Abstract
BACKGROUND:
Healthcare systems have increasingly focused on patient engagement in efforts to improve patient-centered care. Appointment attendance is an integral component of patient engagement, and missed appointments are an ongoing problem for healthcare systems. Virtually no studies have examined how sense of belonging is related to patient engagement within a healthcare system.
OBJECTIVE:
To examine patient experiences in the Veterans Health Administration (VA) with outpatient appointment attendance to identify factors that affect sense of belonging and patient engagement.
RESEARCH DESIGN AND PARTICIPANTS:
This study draws from qualitative data collected as part of a study to reduce missed appointments through use of enhanced appointment reminder letters. We conducted semi-structured interviews with 27 VA patients with primary care or mental health clinic visits, using deductive and inductive analysis to develop themes. More than half of the participants were Vietnam veterans, 24 were over 40 years old, 21 were white, and 18 were men.
RESULTS:
We identified three factors that influence sense of belonging within the VA: 1) feelings of camaraderie and commitment toward other veterans were relevant to patient experience in the VA; 2) interactions with all staff influenced the engagement a patient felt with a particular clinic, care team, and the VA; 3) personalized communication and messaging could humanize the VA and demonstrate its interest in engaging with veterans. Lastly, we found 4) sense of belonging appeared to promote appointment attendance and patient engagement.
CONCLUSIONS:
There are multiple opportunities to strengthen patients’ sense of belonging within the healthcare system that serves them. For veterans, strategies that build their sense of belonging may be a novel approach to increase appointment attendance and patient engagement in their healthcare.
Keywords: sense of belonging, clinician-patient relationship, patient experience, appointment attendance, interviews
INTRODUCTION
Healthcare systems have increasingly focused on patient engagement in efforts to improve patient-centered care. Patient engagement centers on the idea of active patient involvement in healthcare through participation in health-related decisions in a supportive environment.1,2 In clinical settings, patient engagement has potential benefits such as increasing patient understanding of health conditions, treatments, and outcomes.3
Appointment attendance is an integral component of patient engagement, and missed appointments or ‘no-shows’— when a patient neither attends nor cancels— are an ongoing problem for healthcare systems. Missed appointments can impact continuity of care, quality of care, and the overall patient experience.4
The Veterans Health Administration (VA) is the largest integrated healthcare system in the U.S. serving more than 9 million enrolled veterans each year.5 While the VA prioritizes patient engagement, missed appointments have remained high for years despite efforts to reduce them. Data from 2019 show 12.5% of all appointments scheduled were missed.6
To address this issue, we are conducting a pragmatic clinical trial to investigate the impacts of enhanced messaging in appointment reminder letters on appointment attendance in VA primary care and mental health clinics. As part of the intervention development process, we conducted interviews with patients and included inquiry about their perceptions of care in relation to their decision of whether to attend scheduled outpatient appointments.
The VA is unique in that it serves a patient population with shared experiences and identity as military veterans. Military experience builds a shared culture that can evoke feelings of unity and connection that often extend beyond military service into feelings of kinship among veterans.7 Given this unique context, our research team sought to identify factors that affect veteran experiences of care and appointment attendance in order to identify potential strategies to improve patient engagement within the VA healthcare system.
Our results suggest that sense of belonging may be a useful concept for understanding appointment attendance and patient engagement. A sense of belonging occurs when a person feels as though they are an integral part of a system or environment in which they are involved.8 In addition to feeling integral, a sense of belonging implies acceptance and inclusion,9,10 and draws on shared identities and complementary characteristics among group members. Recent research on sense of belonging has focused on mental health implications, such as measuring loneliness or ‘thwarted’ belongingness.11,12 Research has rarely examined healthcare systems as organizations or places to ‘belong.’ Those studies that do exist have tended to focus on healthcare providers.13,14 Virtually nothing has been studied from a patient perspective. In this study, we aimed to help fill these gaps of knowledge around sense of belonging by focusing on the patient perspective within the VA healthcare system, including but not limited to mental health.
