Article

The Veterans Health Administration (VHA) is now in the sixth year of its enterprise-wide transformation into a high reliability organization (HRO). This effort began with a 2016 pilot project and is now implemented in 170 VHA medical centers.^1-4 This transformation reflects a commitment to implementing standardized and reliable health care practices.

The VHA HRO implementation strategy includes a multifaceted approach to engage leadership through education, training, leader coaching, and change management initiatives.² Despite the diversity of facilities in terms of cultures, geographies, and complexities, US Department of Veterans Affairs (VA) medical centers (VAMCs) have increasingly embraced standardized HRO practices. These changes are evident in improvements in VHA All Employee Survey scores, which assess 4 key patient safety culture dimensions: risk identification and just culture, error transparency and mitigation, supervisor communication and trust, and team cohesion and engagement.⁵ Positive trends in these dimensions highlight a cultural shift toward greater reliability, even amid challenges introduced by the COVID-19 pandemic.

However, this progress has encountered some challenges. Leadership turnover, budgetary constraints, and extensive educational demands for implementing and sustaining HRO practices have created obstacles, particularly for frontline health care practitioners.⁶ Additionally, there are pockets of resistance similar to what the airline industry faced when implementing crew resource management (CRM). Specifically, senior pilots and legacy leaders were reluctant to abandon their high-status, autocratic management styles and embrace CRM, despite its proven benefits for enhancing commercial airline safety.⁷ Similarly, some VHA staff have expressed resistance to foundational HRO practices, which include safety huddles, safety forums, leader rounding, and visual management systems.^6,8

The training requirements for HRO practices range from a 25-minute introductory course (HRO 101) to a 7.5-hour team training session facilitated by the VHA National Center for Patient Safety (NCPS).⁹ While some supervisors view these requirements as burdensome, others have demonstrated strong enthusiasm for the process.⁶ Understanding the perspectives of unit and departmental managers regarding factors that enhance or hinder the adoption of HRO practices is critical for continuous improvement.^10-12 Research has suggested that fostering psychological safety can create an environment where new ideas are shared openly, helping organizations navigate resistance to change.^13-16

A 2024 quality improvement study, drawing on the perceptions of HRO leads, identified key facilitators, including training, coaching, leader approachability, and psychological safety, as well as barriers such as inadequate training and lack of accountability among managers.¹⁷ Building on this work, the current study focused on frontline supervisors, who are directly involved in integrating HRO practices into patient care activities. By addressing both barriers and facilitators, this expanded approach aims to provide a more comprehensive understanding of the challenges influencing HRO implementation in day-to-day operations.

Methods

This quality improvement initiative examined facilitators and barriers to establishing just culture and implementing high reliability practices, focusing on frontline supervisors overseeing clinical care teams (eg, emergency department, critical care) or patient-support functions (eg, dietary services). A questionnaire was sent to a randomized sample of VHA facility supervisors.

A qualitative grounded theory approach was employed to provide a deeper understanding of nuanced phenomena that cannot be captured through numerical data alone. This method enables systematic analysis using open, axial, and thematic coding, ensuring that emerging themes achieve saturation.^18,19 It is particularly suited for this study, given the limited prior data on frontline supervisors. Additionally, qualitative methods help mitigate biases common in Likert-style scales, where respondents may lean toward agreement, potentially skewing results.²⁰

Inclusion Criteria

Participants were required to have served as a frontline supervisor for ≥ 6 months. Frontline supervisors are assigned responsibility for supporting staff who deliver services to VHA patients, including clinical care, dietary support, and other functions. These staff must complete baseline HRO cultural training as well as NCPS team training and are responsible for supporting quality, safety, and patient experience. Potential participants were identified from a list of frontline supervisors provided by VHA management. A subset was chosen through random sampling across geographically distributed VHA hospital facilities that vary in size and complexity. Invitations to participate in completing the questionnaire were sent via email, explaining the quality improvement initiative’s purpose, and encouraging voluntary participation. Of 2000 frontline supervisors invited to participate in the initiative, 97 completed the questionnaire. Participants represented a mix of VHA sites in terms of geography, size, and complexity.

Procedures

The authors used a qualitative approach and administered a confidential online survey. Demographic data were collected within the survey to understand characteristics of the participant population, including length of time as a frontline supervisor, facility complexity level, and professional background (clinical vs nonclinical). Survey questions were developed to elicit responses to specific areas of interest based on existing literature related to HRO and just culture.

Facilitators were defined as factors that increase the likelihood of establishing or sustaining high reliability practices and/or culture. Barriers were defined as factors that decrease or inhibit the likelihood of establishing or sustaining high reliability practices and/or culture. The questionnaire consisted of open-ended questions asking frontline supervisors to describe HRO practices and just culture at their individual facility and within their role. Participants also were asked to identify facilitators and barriers that helped or hindered their efforts to establish and maintain high reliability practices and just culture. The questionnaire solicited recommendations for additional support, training, resources, or leadership interventions to strengthen high reliability practices and just culture from each participant.

Analysis

Participant characteristics were analyzed using descriptive statistics. Responses to the 7 open-ended questions were coded and analyzed using ATLAS.ti v.24 qualitative data analysis software by an experienced researcher and coauthor. Grounded theory methodology allowed themes to emerge from the data and although the response rate was limited, the themes reached a saturation point.^18,19

Ethical Considerations

Institutional review board (IRB) review and approval were not required for this quality improvement initiative. Formal IRB review and approval of a quality improvement initiative are not required by VHA. Participation was confidential and voluntary, and participants could withdraw at any time without consequences. Completion of the survey indicated consent, and facility names and participant identifiers were not used. Unique numbers were assigned to each participant and all responses were kept confidential and nonattributional. Frequency coding was used to identify the facilitators and barriers to high reliability practices implementation and just culture among frontline supervisors until thematic saturation was obtained.

Results

A total of 2000 frontline supervisors were invited to participate, of whom 97 completed the questionnaire (response rate, 4.9%). Participants were first asked to describe just culture and high reliability practices in their own words. The consensus was that a just culture emphasizes a nonpunitive environment where employees can report errors or incidents without fear of retaliation. It encourages accountability at the systems level, focusing on learning from mistakes to improve processes. In response to a question asking respondents to describe HRO practices and just culture in their own words, participants noted that organizations with a just culture promote open communication, allowing staff to discuss safety issues and concerns without fear of personal blame. Additionally, participants agreed that HRO practices were defined as a set of principles and practices aimed at minimizing errors and promoting safety, especially within complex and high-risk environments. Participants responded that key characteristics include a preoccupation with failure, sensitivity to operations, reluctance to simplify, and a commitment to resilience. HRO practices entail proactively identifying and mitigating risks through open communication and collaboration among team members, they added.

Overall, participants were aligned with their view of the role a frontline supervisor plays in supporting just culture and HRO principles at their facility by fostering open communication and psychological safety, encouraging continuous learning and improvement, and promoting team collaboration and shared accountability. Among frontline supervisors, 93 (96%) identified their role as being critical to creating a safe space and reinforcing just culture and HRO principles at their facility, while 4 (4%) failed to identify a single duty.

Identified Themes

Table 1 summarizes 6 key themes identified from participants’ responses, highlighting the most frequently cited facilitators and barriers to implementing and sustaining high reliability practices and a just culture. Table 2 shows the classification of several themes in relation to facility complexity, emphasizing leadership commitment and support as a pivotal facilitator, while listing resistance to change and entrenched attitudes as a prominent barrier.

Role of Leadership

Facilitators. Leadership commitment and support were the most frequently identified facilitator, accounting for 44 mentions (45%). This aligns with participants’ descriptions of leadership involvement as crucial, particularly in setting standards and fostering accountability throughout the organization. For example, a frontline supervisor with < 5 years of experience from a nonclinical background at a 1B facility remarked, “Facility leadership are involved, which trickles down to lower-level leads and supervisors, which keeps everyone accountable and holds everyone to the same standards.” Participants frequently identified that leaders setting the standard and communicating expectations as paramount facilitators for strengthening high reliability practices and just culture at their facility.

Barriers. A lack of leadership commitment and support was a significant barrier, cited in 17 responses (18%). Participants described this barrier as a deficiency in follow-through, transparency, and presence, which undermines efforts to sustain just culture and high reliability principles. Notably, the lack of leadership commitment and support stood out as a distinct and recurring theme, underscoring its critical role as an independent challenge to achieving organizational goals. “Many leaders are not yet fully bought in,” a respondent explained. “They take the training and pass it off and go right back to their units and focus on blaming or chastis[ing] people for speaking up.” This theme frequently intersected with mentions of insufficient resources and entrenched attitudes, amplifying other challenges.

Open Communication and Transparency

Facilitators. Open communication and transparency were identified as facilitators in 12 responses (12%). Participants emphasized the importance of mechanisms such as HRO meetings and the sharing of “real” examples of positive outcomes from applying HRO principles. Transparent communication fosters psychological safety, allowing staff to report concerns without fear of reprisal. One participant with < 5 years of experience from a clinical background at a 1A facility encapsulated this theme by saying, “Quarterly ‘fireside chats’ are helpful, [this] creates open dialogue about where the next safety issue may occur, what staff need to do their job safely, while also imparting more of the philosophy of HRO that staff may not be aware of.”

Barriers. While communication serves as a facilitator, participants also highlighted barriers such as siloed communication and fear of reprisal. These reflect challenges in creating open and transparent feedback loops essential to high reliability. For example, a participant concluded, “Leadership does not communicate problem-solving efforts and resolution down the chain, they do not see the problems.” Another participant added, “[HRO principles] are not discussed that much.” While this theme presented as a barrier, it was noted less frequently.

Education and Training

Facilitators. Education and training were noted as facilitators in 10 responses (10%), underscoring their role in establishing high reliability practices. Participants suggested tailored training, simulation-based exercises, and mentorship to enhance practical application. However, they noted the importance of linking training to real change and ensuring leadership enforcement of learned behaviors. This theme is best represented by a participant who concluded, “Trainings have helped, but I think as a supervisor, being involved and interacting with your staff, observing, doing the work they do to help identify potential problems areas, especially when new systems are introduced are key. Being hands-on is the only way to successfully manage your team.”

Barriers. Insufficient resources, including time and staffing constraints, were identified as barriers to education and training, accounting for 24 responses (25%). Participants observed that mandatory training without mentorship or application diminishes its effectiveness.

Insufficient Resources and Funding

Barriers. Resource constraints, including low staffing levels and budget cuts, accounted for 24 responses (25%). Participants reported these limitations prevented staff from attending training and affected the overall implementation of just culture and HRO principles. “Low staffing in supporting services as well as in my own service line have created barriers,” a participant reported. Another participant responded that barriers to HRO were primarily “…financial, as the focus is how to curb costs and bring in more funding rather than taking the time to review and apply the concepts of high reliability.”

Resistance to Change and Entrenched Attitudes

Barriers. Resistance to change was the most frequently identified barrier, with 31 responses (32%). One participant described a persistent “gotcha” culture, where blame and punishment hinder progress toward just culture. This entrenched mindset creates significant obstacles to adopting HRO practices and requires active leadership and supervisor intervention to overcome. This theme is best captured by a respondent who noted that “culture change is difficult, especially among staff with such long tenure. It’s a long game.”

Synthesis and Integration of Findings

The data in Table 1 and Table 2 reinforce the themes identified in the qualitative analysis. Leadership commitment and support are pivotal, both as a facilitator and barrier. Open communication and education and training, while recognized as facilitators, were less frequently mentioned, but still critical. Resistance to change and insufficient resources were the most prominent barriers, indicating where organizational efforts should focus to further foster a culture of high reliability.

By addressing these barriers, particularly resistance to change and resource constraints, and leveraging facilitators like leadership engagement and transparent communication, organizations can enhance their implementation of just culture and high reliability practices. These efforts require deliberate strategies, including effective training, mentorship, and the active presence of leadership.

Discussion

This quality improvement initiative builds on prior research by examining the implementation of HRO practices from the perspective of frontline supervisors. Unlike earlier research focused on HRO leads, this study explores the critical role of supervisors who integrate HRO principles into clinical and administrative operations.¹⁷ By analyzing their experiences, this study offers practical insights into facilitating HRO implementation across organizational levels.

The findings highlight broad agreement on the value of just culture and HRO principles in fostering safe, accountable health care environments. Participants described just culture as promoting system—level accountability rather than individual blame, encouraging error reporting and learning for continuous improvement. Similarly, HRO practices—emphasizing a preoccupation with failure, operational sensitivity, and resilience— were seen as vital for patient safety in complex settings.

Frontline supervisors play a pivotal role, with 96% of respondents identifying their influence on fostering open communication, psychological safety, and shared accountability. Key facilitators included leadership commitment, open communication, and mentorship. Active leadership involvement was particularly valued, as it trickles down to reinforce standards across all organizational levels. HRO meetings using real-world examples were seen as instrumental in demonstrating the tangible benefits of these principles, helping embed them into daily practices.

Despite these facilitators, several barriers to implementation were noted. Resistance to change and entrenched attitudes, and a persistent gotcha culture undermined efforts to establish just culture. Resource constraints, including staffing shortages and budget limitations, further hindered the adoption of HRO practices. The lack of consistent leadership engagement, marked by limited visibility, follow-through, and transparency, exacerbated these challenges.

HRO leads are important for promoting education and embedding HRO principles into daily operations. These individuals provide vital support to frontline supervisors, translating HRO concepts into actionable practices. However, organizational challenges such as staff turnover and redirected funding have weakened the infrastructure supporting HRO initiatives. The elimination of HRO lead roles due to budgetary pressures at several facilities reflects a short-term focus on operational demands at the expense of long-term cultural transformation.

Additional barriers included siloed communication, fear of reprisal, bureaucratic obstacles, and outdated technology. These challenges limit progress toward high reliability and diminish the effectiveness of HRO principles.

Participants proposed strategies focused on education, training, and leadership engagement. Simulation-based training tailored to specific roles was identified as an effective tool for preparing staff to apply HRO principles in real-world scenarios. Enhanced communication, such as regular leadership rounding and transparent updates on safety concerns, was also emphasized. Participants stressed the importance of showing staff how their feedback influences organizational decisions to build trust and accountability. Finally, standardizing procedures and protocols across facilities was seen as critical for aligning practices and reducing variability in safety processes.

This study underscores the need for sustained leadership commitment and infrastructure to ensure the long-term success of HRO implementation. Addressing the identified barriers and leveraging the proposed mitigation strategies can foster a culture of safety and reliability across the organization.

Limitations

This quality improvement initiative used qualitative grounded theory methods and sampled a relatively small group of experienced leaders specifically involved in implementing HRO within the VHA. In addition, while saturation of themes was reached, the number of responses represents a small sample of VHA frontline supervisors. As such, the findings may not be fully representative of the perspectives of all unit and departmental leaders across the VHA or other health care systems. A previous qualitative quality improvement initiative focused on the perceptions of HRO leads regarding facilitators and barriers to just culture.¹⁷ This quality improvement initiative broadened that focus by examining the perspectives of frontline supervisors in the operational environment, who may not be HRO experts but work to implement HRO principles with the guidance of HRO leads (HRO subject matter experts).

There remains an opportunity to address a critical gap by assessing facilitators and barriers beyond the facility level, incorporating both the Veterans Integrated Service Networks (VISN) and VHA Central Office (VHACO). While qualitative methods, such as those used in this study, provide deep insights and detailed understanding, they are limited in their ability to identify system-wide trends and variations at a more strategic VISN and VHACO level. Addressing this could enhance the broader applicability of HRO principles across the VHA.

