Background
Evaluation methods
Evaluation design and setting
LET Construct | Definition | Sample Questions | |
---|---|---|---|
1 | Impetus for EWH implementation | Motivation behind EWH implementation | • Can you tell me about the history of how and when EWH initially got started at your site? • Are there other Whole Health programs for Veterans occurring at your site, and what are they? |
2 | Leadership commitment to EWH | Senior leaders and middle management engage in EWH, and participate in EWH activities | • What was the involvement of medical center leadership for EWH? • What was the attitude of service chiefs/service line managers and front-line supervisors regarding EWH? • To your knowledge, do leaders in this medical center participate in EWH themselves? |
3 | EWH implementation initiatives | Systematic organizational efforts to plan, schedule and conduct EWH activities | • What, specifically, is happening regarding EWH at your site? (Activities may include employee orientation training, other trainings, yoga classes, meditation, nutrition, coaching, Whole Health committee, etc.) |
4 | Alignment of EWH across the organization | Leaders across levels and departments encourage involvement in EWH, and provide resources (e.g., protected time, equipment) for EWH implementation | • Did the implementation team or executive leadership have a strategy for implementing EWH? • What did leaders do to support the implementation of EWH? • Do employees believe that they can take time to participate in EWH during working hours guilt-free, or with their supervisors’ approval? |
5 | Integration of EWH across internal boundaries | Staff work together effectively and willingly across department and service lines | • Did your organization try to implement EWH across the whole medical center at once or start in a particular area of the medical center? Are there areas/departments or services where this has really taken off? • Are there other services within the medical center that the EWH initiative collaborates with or is dependent upon? |
6 | Communication around EWH | Communication tools and actions to raise awareness around EWH within, across and outside the organization | • How is EWH information communicated? • Is there regular communication to employees about Employee Whole Health? • Does your site have a formal communication plan? |
7 | EWH knowledge and skills | Organization help staff build EWH knowledge and skills; staff use these to improve health/life balance and overall well-being | • Have you heard from participants that EWH has made a personal difference? • To your knowledge, has any of them shared their experiences with other co-workers? |
8 | Informed decision-making | Meaningful data regarding key EWH activities is collected and tracked to inform EWH implementation progress | • Do you track or monitor data on EWH activities? |
9 | Employee/staff engagement | Employees’ feedback is received and used as part of EWH implementation | • How receptive do front-line employees seem to be about EWH implementation? |
10 | Organization culture | What people – not only managers but also staff–value and expect as being appropriate EWH behavior | • Do you think the culture of this medical center values participation in EWH activities? • Does perception of EWH vary by different parts of the medical center? |
11 | Staffing | Staffing levels and skills are adequate for EWH implementation | • What resources does your medical center provide for Employee Whole Health implementation? • Who else is on your EWH implementation team? (their roles and how you interact with them) |
12 | Using EWH experts | EWH experts are solicited and transfer key knowledge to sites’ EWH implementation team | • What was the involvement of the national program office? • Is your site working in partnership or collaboration with your VISN for EWH operations? |
Site selection
Sample of participants
Key informant roles | n |
---|---|
WH/health promotion program manager | 9 |
Health coordination or health coaching | 5 |
EWH program manager | 4 |
Leadership (senior and mid-level) | 3 |
Education support | 3 |
Program assistant | 3 |
Total | 27 |
Eligibility criteria
Data collection
Semi-structured interview guide
Interview procedure
Data analysis
Results
Participant characteristics
Factors affecting EWH implementation
1. Key factors by construct from the extended Lean Enterprise Transformation model | ||
---|---|---|
Construct | Facilitator | Barrier |
EWH initiatives | Sites implemented a variety of EWH activities in various formats to engage staff | Sites faced challenges to reach specific groups of employees |
Multilevel leadership support | Senior leadership • Provided clear directives for and engaged in strategic planning for EWH • Personally took part in EWH activities Middle management • Understood the importance of employee self-care • Allowed time for staff to engage in EWH activities Program leadership • Drive for results helped achieve program goals • Champions engaged staff by making connections across services • Worked in well-functioning EWH committees | Senior leadership • Did not support giving staff protected time to engage in EWH activities • Turnover at times decreased the level of support for EWH implementation Middle management • Support was not uniform across services within a medical center • Limited or denied employees protected time to engage in EWH • Concerns for staff productivity led to lack of support for EWH Program leadership • Uncertainty about EWH’s place in the organizational structure • Struggles to advocate effectively for program in the absence of formal EWH committee to guide implementation efforts |