METHODS
This study draws from data collected during development of an intervention for a pragmatic clinical trial examining the effect of enhanced appointment reminder letters on missed appointment rates.15 Interviews were conducted in order to inform selection of messaging to be included in the appointment reminders.16 Potential study participants were drawn from veterans who had at least one primary care or mental health clinic visit between December 2018 and February 2019 at one of eight clinic sites within a single VA, as identified in the VA Corporate Data Warehouse. Purposive sampling was used to recruit participants with a diversity across characteristics including gender, military service era, and no-show rate. Interviews were conducted in-person using a semi-structured guide that 1) addressed feedback on wording for the messaging; 2) reviewed status quo and draft intervention appointment reminder letters; and 3) asked about experiences with attending, missing, and rescheduling appointments. A detailed description of the recruitment and interview process was published in preceding papers.15,16 The VA Portland Healthcare System Institutional Review Board reviewed and approved the study.
We conducted both deductive and inductive analysis based on transcript summaries and open coding to identify expected and emergent themes. We first utilized a deductive analytic approach, creating transcript summaries of key points17, organized into four domains based on research aims reflected in the interview guide: 1) participant background; 2) self-report of appointment attendance; 3) experiences with VA; and 4) preferences regarding messaging and communication.
We then used an inductive approach based on close readings of the transcripts, analytic memos (open coding), and discussions to identify and interpret emergent findings. Open coding identified passages of text representing themes that did not fit in the pre-set domains, such as sense of belonging in the VA and veteran camaraderie. All transcripts were summarized and analyzed by two team members trained in qualitative methods (M.L. and W.S.) to ensure ongoing agreement through discussion. Transcript summaries were collated into a matrix for further thematic analysis across domains, allowing us to compare experiences of participants while maintaining holistic understandings of individual narratives. The matrix was shared and discussed with additional team members resulting in a common understanding and interpretation of the data. We then selected exemplary quotes from a variety of participants to illustrate the conceptual themes in this paper.
RESULTS
Table 1 provides descriptive characteristics for the 27 participants we interviewed; pseudonyms are provided for ease of identification of participants mentioned in the results, as well as each participant’s no-show rate. More than half of the participants were Vietnam veterans, 24 were over 40 years old, 21 were white, and 18 were men.
Table 1:
Descriptive characteristics of participants (N=27)
| Pseudonym | Age | Sex | Race/Ethnicity | Service Era | New/Est | # of appoint-ments in prior 2 years | # of no-shows in prior 2 years | No-show rate |
|---|
F=female; M=male; New=new patient; Est=established patient
Based on interviews about patient experiences and appointment attendance at the VA, we identified four findings around sense of belonging and patient engagement (Figure 1). Three factors shape perceptions of care and sense of belonging: 1) veteran camaraderie and commitment toward each other; 2) interactions with all staff; and 3) communication and messaging between patient and the healthcare system. Lastly, we found 4) sense of belonging influences appointment attendance and patient engagement in their healthcare.
Figure 1:
Main findings around sense of belonging and patient engagement
1. Veteran camaraderie and commitment toward each other were relevant to their experience as patients in the VA
Veterans’ experiences in the military influenced their beliefs and attitudes about accountability to others and the role one plays as part of a team. Various branches of service instill commitment as a primary value, such as the Marines who use commitment to promote ‘the highest order of discipline for unit and self’ and ‘concern for others.’18 Participants referenced such values while talking about other veterans: ‘I think a lot of veterans are really big on accountability, because that was something that was…engrained in us. (…) Your actions and you affect the team.’ (Gloria, n/a)
Many participants spoke of the bonds they developed with servicemembers— often in kinship terms that implied a sense of belonging and commitment to the larger group. Oscar (0%) explained: ‘I think veterans, for the most part, are close. It’s… for lack of better term, fraternal, I mean you’ve got a bond.’ Participants also said they want to ‘do their part’ to help other veterans, such as Haley (4%) who said: ‘I…had a camaraderie when I was in the Air Force…having a camaraderie to help people, help other veterans, is great. Because that’s what we’re here [for] and like to do, is to help people.’
