Program Evaluation, Literature & Medicine Program, Healthcare Facilities, United States Department of Veterans Affairs 2011 Prepared for the Maine Humanities Council Under a Grant Funded by the National Endowment for the Humanities By Dr. Bruce B. Clary Muskie School of Public Service University of Southern Maine April, 2012 The author would like to acknowledge the contributions of Elizabeth Sinclair, Victoria Bonebakker, and Denise Tepler in the development of the research design and instrumentation for the evaluation. The compilation of data from the open-ended comments was performed by Elizabeth Sinclair. Contacts The Maine Humanities Council (http://www.mainehumanities.org/ and Bruce B. Clary, Professor, Muskie School of Public Service (bclary@usm.maine.edu )
Executive Summary Literature & Medicine is a health facilities-based, scholar-led humanities reading and discussion program for professionals and staff in the field that is designed to benefit both them and their patients. This report details an evaluation survey of 124 individuals who participated in the program in 2011. All of the participants held positions as staff members in hospitals/health facilities administered by the United States Department of Veterans Affairs. With support from a grant from the National Endowment for the Humanities, the Maine Humanities Council offered the program at 17 health sites through partnerships with state humanities councils. Literature & Medicine is well administered. Respondents indicate a high level of satisfaction with activities such as discussions, and the role of facilitators. Findings on the reasons for participation suggest the Program has broad value, having the power to address both professional and personal aspects of a person s life. The Program had a positive effect on participant attitudes measured through standardized scales (empathy, cultural awareness, interpersonal relations, communication, job satisfaction). Open-ended comments on the workplace environment cover a wide range of personal and professional themes that serve to indicate the broad impact that Literature & Medicine has. The survey showed considerable reflection by participants on how actual events in their professional life were influenced by the readings and discussion. The impact that the program has had on empathy toward patients and other caregivers is noteworthy. This dimension encompasses elements of personal and professional growth that are not easily taught through training and development workshops. The program has made a significant contribution, adding to professional development in this area. Further, measurable gains were made in the area of cultural awareness. Issues related to diversity in the workplace have proven to be difficult organizational challenges, not just in the medical, but all fields. The approach used by Literature & Medicine should be seriously examined by the VA as a means to increase understanding and communication in diverse employment settings. A major focus of the VA Literature & Medicine program was on Post-Traumatic Stress Disorder. More than a majority of the participants said that their experience had a positive influence on their knowledge about this dimension of care giving. Given the challenges that PTSD poses for Veterans Hospitals, it is significant that literature, and discussion of it, can help health professionals address and cope with it. It represents a comparatively inexpensive approach with the potential to involve a large number of participants within the VA health care system. Overall, Literature & Medicine produced a variety of positive effects on staff, both in personal and professional terms. The VA should continue to encourage Literature & Medicine in its facilities as a way to address the many challenges facing its medical personnel. It allows for a variety of topics to be examined, many of which are difficult for an individual to address alone. Reading books and discussing them with colleagues allows for a sharing of experience, knowledge and feelings, something that is difficult, if not often impossible, to achieve in the everyday medical workplace. 2
Overview of the Program This report summarizes the results from a program evaluation survey administered to staff members of VA hospitals who participated in the Literature & Medicine program in 2011. With support from a grant from the National Endowment for the Humanities, the Maine Humanities Council offered the program to the staff at 17 VA hospitals and health care facilities through partnerships with state humanities councils. This report presents the results from an evaluation survey administered to these staff members. The general philosophy of the Program is described on its web site, (http://www.mainehumanities.org/programs/litandmed/lm_program.html): Created by the Maine Humanities Council, Literature & Medicine: Humanities at the Heart of Health Care is a national award-winning, hospital-based, scholar-led humanities reading and discussion program for health care professionals that benefits both them and their patients. The Maine Hospital Association has cited it as a patientquality initiative. The program encourages participants to connect the worlds of science and lived experience, giving them the opportunity to reflect on their professional roles and relationships through plays, short stories, poetry, fiction and personal narratives in a setting where they can share their reflections with colleagues. It has a significant effect on the way participants understand their work and their relationships with patients and with each other. It is also an innovative and cost-effective way to improve patient care. Literature & Medicine is representative of the emerging field of medical humanism. It represents a broad perspective on health care as a system. There are many different actors in various roles and locations, both formal and informal, with varied perspectives. A basic premise of the Program is that the experience of patients should be viewed from a holistic perspective, that health is a function of more than medicine and treatment. The value of these activities is not diminished, only that the factors that make up the healing experience for patients go beyond the medical model. While nurses and physicians may have the most day-to-day-contact with patients, how patients respond to care includes all the elements of the healthcare system, and interpersonal factors as well. Conversations with housecleaning staff, for example, may represent