Alignment | • Leadership facilitated the acquisition of equipment • Leadership provided staff protected time for EWH • Dedicated physical space | • Leadership either denied or prevented resource provision • Lack of protected time prevented staff from engaging in EWH activities • Inadequate space for EWH activities |
Integration | • Networks provided direct advocacy and support for local EWH programs • Partnerships/collaborations across services within sites helped with communication and increased awareness | • Perception that networks had little to no direct involvement with local EWH programs • Lack of collaboration between services at some sites hindered engagement in EWH activities |
Employee engagement | Employees • Understand the importance of health and well-being • Interest in, enthusiasm for, and receptivity regarding EWH activities • Testimonials, word of mouth and positive feedback Spread of EWH • Synergies across services and departments • Focus on specific services or workgroups | Employees • Religious beliefs preventing participation in EWH activities • Not being used to self-care • Reluctance in the absence of clear guidance for participation • Fear of retaliation or to be misperceived by managers • Conflicts with timing of sessions offering (e.g., after working hours) Spread of EWH • Uneven opportunities to engage in EHW for some services • Lack of awareness or exposure in specific services (e.g., canteen staff) |
Communication | • Technology helped build communities and made leadership direct interaction on platforms visible • Clear and consistent messages from senior leadership promote EWH • Inclusion of EWH in new employee orientation and the use of flyers and printed materials at events helped raise awareness and interest in EWH | • Some employees disliked mass emails • Employees who were not added to EWH-specific group lists didn’t receive the information on EWH activities • Limited access to communication tools prevented wider scale information-sharing |
Staffing | EWH implementation team • Staff consistency and longer tenure contributes to efficient work • Timely hiring of team members with the right skillsets was valuable • Having a Whole Health department leveraged human resources for EWH | EWH implementation team • Missing key roles due to slow hiring process or site-imposed limitations • Understaffing (e.g., split positions, staff detailed due to COVID-19) • Loss of key implementation roles disrupted established processes that they managed Employees • Staff with heavy workload due to understaffing could not engage in EWH activities |
Culture | • Employee-positive culture on self-care motivated employees • Newer staff in sites with mixed culture were enthusiastic about EWH | • Staff with longevity at sites with mixed culture did not embrace EWH • Being in a state or community where culture did not prioritize health • Being at a site where the culture prioritized work duties above all else |
2. Emergent factor | ||
Construct | Facilitator | Barrier |
Impact of COVID-19 pandemic | • Moving to virtual platforms allowed for inclusion of larger workforce segments • Increased interest in using EWH to help address employees’ burnout | • Limits placed on the types of EWH activities to maintain safety • Human resources were mobilized to address the pandemic and diverted from the EWH program • Shifting priorities reduced traction for EWH, and overall resources made available for EWH activities |
Construct | Exemplar Quotes |
---|---|
1. EWH initiatives |
Facilitator
|
“I think that about where we found our sweet spot was when we started implementing these sessions (lunch and learn) because then it all started to come together and so it – it started off slow and then we just took off.” (site 2) | |
“My team from the Department, they were all like, “Let’s do that as much as we can,” ‘cause, we deal with complicated patients, and we need a release, and we’re working 10-hour days, and we never give ourselves that time. Even that 15 minutes of time is just -- it just makes a world of difference just to release some of that pent-up energy. And, so, it’s very well received, very much appreciated.” (Site 9) | |
Barrier
| |
“Being a tertiary Mental Health Clinic, we’ve just got a ton of licensed people running around, and all of their ethical practice guidelines do not allow for engaging in dual relationships. And, so, utilizing a shared gym area with the Veterans we serve, having employees do that with the Veterans, could potentially constitute an environment of dual relationships, and, so, we cannot do that. Just too many licensed people.” (Site 10) | |
“I think the biggest challenge that we have is how do we access those people who do not work in front of a computer… employees who are working in housekeeping, the people who are working in the cafeteria and basically, they work nonstop, and they get two 15-minute breaks, and they get a 30-minute lunch…That’s the part of the workforce that we don’t have a plan for yet.” (Site 1) | |