A strong emotional response was evoked for some veterans during the interviews when they examined the following proposed appointment reminder messaging during interviews: ‘Each appointment a veteran misses is an appointment that could have been used to provide needed care to another veteran’:
Okay, that hits me in the heart, because I care about veterans…it motivates me to do the right thing and come to my appointments. (…) Veterans always want to try to help support each other and like help each other. (…) I feel like I would take it as like a personal responsibility.
(Gloria, n/a)
It kind of puts us on the same team, if you will, in that statement…it’s the emotional part of not wanting to miss an appointment, because somebody else could have had that appointment. (…) As a veteran, when you talk about other veterans, there’s already that commonality…camaraderie that we had in the military with them.
(Leeann, n/a)
While participants were committed to helping other veterans as individuals and as a shared community, they felt less of a sense of responsibility to the VA as a system. Some veterans associated the VA with ‘big government’, despite its mission to care for veterans. Several participants said that veterans tend to think ‘they owe it to me’ (Shannon, 5%) and they will not care about wasting the VA’s money because ‘it’s the government’ (Justin 3%). These veterans explained why they preferred messaging focused on consequences to other veterans rather than the VA:
Make it more about brothership, brotherhood, about your fellow veterans instead of what it’s costing the VA. Make it about…each other, instead of about the big DVA. (…) We’re all here for each other. You know, that’s the military mindset.
(Veronica, 25%)
‘It costs the VA $200.’ That to me is not a motivator. (…) Knowing that I could have got [another veteran] in my place is a motivator for me.
(Owen, 15%)
2. Interactions with all staff contribute to feeling cared for and influence the engagement a patient feels with their care team and the VA
Participants often discussed their experiences and relationships with clinicians and staff at VA clinics in terms feeling listened to, cared for, and respected. The importance of feeling cared for and mattering as an individual extended beyond relationships with providers and included interactions with all VA staff, both in-person and over the phone. The quality of interactions with staff in various roles, such as scheduling or administrative, influenced perceptions of VA and its values as well as the connection a patient feels to a particular clinic, care team, and the wider VA system.
When Shannon (5%) was asked what motivates her to attend appointments, she responded: ’knowing I’ve got good doctors that understand me and understand what I went through in the Navy, and they’re trying to work through it with me. It has been a big help.’ In addition, she stressed the importance of feeling cared for and gave an example of an ‘ideal’ provider who reached out when she missed an appointment: ’She called me and was worried about me, and I thought that was really kind of nice.’
Many participants talked about the importance of communication from their care teams as something that affected appointment attendance. Patrice (20%) said she used to miss appointments while going through mental health challenges and reflected on how check-in calls from the clinic helped her remember her appointments and feel like the whole team was invested in her well-being: ‘that little reminder for that mattered…it made a difference, and it also made me feel human. Like it mattered to them that I got better.’
Similarly, Ashley (7%) said some of her providers reach out when they are concerned about her: ‘If you have really compassionate doctors and therapists and things like that, they really do know you very well. They know that when you get quiet or you don’t attend, that you’re really hurting or struggling.’
Feeling that care teams took time and interest to understand patient needs was important to participants. They wanted their interactions with clinicians and staff at the VA to feel intentional and not rushed. For instance, Tony (33%) contrasted the personalized care he felt at some clinics with another clinic where he felt the staff lacked interest in individual patients:
I got thrown into a PTSD clinic, and that seriously felt like a check the box. (…) They didn’t give a shit about what was going on in my personal life, which affects the PTSD. (…) Some clinics are it’s like ‘you’re a number, you’re done. Get out.’ Other clinics, they take that time.
Interactions over time with various staff and clinics affected participants’ views of the VA as an organization. Andrew (14%), for instance, described feeling a sense of belonging and vested interest within the VA, which he likened to feelings of kinship:
The VA has this pervasive attitude of ‘thank you for your service… we really appreciate all that you’ve given for your country, and we’re here to serve you and we’re here to give you the best possible care that we can provide.’ That just permeates the atmosphere of— that we’re a big family.
