical settings (18.7%) (Table 1). On structured attitudinal-based questions, respondents largely agreed that WH was valuable but were less likely to report incorporating WH into their interactions with patients or support for WH within the organization (item means shown in Table 2). One-way analysis of variance indicated minimal differences between sites, with effect sizes ranging from 0.00 to 0.02.

Four hundred and seventy-five survey respondents (25%) provided substantive free-text responses, elaborating on their perceptions of WH. We found no significant differences on structured questions for respondents who provided open-text comments and those who did not (p > 0.05). In our analysis of open-ended responses, we found similar themes expressed by clinical and nonclinical respondents at all sites, comprising three overarching themes: conceptualizations of WH, acceptance and perceived value of WH, and how organizational context contributed to perceptions.

Discussion

Successfully transforming the culture of care will require shifting underlying mindsets of health care workers to understand that their role extends beyond treating biomedical disease to creating health and well-being as uniquely envisioned by each patient. While some respondents in our study clearly associated WH with a philosophical shift that had great potential to improve Veterans' lives, many narrowly described it as a service to which patients could be referred, conflating WH as a person-centered approach with WH-aligned services and CIH. This perception existed despite efforts made by all Flagship sites to train staff broadly in WH concepts and to integrate WH as a person-centered approach into care. ²⁰ Others misconstrued WH as another approach to change health behaviors (e.g., weight loss, chronic disease management), as an ends in themselves to mitigate disease. These conceptualizations of WH miss that attending to patients' goals can facilitate engagement in self-care help patients achieve well-being as they define it.

Implementing new approaches in health care, including WH, requires readiness to change. ^{1,21 –24} In our survey, narrower conceptualizations of WH had a marked impact on employee readiness to use a person-centered WH approach with Veterans. When respondents focused on WH as CIH/well-being services, they expressed reservations about WHs relevance to their patients or practice, sharing skepticism of the evidence for WH and doubt that these services would be of value or interest to Veterans despite studies to the contrary. ^25,26 These perceptions were reinforced when supervisors messaged WH as something not performed in their departments or denied access to WH-related training, reflecting a gap in understanding that WH is also an approach applicable to all patients and employees.

Incorporating WH into practice also necessitates recognition that this approach is novel. In our survey, several respondents perceived no difference between WH and their profession's approach in clinical practice. In turn, this fostered resentment associated with feeling professionally threatened and concern that needed resources were allocated to WH rather than their departments. Consistent with perceptions of patient-centered care implementation, ²⁷ when employees perceive new approaches as synonymous with existing practice, the ability to transform the culture of care falls short with missed opportunities for true person-centered interactions. Our findings also reflect the challenges associated with transforming culture when distinct subgroups in health care organizations embody varied values, leading to competition for resources and status. ^{28 –30}

Finally, we found that contextual factors contributed to how employees conceptualized WH. Early WH implementation efforts in all Flagship sites emphasized creating infrastructure and developing WH-aligned services. ^8,14,31 Thus, it is not surprising that respondents' depictions of WH reflected a narrower programmatic focus rather than capturing the philosophical shift associated with cultural transformation. When respondents characterized WH as services delivered elsewhere in the organization, they missed person-centered communication as a key aspect of a WH approach, limiting the transformation of the culture of care to one in which aligning care with patients' personal goals is a top priority. While WH-aligned services are necessary to support patients' goals, focusing implementation on services, rather than the far more complex process of changing the culture of how employees interact with patients, will be insufficient for transforming care.

As health care systems move toward WH, attending to employee conceptualizations of WH will be important for transforming the culture of care. First, attending to the person-centered aspects of a WH approach may help to clarify and differentiate WH concepts as both an approach to care and delivery of services to support patients' goals, while delineating WH from existing biomedical practices (e.g., diabetes management). Second, training employees in person-centered communication and providing opportunities to practice these skills with ongoing feedback as they are developed may better help clinical employees integrate this approach into practice, ^32,33 as the VA is now undertaking. Third, using strategies that promote buy-in (i.e., presenting the evidence for WH ^34,35 and associated CIH therapies, and marketing WH as valuable for patients and employees alike ³⁶ ) can facilitate readiness for adoption. Targeting supervisors and leaders will be especially important given their known role in transforming culture. ^{30,37 –39} Finally, as organizations shift the focus from developing infrastructure for WH-aligned services to transforming the culture of care, consideration should be given to how existing structures/processes, silos, and messaging contribute to perceptions. As such, future communication about WH will need to incorporate language that encompasses WH as both a shift in interactions with patients and incorporation of new services to promote nuanced understandings of WHS as complex multicomponent approaches to care.

Conclusions

Delivering WH care that requires a fundamental shift in how health care workers interact with patients is being prioritized and spread within the VHA and into U.S. health care systems more broadly. ¹ To fully transform the philosophy of care to align with the person-centered, health creation and well-being-focused approach envisioned in WH, attention to frontline employees and leadership alike is needed. Our study indicates that without clear and consistent messaging about the person-centered nature of a WH approach in clinical settings and how it relates to WH-aligned services, integration of this approach into practice will lag as employees dismiss WH as something other than what it is intended to be. Moreover, without access to trainings that clarify WH concepts and teach the person-centered communication skills necessary to incorporate a WH-approach into care, opportunities to expand understandings of WH are likely to be missed. Consistent with the literature on organizational and cultural transformation in health care, ^{28,30,38,39,44 –49} our findings on the importance of training, multilevel leadership support, and communications provide actionable guidance for future WH transformation endeavors. As health care systems begin to adopt WH, as recommended by the National Academies of Science, Engineering, and Medicine, ¹ incorporating these elements will support the cultural and structural transformations necessary to deliver WH care.

Prior Presentations

This work has not been previously presented.