2. Multilevel leadership support |
Facilitator
|
“I’ve had complete support…We have our medical center director kind of lead opening remarks, that type thing. So very much hands-on in that respect.” (Site 2) | |
“So the supervisor…they’ve actually have helped us with recruiting by sending emails out themselves and they’ve taken some of the courses themselves so that way they know what is going on and they can actually get those same skills that their supervisors and employees are getting.” (Site 1) | |
“When you see your leaders participating, I think that sends a really big message that it’s okay to participate in certain things…I have been pleasantly surprised at how many of our service chiefs have been involved. Sometimes our service chiefs are teaching the classes.” (Site 3) | |
Barrier
| |
“One of the biggest things is none of our leadership has even come to any Whole Health opportunity, ever. I mean that is the first, like, easiest step to me -- to at least come to something, participate in something, and show some type of interest.” (Site 8) | |
3. Alignment |
Facilitator
|
“The game changer was the [Learning Collaborative 2] funding. I mean that really made the big difference for us and it just allowed us to decide whether we wanted a fulltime employee heading Employee Whole Health and we already knew we wanted to do that before we got the money.” (Site 9) | |
Barrier
| |
“We really need some time for our providers or clinicians, all of our staff to be able to participate in these programs and then to really understand what it’s about to make those fundamental changes…. So, I think there have to be some systemic changes. So, yes, we will need funding. We will need personnel, and we need time.” (Site 9) | |
4. Integration of EWH |
Facilitator
|
“We do outreach to new employees.…This is an email or a phone call. …In our core team, we do feel it is important to educate new employees early because really Whole Health is something that we hope to have them bring not just to their employee journey, but their experience with the Veterans as well. So, it’s better to set the bar early than to kind of change a behavior later.” (Site 8) | |
Barrier
| |
“So, supervisors understood that their staff needed some kind of support, but at the same time there was like a real anxiety around workload, and I think…trying to find that balance, for supervisors, was really -- I think that was probably really hard for them.” (Site 5) “I think sometimes the politics are present and…I feel like the way they’ve divided things up just creates more silos and that there’s a lot of overlap between things and like if people that are working on Whole Health within the Behavioral Health service line don’t know what leadership has planned or what’s going on in Employee Wellness… I just find it very frustrating.” (Site 6) | |
5. Employee engagement |
Facilitator
|
“I’ve had people stop me in the hallway and say, ‘hey, you know, we were encouraged by seeing everybody out there and I’m trying to do, you know, I’ve got some wellness goals and things of that nature and people share those with me, which I think is really neat.” (Site 7) | |
“You find these people that want to be champions, and then you work with them and then that way their departments get engaged, whether that was a formal agreement or not at the beginning…Our Whole Health [team member]… she’s developed a following during her Thriving Thursday series because she’s able, … I have employees who are just terrific and they can identify what they wanna teach to their fellow coworkers and I find that – for their own job site satisfaction, it makes a huge difference.” (Site 1) | |
Barrier
| |
“I think that’s because they are afraid of, you know, feeling guilty or getting blamed for something or get in trouble because we don’t have the executive leadership saying, yes this is protective time, this is okay if you wanna go, we approve it…if we could get that I think that would really change a lot of things.” (Site 5) | |
“It depends on the service…the PACT teams just feel buried and they don’t – if they – if they have a few extra minutes, they’re not gonna get their mindfulness call, they’re gonna go take lunch.” (Site 9) | |
6. Communication |
Facilitator
|
“I work in Employee Occupational Wellness and a lot of people come through…every interaction is a Whole Health opportunity” (Site 6) | |
“I work with our Public Affairs officer, and she’s been wonderful to work with and help us get information out in that weekly missive and then also keep us connected with opportunities that might come from other areas around the state and other communities, and how we can engage employees that work in those communities in those opportunities.” (Site 10) | |
Barrier
| |
“Our team very much frowns on the idea of a lot of this stuff … I think it’s an argument over beautification versus information. It’s one thing whenever we put up posters and signs, and it may be great to get this information out there but if those responsible are not coming around and taking it down afterwards, it causes squatter to build and so they very quickly said, no, no, no, no we’re not allowing this anymore.” (Site 2) | |