Conclusions

Successful implementation of the recommendations reported in this study will require sustained focus and continued commitment from all stakeholders across the VHA. As the VHA enters its seventh year on the HRO journey, the risk of organizational drift remains an ongoing concern. Progress has been made, as evidenced by incremental improvements in All Employee Survey scores and increased reporting of adverse events and near misses, but the challenge will be to maintain focus and continue to build upon progress amid the current climate of budgetary constraints.

This study builds on previous quality improvement efforts and provides valuable insights into the barriers and facilitators that can either hinder or support the VHA’s ongoing pursuit of high reliability. The findings offer a model for understanding the complexities of this journey—one that requires continuous effort and adaptation, as there is no definitive endpoint in the quest for high reliability.

Since completion of this study in 2024, the VHA has entered a period of organizational transition and restructuring. Such transitions are often accompanied by increased operational demands and organizational strain. These include realignments, personnel changes, staffing adjustments, workforce reductions, and continued implementation of a new electronic health record system. In this context, maintaining attention to culture, communication, frontline engagement, and mechanisms that provide visibility into organizational climate is essential to sustain momentum in high-reliability efforts.

The Veterans Health Administration (VHA) is now in the sixth year of its enterprise-wide transformation into a high reliability organization (HRO). This effort began with a 2016 pilot project and is now implemented in 170 VHA medical centers.^1-4 This transformation reflects a commitment to implementing standardized and reliable health care practices.

The VHA HRO implementation strategy includes a multifaceted approach to engage leadership through education, training, leader coaching, and change management initiatives.² Despite the diversity of facilities in terms of cultures, geographies, and complexities, US Department of Veterans Affairs (VA) medical centers (VAMCs) have increasingly embraced standardized HRO practices. These changes are evident in improvements in VHA All Employee Survey scores, which assess 4 key patient safety culture dimensions: risk identification and just culture, error transparency and mitigation, supervisor communication and trust, and team cohesion and engagement.⁵ Positive trends in these dimensions highlight a cultural shift toward greater reliability, even amid challenges introduced by the COVID-19 pandemic.

However, this progress has encountered some challenges. Leadership turnover, budgetary constraints, and extensive educational demands for implementing and sustaining HRO practices have created obstacles, particularly for frontline health care practitioners.⁶ Additionally, there are pockets of resistance similar to what the airline industry faced when implementing crew resource management (CRM). Specifically, senior pilots and legacy leaders were reluctant to abandon their high-status, autocratic management styles and embrace CRM, despite its proven benefits for enhancing commercial airline safety.⁷ Similarly, some VHA staff have expressed resistance to foundational HRO practices, which include safety huddles, safety forums, leader rounding, and visual management systems.^6,8

The training requirements for HRO practices range from a 25-minute introductory course (HRO 101) to a 7.5-hour team training session facilitated by the VHA National Center for Patient Safety (NCPS).⁹ While some supervisors view these requirements as burdensome, others have demonstrated strong enthusiasm for the process.⁶ Understanding the perspectives of unit and departmental managers regarding factors that enhance or hinder the adoption of HRO practices is critical for continuous improvement.^10-12 Research has suggested that fostering psychological safety can create an environment where new ideas are shared openly, helping organizations navigate resistance to change.^13-16

A 2024 quality improvement study, drawing on the perceptions of HRO leads, identified key facilitators, including training, coaching, leader approachability, and psychological safety, as well as barriers such as inadequate training and lack of accountability among managers.¹⁷ Building on this work, the current study focused on frontline supervisors, who are directly involved in integrating HRO practices into patient care activities. By addressing both barriers and facilitators, this expanded approach aims to provide a more comprehensive understanding of the challenges influencing HRO implementation in day-to-day operations.

Methods

This quality improvement initiative examined facilitators and barriers to establishing just culture and implementing high reliability practices, focusing on frontline supervisors overseeing clinical care teams (eg, emergency department, critical care) or patient-support functions (eg, dietary services). A questionnaire was sent to a randomized sample of VHA facility supervisors.

A qualitative grounded theory approach was employed to provide a deeper understanding of nuanced phenomena that cannot be captured through numerical data alone. This method enables systematic analysis using open, axial, and thematic coding, ensuring that emerging themes achieve saturation.^18,19 It is particularly suited for this study, given the limited prior data on frontline supervisors. Additionally, qualitative methods help mitigate biases common in Likert-style scales, where respondents may lean toward agreement, potentially skewing results.²⁰

Inclusion Criteria

Participants were required to have served as a frontline supervisor for ≥ 6 months. Frontline supervisors are assigned responsibility for supporting staff who deliver services to VHA patients, including clinical care, dietary support, and other functions. These staff must complete baseline HRO cultural training as well as NCPS team training and are responsible for supporting quality, safety, and patient experience. Potential participants were identified from a list of frontline supervisors provided by VHA management. A subset was chosen through random sampling across geographically distributed VHA hospital facilities that vary in size and complexity. Invitations to participate in completing the questionnaire were sent via email, explaining the quality improvement initiative’s purpose, and encouraging voluntary participation. Of 2000 frontline supervisors invited to participate in the initiative, 97 completed the questionnaire. Participants represented a mix of VHA sites in terms of geography, size, and complexity.

Procedures

The authors used a qualitative approach and administered a confidential online survey. Demographic data were collected within the survey to understand characteristics of the participant population, including length of time as a frontline supervisor, facility complexity level, and professional background (clinical vs nonclinical). Survey questions were developed to elicit responses to specific areas of interest based on existing literature related to HRO and just culture.

Facilitators were defined as factors that increase the likelihood of establishing or sustaining high reliability practices and/or culture. Barriers were defined as factors that decrease or inhibit the likelihood of establishing or sustaining high reliability practices and/or culture. The questionnaire consisted of open-ended questions asking frontline supervisors to describe HRO practices and just culture at their individual facility and within their role. Participants also were asked to identify facilitators and barriers that helped or hindered their efforts to establish and maintain high reliability practices and just culture. The questionnaire solicited recommendations for additional support, training, resources, or leadership interventions to strengthen high reliability practices and just culture from each participant.

Analysis

Participant characteristics were analyzed using descriptive statistics. Responses to the 7 open-ended questions were coded and analyzed using ATLAS.ti v.24 qualitative data analysis software by an experienced researcher and coauthor. Grounded theory methodology allowed themes to emerge from the data and although the response rate was limited, the themes reached a saturation point.^18,19

Ethical Considerations

Institutional review board (IRB) review and approval were not required for this quality improvement initiative. Formal IRB review and approval of a quality improvement initiative are not required by VHA. Participation was confidential and voluntary, and participants could withdraw at any time without consequences. Completion of the survey indicated consent, and facility names and participant identifiers were not used. Unique numbers were assigned to each participant and all responses were kept confidential and nonattributional. Frequency coding was used to identify the facilitators and barriers to high reliability practices implementation and just culture among frontline supervisors until thematic saturation was obtained.

Results

A total of 2000 frontline supervisors were invited to participate, of whom 97 completed the questionnaire (response rate, 4.9%). Participants were first asked to describe just culture and high reliability practices in their own words. The consensus was that a just culture emphasizes a nonpunitive environment where employees can report errors or incidents without fear of retaliation. It encourages accountability at the systems level, focusing on learning from mistakes to improve processes. In response to a question asking respondents to describe HRO practices and just culture in their own words, participants noted that organizations with a just culture promote open communication, allowing staff to discuss safety issues and concerns without fear of personal blame. Additionally, participants agreed that HRO practices were defined as a set of principles and practices aimed at minimizing errors and promoting safety, especially within complex and high-risk environments. Participants responded that key characteristics include a preoccupation with failure, sensitivity to operations, reluctance to simplify, and a commitment to resilience. HRO practices entail proactively identifying and mitigating risks through open communication and collaboration among team members, they added.

Overall, participants were aligned with their view of the role a frontline supervisor plays in supporting just culture and HRO principles at their facility by fostering open communication and psychological safety, encouraging continuous learning and improvement, and promoting team collaboration and shared accountability. Among frontline supervisors, 93 (96%) identified their role as being critical to creating a safe space and reinforcing just culture and HRO principles at their facility, while 4 (4%) failed to identify a single duty.

Identified Themes

Table 1 summarizes 6 key themes identified from participants’ responses, highlighting the most frequently cited facilitators and barriers to implementing and sustaining high reliability practices and a just culture. Table 2 shows the classification of several themes in relation to facility complexity, emphasizing leadership commitment and support as a pivotal facilitator, while listing resistance to change and entrenched attitudes as a prominent barrier.

Role of Leadership

Facilitators. Leadership commitment and support were the most frequently identified facilitator, accounting for 44 mentions (45%). This aligns with participants’ descriptions of leadership involvement as crucial, particularly in setting standards and fostering accountability throughout the organization. For example, a frontline supervisor with < 5 years of experience from a nonclinical background at a 1B facility remarked, “Facility leadership are involved, which trickles down to lower-level leads and supervisors, which keeps everyone accountable and holds everyone to the same standards.” Participants frequently identified that leaders setting the standard and communicating expectations as paramount facilitators for strengthening high reliability practices and just culture at their facility.

Barriers. A lack of leadership commitment and support was a significant barrier, cited in 17 responses (18%). Participants described this barrier as a deficiency in follow-through, transparency, and presence, which undermines efforts to sustain just culture and high reliability principles. Notably, the lack of leadership commitment and support stood out as a distinct and recurring theme, underscoring its critical role as an independent challenge to achieving organizational goals. “Many leaders are not yet fully bought in,” a respondent explained. “They take the training and pass it off and go right back to their units and focus on blaming or chastis[ing] people for speaking up.” This theme frequently intersected with mentions of insufficient resources and entrenched attitudes, amplifying other challenges.

Open Communication and Transparency

Facilitators. Open communication and transparency were identified as facilitators in 12 responses (12%). Participants emphasized the importance of mechanisms such as HRO meetings and the sharing of “real” examples of positive outcomes from applying HRO principles. Transparent communication fosters psychological safety, allowing staff to report concerns without fear of reprisal. One participant with < 5 years of experience from a clinical background at a 1A facility encapsulated this theme by saying, “Quarterly ‘fireside chats’ are helpful, [this] creates open dialogue about where the next safety issue may occur, what staff need to do their job safely, while also imparting more of the philosophy of HRO that staff may not be aware of.”

Barriers. While communication serves as a facilitator, participants also highlighted barriers such as siloed communication and fear of reprisal. These reflect challenges in creating open and transparent feedback loops essential to high reliability. For example, a participant concluded, “Leadership does not communicate problem-solving efforts and resolution down the chain, they do not see the problems.” Another participant added, “[HRO principles] are not discussed that much.” While this theme presented as a barrier, it was noted less frequently.

Education and Training

Facilitators. Education and training were noted as facilitators in 10 responses (10%), underscoring their role in establishing high reliability practices. Participants suggested tailored training, simulation-based exercises, and mentorship to enhance practical application. However, they noted the importance of linking training to real change and ensuring leadership enforcement of learned behaviors. This theme is best represented by a participant who concluded, “Trainings have helped, but I think as a supervisor, being involved and interacting with your staff, observing, doing the work they do to help identify potential problems areas, especially when new systems are introduced are key. Being hands-on is the only way to successfully manage your team.”

Barriers. Insufficient resources, including time and staffing constraints, were identified as barriers to education and training, accounting for 24 responses (25%). Participants observed that mandatory training without mentorship or application diminishes its effectiveness.

Insufficient Resources and Funding

Barriers. Resource constraints, including low staffing levels and budget cuts, accounted for 24 responses (25%). Participants reported these limitations prevented staff from attending training and affected the overall implementation of just culture and HRO principles. “Low staffing in supporting services as well as in my own service line have created barriers,” a participant reported. Another participant responded that barriers to HRO were primarily “…financial, as the focus is how to curb costs and bring in more funding rather than taking the time to review and apply the concepts of high reliability.”

Resistance to Change and Entrenched Attitudes

Barriers. Resistance to change was the most frequently identified barrier, with 31 responses (32%). One participant described a persistent “gotcha” culture, where blame and punishment hinder progress toward just culture. This entrenched mindset creates significant obstacles to adopting HRO practices and requires active leadership and supervisor intervention to overcome. This theme is best captured by a respondent who noted that “culture change is difficult, especially among staff with such long tenure. It’s a long game.”

Synthesis and Integration of Findings

The data in Table 1 and Table 2 reinforce the themes identified in the qualitative analysis. Leadership commitment and support are pivotal, both as a facilitator and barrier. Open communication and education and training, while recognized as facilitators, were less frequently mentioned, but still critical. Resistance to change and insufficient resources were the most prominent barriers, indicating where organizational efforts should focus to further foster a culture of high reliability.

By addressing these barriers, particularly resistance to change and resource constraints, and leveraging facilitators like leadership engagement and transparent communication, organizations can enhance their implementation of just culture and high reliability practices. These efforts require deliberate strategies, including effective training, mentorship, and the active presence of leadership.

Discussion

This quality improvement initiative builds on prior research by examining the implementation of HRO practices from the perspective of frontline supervisors. Unlike earlier research focused on HRO leads, this study explores the critical role of supervisors who integrate HRO principles into clinical and administrative operations.¹⁷ By analyzing their experiences, this study offers practical insights into facilitating HRO implementation across organizational levels.

The findings highlight broad agreement on the value of just culture and HRO principles in fostering safe, accountable health care environments. Participants described just culture as promoting system—level accountability rather than individual blame, encouraging error reporting and learning for continuous improvement. Similarly, HRO practices—emphasizing a preoccupation with failure, operational sensitivity, and resilience— were seen as vital for patient safety in complex settings.

Frontline supervisors play a pivotal role, with 96% of respondents identifying their influence on fostering open communication, psychological safety, and shared accountability. Key facilitators included leadership commitment, open communication, and mentorship. Active leadership involvement was particularly valued, as it trickles down to reinforce standards across all organizational levels. HRO meetings using real-world examples were seen as instrumental in demonstrating the tangible benefits of these principles, helping embed them into daily practices.

Despite these facilitators, several barriers to implementation were noted. Resistance to change and entrenched attitudes, and a persistent gotcha culture undermined efforts to establish just culture. Resource constraints, including staffing shortages and budget limitations, further hindered the adoption of HRO practices. The lack of consistent leadership engagement, marked by limited visibility, follow-through, and transparency, exacerbated these challenges.

HRO leads are important for promoting education and embedding HRO principles into daily operations. These individuals provide vital support to frontline supervisors, translating HRO concepts into actionable practices. However, organizational challenges such as staff turnover and redirected funding have weakened the infrastructure supporting HRO initiatives. The elimination of HRO lead roles due to budgetary pressures at several facilities reflects a short-term focus on operational demands at the expense of long-term cultural transformation.

Additional barriers included siloed communication, fear of reprisal, bureaucratic obstacles, and outdated technology. These challenges limit progress toward high reliability and diminish the effectiveness of HRO principles.

Participants proposed strategies focused on education, training, and leadership engagement. Simulation-based training tailored to specific roles was identified as an effective tool for preparing staff to apply HRO principles in real-world scenarios. Enhanced communication, such as regular leadership rounding and transparent updates on safety concerns, was also emphasized. Participants stressed the importance of showing staff how their feedback influences organizational decisions to build trust and accountability. Finally, standardizing procedures and protocols across facilities was seen as critical for aligning practices and reducing variability in safety processes.

This study underscores the need for sustained leadership commitment and infrastructure to ensure the long-term success of HRO implementation. Addressing the identified barriers and leveraging the proposed mitigation strategies can foster a culture of safety and reliability across the organization.

