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Perceptions of Providers and Administrators in the Veterans Health Administration Regarding Complementary and Alternative Medicine

Fletcher, Carol E. PhD, RN*; Mitchinson, Allison R. MPH, NCTMB*; Trumble, Erika L. MPH*; Hinshaw, Daniel B. MD, FACS*; Dusek, Jeffery A. PhD

doi: 10.1097/MLR.0000000000000225
Brief Report

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.

*VA Ann Arbor Medical Center, Ann Arbor, MI

Penny George Institute of Health and Healing, Abbott Northwestern Hospital, Minneapolis, MN

This work was partially supported by the National Center for Complementary & Alternative Medicine of the National Institutes of Health (grant number R01AT006518 to J.D.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. A.R.M. time to work on the project was supported by the VA Ann Arbor Medical Center.

The authors declare no conflict of interest.

Reprints: Carol E. Fletcher, PhD, RN, VA Ann Arbor Medical Center, 2215 Fuller Road (127), Ann Arbor, MI 48105. E-mail:

Complementary and Alternative Medicine (CAM) therapies are used by millions of Americans including veterans to improve health, wellbeing, and relieve symptoms such as pain and anxiety.1–6 The Veterans Health Administration (VHA) has supported peer-reviewed research including randomized controlled trials of CAM modalities.7 Consistent with the commitment of the VHA to provide “personalized, proactive, patient-driven, health care,” 8 CAM therapies are being incorporated into the care offered to veterans.8–10 Like the private sector, implementation of CAM within VHA has been evolving. Providers’ attitudes and knowledge about CAM vary and are important factors in the implementation of CAM programs in both the private sector and the VHA. Although there is some research about providers and administrators attitudes in the private sector, there is little known about the attitudes/knowledge of VA providers and administrators.11–13 The purpose of this qualitative study was to examine the knowledge, attitudes, and perceived barriers and/or facilitators to CAM program implementation among VHA providers and administrators at a large representative VHA facility.

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After Institutional Review Board approval, VHA patient care providers and administrators were chosen to represent a spectrum of positions and services including direct care providers, department heads, and higher-level administrators. Individuals known or speculated to be supportive of CAM were approached as well as those with potentially negative views toward CAM. Possible participants were first contacted via email. Willing participants provided informed consent and were interviewed in a private location. Semi-structured interviews were digitally recorded by 1 research team member from April to November 2013. All participants were asked the same open-ended questions (Table 1).



Interviews averaged 15 minutes (range, 5–28.5 min) depending upon participant response. Interviews were transcribed verbatim by a research assistant and entered into NVivo (version 10).14 Each interview was coded individually by at least 2 members of the research team to develop an initial set of themes. Three team members then met as a group to refine the codes and continue theme coding until consensus was reached.

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Participants are described in Table 2. Whether, to what extent, by whom, and why the VHA should promote CAM was a matter of considerable debate. Responses clustered under 3 general themes, knowledge/opinions, benefits, and barriers and facilitators. Table 3 lists the themes plus brief definitions and excerpts from the transcripts.





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Knowledge about which CAM therapies were actually available at the site varied widely. Massage therapy was most frequently mentioned. Many were vague about other CAM therapies until shown a noninclusive list of CAM examples.

Knowledge about CAM also reflected personal experience often cited as what participants had recommended for patients rather than therapies participants had used themselves. When encouraged to describe their own experience, individuals mentioned massage, meditation, and yoga most frequently. “Personal” experience was also cited as that of a spouse or other family member (Table 2). Only one experience was described negatively.