3. Personalized communication and messaging could humanize the VA and demonstrate its interest in authentically engaging with veterans
In addition to wanting to feel cared for while interacting with staff, participants said they wanted to ‘humanize’ communication with the VA through more personalized communication and messaging that demonstrates the VA appreciates and cares about veterans and them as individuals.
For instance, participants expressed frustration with standardized letters reminding them of upcoming appointments, which they considered impersonal. As Ben (38%) put it: ‘You don’t think about me at all, random VA generator.’ Veterans said letters with individualized information, such as including names of their providers, could make them more likely to communicate in response:
You put a name with that doctor, and it’s like—okay, I want to help them out… Because you know him, and he listens to you… he’s not like a generic doctor. He’s a specific person. And he’s my doctor and you’re being very specific on the letter. This is very personalized. I’m not hiding now.
(Owen, 15%)
Additionally, many participants spoke about the need to ‘humanize’ the VA through messaging that demonstrates it is caring, understanding, and supportive of veterans. For instance, Martin (n/a) said ‘just being more human about it’ has the biggest potential to increase appointment attendance and suggested adding ‘please’ to the letter to make it more ‘personal, more human.’ Similarly, Haley (4%) said she likes letters that begin with ‘I hope this letter finds you well,’ which make her ‘heart feel good.’ Other participants stressed the importance of messaging conveying inclusivity, acceptance, encouragement, and validation.
Participants responded favorably to proposed messaging from the VA where they were thanked for their service and told ‘We’re [VA] here for you.’ Veronica (25%) said it was like something a friend would say, and other veterans commented on the significance of the statement: ‘It’s making a statement that you guys are kind of here to help us… and I think that’s a good line because it reminds people that the VA system is here to serve us, and that’s what a lot of them [veterans] don’t believe, but I like that part.’ (Leon, 14%)
4. Sense of belonging promotes patient engagement in their healthcare
Some participants talked about how over time, as their experiences and interactions with staff had improved throughout the VA, they were more likely to engage with VA care. For instance, Shannon (5%), a Vietnam-era veteran described what her experiences used to feel like as a woman seeking care: We ask for respect and we ask for a doctor to listen, and it didn’t use to be that they listened. ‘Ah yeah, just another whimpering woman.’ Shannon got so tired of ‘being talked down to’ that she stopped coming to the VA until she felt experiences for women veterans improved. She said VA staff attitudes ‘changed dramatically’ over time: ‘The female veterans, they were starting to be treated better, listened to… and not talked down to…And when things turned around, I started coming back.’
Other veterans also said they were more likely to engage in management of their care and avoid missing appointments when they had positive interactions with VA staff. Zoe (0%), who has PTSD, said she occasionally missed VA appointments due to sleeping difficulties and anxiety. She used to avoid calling the VA to reschedule, because talking with schedulers on the phone made her feel bad about missing. She said the attitudes of VA staff on the phone have improved, so now she calls to reschedule without worrying she will upset them.