Limitations

This quality improvement initiative used qualitative grounded theory methods and sampled a relatively small group of experienced leaders specifically involved in implementing HRO within the VHA. In addition, while saturation of themes was reached, the number of responses represents a small sample of VHA frontline supervisors. As such, the findings may not be fully representative of the perspectives of all unit and departmental leaders across the VHA or other health care systems. A previous qualitative quality improvement initiative focused on the perceptions of HRO leads regarding facilitators and barriers to just culture.¹⁷ This quality improvement initiative broadened that focus by examining the perspectives of frontline supervisors in the operational environment, who may not be HRO experts but work to implement HRO principles with the guidance of HRO leads (HRO subject matter experts).

There remains an opportunity to address a critical gap by assessing facilitators and barriers beyond the facility level, incorporating both the Veterans Integrated Service Networks (VISN) and VHA Central Office (VHACO). While qualitative methods, such as those used in this study, provide deep insights and detailed understanding, they are limited in their ability to identify system-wide trends and variations at a more strategic VISN and VHACO level. Addressing this could enhance the broader applicability of HRO principles across the VHA.

Conclusions

Successful implementation of the recommendations reported in this study will require sustained focus and continued commitment from all stakeholders across the VHA. As the VHA enters its seventh year on the HRO journey, the risk of organizational drift remains an ongoing concern. Progress has been made, as evidenced by incremental improvements in All Employee Survey scores and increased reporting of adverse events and near misses, but the challenge will be to maintain focus and continue to build upon progress amid the current climate of budgetary constraints.

This study builds on previous quality improvement efforts and provides valuable insights into the barriers and facilitators that can either hinder or support the VHA’s ongoing pursuit of high reliability. The findings offer a model for understanding the complexities of this journey—one that requires continuous effort and adaptation, as there is no definitive endpoint in the quest for high reliability.

Since completion of this study in 2024, the VHA has entered a period of organizational transition and restructuring. Such transitions are often accompanied by increased operational demands and organizational strain. These include realignments, personnel changes, staffing adjustments, workforce reductions, and continued implementation of a new electronic health record system. In this context, maintaining attention to culture, communication, frontline engagement, and mechanisms that provide visibility into organizational climate is essential to sustain momentum in high-reliability efforts.

The Veterans Health Administration (VHA) is now in the sixth year of its enterprise-wide transformation into a high reliability organization (HRO). This effort began with a 2016 pilot project and is now implemented in 170 VHA medical centers.^1-4 This transformation reflects a commitment to implementing standardized and reliable health care practices.

The VHA HRO implementation strategy includes a multifaceted approach to engage leadership through education, training, leader coaching, and change management initiatives.² Despite the diversity of facilities in terms of cultures, geographies, and complexities, US Department of Veterans Affairs (VA) medical centers (VAMCs) have increasingly embraced standardized HRO practices. These changes are evident in improvements in VHA All Employee Survey scores, which assess 4 key patient safety culture dimensions: risk identification and just culture, error transparency and mitigation, supervisor communication and trust, and team cohesion and engagement.⁵ Positive trends in these dimensions highlight a cultural shift toward greater reliability, even amid challenges introduced by the COVID-19 pandemic.

However, this progress has encountered some challenges. Leadership turnover, budgetary constraints, and extensive educational demands for implementing and sustaining HRO practices have created obstacles, particularly for frontline health care practitioners.⁶ Additionally, there are pockets of resistance similar to what the airline industry faced when implementing crew resource management (CRM). Specifically, senior pilots and legacy leaders were reluctant to abandon their high-status, autocratic management styles and embrace CRM, despite its proven benefits for enhancing commercial airline safety.⁷ Similarly, some VHA staff have expressed resistance to foundational HRO practices, which include safety huddles, safety forums, leader rounding, and visual management systems.^6,8

The training requirements for HRO practices range from a 25-minute introductory course (HRO 101) to a 7.5-hour team training session facilitated by the VHA National Center for Patient Safety (NCPS).⁹ While some supervisors view these requirements as burdensome, others have demonstrated strong enthusiasm for the process.⁶ Understanding the perspectives of unit and departmental managers regarding factors that enhance or hinder the adoption of HRO practices is critical for continuous improvement.^10-12 Research has suggested that fostering psychological safety can create an environment where new ideas are shared openly, helping organizations navigate resistance to change.^13-16

A 2024 quality improvement study, drawing on the perceptions of HRO leads, identified key facilitators, including training, coaching, leader approachability, and psychological safety, as well as barriers such as inadequate training and lack of accountability among managers.¹⁷ Building on this work, the current study focused on frontline supervisors, who are directly involved in integrating HRO practices into patient care activities. By addressing both barriers and facilitators, this expanded approach aims to provide a more comprehensive understanding of the challenges influencing HRO implementation in day-to-day operations.

Methods

This quality improvement initiative examined facilitators and barriers to establishing just culture and implementing high reliability practices, focusing on frontline supervisors overseeing clinical care teams (eg, emergency department, critical care) or patient-support functions (eg, dietary services). A questionnaire was sent to a randomized sample of VHA facility supervisors.

A qualitative grounded theory approach was employed to provide a deeper understanding of nuanced phenomena that cannot be captured through numerical data alone. This method enables systematic analysis using open, axial, and thematic coding, ensuring that emerging themes achieve saturation.^18,19 It is particularly suited for this study, given the limited prior data on frontline supervisors. Additionally, qualitative methods help mitigate biases common in Likert-style scales, where respondents may lean toward agreement, potentially skewing results.²⁰

Inclusion Criteria

Participants were required to have served as a frontline supervisor for ≥ 6 months. Frontline supervisors are assigned responsibility for supporting staff who deliver services to VHA patients, including clinical care, dietary support, and other functions. These staff must complete baseline HRO cultural training as well as NCPS team training and are responsible for supporting quality, safety, and patient experience. Potential participants were identified from a list of frontline supervisors provided by VHA management. A subset was chosen through random sampling across geographically distributed VHA hospital facilities that vary in size and complexity. Invitations to participate in completing the questionnaire were sent via email, explaining the quality improvement initiative’s purpose, and encouraging voluntary participation. Of 2000 frontline supervisors invited to participate in the initiative, 97 completed the questionnaire. Participants represented a mix of VHA sites in terms of geography, size, and complexity.

Procedures

The authors used a qualitative approach and administered a confidential online survey. Demographic data were collected within the survey to understand characteristics of the participant population, including length of time as a frontline supervisor, facility complexity level, and professional background (clinical vs nonclinical). Survey questions were developed to elicit responses to specific areas of interest based on existing literature related to HRO and just culture.

Facilitators were defined as factors that increase the likelihood of establishing or sustaining high reliability practices and/or culture. Barriers were defined as factors that decrease or inhibit the likelihood of establishing or sustaining high reliability practices and/or culture. The questionnaire consisted of open-ended questions asking frontline supervisors to describe HRO practices and just culture at their individual facility and within their role. Participants also were asked to identify facilitators and barriers that helped or hindered their efforts to establish and maintain high reliability practices and just culture. The questionnaire solicited recommendations for additional support, training, resources, or leadership interventions to strengthen high reliability practices and just culture from each participant.

Analysis

Participant characteristics were analyzed using descriptive statistics. Responses to the 7 open-ended questions were coded and analyzed using ATLAS.ti v.24 qualitative data analysis software by an experienced researcher and coauthor. Grounded theory methodology allowed themes to emerge from the data and although the response rate was limited, the themes reached a saturation point.^18,19

Ethical Considerations

Institutional review board (IRB) review and approval were not required for this quality improvement initiative. Formal IRB review and approval of a quality improvement initiative are not required by VHA. Participation was confidential and voluntary, and participants could withdraw at any time without consequences. Completion of the survey indicated consent, and facility names and participant identifiers were not used. Unique numbers were assigned to each participant and all responses were kept confidential and nonattributional. Frequency coding was used to identify the facilitators and barriers to high reliability practices implementation and just culture among frontline supervisors until thematic saturation was obtained.

Results

A total of 2000 frontline supervisors were invited to participate, of whom 97 completed the questionnaire (response rate, 4.9%). Participants were first asked to describe just culture and high reliability practices in their own words. The consensus was that a just culture emphasizes a nonpunitive environment where employees can report errors or incidents without fear of retaliation. It encourages accountability at the systems level, focusing on learning from mistakes to improve processes. In response to a question asking respondents to describe HRO practices and just culture in their own words, participants noted that organizations with a just culture promote open communication, allowing staff to discuss safety issues and concerns without fear of personal blame. Additionally, participants agreed that HRO practices were defined as a set of principles and practices aimed at minimizing errors and promoting safety, especially within complex and high-risk environments. Participants responded that key characteristics include a preoccupation with failure, sensitivity to operations, reluctance to simplify, and a commitment to resilience. HRO practices entail proactively identifying and mitigating risks through open communication and collaboration among team members, they added.

Overall, participants were aligned with their view of the role a frontline supervisor plays in supporting just culture and HRO principles at their facility by fostering open communication and psychological safety, encouraging continuous learning and improvement, and promoting team collaboration and shared accountability. Among frontline supervisors, 93 (96%) identified their role as being critical to creating a safe space and reinforcing just culture and HRO principles at their facility, while 4 (4%) failed to identify a single duty.

Identified Themes

Table 1 summarizes 6 key themes identified from participants’ responses, highlighting the most frequently cited facilitators and barriers to implementing and sustaining high reliability practices and a just culture. Table 2 shows the classification of several themes in relation to facility complexity, emphasizing leadership commitment and support as a pivotal facilitator, while listing resistance to change and entrenched attitudes as a prominent barrier.

Role of Leadership

Facilitators. Leadership commitment and support were the most frequently identified facilitator, accounting for 44 mentions (45%). This aligns with participants’ descriptions of leadership involvement as crucial, particularly in setting standards and fostering accountability throughout the organization. For example, a frontline supervisor with < 5 years of experience from a nonclinical background at a 1B facility remarked, “Facility leadership are involved, which trickles down to lower-level leads and supervisors, which keeps everyone accountable and holds everyone to the same standards.” Participants frequently identified that leaders setting the standard and communicating expectations as paramount facilitators for strengthening high reliability practices and just culture at their facility.

Barriers. A lack of leadership commitment and support was a significant barrier, cited in 17 responses (18%). Participants described this barrier as a deficiency in follow-through, transparency, and presence, which undermines efforts to sustain just culture and high reliability principles. Notably, the lack of leadership commitment and support stood out as a distinct and recurring theme, underscoring its critical role as an independent challenge to achieving organizational goals. “Many leaders are not yet fully bought in,” a respondent explained. “They take the training and pass it off and go right back to their units and focus on blaming or chastis[ing] people for speaking up.” This theme frequently intersected with mentions of insufficient resources and entrenched attitudes, amplifying other challenges.

Open Communication and Transparency

Facilitators. Open communication and transparency were identified as facilitators in 12 responses (12%). Participants emphasized the importance of mechanisms such as HRO meetings and the sharing of “real” examples of positive outcomes from applying HRO principles. Transparent communication fosters psychological safety, allowing staff to report concerns without fear of reprisal. One participant with < 5 years of experience from a clinical background at a 1A facility encapsulated this theme by saying, “Quarterly ‘fireside chats’ are helpful, [this] creates open dialogue about where the next safety issue may occur, what staff need to do their job safely, while also imparting more of the philosophy of HRO that staff may not be aware of.”

Barriers. While communication serves as a facilitator, participants also highlighted barriers such as siloed communication and fear of reprisal. These reflect challenges in creating open and transparent feedback loops essential to high reliability. For example, a participant concluded, “Leadership does not communicate problem-solving efforts and resolution down the chain, they do not see the problems.” Another participant added, “[HRO principles] are not discussed that much.” While this theme presented as a barrier, it was noted less frequently.

Education and Training

Facilitators. Education and training were noted as facilitators in 10 responses (10%), underscoring their role in establishing high reliability practices. Participants suggested tailored training, simulation-based exercises, and mentorship to enhance practical application. However, they noted the importance of linking training to real change and ensuring leadership enforcement of learned behaviors. This theme is best represented by a participant who concluded, “Trainings have helped, but I think as a supervisor, being involved and interacting with your staff, observing, doing the work they do to help identify potential problems areas, especially when new systems are introduced are key. Being hands-on is the only way to successfully manage your team.”

Barriers. Insufficient resources, including time and staffing constraints, were identified as barriers to education and training, accounting for 24 responses (25%). Participants observed that mandatory training without mentorship or application diminishes its effectiveness.

Insufficient Resources and Funding

Barriers. Resource constraints, including low staffing levels and budget cuts, accounted for 24 responses (25%). Participants reported these limitations prevented staff from attending training and affected the overall implementation of just culture and HRO principles. “Low staffing in supporting services as well as in my own service line have created barriers,” a participant reported. Another participant responded that barriers to HRO were primarily “…financial, as the focus is how to curb costs and bring in more funding rather than taking the time to review and apply the concepts of high reliability.”

Resistance to Change and Entrenched Attitudes

Barriers. Resistance to change was the most frequently identified barrier, with 31 responses (32%). One participant described a persistent “gotcha” culture, where blame and punishment hinder progress toward just culture. This entrenched mindset creates significant obstacles to adopting HRO practices and requires active leadership and supervisor intervention to overcome. This theme is best captured by a respondent who noted that “culture change is difficult, especially among staff with such long tenure. It’s a long game.”

Synthesis and Integration of Findings

The data in Table 1 and Table 2 reinforce the themes identified in the qualitative analysis. Leadership commitment and support are pivotal, both as a facilitator and barrier. Open communication and education and training, while recognized as facilitators, were less frequently mentioned, but still critical. Resistance to change and insufficient resources were the most prominent barriers, indicating where organizational efforts should focus to further foster a culture of high reliability.

By addressing these barriers, particularly resistance to change and resource constraints, and leveraging facilitators like leadership engagement and transparent communication, organizations can enhance their implementation of just culture and high reliability practices. These efforts require deliberate strategies, including effective training, mentorship, and the active presence of leadership.

Discussion

This quality improvement initiative builds on prior research by examining the implementation of HRO practices from the perspective of frontline supervisors. Unlike earlier research focused on HRO leads, this study explores the critical role of supervisors who integrate HRO principles into clinical and administrative operations.¹⁷ By analyzing their experiences, this study offers practical insights into facilitating HRO implementation across organizational levels.

The findings highlight broad agreement on the value of just culture and HRO principles in fostering safe, accountable health care environments. Participants described just culture as promoting system—level accountability rather than individual blame, encouraging error reporting and learning for continuous improvement. Similarly, HRO practices—emphasizing a preoccupation with failure, operational sensitivity, and resilience— were seen as vital for patient safety in complex settings.

Frontline supervisors play a pivotal role, with 96% of respondents identifying their influence on fostering open communication, psychological safety, and shared accountability. Key facilitators included leadership commitment, open communication, and mentorship. Active leadership involvement was particularly valued, as it trickles down to reinforce standards across all organizational levels. HRO meetings using real-world examples were seen as instrumental in demonstrating the tangible benefits of these principles, helping embed them into daily practices.

Despite these facilitators, several barriers to implementation were noted. Resistance to change and entrenched attitudes, and a persistent gotcha culture undermined efforts to establish just culture. Resource constraints, including staffing shortages and budget limitations, further hindered the adoption of HRO practices. The lack of consistent leadership engagement, marked by limited visibility, follow-through, and transparency, exacerbated these challenges.

HRO leads are important for promoting education and embedding HRO principles into daily operations. These individuals provide vital support to frontline supervisors, translating HRO concepts into actionable practices. However, organizational challenges such as staff turnover and redirected funding have weakened the infrastructure supporting HRO initiatives. The elimination of HRO lead roles due to budgetary pressures at several facilities reflects a short-term focus on operational demands at the expense of long-term cultural transformation.