When asked to rate their top choices for CAM availability to veterans, massage, meditation, acupuncture, and yoga were rated highest (Table 4). These choices appeared to track participants’ own experiences or were based upon perceptions of veterans’ familiarity with and/or acceptance of these therapies plus the need to relieve chronic pain. Opinions regarding CAM in the VHA ranged from strongly supportive to qualified to unsupportive. Participants sensed a difference between the attitudes of physicians and nurses. Specifically, physicians were generally described as “pretty suspicious” of nontraditional treatments. One physician argued that chiropractic, massage, and acupuncture have become standard therapies, so should no longer be called CAM-reflecting the fact that CAM is an evolving field.15



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Participants described multiple benefits of CAM for patients and staff that reflect an approach to care of the whole person integrating body, mind, and spirit. One participant thought CAM could provide the compassionate aspect of patient care that is sometimes missing in today’s medicine. An administrator saw CAM as a key component in the VHA goal of expanding personalized, proactive patient-centered care.

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Barriers and Facilitators

Multiple factors were cited with the potential to be either barriers or facilitators to implementing CAM. Lack of evidence in support of CAM was emphasized in most of the interviews. Some providers were concerned that if CAM was included in their practice it would appear to other providers as being “non-scientific.” Most participants seemed unaware of existing research publications, including randomized controlled trials that demonstrate the efficacy of CAM.

The role of leadership was readily acknowledged as both a facilitator and barrier. The need for a champion was mentioned frequently. A nurse manager identified the role of middle management in influencing staff nurses. Lack of understanding by providers about which CAM therapies were available was ascribed to lack of leadership, resulting in piecemeal decisions about patient eligibility and frustration for veterans not receiving CAM. Some participants mentioned development and deployment of a strategic plan as part of leadership’s responsibility; for example, the former Under Secretary was praised for touting acupuncture nationally to hospital and network directors.

Credentialing of CAM providers within the VHA is currently unresolved and a source of frustration for some participants. Use of contracted practitioners, training staff nurses to do healing touch therapy, and training staff physicians in acupuncture were described as work-around solutions. A number of therapies were cited as being problematic. Pet care, misperception about the intent of massage, sensitivity of roommates to aromas, potential adverse interactions between medicines and herbs, and aversion to being touched were all cited as actual or perceived barriers to the use of CAM. Another participant described a patient whose undisclosed use of herbs increased his bleeding time after surgery, emphasizing the need for veterans to feel comfortable disclosing CAM use to providers.

Time, space, funding, and staff training/experience were mentioned as both facilitators and barriers to expanding CAM. Nurses were particularly concerned with having enough time to use CAM along with completing their other duties. One participant suggested that specially designated persons on a unit might be more practical than expecting all staff nurses to incorporate CAM into patient care. Several participants advocated temporarily sending veterans to outside CAM providers on a “fee basis” when services cannot be provided internally.

Although many participants saw lack of funding as an issue, others thought funding was available in response to a well-planned request. Several individuals pointed out that many CAM therapies are relatively low cost, especially if CAM providers are cross-trained in multiple therapies. One participant thought it would be cost-effective if less expensive staff were hired, for example, an acupuncturist rather than a physician to perform acupuncture. Volunteers providing pet therapy and soft touch hand massage were also seen as low cost resources for expanding CAM services.

Examples were cited involving past challenges in staff training and funding. Issues include limited funding for acupuncture training for physicians and lack of compensatory time off for nurses taking healing touch therapy training. Participants thought training/education in providing CAM is not promoted within the VHA because of a lack of “key stakeholders” who understand the benefits of CAM. The importance of stakeholder awareness of the positive impact of CAM upon veterans’ quality of life was noted.

Many participants supported a need for cultural change involving both providers and veterans. Providers seemed to be more accepting of CAM if they had personally experienced these interventions. One participant suggested that providers be encouraged to personally try CAM as a means to understand how interventions could benefit veterans.

Some participants saw veterans as “demanding” CAM; others feared veterans view CAM as “wishy-washy.” The consensus was that veterans should know CAM is available. In summary, factors identified as impeding CAM as an option included lack of: ownership for promoting CAM; referral criteria; provider knowledge; consistent funding; and insufficient numbers of providers resulting in “luck of the draw” over which veterans receive therapies.