the most regular contact a hospital patient has with anyone on a daily basis. This kind of interaction can be an important part of the healing process (see Cassell, 1985, Crellin, 2005). Pilot programs in Maine and Vermont VA hospitals indicated positive impacts on participants, where work and stress loads have been both changed and increased due to the influx of soldiers from the Afghan and Iraq wars. In particular, these veterans frequently struggle with post-traumatic stress disorder (PTSD), severe physical disabilities, substance abuse, chronic illness, homelessness, poverty and a system that at times is not able to meet their needs. These problems are often manifested in frustration and anger directed at those who care for them. Because of the particular context and needs of health care professionals in VA hospitals, the Maine Humanities Council modified its established Literature & Medicine trainings and materials. The core of the Program remains, a series of discussions where plays, short stories, poetry, fiction and nonfiction books and personal narratives are read and talked about. 3
Consequently, the goals of the Program are quite parallel: (http://mainehumanities.org/programs/litandmed/lm_program.html): The program encourages participants to connect the worlds of science and lived experience, giving them the opportunity to reflect on their professional roles and relationships through plays, short stories, poetry, fiction and personal narratives in a setting where they can share their reflections with colleagues. It has a significant effect on the way participants understand their work, and their relationships with patients and with each other. As in non-va hospitals, readings were selected by the scholars who facilitate Literature & Medicine groups, in consultation with humanities council staff (in the state where the site is located) and the host site s liaison. The readings are designed to raise issues pertinent to caring for people, whether they are well, sick, or dying. An anthology of readings pertinent to the program was created, Imagine What It s Like, (Nadelhaft and Bonebakker, 2008). Additionally, for the VA program, another anthology was developed, Echoes of War (Brown, 2009), which specifically focuses on issues related to the treatment and care of veterans. The evaluation approach is based on a logic model format developed by the Kellogg Foundation (2001). It involves the specification of goals, resource inputs, program activities, outputs and outcomes. This report primarily focuses on the outcomes of Literature & Medicine at an individual level (professional and staff) although data are also provided on the assessment of program administration. See Figure 1 for an outline of the logic model. The report includes an analysis of the survey findings, which involves both open and close-ended questions. Additionally, background data on the respondents are summarized. The main focus of the report is the extent to which participants evidenced personal and professional growth in terms of five major goals of the Literature & Medicine: Increased empathy for patients Greater cultural awareness Improved interpersonal relations Better communication More job satisfaction Some additions were made in the instrument to accommodate for the particular challenges faced by VA health care facilities. In addition to the above dimensions, seven other elements of health care were separately assessed in terms of the program s impact: Post-traumatic Stress Disorder Geriatric Services Dealing with Employee Burn-out Emphasizing Patient-Centered Care Accepting Cultural Diversity within the Workplace Treatment of Traumatic Brain Injury Addressing Sexual Trauma 4
Survey Design The survey is based on the responses of staff members in Veterans Administration health facilities who enrolled in Literature & Medicine during 2011. Administration of the survey was through an Internet provider (http://www.insitefulsurveys.com/default.aspx). Email addresses of all participants were collected and the surveys were sent to those addresses. The total population of participants was 124. After two rounds of email follow-ups, 71 respondents returned surveys, for a response rate of 57 percent. This figure is considered acceptable for internet surveys. The conventional level of acceptable response is approximately 50 percent (Coffman, 2004). Nevertheless, a problem of nonresponse error still exists. That is, no ready method is available to determine whether individuals who did not participate in the survey differ in significant ways from those who did respond. One advantage is that the population is relatively homogenous - they are all medical professionals so the likelihood of response differences between respondents and those who did not answer the survey is arguably reduced. VA facilities in 16 states were included in the survey population. Using the standard US definition of regions (www.census.gov/geo/www/us_regdiv.pdf), there is parity in the number of participating institutions across the country: Northeast (29 percent), South (29 percent), and West (29 percent). Only in the Midwest (12 percent) is there a relatively small number of VA centers. The number of institutions is not proportional to the regional distribution of VA centers, but the sample does have a focus that is largely national in scope. Program Participation A difference between Literature & Medicine offered in non-va compared to VA facilities is that in the latter there are fewer participants with experience in the program. 64 percent of the VA participants were involved for the first time in 2010. The number is lower, 55 percent for VA programs in 2011. Although the difference is not major, the VA Program is becoming similar to Literature & Medicine in general. Individuals who once participate are likely to continue their involvement. Focus group evidence indicated that individuals who have enrolled more than once can provide an important peer learning environment. Prior research underscores this finding, showing that the knowledge of peers in a classroom has a positive effect on student achievement (Hanushek, 2003). At the same time, should the VA continue to offer Literature & Medicine, it is important that attention is given to the recruitment of new participants. Despite its success in terms of the recidivism of participants, total enrollment does not necessarily indicate an increase in the coverage of the program in reaching individuals in the VA medical system. The appeal of Literature & Medicine is evident in the specific reasons cited for enrollment. Table 1 summarizes the data. The question was open-ended and responses were grouped into 9 categories. They can be broadly divided into professional versus personal reasons for choosing to participate. Three categories focus on personal factors. They reflect an individual orientation toward the readings and discussions and their potential benefit to them personally. The categories include: value of literature, personal interest and intellectual stimulation. Four categories are more professional in focus: improved care giving, collegial interaction, learning about issues in medicine, professional growth and development. The majority of reasons deal with professional aspects of the health care field, 54 percent. Nonetheless, personal factors also play an important role with 46 percent focusing on this aspect. 5
