Table 3.

Respondents' Descriptions of Barriers to Promotion of Complementary and Integrative Health Within the Veterans Health Administration

Themes	Sample coded text
Personal level
Lack of providers' personal experience with CIH	“It's easier if people in administration or leadership positions have experienced themselves and found out how it can make a difference in somebody's life.”
Having to use personal time or funds to obtain training	“My initial training was all through outside sources that I self-funded.… I have been able to get staff funded through the VA.… They did it on their own time.”
	“The nurses that are involved in the healing touch project; we're all doing it on our own time.”
Practitioners who fear accepting new ideas	“A lot of people are just not … they don't want to know. They don't want to accept it.”
	“It's kind of sad that they prefer oral analgesics when there's alternative treatments.”
Preexisting provider or patient mindsets	“Everyone's afraid to treat pain”
Facility level
Unsupportive management	“It's nothing that they've brought forth to me … so I am taking some preliminary actions to try to come up with a plan that my VISN might find acceptable.”
	“Our management here doesn't really have much vision.”
Dependence upon volunteers	“We also had students coming from the acupuncture school and it was limited to Neurology only, and it was limited to chronic pain … there was a waiting list.”
	“There is no mechanism that I am aware of that would allow volunteer experts.… These are people that just out of the goodness of their hearts want to do something for vets.”
Therapies available only to targeted groups of veterans	“I don't think you'll find anything that's available to 100% of the veterans.”
	“It's just outpatient at this point.”
Complicated and/or limited availability of referrals	“Veterans can sign up for yoga classes but there's not enough slots and there's waitlists.”
Need for multiple approvals to initiate a program	“It takes a long time to get approvals … the system is not designed to think outside of the box.”
Difficulty incorporating volunteers	“The yoga instructors … there's competencies that they're expected to display … but they're basically volunteers. I wish there was more in the budget so that we could pay those yoga teachers.”
Lack of space, time, or funds	“I'd like to have an entire Pain Center that is integrative …. to manage the huge pain population that we have in the VA.”
	“Space is more of an issue when you have equipment. You need a quiet private spot.”
VA-wide level
Struggle to provide basic healthcare to overwhelming number of veterans	“The way the scheduling system operates presents a real barrier to make or cancel appointments.”
Cost and/or lack of cost-benefit data	“Data tracking is a very important part of what we do … we need to show results.”
Lack of position descriptions	“We have a provider who has been trained in acupuncture, but has not been credentialed.”
System focused on medications and illness	“At my VA? No, we don't have any alternative therapy.”
	“CPRS is a huge obstacle.… It is absolutely focused on illness and medications.”
Unstable funding (e.g., grants)	“The program … was completely supported by first a postdoc fellow and then research dollars from the NIH followed by research funding through the VA. When that funding ran out the PI tried to get support from mental health and from nursing service, just to keep the clinic open … that program is not offered as widely as it could be.”
Lack of funding from Congress	“There is no funding. We're just doing it.”

CIH, complementary and integrative health; VA, Veterans Health Administration; VISN, Veterans Integrated Service Network; CPRS, computerized patient record system; PI, principal investigator.