Additional barriers included siloed communication, fear of reprisal, bureaucratic obstacles, and outdated technology. These challenges limit progress toward high reliability and diminish the effectiveness of HRO principles.

Participants proposed strategies focused on education, training, and leadership engagement. Simulation-based training tailored to specific roles was identified as an effective tool for preparing staff to apply HRO principles in real-world scenarios. Enhanced communication, such as regular leadership rounding and transparent updates on safety concerns, was also emphasized. Participants stressed the importance of showing staff how their feedback influences organizational decisions to build trust and accountability. Finally, standardizing procedures and protocols across facilities was seen as critical for aligning practices and reducing variability in safety processes.

This study underscores the need for sustained leadership commitment and infrastructure to ensure the long-term success of HRO implementation. Addressing the identified barriers and leveraging the proposed mitigation strategies can foster a culture of safety and reliability across the organization.

Limitations

This quality improvement initiative used qualitative grounded theory methods and sampled a relatively small group of experienced leaders specifically involved in implementing HRO within the VHA. In addition, while saturation of themes was reached, the number of responses represents a small sample of VHA frontline supervisors. As such, the findings may not be fully representative of the perspectives of all unit and departmental leaders across the VHA or other health care systems. A previous qualitative quality improvement initiative focused on the perceptions of HRO leads regarding facilitators and barriers to just culture.¹⁷ This quality improvement initiative broadened that focus by examining the perspectives of frontline supervisors in the operational environment, who may not be HRO experts but work to implement HRO principles with the guidance of HRO leads (HRO subject matter experts).

There remains an opportunity to address a critical gap by assessing facilitators and barriers beyond the facility level, incorporating both the Veterans Integrated Service Networks (VISN) and VHA Central Office (VHACO). While qualitative methods, such as those used in this study, provide deep insights and detailed understanding, they are limited in their ability to identify system-wide trends and variations at a more strategic VISN and VHACO level. Addressing this could enhance the broader applicability of HRO principles across the VHA.

Conclusions

Successful implementation of the recommendations reported in this study will require sustained focus and continued commitment from all stakeholders across the VHA. As the VHA enters its seventh year on the HRO journey, the risk of organizational drift remains an ongoing concern. Progress has been made, as evidenced by incremental improvements in All Employee Survey scores and increased reporting of adverse events and near misses, but the challenge will be to maintain focus and continue to build upon progress amid the current climate of budgetary constraints.

This study builds on previous quality improvement efforts and provides valuable insights into the barriers and facilitators that can either hinder or support the VHA’s ongoing pursuit of high reliability. The findings offer a model for understanding the complexities of this journey—one that requires continuous effort and adaptation, as there is no definitive endpoint in the quest for high reliability.

Since completion of this study in 2024, the VHA has entered a period of organizational transition and restructuring. Such transitions are often accompanied by increased operational demands and organizational strain. These include realignments, personnel changes, staffing adjustments, workforce reductions, and continued implementation of a new electronic health record system. In this context, maintaining attention to culture, communication, frontline engagement, and mechanisms that provide visibility into organizational climate is essential to sustain momentum in high-reliability efforts.

The Veterans Health Administration (VHA) is transitioning from its native electronic health record (EHR) Vista/Computerized Patient Record System to the commercial Cerner/Oracle Health EHR. Though this process was temporarily discontinued in April 2023 due to patient safety, usability, and reliability concerns, it resumed in April 2026. It was originally projected to cost $50 billion to implement. ^1-3 As of March 9, 2024, 6 sites had transitioned to the new EHR.² The transition is the largest of its kind in the US, offering an unparalleled opportunity to examine the effects of EHR transitions on an often overlooked part of the workforce: health professions trainees (HPTs).

HPTs serve a central role in VHA. About one-third of patients receive care directly from HPTs who make up about one-third of the VHA workforce. VHA trains > 60 clinical disciplines, comprising > 122,000 trainees annually.^4,5 A paucity of literature exists exploring the experiences of HPTs during EHR transitions, and many studies are often limited to single-site or small populations. HPTs face distinct challenges and needs during EHR transitions and are particularly vulnerable to their negative impacts on retention, clinical training, and efficiency and confidence in EHR use.^6-10 HPTs at VHA sites that have already transitioned to the Cerner/Oracle Health EHR identified many challenges, including significant delays in gaining EHR access, pervasive perceptions of poor training, concerns that EHR functionality issues limited patient care, and decreased ability to track clinical skill acquisition.⁶ These challenges may impact some HPTs more than others (eg, students on short rotations are affected more acutely by delayed EHR access and usage).

This quality improvement project evaluated HPT EHR transition experiences at the Captain James A. Lovell Federal Health Care Center (FHCC). This article contributes to the limited literature on HPT transition experiences, identifies opportunities to support HPTs, and informs broader efforts in teaching HPTs new technologies.

Methods

FHCC is jointly operated by the US Department of Defense and US Department of Veterans Affairs (VA). It treats 80,000 inpatient and outpatients annually. FHCC was the sixth VA facility to transition to the new EHR, which went live on March 9, 2024.^2,11 About 700 HPTs rotate through FHCC annually. HPTs were eligible for inclusion if they were present during the March 9 transition according to a VA Office of Academic Affiliations database. A total of 216 HPTs were identified for inclusion.

Preparations for the transition included scaling down operations (ie, blocking clinician schedules, not scheduling future appointments that may conflict with the transition, making decisions on new facility- and service-line workflows, required EHR training, and speaking with support staff, including VHA National EHR Modernization Supplemental Staffing Unit [NESSU]). This evaluation was designated nonresearch/quality improvement by the VA Bedford Healthcare System Institutional Review Board.

Surveys

Forty-seven interviews were conducted with HPTs, site leaders, and supervisors from January 2024 to June 2024 (Table 1). Participants were identified by service leads and recruited via email; snowball sampling identified additional participants.

The evaluation team developed semistructured interview guides using grounded probes based on a pilot evaluation and existing research on EHR transitions.¹² Questions focused on participant experiences preparing for the EHR transition, learning and using the site’s EHR, and the impact the transition had on clinical training experiences. Interviews were conducted at different times to capture the range of user experiences: 1 month prelaunch, 2 to 6 weeks postlaunch, and 2 months postlaunch. Interviewees were informed of participant rights and provided verbal consent.

HPTs present at FHCC at each survey’s release were emailed invitations and 2 reminders. The anonymous surveys took about 10 minutes to complete. Survey items queried HPTs about their experiences preparing to use the new EHR, perceptions of the current EHR (adapted from the System Usability Scale), satisfaction with VHA training, impact on clinical training, ability to work with preceptors and patients, and experiences with the VHA clinical learning environment (adapted from the VHA Learners Preceptor Survey).^13-15 Survey questions used a 5-point Likert response scale.

Analysis

Interviewers completed postinterview summaries for team debriefing and consensus building. Interviews were coded using a priori (from piloting evaluations and relevant literature) and emergent (refined and developed from data) codes. Deductive and inductive content analyses were conducted. ¹⁶ Deductive analysis used a priori categories (eg, care coordination, EHR training). Inductive content analysis consisted of open and unstructured coding, capturing data outside a priori categories. Emergent codes captured unidentified categories. Qualitative researchers met weekly to discuss data and reach consensus on interpretation.

Descriptive analysis was conducted using top-2 box scoring (proportion responding within the 2 most favorable responses [agree/ strongly agree]). Survey data were analyzed in SAS.¹⁷ The analysis used a merging approach on simultaneously collected qualitative and quantitative data to reach findings consensus.¹⁸

Researcher and research team decisions may shape the data collected due to prior assumptions and experience.¹⁹ This analysis attempted to integrate reflexivity practices to enhance awareness of the researchers’ assumptions and positionality, including by integrating intent collaborative conversing and memorandum writing into the processes.^20,21

Results

This analysis created a survey and fielded responses from HPTs present at FHCC across 3 time points (6 months prelaunch, 1 month prelaunch, and 2 months postlaunch), resulting in a total of 103 responses and an average response rate of 19.0% (Table 2). Six key findings were identified in analysis of responses: (1) critiques of transition management; (2) concerns with training; (3) hope about the EHR; (4) at-the-elbow support was essential; (5) HPTs adjusted to, and later preferred, the new EHR; and (6) transition impacted clinical training, but not overall career plans for HPTs. Findings are presented in this section, with illustrative quantitative data and qualitative data quotes available in the eAppendix.

Critiques of the Transition’s Management

While participants were aware of the transition to the new EHR, most felt they did not have enough information or time to prepare for it, indicating it was “too little, too late.” HPTs felt necessary workflow processes for Cerner/Oracle Health were not determined with enough time to learn them prior to transition. Supervisors shared that important workflow and onboarding decisions remained undecided mere weeks before the transition. Some service lines did not decrease patient loads until right before the transition, making it difficult to manage their schedules and resulting in insufficient time to learn the new EHR.

EHR Training Concerns

Overall, HPTs expressed low satisfaction with computer-based Training Management System (TMS) EHR training, believing it did not prepare them for the new EHR. The percentage of HPTs satisfied or very satisfied with the quality of TMS training was lower than that of instructor-based training pre- and posttransition, with 50% of 36 prelaunch respondents, and 43% of 29 postlaunch respondents expressing satisfaction with computer-based trainings (Figure 1). HPTs were dissatisfied with the training content. They felt it was too general and failed to teach basic tasks in the workflow for their service areas and roles, such as writing a note or order. Furthermore, poor content was exacerbated by poor and unengaging instruction, and HPTs were dissatisfied with the practice EHR used in training, which glitched frequently.

EHR Transition Optimism

Even though the transition was stressful, most HPTs hoped it would be a temporary disruption and that they would quickly adjust to the new EHR. Many participants expected that once they switched to the new EHR, they would pick it up quickly. In addition, many anticipated Cerner/Oracle Health would be better and easier to use in the long run.

At-The-Elbow Support Essential

VHA peer support with NESSU was highly valued among HPTs. NESSU staff were highly knowledgeable and could provide both broad and service-line-specific support. NESSU provided prompt answers to EHR questions. This was particularly critical as other forms of in-person support were often inaccessible or absent during the transition.

HPTs found facility support helpful: 85% of 36 respondents reported being satisfied/ very satisfied with support from supervisors and preceptors, and 84% of 36 respondents were satisfied/very satisfied with technical support from facility informatics staff pretransition (n = 36) (Figure 2). NESSU and supervisor support with daily workflows were particularly helpful, as pretransition training only provided a general introduction to the EHR.

HPTs Adjusted to and Later Preferred the New EHR

The EHR learning experience was intense but short, with many HPTs feeling able to use it only 2 to 4 weeks posttransition. Confidence grew as HPTs came to view Cerner/Oracle Health as a more integrated and intuitive system than the previous EHR. Most participants preferred the new EHR, even if they criticized some features (eg, no group documentation capabilities). Survey participants frequently rated Cerner/Oracle Health usability higher than the original. A total of 32% of 29 posttransition respondents agreed or strongly agreed that Cerner/Oracle Health helps prevent situations that can lead to patient safety risks—higher than pretransition rates. Additionally, fewer respondents found the new EHR unnecessarily complex or thought it contained too many alerts and flags compared to the original EHR (Figure 3).

Impact on Clinical Training, Not Career Plans

The extensive time and energy the transition demanded of HPTs caused stress and affected their clinical training. Many believed they would have learned more if their training had happened outside the transition.

Concerns that the transition affected learning were most acutely felt pretransition. HPTs reporting that EHR implementation positively affected their clinical education fell from 38% of 36 respondents 6 months pretransition to 19% of 29 respondents 1 month pretransition, but returned to 37% posttransition (Figure 4). However, some HPTs believed there was a silver lining: it provided a learning experience they otherwise would not have had.

HPTs who believed the transition positively impacted their likelihood of pursuing future career opportunities within the VHA rose to 33% of 29 respondents posttransition. Overall, Cerner/Oracle Health was characterized as a tool: something used in training, but not something that precluded wanting VHA careers or having meaningful experiences, such as caring for patients.

Discussion

This evaluation addressed an underexplored aspect of EHR transitions: their impact on HPTs. It identified HPT challenges, including dissatisfaction with poor transition preparation and EHR training experiences. Promising findings include positive experiences with transition support, EHR uptake, and overall positive educational experiences despite the transition’s disruption.

When EHR users, including HPTs, are dissatisfied with transition preparations, consequent stress can lead to undesired effects, including increased burnout, inappropriate EHR use, and low work satisfaction.^22-24 Negative EHR transition experiences shape HPTs’ subsequent EHR adoption, user satisfaction, as well as confidence and career intent.^3,25,26 Health systems have strong incentives to implement effective transition change management.

HPTs at previous VHA EHR transition sites reported significantly more disruption to their clinical training compared with HPTs at FHCC. Academic programs were shut down at the first transition site, and HPTs expressed decreased interest in VHA careers at another, even a year posttransition.^6,27 These findings are consistent with the limited literature on the adverse impacts that EHR transitions have on HPTs.^7,28

HPT retention is critical. VA is mandated to prepare the next generation of HPTs for its needs, and those of the nation. The VA relies heavily on HPT retention to recruit clinicians: > 65% of VHA physicians nationwide participated in VHA training programs prior to recruitment into staff positions.^5,29

VHA should invest in transition change management with demonstrated, positive impacts on HPTs, such as in-house support from clinicians. Previous research found that lack of support was a major source of stress and negative outcomes.^6,27 Consequently, supporting HPTs through EHR transitions directly contributes to the VHA’s ability to attract high-quality staff from its HPTs. The challenges and promising practices described in this analysis underscore the necessity of understanding how all EHR users are affected by transitions. What happens to them has direct implications for the VA mission to provide safe, efficient care, and its mandate to provide quality clinical training to HPTs.

These findings hold hopeful implications for supporting HPT EHR use, both during and outside EHR transitions. HPTs expressing that an EHR is only 1 part of their clinical training experience suggests that change management can improve EHR transitions. HPT learning can enhance known factors that are important for HPTs in clinical training, including the health care organization’s mission, caring for patients, and personal development.

Further investigations may engage HPTs at future VHA sites making the transition to the new EHR. One focus would involve applying a learning health systems framework to examine the nature of change management efforts—and their effects on HPT transition experiences—iteratively across transition sites to evaluate the effect of the efforts. Another focus may be longitudinal engagement with HPTs at health care systems and sites transitioning to new EHRs. Research has found that disruptions to EHR usability, satisfaction, and care provision can persist for 2 years and beyond following an EHR transition.³⁰ Evaluating the long-term effects of transitions on HPTs is of interest, given their distinct characteristics and differences from employees.

Limitations

Study data came from voluntary participants at 1 highly engaged site, raising the possibility of self-selection bias. HPT experiences at other VA and non-VA sites may differ. Employees and HPTs were engaged during a high-stress event; snowballing recruitment reach was limited by high workloads and limited time for engagement. Statistical data were descriptive and should not be interpreted as causal. Results may reflect, in part, temporal effects, and respondents include HPTs at different stages of training and with different levels of VA experience. Survey sample sizes may limit generalizability; however, merging data streams strengthened the reliability of findings.

Conclusions

The results of this analysis of FHCC HPTs were notably more positive than those of HPTs at previous VHA EHR transition sites. VHA is one of many health care systems that provide clinical training for HPTs and relies on this population to provide patient care. By highlighting challenges and positive experiences of HPTs during an EHR transition, this evaluation produces actionable insights that can inform the actions of health care systems seeking to support HPTs during disruptive EHR transitions.