This finding suggests an important value of Literature & Medicine. It has the power to address both professional and personal aspects of a person's life, which is an important element in the organization s mission. This aspect of the Program is exemplified in the ranking of reasons for participation. Personal reasons for involvement, the value of literature, and a professional one, collegial interaction, are both listed by 32 percent of the participants, the categories ranked highest. Hence, for many participants, the program has successfully connected the personal dimension, to the health field, potentially broadening both what a person reads about the health field and how it affects his or her life. Interaction with colleagues is equally important as a reason for involvement. In open-ended responses, many respondents indicated that it was the opportunity to collaborate with co-workers outside the traditional confines of their roles that attracted them to Literature & Medicine. This benefit is clearly multidimensional. It has professional implications if better communication in the workplace results; alternatively it suggests the importance to medical staff of communicating with others, a personal dimension. The remaining reasons are less frequently cited (only one is mentioned by 10 percent), but they again point to the dual attraction of Literature & Medicine. Four are professional in focus, three are personal. Consequently, the program is a vehicle that serves both the personal needs of an individual and his or her professional aspirations. The interaction that occurs between these factors is also significant. There are many instances where respondents cite multiple reasons that reflect both dimensions. Given the frequency with which reading literature and the opportunity to discuss it with colleagues is mentioned, there is evidence that the basic structure of the program is successful in bridging the personal side of health care with the professional role. The presence of both personal and professional reasons for engaging in the seminar reflects a basic supposition of medical humanities, of which Literature & Medicine is an applied example. Many themes addressed in the literature and arts of the field encompass both dimensions: the nature of the human condition, responsibilities to others, empathy, self reflection, and the social milieu within which people act (Crellin, J. K., 2005). Background of the Participants The vast majority of the participants are middle-aged. Just 17 percent are 40 years or less in age. Given this age distribution, most are mid-career or later in their field. Eighty two percent indicate they have been in the healthcare field for more 10 years or more. The vast majority of participants are female, 75 percent. If the program is to be continued in VA health facilities, these indicators suggest the need to broaden the pool of participants. Strategies should be examined which allow for targeted efforts to recruit younger, less experienced and male participants. The challenge in recruiting younger participants into Literature and Medicine parallels a problem facing the medical field in general. The issue of an aging workforce has been raised in a variety of medical profession publications in the healthcare field (AHA Strategic Policy Planning Committee, 2001). Also, the difference in the number of women versus men (a ratio of 3 to 1) participating in the program should be considered. Gender disparities in the medical profession have long been evident in a variety of areas, from nursing to clinical practice (American Medical Association, 1998). An important program question for the future of Literature and Medicine is why such a difference exists across gender groupings and how it can be addressed. 6
Participants are a relatively well-educated group. Fifty seven percent have a graduate academic degree. In terms of professional degrees, nurses comprise the largest group. Forty four percent have either an RN or BSRN. Twenty five percent indicate they have an MD degree. A possible argument is that their participation in Literature and Medicine should be higher since they play such a pivotal role in the health care system. But, to some extent, their involvement depends upon the total number of physicians compared to other health care providers and support staff. Various censuses of physicians indicate that their number has been decreasing since 2000 (Salsberg, 2005). At the same time, the number of support staff is increasing and now at 4.5 to 1 ratio (Rhie and Volmert, 2003). Even given this evidence, Literature and Medicine should emphasize strategies that target physicians in light of their critical role in patient care. Positions presently held by the participants represent a diverse set of activities within the health field. The largest number holds nursing positions, 24 percent. Administrative positions account for the second largest total, 22 percent. Examples include program directors, medical librarians and referral specialists. Physicians also account for 22 percent, up from 15 percent from the 2010 Literature and Medicine seminars. The varied backgrounds of participants fit the goal of Literature & Medicine to draw professionals and staff from throughout the healthcare. A basic premise of the program is that the experience of patients should be viewed from a holistic perspective, that health is a function of more than medicine and treatment. It encompasses all the factors that make up the medical experience. While nurses and physicians may have the most day-to-day-contact with patients, how patients respond