“Our poor program assistant just got some really nasty emails back from staff about “stop emailing me this crap,” you know, “I don’t appreciate it. You’re bogging down my email. I don’t need this stuff. I don’t have time for this. Stop sending me this.” Like, there was just a lot of negativity sent to her when she was just simply the messenger.” (Site 8) | |
7. Staffing |
Facilitator
|
“[EWH program manager] could hit the ground running and had a lot of things already in her toolbox.” (Site 9) | |
“Last year we got our first Whole Health [full time equivalent employee]. We have a [Patient Services Assistant] and she is really the backbone now for everything Whole Health. It’s not just Employee Whole Health, it’s Whole Health for the whole facility.” (Site 6) | |
Barrier
| |
“The Whole Health partners are imbedded in the services and you – and you have the coordinator that has a split duty doing something else as well.” (Site 3) | |
“I think the staffing issue in particular is to be noted because if you have an extreme shortage of staffing, not only are those people working very feverishly to take care of Veterans, but it would also be perceived very poorly if they were to engage in wellness activities.” (Site 2) | |
“I can say personally as a provider working in Whole Health for almost three years now, I’m extremely burnt out of Whole Health, just from just a lack of support and just knowing that, yes, there are people that are divinely interested in Whole Health and do talk the talk and walk the walk, but there are so few of us that we’re so dulled that our flames are, like, out.” (Site 8) | |
“So, supervisors were just like itching for something to offer staff ‘cause they knew. Like, they understood that their staff needed some kind of support, but at the same time there was like a real anxiety around workload and I think…tryin’ to find that balance, for supervisors, was really -- I think that was probably really hard for them.” (Site 5) | |
8. Culture |
Facilitator
|
“People are encouraged to take their lunch break and to get outside on their lunch break. We have a beautiful campus… When I would go outside to eat lunch or something on a picnic table, people were out there walking… nurses in their scrubs going for a quick walk, and so it just really is a culture at the medical center that continues to become the norm to take care of yourself and to take a break and get some exercise even if it’s a short walk, it just helps… Five years ago, you’d never seen people out walking on their lunch break…So, to see that transition, I – it’s just really nice.” (Site 7) | |
“There was a staff member that attended a session, that was like ‘this is what gets me through.’ …Wednesdays are a hard day for their clinic. And she shared with us this is what gets her through the second half of her day. So, being able to have protected time where your -- you know, it’s one thing to get up and walk away from your computer…. You have that protected time for self-care. So, she said that she couldn’t get through her Wednesdays without that.” (Site 8) | |
Barrier
| |
“A lot of our administrative staff feel a little bit more free to participate in Whole Health activities or just getting outdoors and say going for a ten-minute walk on a break. Whereas medical or mental health units where their task of being there to provide care or in our outpatient clinics, it’s a little bit more challenging. It’s like they don’t have the same sense of freedom to be able to participate like you see in the administrative areas.” (Site 10) | |
9. The impact of COVID-19 |
Facilitator
|
“I know COVID has caused us a lot of grief but in a lot of ways it’s felt to open our eyes to other possibilities and so, … we’ve continued these Lunch and Learns. There’s no reason why we can’t continue that ‘cause employees love it.” (Site 2) | |
Barrier
| |
“So, with COVID all that stuff had to stop in-person and it just seems like it’s been a little bit of a struggle with like upper management to allow us to have time to set up, you know, the [VA Video Connect] or Teams links, you know, to offer the classes.” (Site 5) |
EWH initiatives
“My team from the Department, they were all like, “Let’s do that as much as we can,” ‘cause, we deal with complicated patients, and we need a release, and we’re working 10-hour days, and we never give ourselves that time. Even that 15 minutes of time—it just makes a world of difference just to release some of that pent-up energy. And, so, it’s very well received, very much appreciated.” (Site 9)
“I think the biggest challenge that we have is how do we access those people who do not work in front of a computer… employees who are working in housekeeping, the people who are working in the cafeteria and basically, they work nonstop, and they get two 15-minute breaks, and they get a 30-minute lunch…That’s the part of the workforce that we don’t have a plan for yet.” (Site 1)
Multilevel leadership support
Senior and middle management leadership
“When you see your leaders participating, I think that sends a really big message that it’s okay to participate in certain things...I have been pleasantly surprised at how many of our service chiefs have been involved. Sometimes our service chiefs are teaching the classes.” (Site 3)