The Veterans Health Administration (VHA) is transitioning from its native electronic health record (EHR) Vista/Computerized Patient Record System to the commercial Cerner/Oracle Health EHR. Though this process was temporarily discontinued in April 2023 due to patient safety, usability, and reliability concerns, it resumed in April 2026. It was originally projected to cost $50 billion to implement. ^1-3 As of March 9, 2024, 6 sites had transitioned to the new EHR.² The transition is the largest of its kind in the US, offering an unparalleled opportunity to examine the effects of EHR transitions on an often overlooked part of the workforce: health professions trainees (HPTs).

HPTs serve a central role in VHA. About one-third of patients receive care directly from HPTs who make up about one-third of the VHA workforce. VHA trains > 60 clinical disciplines, comprising > 122,000 trainees annually.^4,5 A paucity of literature exists exploring the experiences of HPTs during EHR transitions, and many studies are often limited to single-site or small populations. HPTs face distinct challenges and needs during EHR transitions and are particularly vulnerable to their negative impacts on retention, clinical training, and efficiency and confidence in EHR use.^6-10 HPTs at VHA sites that have already transitioned to the Cerner/Oracle Health EHR identified many challenges, including significant delays in gaining EHR access, pervasive perceptions of poor training, concerns that EHR functionality issues limited patient care, and decreased ability to track clinical skill acquisition.⁶ These challenges may impact some HPTs more than others (eg, students on short rotations are affected more acutely by delayed EHR access and usage).

This quality improvement project evaluated HPT EHR transition experiences at the Captain James A. Lovell Federal Health Care Center (FHCC). This article contributes to the limited literature on HPT transition experiences, identifies opportunities to support HPTs, and informs broader efforts in teaching HPTs new technologies.

Methods

FHCC is jointly operated by the US Department of Defense and US Department of Veterans Affairs (VA). It treats 80,000 inpatient and outpatients annually. FHCC was the sixth VA facility to transition to the new EHR, which went live on March 9, 2024.^2,11 About 700 HPTs rotate through FHCC annually. HPTs were eligible for inclusion if they were present during the March 9 transition according to a VA Office of Academic Affiliations database. A total of 216 HPTs were identified for inclusion.

Preparations for the transition included scaling down operations (ie, blocking clinician schedules, not scheduling future appointments that may conflict with the transition, making decisions on new facility- and service-line workflows, required EHR training, and speaking with support staff, including VHA National EHR Modernization Supplemental Staffing Unit [NESSU]). This evaluation was designated nonresearch/quality improvement by the VA Bedford Healthcare System Institutional Review Board.

Surveys

Forty-seven interviews were conducted with HPTs, site leaders, and supervisors from January 2024 to June 2024 (Table 1). Participants were identified by service leads and recruited via email; snowball sampling identified additional participants.

The evaluation team developed semistructured interview guides using grounded probes based on a pilot evaluation and existing research on EHR transitions.¹² Questions focused on participant experiences preparing for the EHR transition, learning and using the site’s EHR, and the impact the transition had on clinical training experiences. Interviews were conducted at different times to capture the range of user experiences: 1 month prelaunch, 2 to 6 weeks postlaunch, and 2 months postlaunch. Interviewees were informed of participant rights and provided verbal consent.

HPTs present at FHCC at each survey’s release were emailed invitations and 2 reminders. The anonymous surveys took about 10 minutes to complete. Survey items queried HPTs about their experiences preparing to use the new EHR, perceptions of the current EHR (adapted from the System Usability Scale), satisfaction with VHA training, impact on clinical training, ability to work with preceptors and patients, and experiences with the VHA clinical learning environment (adapted from the VHA Learners Preceptor Survey).^13-15 Survey questions used a 5-point Likert response scale.

Analysis

Interviewers completed postinterview summaries for team debriefing and consensus building. Interviews were coded using a priori (from piloting evaluations and relevant literature) and emergent (refined and developed from data) codes. Deductive and inductive content analyses were conducted. ¹⁶ Deductive analysis used a priori categories (eg, care coordination, EHR training). Inductive content analysis consisted of open and unstructured coding, capturing data outside a priori categories. Emergent codes captured unidentified categories. Qualitative researchers met weekly to discuss data and reach consensus on interpretation.

Descriptive analysis was conducted using top-2 box scoring (proportion responding within the 2 most favorable responses [agree/ strongly agree]). Survey data were analyzed in SAS.¹⁷ The analysis used a merging approach on simultaneously collected qualitative and quantitative data to reach findings consensus.¹⁸

Researcher and research team decisions may shape the data collected due to prior assumptions and experience.¹⁹ This analysis attempted to integrate reflexivity practices to enhance awareness of the researchers’ assumptions and positionality, including by integrating intent collaborative conversing and memorandum writing into the processes.^20,21

Results

This analysis created a survey and fielded responses from HPTs present at FHCC across 3 time points (6 months prelaunch, 1 month prelaunch, and 2 months postlaunch), resulting in a total of 103 responses and an average response rate of 19.0% (Table 2). Six key findings were identified in analysis of responses: (1) critiques of transition management; (2) concerns with training; (3) hope about the EHR; (4) at-the-elbow support was essential; (5) HPTs adjusted to, and later preferred, the new EHR; and (6) transition impacted clinical training, but not overall career plans for HPTs. Findings are presented in this section, with illustrative quantitative data and qualitative data quotes available in the eAppendix.

Critiques of the Transition’s Management

While participants were aware of the transition to the new EHR, most felt they did not have enough information or time to prepare for it, indicating it was “too little, too late.” HPTs felt necessary workflow processes for Cerner/Oracle Health were not determined with enough time to learn them prior to transition. Supervisors shared that important workflow and onboarding decisions remained undecided mere weeks before the transition. Some service lines did not decrease patient loads until right before the transition, making it difficult to manage their schedules and resulting in insufficient time to learn the new EHR.

EHR Training Concerns

Overall, HPTs expressed low satisfaction with computer-based Training Management System (TMS) EHR training, believing it did not prepare them for the new EHR. The percentage of HPTs satisfied or very satisfied with the quality of TMS training was lower than that of instructor-based training pre- and posttransition, with 50% of 36 prelaunch respondents, and 43% of 29 postlaunch respondents expressing satisfaction with computer-based trainings (Figure 1). HPTs were dissatisfied with the training content. They felt it was too general and failed to teach basic tasks in the workflow for their service areas and roles, such as writing a note or order. Furthermore, poor content was exacerbated by poor and unengaging instruction, and HPTs were dissatisfied with the practice EHR used in training, which glitched frequently.

EHR Transition Optimism

Even though the transition was stressful, most HPTs hoped it would be a temporary disruption and that they would quickly adjust to the new EHR. Many participants expected that once they switched to the new EHR, they would pick it up quickly. In addition, many anticipated Cerner/Oracle Health would be better and easier to use in the long run.

At-The-Elbow Support Essential

VHA peer support with NESSU was highly valued among HPTs. NESSU staff were highly knowledgeable and could provide both broad and service-line-specific support. NESSU provided prompt answers to EHR questions. This was particularly critical as other forms of in-person support were often inaccessible or absent during the transition.

HPTs found facility support helpful: 85% of 36 respondents reported being satisfied/ very satisfied with support from supervisors and preceptors, and 84% of 36 respondents were satisfied/very satisfied with technical support from facility informatics staff pretransition (n = 36) (Figure 2). NESSU and supervisor support with daily workflows were particularly helpful, as pretransition training only provided a general introduction to the EHR.

HPTs Adjusted to and Later Preferred the New EHR

The EHR learning experience was intense but short, with many HPTs feeling able to use it only 2 to 4 weeks posttransition. Confidence grew as HPTs came to view Cerner/Oracle Health as a more integrated and intuitive system than the previous EHR. Most participants preferred the new EHR, even if they criticized some features (eg, no group documentation capabilities). Survey participants frequently rated Cerner/Oracle Health usability higher than the original. A total of 32% of 29 posttransition respondents agreed or strongly agreed that Cerner/Oracle Health helps prevent situations that can lead to patient safety risks—higher than pretransition rates. Additionally, fewer respondents found the new EHR unnecessarily complex or thought it contained too many alerts and flags compared to the original EHR (Figure 3).

Impact on Clinical Training, Not Career Plans

The extensive time and energy the transition demanded of HPTs caused stress and affected their clinical training. Many believed they would have learned more if their training had happened outside the transition.

Concerns that the transition affected learning were most acutely felt pretransition. HPTs reporting that EHR implementation positively affected their clinical education fell from 38% of 36 respondents 6 months pretransition to 19% of 29 respondents 1 month pretransition, but returned to 37% posttransition (Figure 4). However, some HPTs believed there was a silver lining: it provided a learning experience they otherwise would not have had.

HPTs who believed the transition positively impacted their likelihood of pursuing future career opportunities within the VHA rose to 33% of 29 respondents posttransition. Overall, Cerner/Oracle Health was characterized as a tool: something used in training, but not something that precluded wanting VHA careers or having meaningful experiences, such as caring for patients.

Discussion

This evaluation addressed an underexplored aspect of EHR transitions: their impact on HPTs. It identified HPT challenges, including dissatisfaction with poor transition preparation and EHR training experiences. Promising findings include positive experiences with transition support, EHR uptake, and overall positive educational experiences despite the transition’s disruption.

When EHR users, including HPTs, are dissatisfied with transition preparations, consequent stress can lead to undesired effects, including increased burnout, inappropriate EHR use, and low work satisfaction.^22-24 Negative EHR transition experiences shape HPTs’ subsequent EHR adoption, user satisfaction, as well as confidence and career intent.^3,25,26 Health systems have strong incentives to implement effective transition change management.

HPTs at previous VHA EHR transition sites reported significantly more disruption to their clinical training compared with HPTs at FHCC. Academic programs were shut down at the first transition site, and HPTs expressed decreased interest in VHA careers at another, even a year posttransition.^6,27 These findings are consistent with the limited literature on the adverse impacts that EHR transitions have on HPTs.^7,28

HPT retention is critical. VA is mandated to prepare the next generation of HPTs for its needs, and those of the nation. The VA relies heavily on HPT retention to recruit clinicians: > 65% of VHA physicians nationwide participated in VHA training programs prior to recruitment into staff positions.^5,29

VHA should invest in transition change management with demonstrated, positive impacts on HPTs, such as in-house support from clinicians. Previous research found that lack of support was a major source of stress and negative outcomes.^6,27 Consequently, supporting HPTs through EHR transitions directly contributes to the VHA’s ability to attract high-quality staff from its HPTs. The challenges and promising practices described in this analysis underscore the necessity of understanding how all EHR users are affected by transitions. What happens to them has direct implications for the VA mission to provide safe, efficient care, and its mandate to provide quality clinical training to HPTs.

These findings hold hopeful implications for supporting HPT EHR use, both during and outside EHR transitions. HPTs expressing that an EHR is only 1 part of their clinical training experience suggests that change management can improve EHR transitions. HPT learning can enhance known factors that are important for HPTs in clinical training, including the health care organization’s mission, caring for patients, and personal development.

Further investigations may engage HPTs at future VHA sites making the transition to the new EHR. One focus would involve applying a learning health systems framework to examine the nature of change management efforts—and their effects on HPT transition experiences—iteratively across transition sites to evaluate the effect of the efforts. Another focus may be longitudinal engagement with HPTs at health care systems and sites transitioning to new EHRs. Research has found that disruptions to EHR usability, satisfaction, and care provision can persist for 2 years and beyond following an EHR transition.³⁰ Evaluating the long-term effects of transitions on HPTs is of interest, given their distinct characteristics and differences from employees.

Limitations

Study data came from voluntary participants at 1 highly engaged site, raising the possibility of self-selection bias. HPT experiences at other VA and non-VA sites may differ. Employees and HPTs were engaged during a high-stress event; snowballing recruitment reach was limited by high workloads and limited time for engagement. Statistical data were descriptive and should not be interpreted as causal. Results may reflect, in part, temporal effects, and respondents include HPTs at different stages of training and with different levels of VA experience. Survey sample sizes may limit generalizability; however, merging data streams strengthened the reliability of findings.

Conclusions

The results of this analysis of FHCC HPTs were notably more positive than those of HPTs at previous VHA EHR transition sites. VHA is one of many health care systems that provide clinical training for HPTs and relies on this population to provide patient care. By highlighting challenges and positive experiences of HPTs during an EHR transition, this evaluation produces actionable insights that can inform the actions of health care systems seeking to support HPTs during disruptive EHR transitions.

The Veterans Health Administration (VHA) is transitioning from its native electronic health record (EHR) Vista/Computerized Patient Record System to the commercial Cerner/Oracle Health EHR. Though this process was temporarily discontinued in April 2023 due to patient safety, usability, and reliability concerns, it resumed in April 2026. It was originally projected to cost $50 billion to implement. ^1-3 As of March 9, 2024, 6 sites had transitioned to the new EHR.² The transition is the largest of its kind in the US, offering an unparalleled opportunity to examine the effects of EHR transitions on an often overlooked part of the workforce: health professions trainees (HPTs).

HPTs serve a central role in VHA. About one-third of patients receive care directly from HPTs who make up about one-third of the VHA workforce. VHA trains > 60 clinical disciplines, comprising > 122,000 trainees annually.^4,5 A paucity of literature exists exploring the experiences of HPTs during EHR transitions, and many studies are often limited to single-site or small populations. HPTs face distinct challenges and needs during EHR transitions and are particularly vulnerable to their negative impacts on retention, clinical training, and efficiency and confidence in EHR use.^6-10 HPTs at VHA sites that have already transitioned to the Cerner/Oracle Health EHR identified many challenges, including significant delays in gaining EHR access, pervasive perceptions of poor training, concerns that EHR functionality issues limited patient care, and decreased ability to track clinical skill acquisition.⁶ These challenges may impact some HPTs more than others (eg, students on short rotations are affected more acutely by delayed EHR access and usage).

This quality improvement project evaluated HPT EHR transition experiences at the Captain James A. Lovell Federal Health Care Center (FHCC). This article contributes to the limited literature on HPT transition experiences, identifies opportunities to support HPTs, and informs broader efforts in teaching HPTs new technologies.

Methods

FHCC is jointly operated by the US Department of Defense and US Department of Veterans Affairs (VA). It treats 80,000 inpatient and outpatients annually. FHCC was the sixth VA facility to transition to the new EHR, which went live on March 9, 2024.^2,11 About 700 HPTs rotate through FHCC annually. HPTs were eligible for inclusion if they were present during the March 9 transition according to a VA Office of Academic Affiliations database. A total of 216 HPTs were identified for inclusion.

Preparations for the transition included scaling down operations (ie, blocking clinician schedules, not scheduling future appointments that may conflict with the transition, making decisions on new facility- and service-line workflows, required EHR training, and speaking with support staff, including VHA National EHR Modernization Supplemental Staffing Unit [NESSU]). This evaluation was designated nonresearch/quality improvement by the VA Bedford Healthcare System Institutional Review Board.

Surveys

Forty-seven interviews were conducted with HPTs, site leaders, and supervisors from January 2024 to June 2024 (Table 1). Participants were identified by service leads and recruited via email; snowball sampling identified additional participants.

The evaluation team developed semistructured interview guides using grounded probes based on a pilot evaluation and existing research on EHR transitions.¹² Questions focused on participant experiences preparing for the EHR transition, learning and using the site’s EHR, and the impact the transition had on clinical training experiences. Interviews were conducted at different times to capture the range of user experiences: 1 month prelaunch, 2 to 6 weeks postlaunch, and 2 months postlaunch. Interviewees were informed of participant rights and provided verbal consent.