to care can include all the elements of the health system and interpersonal factors as well. For example, conversations with housecleaning staff may represent the most regular contact a hospital patient has with anyone on a daily basis, a needed outlet for interaction with others, which can be an important part of the healing process (see Cassell, 1985). Program Administration Participant ratings indicate that Literature & Medicine is well-designed and implemented. The program has sufficient fiscal resources to support a wide network of sites: 17 seminars distributed across 16 states. There is active communication within this network through telephone and email, the web site and periodic newsletters. As part of the VA program, Literature & Medicine held a national conference and a summer training workshop for its partners (councils, facilitators and liaisons). Eight survey questions on program administration were asked of the participants. A three point rating scale was employed: positive, satisfactory and needs improvement. An average of 78 percent rated the administration as positive across eight survey questions: Facilitator knowledge of the content (89%) Stimulation of discussion by the facilitator (82%) Facilitator moderation of the discussion (81%) Session format (78%) Time of day (75%) Meeting room (74%) Size of the group (73%) Session length (69%) 7
These findings indicate that the program is well-run across a variety of important administrative dimensions. The role of the facilitator is considered the most important, whether assessed in terms of knowledge, stimulation and/or moderation of the discussion. These survey results clearly underscore the importance of the facilitation role in the success of Literature & Medicine. Program Outcomes: Individual Scale Scores The main purpose of the survey is to collect data on the effects of Literature & Medicine on the attitudes and behavior of its participants. A variety of literature was reviewed to identify potential measurement scales, particularly within the context of the medical field. The logic model was devised, in part, to help clarify goals of the program, and how they relate to expected outcomes. The focus of the survey is how professionals feel about themselves and understand others, dimensions critical to patient care and central to medical humanities, (Crellin, J. K., 2005). Five outcome dimensions were identified: Empathy for Patients, Cultural Awareness, Job Satisfaction, Interpersonal Relations and Communication. Between 5 and 8 variables (questions) were developed to measure each domain. Measurement was based on 4 point, Likert equal-appearing interval scale (large, medium, small or no influence/improvement due to involvement in the Program). The variables within each domain were added together and divided by the number of variables to get a mean score in the same range as the original measures. This score provides a composite value for the domain based on all variables used to measure it. This procedure is typical for construction of scales in attitudinal measurement. The general assumption is that a dimension is best measured by multiple variables, not just one. Since most attitudinal constructs are multi-dimensional, a preferred procedure is to develop a number of variables, between 5 and 30, that represent the possible definition of its meaning. Two methods were used to establish the validity of the five measurement scales. First, as described below for each domain, the literature on the scale concepts (e. g. patient empathy) was reviewed. The effort was made to draw from pre-existing variables that measured the same or similar dimensions in earlier studies. These existing scales were generally based on the concept of content validity. They were considered representative of how the idea was discussed in the literature and in practice (see Cronbach and Meehl, 1955). Secondly, a form of statistical validity, Cronbach s alpha, was applied to data gathered from an earlier round of surveys administered in 2007. Cronbach s alpha is a way to estimate whether variables that make up a scale actually represent what the scale purports to measure. The alpha value is a function of the number of test items, and the average inter-correlation among them, ranging on a numeric scale of 0 to 1. A value of.70 is generally accepted as evidence for the validity of a scale (UCLA Academic Technology Services, no date). The alpha values for each of the 5 scales meet this criterion. All of them are.90 or higher. Based on this test of empirical validity, the variables included in each of the 5 scales are strongly representative of the attributes they are intended to measure. Literature & Medicine has a significant effect on all five domains (see Table 2 for a list 8
of the variables and the scores). The percent improvement ( medium to large ) for the five dimensions ranges between 51 percent and 82 percent. The average or mean improvement was 63 percent. The scores for each dimension are: Percent of Participants Who Indicated Medium and Large Influence from the Seminar Empathy for Patients 82% Interpersonal Relations 62% Job Satisfaction 61% Cultural Awareness 59% Communication 51% Although there is no benchmark for effective performance for a program of this type, Literature & Medicine appears to have a significant influence on attitudes and behavior change across a broad range of dimensions within the VA health setting. Each of the five dimensions is discussed below: Empathy for Patients Empathy is a concept denoting cognitive as well as affective or emotional dimensions. The cognitive domain involves the ability to understand another person's inner experiences and feelings as well as a capacity to view the outside world from another s perspective. The affective domain is the potential to enter into the experiences, and feelings of another individual. In terms of patient-care situations, an empathetic perspective allows the health practitioner to understand the patient s views and experiences and an ability to communicate at this level. The work of Hojat, et. al. (2001) in this area served as the framework in developing the five variables included in this domain. For 4 of the 5 variables that comprise the empathy scale, over 75 percent indicate Literature & Medicine had a medium to large influence. The mean percent across the 5 variables is 82, 21 points higher than the next ranked category, Job Satisfaction. The only score below 75 percent is understanding nonverbal cues of