“One of the biggest things is none of our leadership has even come to any Whole Health opportunity, ever. I mean that is the first, like, easiest step to me -- to at least come to something, participate in something, and show some type of interest.” (Site 8)
Program Leadership
Alignment
“The game changer was the [Learning Collaborative 2] funding. I mean that really made the big difference for us and it just allowed us to decide whether we wanted a fulltime employee heading Employee Whole Health and we already knew we wanted to do that before we got the money.” (Site 9)
“We really need some time for our providers or clinicians, all of our staff to be able to participate in these programs and then to really understand what it’s about to make those fundamental changes…. So, I think there have to be some systemic changes. So, yes, we will need funding. We will need personnel, and we need time.” (Site 9)
Integration
“We do outreach to new employees…This is an email or a phone call…In our core team, we do feel it is important to educate new employees early because really Whole Health is something that we hope to have them bring not just to their employee journey, but their experience with the Veterans as well. So, it’s better to set the bar early than to kind of change a behavior later.” (Site 8)
“I think sometimes the politics are present and…I feel like the way they’ve divided things up just creates more silos and that there’s a lot of overlap between things and like if people that are working on Whole Health within the Behavioral Health service line don’t know what leadership has planned or what’s going on in Employee Wellness… I just find it very frustrating.” (Site 6)
Employee engagement
“I’ve had people stop me in the hallway and say, ‘hey, you know, we were encouraged by seeing everybody out there and I’m trying to do, you know, I’ve got some wellness goals and things of that nature and people share those with me, which I think is really neat.” (Site 7)
“I think that’s because they are afraid of, you know, feeling guilty or getting blamed for something or get in trouble because we don’t have the executive leadership saying, yes this is protective time, this is okay if you wanna go, we approve it… if we could get that I think that would really change a lot of things.” (Site 5)
Communication
“I work with our Public Affairs officer, and she’s been wonderful to work with and help us get information out in that weekly missive and then also keep us connected with opportunities that might come from other areas around the state and other communities, and how we can engage employees that work in those communities in those opportunities.” (Site 10)
Our team very much frowns on the idea of a lot of this stuff…I think it’s an argument over beautification versus information. It’s one thing whenever we put up posters and signs, and it may be great to get this information out there but if those responsible are not coming around and taking it down afterwards, it causes [squalor] to build and so they very quickly said, no, no, no, no we’re not allowing this anymore. (Site 2)
Staffing
Last year we got our first Whole Health [full time equivalent employee]. We have a [Patient Service Assistant] and she is really the backbone now for everything Whole Health. It’s not just Employee Whole Health, it’s Whole Health for the whole facility. (Site 6)
“I can say personally as a provider working in Whole Health for almost three years now, I’m extremely burnt out of Whole Health, just from just a lack of support and just knowing that, yes, there are people that are divinely interested in Whole Health and do talk the talk and walk the walk, but there are so few of us that we’re so dulled that our flames are, like, out.” (Site 8)
Culture
“People are encouraged to take their lunch break and to get outside on their lunch break. We have a beautiful campus… When I would go outside to eat lunch or something on a picnic table, people were out there walking... nurses in their scrubs going for a quick walk, and so it just really is a culture at the medical center that continues to become the norm to take care of yourself and to take a break and get some exercise even if it’s a short walk, it just helps... Five years ago, you’d never see people out walking on their lunch break…So, to see that transition, I – it’s just really nice.” (Site 7)
“A lot of our administrative staff feel a little bit more free to participate in Whole Health activities or just, getting outdoors and say going for a ten-minute walk on a break. Whereas medical or mental health units where their task of being there to provide care or in our outpatient clinics, it’s a little bit more challenging. It’s like they don’t have the same sense of freedom to be able to participate like you see in the administrative areas.” (Site 10)
The impact of the COVID-19 pandemic on EWH implementation
“So, with COVID all that stuff had to stop in-person and it just seems like it’s been a little bit of a struggle with like upper management to allow us to have time to set up, you know, the [VA Video Connect] or Teams links, you know, to offer the classes.” (Site 5)
“I know COVID has caused us a lot of grief but in a lot of ways it’s felt to open our eyes to other possibilities and so, … we’ve continued these Lunch and Learns. There’s no reason why we can’t continue that ‘cause employees love it.” (Site 2)