HPTs present at FHCC at each survey’s release were emailed invitations and 2 reminders. The anonymous surveys took about 10 minutes to complete. Survey items queried HPTs about their experiences preparing to use the new EHR, perceptions of the current EHR (adapted from the System Usability Scale), satisfaction with VHA training, impact on clinical training, ability to work with preceptors and patients, and experiences with the VHA clinical learning environment (adapted from the VHA Learners Preceptor Survey).^13-15 Survey questions used a 5-point Likert response scale.

Analysis

Interviewers completed postinterview summaries for team debriefing and consensus building. Interviews were coded using a priori (from piloting evaluations and relevant literature) and emergent (refined and developed from data) codes. Deductive and inductive content analyses were conducted. ¹⁶ Deductive analysis used a priori categories (eg, care coordination, EHR training). Inductive content analysis consisted of open and unstructured coding, capturing data outside a priori categories. Emergent codes captured unidentified categories. Qualitative researchers met weekly to discuss data and reach consensus on interpretation.

Descriptive analysis was conducted using top-2 box scoring (proportion responding within the 2 most favorable responses [agree/ strongly agree]). Survey data were analyzed in SAS.¹⁷ The analysis used a merging approach on simultaneously collected qualitative and quantitative data to reach findings consensus.¹⁸

Researcher and research team decisions may shape the data collected due to prior assumptions and experience.¹⁹ This analysis attempted to integrate reflexivity practices to enhance awareness of the researchers’ assumptions and positionality, including by integrating intent collaborative conversing and memorandum writing into the processes.^20,21

Results

This analysis created a survey and fielded responses from HPTs present at FHCC across 3 time points (6 months prelaunch, 1 month prelaunch, and 2 months postlaunch), resulting in a total of 103 responses and an average response rate of 19.0% (Table 2). Six key findings were identified in analysis of responses: (1) critiques of transition management; (2) concerns with training; (3) hope about the EHR; (4) at-the-elbow support was essential; (5) HPTs adjusted to, and later preferred, the new EHR; and (6) transition impacted clinical training, but not overall career plans for HPTs. Findings are presented in this section, with illustrative quantitative data and qualitative data quotes available in the eAppendix.

Critiques of the Transition’s Management

While participants were aware of the transition to the new EHR, most felt they did not have enough information or time to prepare for it, indicating it was “too little, too late.” HPTs felt necessary workflow processes for Cerner/Oracle Health were not determined with enough time to learn them prior to transition. Supervisors shared that important workflow and onboarding decisions remained undecided mere weeks before the transition. Some service lines did not decrease patient loads until right before the transition, making it difficult to manage their schedules and resulting in insufficient time to learn the new EHR.

EHR Training Concerns

Overall, HPTs expressed low satisfaction with computer-based Training Management System (TMS) EHR training, believing it did not prepare them for the new EHR. The percentage of HPTs satisfied or very satisfied with the quality of TMS training was lower than that of instructor-based training pre- and posttransition, with 50% of 36 prelaunch respondents, and 43% of 29 postlaunch respondents expressing satisfaction with computer-based trainings (Figure 1). HPTs were dissatisfied with the training content. They felt it was too general and failed to teach basic tasks in the workflow for their service areas and roles, such as writing a note or order. Furthermore, poor content was exacerbated by poor and unengaging instruction, and HPTs were dissatisfied with the practice EHR used in training, which glitched frequently.

EHR Transition Optimism

Even though the transition was stressful, most HPTs hoped it would be a temporary disruption and that they would quickly adjust to the new EHR. Many participants expected that once they switched to the new EHR, they would pick it up quickly. In addition, many anticipated Cerner/Oracle Health would be better and easier to use in the long run.

At-The-Elbow Support Essential

VHA peer support with NESSU was highly valued among HPTs. NESSU staff were highly knowledgeable and could provide both broad and service-line-specific support. NESSU provided prompt answers to EHR questions. This was particularly critical as other forms of in-person support were often inaccessible or absent during the transition.

HPTs found facility support helpful: 85% of 36 respondents reported being satisfied/ very satisfied with support from supervisors and preceptors, and 84% of 36 respondents were satisfied/very satisfied with technical support from facility informatics staff pretransition (n = 36) (Figure 2). NESSU and supervisor support with daily workflows were particularly helpful, as pretransition training only provided a general introduction to the EHR.

HPTs Adjusted to and Later Preferred the New EHR

The EHR learning experience was intense but short, with many HPTs feeling able to use it only 2 to 4 weeks posttransition. Confidence grew as HPTs came to view Cerner/Oracle Health as a more integrated and intuitive system than the previous EHR. Most participants preferred the new EHR, even if they criticized some features (eg, no group documentation capabilities). Survey participants frequently rated Cerner/Oracle Health usability higher than the original. A total of 32% of 29 posttransition respondents agreed or strongly agreed that Cerner/Oracle Health helps prevent situations that can lead to patient safety risks—higher than pretransition rates. Additionally, fewer respondents found the new EHR unnecessarily complex or thought it contained too many alerts and flags compared to the original EHR (Figure 3).

Impact on Clinical Training, Not Career Plans

The extensive time and energy the transition demanded of HPTs caused stress and affected their clinical training. Many believed they would have learned more if their training had happened outside the transition.

Concerns that the transition affected learning were most acutely felt pretransition. HPTs reporting that EHR implementation positively affected their clinical education fell from 38% of 36 respondents 6 months pretransition to 19% of 29 respondents 1 month pretransition, but returned to 37% posttransition (Figure 4). However, some HPTs believed there was a silver lining: it provided a learning experience they otherwise would not have had.

HPTs who believed the transition positively impacted their likelihood of pursuing future career opportunities within the VHA rose to 33% of 29 respondents posttransition. Overall, Cerner/Oracle Health was characterized as a tool: something used in training, but not something that precluded wanting VHA careers or having meaningful experiences, such as caring for patients.

Discussion

This evaluation addressed an underexplored aspect of EHR transitions: their impact on HPTs. It identified HPT challenges, including dissatisfaction with poor transition preparation and EHR training experiences. Promising findings include positive experiences with transition support, EHR uptake, and overall positive educational experiences despite the transition’s disruption.

When EHR users, including HPTs, are dissatisfied with transition preparations, consequent stress can lead to undesired effects, including increased burnout, inappropriate EHR use, and low work satisfaction.^22-24 Negative EHR transition experiences shape HPTs’ subsequent EHR adoption, user satisfaction, as well as confidence and career intent.^3,25,26 Health systems have strong incentives to implement effective transition change management.

HPTs at previous VHA EHR transition sites reported significantly more disruption to their clinical training compared with HPTs at FHCC. Academic programs were shut down at the first transition site, and HPTs expressed decreased interest in VHA careers at another, even a year posttransition.^6,27 These findings are consistent with the limited literature on the adverse impacts that EHR transitions have on HPTs.^7,28

HPT retention is critical. VA is mandated to prepare the next generation of HPTs for its needs, and those of the nation. The VA relies heavily on HPT retention to recruit clinicians: > 65% of VHA physicians nationwide participated in VHA training programs prior to recruitment into staff positions.^5,29

VHA should invest in transition change management with demonstrated, positive impacts on HPTs, such as in-house support from clinicians. Previous research found that lack of support was a major source of stress and negative outcomes.^6,27 Consequently, supporting HPTs through EHR transitions directly contributes to the VHA’s ability to attract high-quality staff from its HPTs. The challenges and promising practices described in this analysis underscore the necessity of understanding how all EHR users are affected by transitions. What happens to them has direct implications for the VA mission to provide safe, efficient care, and its mandate to provide quality clinical training to HPTs.

These findings hold hopeful implications for supporting HPT EHR use, both during and outside EHR transitions. HPTs expressing that an EHR is only 1 part of their clinical training experience suggests that change management can improve EHR transitions. HPT learning can enhance known factors that are important for HPTs in clinical training, including the health care organization’s mission, caring for patients, and personal development.

Further investigations may engage HPTs at future VHA sites making the transition to the new EHR. One focus would involve applying a learning health systems framework to examine the nature of change management efforts—and their effects on HPT transition experiences—iteratively across transition sites to evaluate the effect of the efforts. Another focus may be longitudinal engagement with HPTs at health care systems and sites transitioning to new EHRs. Research has found that disruptions to EHR usability, satisfaction, and care provision can persist for 2 years and beyond following an EHR transition.³⁰ Evaluating the long-term effects of transitions on HPTs is of interest, given their distinct characteristics and differences from employees.

Limitations

Study data came from voluntary participants at 1 highly engaged site, raising the possibility of self-selection bias. HPT experiences at other VA and non-VA sites may differ. Employees and HPTs were engaged during a high-stress event; snowballing recruitment reach was limited by high workloads and limited time for engagement. Statistical data were descriptive and should not be interpreted as causal. Results may reflect, in part, temporal effects, and respondents include HPTs at different stages of training and with different levels of VA experience. Survey sample sizes may limit generalizability; however, merging data streams strengthened the reliability of findings.

Conclusions

The results of this analysis of FHCC HPTs were notably more positive than those of HPTs at previous VHA EHR transition sites. VHA is one of many health care systems that provide clinical training for HPTs and relies on this population to provide patient care. By highlighting challenges and positive experiences of HPTs during an EHR transition, this evaluation produces actionable insights that can inform the actions of health care systems seeking to support HPTs during disruptive EHR transitions.

Droperidol is a butyrophenone antipsychotic approved by the US Food and Drug Administration (FDA) for use in postoperative nausea and vomiting (PONV). Off-label, it has also been utilized for its sedative, anxiolytic, and analgesic properties.¹ While its exact mechanism of action remains elusive, it is believed that binding to postsynaptic γ-aminobutyric acid receptors induces anxiolysis and sedation, while dopaminergic activity in the chemoreceptor trigger zone contributes to its antiemetic effects.² Since the introduction of droperidol in 1967, it has been widely used by emergency physicians, psychiatrists, and anesthesiologists globally.¹

Despite its therapeutic efficacy, use of droperidol has been tempered by concerns regarding its cardiovascular safety profile, specifically its potential to prolong the QT interval and precipitate cardiac arrhythmias. In 2001, the FDA placed a boxed warning on droperidol that mandated electrocardiogram (EKG) monitoring before and after treatment. This requirement has led to a widespread decrease in use, and the FDA decision sparked significant controversy among clinicians, with many organizations arguing that the evidence did not support this mandate.¹

Further review of the cases cited by the FDA revealed that there were 277 reported cases of droperidol-related adverse events (AEs), but many of these cases were duplicates and occurred outside the US.³ Additionally, the doses of droperidol used in these cases were significantly higher than the typical doses used in the emergency department (ED), ranging from 25 to 250 mg.⁴ Typical doses for PONV range from 0.625 to 2.5 mg intravenous (IV) or intramuscular (IM). Recommended doses for agitation typically range from 2.5 to 10 mg IV and 5 to 10 mg IM.⁵

There has been growing interest in reevaluating the risk-benefit profile of droperidol in the ED. Since the original decision by the FDA, multiple publications have challenged the idea that droperidol has significantly higher risks associated with its use. The 2014 review by the Clinical Guidelines Committee of the American Academy of Emergency Medicine did not find evidence that low-dose droperidol (< 2.5 is unsafe for use in the ED.⁶ A retrospective cohort study from 2020 found no fatalities in 5784 patients. Furthermore, a prospective observational study of 1009 patients at 6 EDs who received high-dose droperidol (≤ 20.0 mg) found no evidence of increased risk for QT prolongation.⁷ The evidence supports the safety of droperidol for use in prehospital and hospital settings as well as in pediatric, adult, and geriatric populations.^8-14 Droperidol was eventually reintroduced in 2019, which led to increased use.

The US Department of Veterans Affairs (VA) formulary has limited options (eg, haloperidol and olanzapine) that have robust evidence supporting their use to treat aggression or psychosis-related agitation. Ziprasidone injections are not on the formulary and require authorization for use, which may delay patient care and pose a safety risk. In 2021, VA Greater Los Angeles Healthcare System (VAGLAHS) received Pharmacy and Therapeutics Committee approval to use droperidol in the ED for agitation or nausea and vomiting. The purpose of this study was to evaluate safety outcomes for patients prescribed droperidol and the need for rescue medications (ie, effectiveness) in the VAGLAHS ED.

Methods

This retrospective chart review analyzed patients administered droperidol in the VAGLAHS ED from February 1, 2021, through April 30, 2023. A list of patients who had droperidol ordered in the VAGLAHS ED was obtained from the Veterans Health Information Systems and Technology Architecture. Charts were reviewed using the Computerized Patient Record System to confirm droperidol administration. Nurse documentation was reviewed to confirm the time, dose, and route of administration. In addition, droperidol dosages were categorized as < 5 mg, 5 to 10 mg, and > 10 mg to review outcomes based on the total amount administered to each patient.

Patients included in the study received droperidol in the ED within the study period, were aged ≥ 18 years, and received droperidol for acute agitation or antiemesis. Patients were excluded if they received droperidol for an indication other than agitation or antiemesis.

The study team reviewed the list of patients and audited the collected data. Reviewers were trained on the study protocols and variables identified. The following data were collected: patient demographics (age, sex, race, height, weight, allergies), Charlson Comorbidity Index (CCI) conditions, cardiac comorbidities, laboratory values at admission, basic metabolic panels, liver function tests, droperidol use (doses, indications, and documentation of safety), concomitant medications ordered with the initial droperidol order, AEs (arrhythmias, extrapyramidal symptoms [EPS], respiratory depression, mortality), medications used within 60 minutes of droperidol administration (rescue medications), other medications used within 24 hours after droperidol administration, and EKG/QTc (corrected QT interval) intervals. The data reviewed and recorded were from the date of the initial patient ED visit.

Outcomes

The primary outcome was all-cause mortality within 24 hours after droperidol administration. This outcome was measured in all patients included in this study. Secondary outcomes included rescue medications needed after droperidol administration, incidence of QT prolongation, incidence of EPS (defined as akathisia, dystonia, parkinsonism, or tardive dyskinesia), and incidence of respiratory depression. Clinically significant QTc was defined as an interval of ≥ 500 ms with incidence of arrhythmias, code blues, or intubations. Baseline risk factors for QTc prolongation were taken into consideration including electrolyte abnormalities, concomitant QT-prolonging medications, CCI score, and cardiac comorbidities. Incidence of EPS was counted if patients received medications such as diphenhydramine or benztropine after droperidol administration in addition to documentation of EPS signs and symptoms. Incidences of EPS findings were reviewed by emergency department physicians to confirm the diagnosis.

Safety was assessed by quantifying mortality rates 24 hours after droperidol administration along with incidence of AEs associated with droperidol use including QT prolongation, EPS, and respiratory depression.

The necessity of rescue medication use was assessed by nursing documentation, additional medications ordered, and/or no additional medications required for agitation within 60 minutes of droperidol administration. Sixty minutes was the chosen timeframe given that the onset of droperidol action is between 3 and 10 minutes and peaks in about 30 minutes. Medications that were considered rescue medications included diphenhydramine < 25 mg, diphenhydramine 25 to 50 mg, lorazepam < 1 mg, lorazepam 1 to 2 mg, diphenhydramine < 25 mg and lorazepam < 1 mg, diphenhydramine < 25 mg and lorazepam 1 to 2 mg, diphenhydramine 25 to 50 mg and lorazepam 1 to 2 mg, and other medications, the names and doses of which were manually documented by investigators.

Statistical Analysis

For all variables in the study, descriptive analysis was used to categorize findings. Microsoft Excel was used to calculate means, frequency counts, percentages, and categorize data.