patients (69%). A possible explanation for this lower ranking is that it is difficult to convey this aspect of medical care through the written word, including the type of fiction, nonfiction and poetry readings used in the Program. More typically, training in this area relies upon the use of exercises and other forms of experiential education (see Blatner, A., 1985). Interpersonal Relations Among the competencies identified by the Accreditation Council for Graduate Medical Education (2006) are interpersonal skills. The Council developed a Humanism Scale which encompasses a wide variety of interpersonal dimensions that relate to the medical profession: cooperation with medical colleagues and paramedical staff, physician-patient relationships, rendering comfort and empathy, involving patients in decisions and addressing their concerns, and willingness to admit errors. These elements of care giving form the basis of the 8 variable scale measuring interpersonal relations in the survey. The average is 62 percent in terms of those who rank the impact medium to large. It is 9
ranked second among the six domains included in the survey. For 4 of the 8 variables, approximately 60 percent of the respondents rate the impact of the program at high or medium levels. The highest ranked factors are trying to put patients at ease (71 percent) and attentiveness to patient concerns (69 percent). The data provide evidence that Literature & Medicine is achieving its goal of improving relationships among colleagues and patients in the health care setting. Job Satisfaction Job satisfaction is a complex concept. For example, in the widely referenced work of Herzberg (1959) on motivation in the workplace, 12 factors are cited as relevant to this aspect of worker's attitudes: organizational policies and administration, recognition, supervision, working conditions, interpersonal relations, salary, status, security, achievement, recognition, advancement and job interest. Job satisfaction and the factors related to it have been investigated in the medical field as well (Lichtenstein, 1984; Shjader, 2001). The 5 variables included in the scale are based on this literature. Job satisfaction is the third ranked domain although only 2 percentage points behind interpersonal relations. Across the 5 variables, the average is 61 percent who rate the program s influence as medium to large. The area where Literature & Medicine had its greatest impact was your appreciation of your colleagues and coworkers skills and contributions (77 percent). A main goal of Literature & Medicine was to encourage participants to examine their relationships with each other in the workplace. Cultural Awareness The National Center for Cultural Competency at Georgetown University (no date) created an instrument, Cultural Competence Health Practitioner Assessment (CCHPA), and its questions formed the basis of the scale used in this evaluation. The purpose of the instrument is to foster greater cultural competence among practitioners in regard to different racial and ethnic groups. The instrument includes questions for six subscales. Of particular relevance to the Literature & Medicine evaluation was the Clinical Decision-Making subscale, which asks questions about how knowledge of the risk factors of diverse groups are integrated into practice. The average score for the 6 variables ( medium to large influence) in this domain is 59 percent. It is the fourth ranked domain. For all the indicators, a majority (50 percent or more) indicate this level of influence. For 3 of the variables, over 60 percent rated the impact of the program as high or medium: the value of culturally relevant information from family members, attention to diverse values and belief systems about health and disease, and patient perceptions of the reasons for their disease. Discussions with program managers involved in non-va Literature & Medicine programs indicate cultural and diversity topics have been difficult to approach from a training perspective. In contrast, the Program has clearly had an impact on the VA participants in this regard. VA health facilities should investigate the ways in which humanistic readings could be included in training and development initiatives in these and related areas. 10
Communication There is increasing emphasis within healthcare on communication as a basic medical skill. Some medical programs have curricula focusing on communication, especially how to work with a variety of stakeholders including patients, physicians, nurses, other healthcare professionals and advocates (Kurtz, 1997). Based on a review of this literature, seven variables were developed to measure the communication dimension. Communication is the lowest ranked domain. Across the scale variables, the average was 51 percent in terms of respondents indicating the program had a medium or strong influence on their communication. Communication in the health professional field (57 percent), people with different backgrounds: cultural, ethnic, economic, educational (55 percent) were the areas where Literature & Medicine had its greatest impact. In contrast, patients of another gender received the lowest score (43 percent). Literature & Medicine should look carefully at these results. There was apparently more success addressing cultural/ethnic than gender diversity, although one question focuses on people, the latter patients. Even given the difference in question wording, the program should explore whether a greater emphasis should be given gender diversity as a topic for future programming. Program Outcomes: Impact on Health Care and Work Environment A second approach to the measurement of program outcomes was to examine the impact of the five domains included in the survey on specific health care and work environment issues in VA hospitals. The five domains, as discussed in the previous section, were: Empathy for Patients, Job Satisfaction, Interpersonal Relations, Cultural Awareness and Communication. Respondents were asked to identify whether these Literature & Medicine topics had a positive influence on aspects of their professional roles. A literature review was conducted to ascertain the major medical and work issues in the hospitals. Seven dimensions were identified. They encompassed care giving, clinical treatment, service provision and workplace issues. Source material included web sites, government reports, professional articles, and newsletters, web sites (see National Center for PTSD, no date; Parrish, 2008; United States Department of Veterans Affairs (2008); Jazieh, 2006; Trent, 2000; GAO, 1998). The data are summarized in Table 3. Seven health care and work environment dimensions are listed in the rows. They represent the combined impact of the program experience in regard to effect on the participants. Patient-Center Care Emphasis on patient-centered care was the dimension most influenced. Two-thirds saw Literature & Medicine as having a positive effect upon this aspect of their professional life. It was the only factor for which 60 percent or more indicated such an impact. The effect of each of the 5 program domains showed little variance. The range in scores only ranged from 63 to 72 percent. Consequently, a better understanding of patient-centered care was an impact of 11