DISCUSSION
Staff matters
Our findings confirm the important roles personalized care and therapeutic alliance play in the patient experience, specifically their engagement and attendance of outpatient appointments.19 However, we found the importance of relationships within the healthcare system extended beyond that of patient-provider and included patient interactions with all staff. Feeling cared for and respected by all staff affected how participants perceived the VA and talked about their own appointment attendance. Other research has similarly found that patients assess the quality of their care in terms of encounters with staff in a variety of roles throughout a healthcare system.20–22
Understanding the important role all staff play in patient care and experience, training courses on ‘human factors skills’ and ‘mental health’ are increasingly used to educate patient-facing staff in healthcare settings.23,24 The VA has recognized and responded to staff-patient relationship needs, as is evident in a ‘soft skills’ training that has been rolled out for front-facing medical staff that includes communication skills and stress reduction.25,26 A 2020 VA review provided evidence that training to improve clinicians’ interpersonal skills can improve patients’ experiences of care and health outcomes.27
Utilizing patient connections to strengthen engagement
In addition, many participants said they feel a sense of camaraderie and commitment to other veterans. This not only aligns with previous research among veterans,28 but also with groups sharing other social identities (a ‘we’ group) as one of a handful of fundamental drivers of people’s behavior.29 While a ‘we’ group identity can be destructive at times (think tribalism), in the case of veterans within the VA, we believe the positive impacts of unity predominate. For instance, one study found veterans are sensitive to healthcare costs not only for themselves, but also for the VA, suggesting they feel social responsibility and commitment to other veterans and their healthcare system.30 Commitment involves the cognitive and emotional factors that capacitate patients to engage with their healthcare and can be fostered through social support.19 This is demonstrated when veterans respond positively to peer-support and peer-led efforts to reduce stigma and increase involvement in their healthcare.31,32
These findings point to the potential of utilizing shared identity and unity of veterans to strengthen patient engagement. While other studies have focused on cohesion at narrower levels of the military unit,33,34 our findings are novel in that they identify evidence of sense of belonging broadly amongst veterans. Establishing programs and fostering a culture focused on helping and connecting veterans could strengthen a sense of community and belonging within the VA. An additional strategy could be promoting its own staff identity, as approximately one-third of VA employees are also veterans. Use of peers (called peer support specialists in the VA) might be another tool that supports this sense. Peer support specialists are veterans with lived experience with mental health recovery who are trained and employed to support other veteran patients, and they have been shown to be as effective as other providers when serving in case management or outreach roles.35 The VA already employs over 1,000 peer support specialists.36
Humanizing healthcare systems
Our findings show that some veterans associate the VA with the government that runs it rather than the veteran population that it serves. One way to shift perceptions of the VA as a cold government entity into a community of veterans and healthcare teams who are committed to veterans is by using more personalized and caring communication. For instance, replacing automated phone systems with human staff to assist veterans would likely ease frustration and soften the VA persona.
Efforts to humanize the VA have been evident through its implementation of ‘Core Values’ that define its organizational culture and underscore its commitment to veterans. Core Values for staff include integrity, commitment, advocacy, respect, and excellence, and were recently amended to include ‘Customer Experience Principles’ including ‘emotion,’ which focuses on making patients ‘feel honored or valued’ in their interactions with the VA. To the extent that the perceived identity of the VA could be transformed into a ‘more human’ and caring organization through more positive interactions with all staff, our findings suggest veterans would be more likely to feel a sense of belonging and connection within the VA.
Conclusion
Our study has several limitations. Because the findings came from analysis of qualitative data gathered in the context of development of an intervention, we were constrained by the questions we could ask explicitly about sense of belonging. Furthermore, our sample consists of an older, white population of veterans that served in Vietnam that is not representative of all veteran experiences. While our findings found feelings of a shared community exist among many veterans, a sense of belonging based on veteran identity alone does not recognize the ways race, ethnicity, gender, sexuality, age, and culture simultaneously shape these feelings. For instance, lesbian, gay, and bisexual service people can feel excluded from membership in the ‘military family’37, and women have perceived the VA’s environment as unwelcoming, particularly if they have had a history of military sexual trauma.38,39 Future research on sense of belonging within healthcare systems should be developed considering, and in partnership with, diverse patient populations and identities.
Despite these limitations, our findings suggest that the VA has opportunities to expand current practices of patient-centered care to strengthen patient sense of belonging to the healthcare system. We argue that there is a need to consider the impact of all patient-staff relationships on patient experience, to humanize communications and messaging between the healthcare system and patient, and to transform veteran camaraderie into a sense of belonging within the VA community. Our findings suggest such efforts could promote patient engagement and increase rates of appointment attendance. Finally, considering the mental health challenges many veterans experience when integrating back into civilian life,7 it is important future research considers how sense of belonging within the VA impacts veteran well-being.
Funding:
This study was supported by a grant (IIR 17-134) from the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development (HSR&D). This manuscript is not under review elsewhere and there is no prior publication of manuscript contents. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.
Footnotes
Conflict of Interest: The authors declare that they do not have a conflict of interest.
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