Results

Between February 1, 2021, and April 16, 2023, 214 patients received droperidol in the VAGLAHS ED, and 207 patients were included in the study. Seven patients did not receive droperidol for the indications included (acute agitation or antiemesis). Most of the study population (89.4%) was male, and the mean age was 51.0 years. The mean CCI was 1.6. In the study, 183 (88.4%) patients received droperidol for agitation and 24 (11.6%) for nausea and vomiting (Table 1).

Primary Outcome

No deaths were observed in a 24-hour period after droperidol administration among the 207 patients included in the study. There were also no arrhythmias, code blues, or intubations observed with the administration of droperidol (Table 2).

Secondary Outcomes

A total of 144 patients (69.6%) received droperidol alone to resolve agitation or nausea and vomiting. In the remaining population, 63 (30.4%) patients were given medications concomitantly with droperidol.

Fifteen patients (7.2%) required rescue medications that were administered within 60 minutes of droperidol administration. Rescue medications were required for 7 patients (4.9%) who initially received droperidol alone compared with 8 patients (12.7%) who were administered concomitant medications with droperidol (Figure).

Extrapyramidal Symptoms

EPS occurred in 2 patients (1.0%). There was 1 incidence of tardive dyskinesia (TD) in which the patient received droperidol 2.5 mg IM for emesis. TD was resolved with diphenhydramine 50 mg. A second patient who experienced dystonia received droperidol 10 mg IM for agitation. Dystonia was resolved with benztropine 2 mg. Both patients had a CCI of 0, no cardiac comorbidities, and laboratory test results were within reference ranges. The second patient received olanzapine within 24 hours of droperidol administration; however, it was after the EPS event.

QTc Prolongation

Baseline EKGs (within 6 months prior to ED visit) were available for 102 patients (49.3%). Nine patients (8.8%) had a reported baseline QTc of ≥ 500 ms (Table 3). Of these patients, 6 had a repeat EKG and 5 had a repeat QTc < 500 ms. One patient had a baseline and repeated QTc of 512 ms with essentially no change after droperidol administration. Only 1 patient was on a potentially QTc-prolonging medication at home. None of the patients with baseline QTc > 500 ms experienced arrhythmias after droperidol administration.

We found that 59 patients (28.5%) had EKGs performed within 24 hours after droperidol administration. Five patients had documented QTc ≥ 500 ms, but no arrhythmias were observed in a 24-hour period. Table 4 describes the additional medications administered after the 60-minute window but within 24 hours after droperidol administration. Quetiapine 300 mg and metoclopramide 5 mg were the only medications documented that can potentially increase QTc. Patient adherence to home medications and the timing of the last dose prior to ED visit were unknown. However, no arrhythmias were noted in these patients with QT^c changes. No patients experienced respiratory depression within 24 hours of droperidol administration.

Older Adult Patients

Thirty-eight patients were aged ≥ 65 years with a mean age of 74.2 years. Thirty-four patients (89.5%) received droperidol for agitation and 4 (10.6%) for nausea and vomiting. Only 21 patients had a baseline EKG, and 4 had QTc ≤ 500 ms. At 24 hours, EKGs were performed for 18 patients and 3 had a QTc ≤ 500 ms. No mortality or arrhythmias were reported and there were no incidences of rescue medications, EPS, or respiratory depression.

Discussion

The study included 207 patients who received droperidol for either agitation or nausea/vomiting in the VAGLAHS ED. No mortality occurred within 24 hours of droperidol administration, which is consistent with recent studies.^8-14

Furthermore, 59 patients (28.5%) had an EKG performed within 24 hours of droperidol administration; 5 patients had documented QTc ≥ 500 ms. Only 3 of the patients with prolonged QTc had baseline readings for comparison. Only 2 patients had an increase in QTc interval. No arrhythmias were observed; however, the effects of observing QTc prolongation were limited due to the lack of post-EKG readings following droperidol administration. Because of the retrospective nature of the study, neither standardization of EKG at baseline nor 24-hour postadministration were possible. The study found that droperidol was effective with only 15 patients (7.3%) requiring rescue medications. In the patients who were given medications concomitantly with droperidol, it was not possible to conclude whether the patients would have required rescue medications to resolve their agitation or nausea/vomiting. Administration of concomitant medications with droperidol may be attributed to practice patterns associated with haloperidol use, which is frequently administered with concomitant medications such as diphenhydramine and/or a benzodiazepine.

AEs were rare with no documentation of respiratory depression and 2 cases (1.0%) of EPS. Both incidences of EPS resolved with diphenhydramine or benztropine. However, given the reliance on nursing documentation to capture AEs, the number of events may have been underreported.

Limitations

Standardization of dosing was a limiting factor that could affect the need for rescue medications. Another limitation was reliance on nursing reports of resolution of symptoms and comfort with agitated patients. Given the retrospective design and small sample size, this study may not have captured all potential AEs. However, the doses administered within this study population were consistent with what was expected based on other studies.^8-14

Conclusions

Droperidol, an antipsychotic, is currently approved for PONV, but is also used off-label for agitation. This study found no fatalities among patients who received droperidol in the ED. The findings suggest that droperidol used for agitation and as an antiemetic, despite its FDA boxed warning, appears to be safe and showed no evidence of mortality, arrhythmias, code blues, or intubations despite the lack of postdose EKG monitoring. Among the 38 patients aged ≥ 65 years, the use of droperidol revealed no increased risks. It should be noted that droperidol appeared safe and few patients required rescue medications within this study population.

Droperidol is a butyrophenone antipsychotic approved by the US Food and Drug Administration (FDA) for use in postoperative nausea and vomiting (PONV). Off-label, it has also been utilized for its sedative, anxiolytic, and analgesic properties.¹ While its exact mechanism of action remains elusive, it is believed that binding to postsynaptic γ-aminobutyric acid receptors induces anxiolysis and sedation, while dopaminergic activity in the chemoreceptor trigger zone contributes to its antiemetic effects.² Since the introduction of droperidol in 1967, it has been widely used by emergency physicians, psychiatrists, and anesthesiologists globally.¹

Despite its therapeutic efficacy, use of droperidol has been tempered by concerns regarding its cardiovascular safety profile, specifically its potential to prolong the QT interval and precipitate cardiac arrhythmias. In 2001, the FDA placed a boxed warning on droperidol that mandated electrocardiogram (EKG) monitoring before and after treatment. This requirement has led to a widespread decrease in use, and the FDA decision sparked significant controversy among clinicians, with many organizations arguing that the evidence did not support this mandate.¹

Further review of the cases cited by the FDA revealed that there were 277 reported cases of droperidol-related adverse events (AEs), but many of these cases were duplicates and occurred outside the US.³ Additionally, the doses of droperidol used in these cases were significantly higher than the typical doses used in the emergency department (ED), ranging from 25 to 250 mg.⁴ Typical doses for PONV range from 0.625 to 2.5 mg intravenous (IV) or intramuscular (IM). Recommended doses for agitation typically range from 2.5 to 10 mg IV and 5 to 10 mg IM.⁵

There has been growing interest in reevaluating the risk-benefit profile of droperidol in the ED. Since the original decision by the FDA, multiple publications have challenged the idea that droperidol has significantly higher risks associated with its use. The 2014 review by the Clinical Guidelines Committee of the American Academy of Emergency Medicine did not find evidence that low-dose droperidol (< 2.5 is unsafe for use in the ED.⁶ A retrospective cohort study from 2020 found no fatalities in 5784 patients. Furthermore, a prospective observational study of 1009 patients at 6 EDs who received high-dose droperidol (≤ 20.0 mg) found no evidence of increased risk for QT prolongation.⁷ The evidence supports the safety of droperidol for use in prehospital and hospital settings as well as in pediatric, adult, and geriatric populations.^8-14 Droperidol was eventually reintroduced in 2019, which led to increased use.

The US Department of Veterans Affairs (VA) formulary has limited options (eg, haloperidol and olanzapine) that have robust evidence supporting their use to treat aggression or psychosis-related agitation. Ziprasidone injections are not on the formulary and require authorization for use, which may delay patient care and pose a safety risk. In 2021, VA Greater Los Angeles Healthcare System (VAGLAHS) received Pharmacy and Therapeutics Committee approval to use droperidol in the ED for agitation or nausea and vomiting. The purpose of this study was to evaluate safety outcomes for patients prescribed droperidol and the need for rescue medications (ie, effectiveness) in the VAGLAHS ED.

Methods

This retrospective chart review analyzed patients administered droperidol in the VAGLAHS ED from February 1, 2021, through April 30, 2023. A list of patients who had droperidol ordered in the VAGLAHS ED was obtained from the Veterans Health Information Systems and Technology Architecture. Charts were reviewed using the Computerized Patient Record System to confirm droperidol administration. Nurse documentation was reviewed to confirm the time, dose, and route of administration. In addition, droperidol dosages were categorized as < 5 mg, 5 to 10 mg, and > 10 mg to review outcomes based on the total amount administered to each patient.

Patients included in the study received droperidol in the ED within the study period, were aged ≥ 18 years, and received droperidol for acute agitation or antiemesis. Patients were excluded if they received droperidol for an indication other than agitation or antiemesis.

The study team reviewed the list of patients and audited the collected data. Reviewers were trained on the study protocols and variables identified. The following data were collected: patient demographics (age, sex, race, height, weight, allergies), Charlson Comorbidity Index (CCI) conditions, cardiac comorbidities, laboratory values at admission, basic metabolic panels, liver function tests, droperidol use (doses, indications, and documentation of safety), concomitant medications ordered with the initial droperidol order, AEs (arrhythmias, extrapyramidal symptoms [EPS], respiratory depression, mortality), medications used within 60 minutes of droperidol administration (rescue medications), other medications used within 24 hours after droperidol administration, and EKG/QTc (corrected QT interval) intervals. The data reviewed and recorded were from the date of the initial patient ED visit.

Outcomes

The primary outcome was all-cause mortality within 24 hours after droperidol administration. This outcome was measured in all patients included in this study. Secondary outcomes included rescue medications needed after droperidol administration, incidence of QT prolongation, incidence of EPS (defined as akathisia, dystonia, parkinsonism, or tardive dyskinesia), and incidence of respiratory depression. Clinically significant QTc was defined as an interval of ≥ 500 ms with incidence of arrhythmias, code blues, or intubations. Baseline risk factors for QTc prolongation were taken into consideration including electrolyte abnormalities, concomitant QT-prolonging medications, CCI score, and cardiac comorbidities. Incidence of EPS was counted if patients received medications such as diphenhydramine or benztropine after droperidol administration in addition to documentation of EPS signs and symptoms. Incidences of EPS findings were reviewed by emergency department physicians to confirm the diagnosis.

Safety was assessed by quantifying mortality rates 24 hours after droperidol administration along with incidence of AEs associated with droperidol use including QT prolongation, EPS, and respiratory depression.

The necessity of rescue medication use was assessed by nursing documentation, additional medications ordered, and/or no additional medications required for agitation within 60 minutes of droperidol administration. Sixty minutes was the chosen timeframe given that the onset of droperidol action is between 3 and 10 minutes and peaks in about 30 minutes. Medications that were considered rescue medications included diphenhydramine < 25 mg, diphenhydramine 25 to 50 mg, lorazepam < 1 mg, lorazepam 1 to 2 mg, diphenhydramine < 25 mg and lorazepam < 1 mg, diphenhydramine < 25 mg and lorazepam 1 to 2 mg, diphenhydramine 25 to 50 mg and lorazepam 1 to 2 mg, and other medications, the names and doses of which were manually documented by investigators.

Statistical Analysis

For all variables in the study, descriptive analysis was used to categorize findings. Microsoft Excel was used to calculate means, frequency counts, percentages, and categorize data.

Results

Between February 1, 2021, and April 16, 2023, 214 patients received droperidol in the VAGLAHS ED, and 207 patients were included in the study. Seven patients did not receive droperidol for the indications included (acute agitation or antiemesis). Most of the study population (89.4%) was male, and the mean age was 51.0 years. The mean CCI was 1.6. In the study, 183 (88.4%) patients received droperidol for agitation and 24 (11.6%) for nausea and vomiting (Table 1).

Primary Outcome

No deaths were observed in a 24-hour period after droperidol administration among the 207 patients included in the study. There were also no arrhythmias, code blues, or intubations observed with the administration of droperidol (Table 2).

Secondary Outcomes

A total of 144 patients (69.6%) received droperidol alone to resolve agitation or nausea and vomiting. In the remaining population, 63 (30.4%) patients were given medications concomitantly with droperidol.

Fifteen patients (7.2%) required rescue medications that were administered within 60 minutes of droperidol administration. Rescue medications were required for 7 patients (4.9%) who initially received droperidol alone compared with 8 patients (12.7%) who were administered concomitant medications with droperidol (Figure).

Extrapyramidal Symptoms

EPS occurred in 2 patients (1.0%). There was 1 incidence of tardive dyskinesia (TD) in which the patient received droperidol 2.5 mg IM for emesis. TD was resolved with diphenhydramine 50 mg. A second patient who experienced dystonia received droperidol 10 mg IM for agitation. Dystonia was resolved with benztropine 2 mg. Both patients had a CCI of 0, no cardiac comorbidities, and laboratory test results were within reference ranges. The second patient received olanzapine within 24 hours of droperidol administration; however, it was after the EPS event.

QTc Prolongation

Baseline EKGs (within 6 months prior to ED visit) were available for 102 patients (49.3%). Nine patients (8.8%) had a reported baseline QTc of ≥ 500 ms (Table 3). Of these patients, 6 had a repeat EKG and 5 had a repeat QTc < 500 ms. One patient had a baseline and repeated QTc of 512 ms with essentially no change after droperidol administration. Only 1 patient was on a potentially QTc-prolonging medication at home. None of the patients with baseline QTc > 500 ms experienced arrhythmias after droperidol administration.

We found that 59 patients (28.5%) had EKGs performed within 24 hours after droperidol administration. Five patients had documented QTc ≥ 500 ms, but no arrhythmias were observed in a 24-hour period. Table 4 describes the additional medications administered after the 60-minute window but within 24 hours after droperidol administration. Quetiapine 300 mg and metoclopramide 5 mg were the only medications documented that can potentially increase QTc. Patient adherence to home medications and the timing of the last dose prior to ED visit were unknown. However, no arrhythmias were noted in these patients with QT^c changes. No patients experienced respiratory depression within 24 hours of droperidol administration.

Older Adult Patients

Thirty-eight patients were aged ≥ 65 years with a mean age of 74.2 years. Thirty-four patients (89.5%) received droperidol for agitation and 4 (10.6%) for nausea and vomiting. Only 21 patients had a baseline EKG, and 4 had QTc ≤ 500 ms. At 24 hours, EKGs were performed for 18 patients and 3 had a QTc ≤ 500 ms. No mortality or arrhythmias were reported and there were no incidences of rescue medications, EPS, or respiratory depression.

Discussion

The study included 207 patients who received droperidol for either agitation or nausea/vomiting in the VAGLAHS ED. No mortality occurred within 24 hours of droperidol administration, which is consistent with recent studies.^8-14

Furthermore, 59 patients (28.5%) had an EKG performed within 24 hours of droperidol administration; 5 patients had documented QTc ≥ 500 ms. Only 3 of the patients with prolonged QTc had baseline readings for comparison. Only 2 patients had an increase in QTc interval. No arrhythmias were observed; however, the effects of observing QTc prolongation were limited due to the lack of post-EKG readings following droperidol administration. Because of the retrospective nature of the study, neither standardization of EKG at baseline nor 24-hour postadministration were possible. The study found that droperidol was effective with only 15 patients (7.3%) requiring rescue medications. In the patients who were given medications concomitantly with droperidol, it was not possible to conclude whether the patients would have required rescue medications to resolve their agitation or nausea/vomiting. Administration of concomitant medications with droperidol may be attributed to practice patterns associated with haloperidol use, which is frequently administered with concomitant medications such as diphenhydramine and/or a benzodiazepine.