Literature & Medicine regardless of the specific foci of the readings and discussions. Cultural Diversity The other dimension where more than a majority indicated the domain had a positive influence was accepting cultural diversity. Fifty-three percent indicated such an effect; the next closest dimension was 44 percent ( responding to post-traumatic stress disorder). The impact of individual seminar topics (e.g. empathy for patients) showed some differences in how they affected the rating by participants, but for four of the domains the range of scores was only from 49 to 55 percent. Consequently, the key element of the readings is not their specific topical focus, but giving participants the opportunity to read and discuss material about cultural diversity. Supporting health care professionals in responding to diversity has always been a complex training and development topic (see Betancourt, J. R., et. al., 2005). It is a concept that involves multiple dimensions, from deep-seated personal feelings to the challenges of dealing with different cultures. Literature & Medicine has proved effective in addressing this dimension throughout its history (see Clary, B. B. 2008). This success is also evident for VA facilities. Ways should be explored to integrate the program s approach into support and educational services for VA employees as they increasingly face a more diverse population of staff and patients. Post-Traumatic Stress Disorder A major focus of the VA Literature & Medicine was Post-Traumatic Stress Disorder. 44 percent said that their experience had a positive influence on their knowledge of this dimension of care giving. It was the third ranked dimension in terms of the program s influence. Given the challenges that PTSD poses for VA Hospitals, it is significant that literature, and discussion of it, can help health professional address and cope with it. In terms of professional development and training, it represents a comparatively inexpensive approach with the potential to involve a large number of participants within the veterans health care system. This finding also underscores the importance of empathy in the health care setting in terms of working with PTSD patients. The percentage indicating that readings /discussion of this topic was 58 percent compared to an average of 41 percent for the other four domains. Other Health Care and Work Environment Factors Of the remaining 5 domains, dealing with employee burn-out was next ranked (42 percent) as a value of the Program. Focus groups held in VA hospitals indicted the importance of this factor in how staff view their job. Many said that a major challenge of PTSD was seeing improvement in patients. This lack of client progress was often cited as a reason why clinicians left the VA. The Literature &Medicine seminars have the capacity to address this issue, even if it is only a start in helping health care managers and medical personnel think about the problem and how to cope with it. The other 4 dimensions, as shown in Table 3, have lower scores, none having a mean average above 30%. 12
Program Outcomes: Open-Ended Questions Participants were asked two open-ended questions. The first focused on the impact of Literature & Medicine on work life. The second was more defined, asking the participants to provide a description of a specific event that was influenced by Literature & Medicine. Impact on the Workplace Environment The respondents provided 124 separate statements regarding how Literature & Medicine affected their work life. Clearly, many respondents were able to link the program experience to improvements in their work life. The open-ended comments are broken down into the same 5 scales for which the individual, close-ended questions were grouped. The percentages of statements within each domain are: empathy (47%), job satisfaction (17%), interpersonal relations (15%), communication (11%) and cultural awareness (10%). This ranking correlates reasonably with that of the close-ended questions. In both cases, empathy for patient is listed most frequently as the benefit of Literature & Medicine. Job Satisfaction and Interpersonal Relations are ranked 2 and 3 for the close-ended questions, although the ranks are reversed across the question types. Communication and Cultural Awareness score last in both rankings. This correspondence provides a form of convergent validity as to the accuracy of the survey in measuring these five dimensions. This form of validity is established when different types of measurement approaches, designed to measure the same phenomenon, yield similar results. In this case, one indicator is quantitative; the other qualitative (see Neal, L. A. et. al., 1994). Empathy As with the scales measuring individual outcomes, empathy is the most-cited value of Literature & Medicine. Forty seven percent of the statements reflect this dimension. A single theme dominates the responses that fall into this category. Participation in the program helped caregivers better understand patients, as well as staff, and the different perspectives they bring to the medical process. The statements reflect a clear understanding of the value of empathy in health care. Representative quotes include: -It has made me more broad minded as to a patient's point of view or background -Increased awareness of what it is like to navigate the health care system-the difficulties and complexities of being ill. -Opens up opportunities to see other viewpoints; reinforces beliefs; leads to out-of-the box thinking. -Reminds me of the complexity of people and to look at the whole person. -Empathy. Looking outside the task at hand at the person's feelings and understanding. Job Satisfaction Seventeen percent of the participants indicate increased job satisfaction as a result of Literature & Medicine, ranked second. It ranked third in the close-ended responses, only 2 percentage points behind the second ranked item. The similarities in rankings underscore the 13