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As CAM use becomes increasingly prevalent in the general population, the VHA needs to acknowledge and incorporate CAM, a fact that has been recognized at the highest levels of VHA.16–18 CAM can be a tool to help veterans with self-care/self-management and is a component of the VHA Office of Patient Centered Care and Cultural Transformation’s Health for Life program.19 In outpatient settings, expansion of CAM services is consistent with the patient aligned care team model as well as the goals of Planetree20 emphasizing personalized, patient-driven care. However, as illustrated above, CAM implementation in VHA will not occur automatically.

Knowledge limits present a stumbling block. Providers are unsure of which CAM therapies are available and/or whether there is sufficient evidence to support usage, despite a growing body of research demonstrating significant impact of CAM on pain and symptom management.7,21–23 For example, meditation has been shown to affect the mind, brain, body, and behavior in ways that have potential to treat many health problems veterans experience and to promote healthy behavior.24 Aromatherapy is now available in individual packets or inhalers that are clinically useful without affecting roommates,25 and pet therapy has been successfully introduced.26

Disconnects between perceptions and reality underline the need for focused education for physicians, nurses, and administrators on the clinical impact of CAM. In addition, the suggestion that providers should experience at least 1 CAM therapy should not be ignored. Participants who had actually used CAM (or had a family member who had done so) were more likely to be positive about promoting CAM for veterans.

Benefits to veterans come from potentially meeting their individual needs, whereas VHA receives value by adding potentially beneficial and cost-effective treatments, especially for chronic pain. Promoting CAM therapy administration by nurses25 is especially promising because once trained, many therapies do not require a practitioner to obtain a physician’s order, for example, music therapy, soft and healing touch. The lack of job descriptions for hiring massage therapists, acupuncturists, and yoga instructors remains a barrier to CAM expansion in the VHA. Being able to hire people directly into these positions will not only assist in meeting demand but can also provide a cost saving when the position does not require a nurse or physician.

Barriers to CAM interfere with the implementation of patient-centered care. Our findings demonstrate that the same factor can be either a barrier or facilitator, for example, proactive administration/champion versus lack thereof. Currently, implementation of CAM depends heavily upon local efforts and leadership,27 with some VHA facilities offering multiple therapies, whereas other sites struggle to implement programs. The participants in this study were aware that simply declaring CAM “will be promoted” is insufficient. Although national leaders need to promote CAM and pursue position descriptions, to turn barriers into facilitators culture change requires a local leader/champion(s) who facilitates strategic planning, education/experience of providers, and long-term commitment.

The millions of veterans treated by the VHA provide both an opportunity and a challenge. Meeting the needs of so many veterans requires multiple modes of service delivery plus targeting specific populations, for example, those with chronic pain, end-of-life needs, and mental health issues. For inpatients, CAM services could be expanded using an integrated medicine (IM) model similar to that adopted in a private sector health care system.28 Although an array of services may seem an ambitious model for many VHA facilities, results from a 2011 survey indicate that 37 VHA facilities reported offering more than 10 CAM modalities.16 A summary of recommendations for promoting CAM in the VHA appears in Table 5.



Our study may be limited because of the low sample size and that the study was conducted at only one site located in the Midwest. Furthermore, results may not apply to other geographic regions or facilities of a different size. However, conversations with persons either providing or attempting to provide CAM at other VHA facilities lead us to believe the study site is not atypical. CAM therapies promote VHA Strategic Goal One by supporting personalized, proactive, and patient-driven care for significant health problems in the veteran population, for example, chronic pain and PTSD. The benefits of CAM to veterans outweigh the challenges of making the needed changes within a large bureaucratic organization. Veterans deserve no less.

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The authors thank Kristen Haven for the advice provided regarding the final version of the paper.

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complementary & alternative medicine (CAM); veterans; personalized; proactive; patient-centered care; evidence-based practice; barriers; facilitators

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