importance of this outcome of the program. Themes which emerge from the statements are: the extent to which the program experience helped participants cope with job demands, understanding one s responsibilities from a non-medical perspective, increased knowledge about patient care and improved relationships with co-workers. Examples of statements made by the participants include: -What it did was to bring more enjoyment into the workplace. -Like many MDs, I teeter on the edge of burnout from the logistics of working with patients, and this reminded me that my job is a privilege, a gift, and that I am fortunate to be able to help provide for basic human needs. -It was refreshing and therapeutic to interact and share with other health providers with similar interests. -It allowed me to reflect on larger themes in health care. Came to appreciate the role of other allied health professionals as I heard them share their experiences and perspectives. -Gave me a glimpse into the work of others outside of my normal circle in the hospital. Interpersonal Relations In terms of statements that participants make about the value of Literature & Medicine, those related to interpersonal relations are third in terms of frequency (15 percent). It was ranked second in terms of the scales for the close-ended questions, underscoring its importance. It is difficult to separate statements about this domain from others addressed in the survey. Interpersonal relations often encompass elements of empathy as well as communication. A challenge in coding open-ended responses was to make distinctions among these areas. It cannot be assumed the various domains, although labeled as separate, can necessarily be divided from one another in coding a statement. One key theme was evident in almost all of the statements related to interpersonal relations. The program engendered better relationships between colleagues in terms of work behavior, willingness to discuss difficult issues with each other, and understanding of different perspectives. Representative statements include: -It is always good to get another person's perspective. I am often struck by how compassionate other people can be -Get to know people from other disciplines. Get to use another part of my brain. I have not sat down with an English professor and delved into writing in a long time -It was refreshing and therapeutic to interact and share with other health providers with similar interests -I have always sought out continuing education opportunities, but found this ongoing 6 month long program to have a more profound impact than I had anticipated. The developing relationships among the group members and opportunity to hear their thoughts and opinions in such a comfortable setting allowed them to be more candid. -The Literature & Medicine Program has helped me see medical staff in a different light. Understanding the complexities of patient medical issues has given me a higher appreciation of the medical staff performs on a daily basis; consequently, interaction with medical staff has become more interactive. 14
Cultural Awareness Ten percent saw their participation in Literature & Medicine as improving their cultural awareness, ranking fourth among the domains. It was also fourth among the scales for the closeended questions. Focus groups that were held for previous Literature & Medicine programs provide some explanation for its lower ranking. Participants often indicated that it was not a lack of concern about cultural diversity that led them to rank it lower in terms of its impact on them. Instead, their healthcare environments tended to be homogeneous in terms of ethnic and racial diversity; therefore, on a day-to-day basis, they may not regularly encounter issues of diversity. A frequent theme in the responses on cultural awareness was how Literature & Medicine increased awareness of racial, ethnic, gender and other differences and how they influence healthcare practice. Below are examples of actual statements made by the respondents: -Not every Veteran is identical, each conflict brings its own set of residual human issues; however they also have common threads of wounds -Helps me understand their experiences better. Reading the stories of other cultures e.g. Malidome's Sommes account of his tribal spiritual experiences; helped broaden my perspectives -Greater sensitivity about why people act the way they do - so much is cultural -See patients in a different perspective -The group discussions and literature opened my eyes to situations that I had not experienced and thus making my knowledge and compassion for diversity grow Communication Eleven percent of the participants gave examples of an impact on communication skills, ranking fifth among the domains. It was also a lower ranked domain for the close-ended scales, ranking last. The comparability of rankings for closed and open-ended questions provides evidence that Literature & Medicine s effect on communication skills is not as significant as for other domains. However, there are substantial overlaps between it and others included in the survey, particularly interpersonal relations and empathy. Coding statements for a specific domain can be difficult, when such overlaps exist. A primary theme in the responses was that participants said their ability to communicate, interact with and listen to patients, other staff members and other departments had increased. Below are examples of this theme: -It has helped me communicate better with nursing staff. -What it did was to bring more enjoyment into the workplace and to stimulate discussion with co-workers in a setting and about topics that we would not otherwise have discussed. -It was refreshing and therapeutic to interact and share with other health providers with similar interests -Increased my awareness of certain things and increased my communication ability. -All areas, mainly in interpersonal communication, between staff and to truly learn to understand and communicate with patients in all its nuances. 15
Examples of Specific Program Impacts Respondents were asked to describe a specific event to illustrate how the Program affected them. The purpose of this question was to get them to think about outcomes, not in a general sense, but in terms of concrete examples. This approach is close to "grounded theory," an attempt to build social science constructs by asking questions and/or observing everyday events of the subjects under study (see Glaser and Strauss, 1967). The goal was to "ground" the responses in terms of daily organizational life. A total of 59 statements were made by the respondents. However, many were general and did not reference a specific event. Given that many of these statements contained multiple sentences, they often included a variety of themes. Consequently, it is difficult to divide the statements into one type of domain, as was the case for the work environment. However, the number of time that themes appear can be counted. Patient Empathy (38 percent) appeared most frequently followed by Job Satisfaction (22 percent), Interpersonal Relations (21 percent), Communication (12 percent) and Cultural Awareness (7 percent). It is important to note that Patient Empathy was ranked first both in terms of the standardized scales and the open-ended question dealing with the impact of Literature & Medicine on the work environment. Clearly, this dimension emerges as the one most impacted by the Seminar. A number of these statements are listed below: - It keeps me grounded about the challenges facing patients and families face when hospitalized: dealing with a crisis, hearing a new diagnosis, or managing daily activities while coping with a dying family or friend. It helps me appreciate the communication skills to assist these patients and families. It allows me to embrace changes without feeling that I've lost or given up something. - I do not know if this program is the direct reason, but I like to spend more time with patients, explaining with the help of models and listening with more understanding. - We see many patients who come multiple times for treatment of substance abuse. Many are seldom, if ever, able to make the significant changes/commitment to become healthier. It is a constant challenge to stay engaged with each patient on readmission. The readings and discussions have given me the time and perspective to keep my frustration in control and stay engaged with each patient in an effective way. - A woman Veteran was having trouble getting her life together and I was more willing to relate to what she had to say because of some things I read in Odysseus in America. All Veterans should read this book - I think I am more aware of patient centered issues as a result of this course. I practice in a specialized setting with a fast pace and these stories allow me to see what other providers do and how they interact with patients. I interact so rapidly and gain their confidence, but then rarely see them again. This type of literature really helps me to see a more whole picture of patients. These statements provide examples of how the participants linked the readings and discussions to their actual working life: be it personal understanding, the support of people, or how individuals and groups interact and care for others. It is difficult to capture the value of literature in program evaluation, but these statements provide a rich and detailed accounting of the impact of Literature & Medicine, and what it meant to participants in their work setting. 16
Conclusion Literature & Medicine is a health facilities-based, scholar-led humanities reading and discussion program for all medical professionals and all allied staff that benefits both them and their patients. This report details an evaluation survey of 124 individuals in VA health facilities who participated in the program during 2011. Seventeen VA sites were represented, covering 16 states. The results of the VA evaluation closely correspond to earlier assessments done of the Literature & Medicine programs offered in a wide variety of non-va health settings. Results from all the surveys correspond closely, indicating that Literature & Medicine has had a consistent and positive impact on participants, regardless of their work setting. Evaluation outcomes significantly reflect the basic program goals: increased empathy for patients, greater cultural awareness, improved interpersonal relations, better communication skills and more job satisfaction. The summary of results from the 2011 VA facility survey indicates: Literature & Medicine is well administered. Respondents indicate a high level of satisfaction with activities such as program structure, content and the role of facilitators. The impact of Literature & Medicine on levels of empathy among participants in the VA system is noteworthy. This is a dimension of personal and professional growth that is not easily taught through training workshops. The program made significant contribution to professional development in this area. Further, smaller, but measurable gains were made in the area of cultural awareness. The general question of diversity in the workplace has proven to be a difficult organizational problem, not just in the medical, but all fields. VA institutions should seriously examine the approach used by Literature & Medicine as a way to increase understanding and communication in diverse employment settings. In light of the evaluation findings, the VA should seriously consider the continuation of this program. The cost is minimal compared to many training programs. It is a program that actively involves medical staff over an extended period of time and provides an opportunity for them to interact with each other on a sustained basis. Throughout the evaluation, a consistent finding was the importance of this dimension to VA health care facility staff. As medical care becomes more specialized, there is increasingly less opportunity for this type of contact to occur. The evaluation also provides evidence that the Program had an impact upon how medical personnel dealt with the difficult problem of Post Traumatic Stress Disorder (PTSD). Clearly, the increased empathy that Literature & Medicine fosters is important to VA staff in dealing with patients with PTSD, especially in communicating with service veterans in terms of issues that they find difficult, if not impossible to discuss. Literature is a powerful tool of human understanding and communication. In the difficult environment of the modern VA health facility, it can make a significant contribution in those areas where the effectiveness of medical practice and technology have limits in responding to the complex process of how humans identify with each other and interact among themselves. 17