AEs were rare with no documentation of respiratory depression and 2 cases (1.0%) of EPS. Both incidences of EPS resolved with diphenhydramine or benztropine. However, given the reliance on nursing documentation to capture AEs, the number of events may have been underreported.

Limitations

Standardization of dosing was a limiting factor that could affect the need for rescue medications. Another limitation was reliance on nursing reports of resolution of symptoms and comfort with agitated patients. Given the retrospective design and small sample size, this study may not have captured all potential AEs. However, the doses administered within this study population were consistent with what was expected based on other studies.^8-14

Conclusions

Droperidol, an antipsychotic, is currently approved for PONV, but is also used off-label for agitation. This study found no fatalities among patients who received droperidol in the ED. The findings suggest that droperidol used for agitation and as an antiemetic, despite its FDA boxed warning, appears to be safe and showed no evidence of mortality, arrhythmias, code blues, or intubations despite the lack of postdose EKG monitoring. Among the 38 patients aged ≥ 65 years, the use of droperidol revealed no increased risks. It should be noted that droperidol appeared safe and few patients required rescue medications within this study population.

Droperidol is a butyrophenone antipsychotic approved by the US Food and Drug Administration (FDA) for use in postoperative nausea and vomiting (PONV). Off-label, it has also been utilized for its sedative, anxiolytic, and analgesic properties.¹ While its exact mechanism of action remains elusive, it is believed that binding to postsynaptic γ-aminobutyric acid receptors induces anxiolysis and sedation, while dopaminergic activity in the chemoreceptor trigger zone contributes to its antiemetic effects.² Since the introduction of droperidol in 1967, it has been widely used by emergency physicians, psychiatrists, and anesthesiologists globally.¹

Despite its therapeutic efficacy, use of droperidol has been tempered by concerns regarding its cardiovascular safety profile, specifically its potential to prolong the QT interval and precipitate cardiac arrhythmias. In 2001, the FDA placed a boxed warning on droperidol that mandated electrocardiogram (EKG) monitoring before and after treatment. This requirement has led to a widespread decrease in use, and the FDA decision sparked significant controversy among clinicians, with many organizations arguing that the evidence did not support this mandate.¹

Further review of the cases cited by the FDA revealed that there were 277 reported cases of droperidol-related adverse events (AEs), but many of these cases were duplicates and occurred outside the US.³ Additionally, the doses of droperidol used in these cases were significantly higher than the typical doses used in the emergency department (ED), ranging from 25 to 250 mg.⁴ Typical doses for PONV range from 0.625 to 2.5 mg intravenous (IV) or intramuscular (IM). Recommended doses for agitation typically range from 2.5 to 10 mg IV and 5 to 10 mg IM.⁵

There has been growing interest in reevaluating the risk-benefit profile of droperidol in the ED. Since the original decision by the FDA, multiple publications have challenged the idea that droperidol has significantly higher risks associated with its use. The 2014 review by the Clinical Guidelines Committee of the American Academy of Emergency Medicine did not find evidence that low-dose droperidol (< 2.5 is unsafe for use in the ED.⁶ A retrospective cohort study from 2020 found no fatalities in 5784 patients. Furthermore, a prospective observational study of 1009 patients at 6 EDs who received high-dose droperidol (≤ 20.0 mg) found no evidence of increased risk for QT prolongation.⁷ The evidence supports the safety of droperidol for use in prehospital and hospital settings as well as in pediatric, adult, and geriatric populations.^8-14 Droperidol was eventually reintroduced in 2019, which led to increased use.

The US Department of Veterans Affairs (VA) formulary has limited options (eg, haloperidol and olanzapine) that have robust evidence supporting their use to treat aggression or psychosis-related agitation. Ziprasidone injections are not on the formulary and require authorization for use, which may delay patient care and pose a safety risk. In 2021, VA Greater Los Angeles Healthcare System (VAGLAHS) received Pharmacy and Therapeutics Committee approval to use droperidol in the ED for agitation or nausea and vomiting. The purpose of this study was to evaluate safety outcomes for patients prescribed droperidol and the need for rescue medications (ie, effectiveness) in the VAGLAHS ED.

Methods

This retrospective chart review analyzed patients administered droperidol in the VAGLAHS ED from February 1, 2021, through April 30, 2023. A list of patients who had droperidol ordered in the VAGLAHS ED was obtained from the Veterans Health Information Systems and Technology Architecture. Charts were reviewed using the Computerized Patient Record System to confirm droperidol administration. Nurse documentation was reviewed to confirm the time, dose, and route of administration. In addition, droperidol dosages were categorized as < 5 mg, 5 to 10 mg, and > 10 mg to review outcomes based on the total amount administered to each patient.

Patients included in the study received droperidol in the ED within the study period, were aged ≥ 18 years, and received droperidol for acute agitation or antiemesis. Patients were excluded if they received droperidol for an indication other than agitation or antiemesis.

The study team reviewed the list of patients and audited the collected data. Reviewers were trained on the study protocols and variables identified. The following data were collected: patient demographics (age, sex, race, height, weight, allergies), Charlson Comorbidity Index (CCI) conditions, cardiac comorbidities, laboratory values at admission, basic metabolic panels, liver function tests, droperidol use (doses, indications, and documentation of safety), concomitant medications ordered with the initial droperidol order, AEs (arrhythmias, extrapyramidal symptoms [EPS], respiratory depression, mortality), medications used within 60 minutes of droperidol administration (rescue medications), other medications used within 24 hours after droperidol administration, and EKG/QTc (corrected QT interval) intervals. The data reviewed and recorded were from the date of the initial patient ED visit.

Outcomes

The primary outcome was all-cause mortality within 24 hours after droperidol administration. This outcome was measured in all patients included in this study. Secondary outcomes included rescue medications needed after droperidol administration, incidence of QT prolongation, incidence of EPS (defined as akathisia, dystonia, parkinsonism, or tardive dyskinesia), and incidence of respiratory depression. Clinically significant QTc was defined as an interval of ≥ 500 ms with incidence of arrhythmias, code blues, or intubations. Baseline risk factors for QTc prolongation were taken into consideration including electrolyte abnormalities, concomitant QT-prolonging medications, CCI score, and cardiac comorbidities. Incidence of EPS was counted if patients received medications such as diphenhydramine or benztropine after droperidol administration in addition to documentation of EPS signs and symptoms. Incidences of EPS findings were reviewed by emergency department physicians to confirm the diagnosis.

Safety was assessed by quantifying mortality rates 24 hours after droperidol administration along with incidence of AEs associated with droperidol use including QT prolongation, EPS, and respiratory depression.

The necessity of rescue medication use was assessed by nursing documentation, additional medications ordered, and/or no additional medications required for agitation within 60 minutes of droperidol administration. Sixty minutes was the chosen timeframe given that the onset of droperidol action is between 3 and 10 minutes and peaks in about 30 minutes. Medications that were considered rescue medications included diphenhydramine < 25 mg, diphenhydramine 25 to 50 mg, lorazepam < 1 mg, lorazepam 1 to 2 mg, diphenhydramine < 25 mg and lorazepam < 1 mg, diphenhydramine < 25 mg and lorazepam 1 to 2 mg, diphenhydramine 25 to 50 mg and lorazepam 1 to 2 mg, and other medications, the names and doses of which were manually documented by investigators.

Statistical Analysis

For all variables in the study, descriptive analysis was used to categorize findings. Microsoft Excel was used to calculate means, frequency counts, percentages, and categorize data.

Results

Between February 1, 2021, and April 16, 2023, 214 patients received droperidol in the VAGLAHS ED, and 207 patients were included in the study. Seven patients did not receive droperidol for the indications included (acute agitation or antiemesis). Most of the study population (89.4%) was male, and the mean age was 51.0 years. The mean CCI was 1.6. In the study, 183 (88.4%) patients received droperidol for agitation and 24 (11.6%) for nausea and vomiting (Table 1).

Primary Outcome

No deaths were observed in a 24-hour period after droperidol administration among the 207 patients included in the study. There were also no arrhythmias, code blues, or intubations observed with the administration of droperidol (Table 2).

Secondary Outcomes

A total of 144 patients (69.6%) received droperidol alone to resolve agitation or nausea and vomiting. In the remaining population, 63 (30.4%) patients were given medications concomitantly with droperidol.

Fifteen patients (7.2%) required rescue medications that were administered within 60 minutes of droperidol administration. Rescue medications were required for 7 patients (4.9%) who initially received droperidol alone compared with 8 patients (12.7%) who were administered concomitant medications with droperidol (Figure).

Extrapyramidal Symptoms

EPS occurred in 2 patients (1.0%). There was 1 incidence of tardive dyskinesia (TD) in which the patient received droperidol 2.5 mg IM for emesis. TD was resolved with diphenhydramine 50 mg. A second patient who experienced dystonia received droperidol 10 mg IM for agitation. Dystonia was resolved with benztropine 2 mg. Both patients had a CCI of 0, no cardiac comorbidities, and laboratory test results were within reference ranges. The second patient received olanzapine within 24 hours of droperidol administration; however, it was after the EPS event.

QTc Prolongation

Baseline EKGs (within 6 months prior to ED visit) were available for 102 patients (49.3%). Nine patients (8.8%) had a reported baseline QTc of ≥ 500 ms (Table 3). Of these patients, 6 had a repeat EKG and 5 had a repeat QTc < 500 ms. One patient had a baseline and repeated QTc of 512 ms with essentially no change after droperidol administration. Only 1 patient was on a potentially QTc-prolonging medication at home. None of the patients with baseline QTc > 500 ms experienced arrhythmias after droperidol administration.

We found that 59 patients (28.5%) had EKGs performed within 24 hours after droperidol administration. Five patients had documented QTc ≥ 500 ms, but no arrhythmias were observed in a 24-hour period. Table 4 describes the additional medications administered after the 60-minute window but within 24 hours after droperidol administration. Quetiapine 300 mg and metoclopramide 5 mg were the only medications documented that can potentially increase QTc. Patient adherence to home medications and the timing of the last dose prior to ED visit were unknown. However, no arrhythmias were noted in these patients with QT^c changes. No patients experienced respiratory depression within 24 hours of droperidol administration.

Older Adult Patients

Thirty-eight patients were aged ≥ 65 years with a mean age of 74.2 years. Thirty-four patients (89.5%) received droperidol for agitation and 4 (10.6%) for nausea and vomiting. Only 21 patients had a baseline EKG, and 4 had QTc ≤ 500 ms. At 24 hours, EKGs were performed for 18 patients and 3 had a QTc ≤ 500 ms. No mortality or arrhythmias were reported and there were no incidences of rescue medications, EPS, or respiratory depression.

Discussion

The study included 207 patients who received droperidol for either agitation or nausea/vomiting in the VAGLAHS ED. No mortality occurred within 24 hours of droperidol administration, which is consistent with recent studies.^8-14

Furthermore, 59 patients (28.5%) had an EKG performed within 24 hours of droperidol administration; 5 patients had documented QTc ≥ 500 ms. Only 3 of the patients with prolonged QTc had baseline readings for comparison. Only 2 patients had an increase in QTc interval. No arrhythmias were observed; however, the effects of observing QTc prolongation were limited due to the lack of post-EKG readings following droperidol administration. Because of the retrospective nature of the study, neither standardization of EKG at baseline nor 24-hour postadministration were possible. The study found that droperidol was effective with only 15 patients (7.3%) requiring rescue medications. In the patients who were given medications concomitantly with droperidol, it was not possible to conclude whether the patients would have required rescue medications to resolve their agitation or nausea/vomiting. Administration of concomitant medications with droperidol may be attributed to practice patterns associated with haloperidol use, which is frequently administered with concomitant medications such as diphenhydramine and/or a benzodiazepine.

AEs were rare with no documentation of respiratory depression and 2 cases (1.0%) of EPS. Both incidences of EPS resolved with diphenhydramine or benztropine. However, given the reliance on nursing documentation to capture AEs, the number of events may have been underreported.

Limitations

Standardization of dosing was a limiting factor that could affect the need for rescue medications. Another limitation was reliance on nursing reports of resolution of symptoms and comfort with agitated patients. Given the retrospective design and small sample size, this study may not have captured all potential AEs. However, the doses administered within this study population were consistent with what was expected based on other studies.^8-14

Conclusions

Droperidol, an antipsychotic, is currently approved for PONV, but is also used off-label for agitation. This study found no fatalities among patients who received droperidol in the ED. The findings suggest that droperidol used for agitation and as an antiemetic, despite its FDA boxed warning, appears to be safe and showed no evidence of mortality, arrhythmias, code blues, or intubations despite the lack of postdose EKG monitoring. Among the 38 patients aged ≥ 65 years, the use of droperidol revealed no increased risks. It should be noted that droperidol appeared safe and few patients required rescue medications within this study population.

Exogenously, hypochlorous acid (HOCl) is a powerful oxidizing agent formed from chlorine dissolved in water. Within the body, it is part of the immune response, created by activated leukocytes, which form HOCl from hydrogen peroxide and chloride. HOCl has been used as a disinfectant in wound care due to its antimicrobial properties via inhibition of DNA synthesis, protein synthesis, and decreased adenosine triphosphate production. It specifically targets bacteria by blocking bacterial cell wall synthesis and decreasing DNA replication.¹ 

During the COVID-19 pandemic, HOCl was recommended by the US Environmental Protection Agency as a disinfectant.² HOCl can be purchased from a supplier, though its major limitation is its shelf life. The main environmental factors affecting its stability are sunlight exposure, temperatures > 25 °C, and air exposure. HOCl is stable and most potent when the pH falls between 3.5 and 5.5.³ It is best stored in a cool, dark environment to maintain efficacy for 2 weeks. Rossi-Fedele et al found that when exposed to sunlight, chlorine reduction starts on day 4, whereas solutions kept in dark storage remained more stable, with this process starting after day 14.⁴ 

HOCl can also be made on-site via a machine, which ranges in price from a portable version costing < $200 to a large commercial option that can cost $7000 to $25,000. HOCl is produced by mixing noniodinated salt and water, and using electrolysis, which generally takes less than 10 minutes before it is ready for use.² Given the cost and nonreusable nature of disinfecting wipes, HOCl may be more worthwhile for economic and disposal purposes in the long term. 

Different concentrations of HOCl are readily available commercially. Because topical application of 1% HOCl may cause skin irritation, solutions with lower concentrations have been developed including Vashe (0.03% HOCl; SteadMed), PhaseOne (0.025% HOCl solution; IHT), OCuSOFT (0.02% HOCl; OCuSOFT), Bruder (0.02% HOCl; Bruder Healthcare), Acuicyn (0.01% HOCl solution in dilute saline; Sonoma Pharmaceuticals), and Avenova (0.01% HOCl solution; NovaBay Pharmaceuticals).⁵ 

Aside from its surface utility, HOCl has been researched for its beneficial effects on skin. HOCl has been shown to be helpful intraoperatively and postoperatively in improving adverse effects (AEs) after hair restoration, including erythema and pruritus, and in optimizing healing by reducing inflammation, likely due to its antimicrobial properties and ability to promote oxygenation.⁶ Bucko et al demonstrated that Microcyn scar gel (with HOCl) was a superior nonirritating, nontoxic method of not only improving scar appearance (vascularity, scar height, and pliability) but also reducing scar symptoms of pain and pruritus in comparison to 100% silicone scar gel (traditional application used to improve scarring).⁷ Zhang et al demonstrated that HOCl consistently improved symptom relief of blepharitis, including meibomian gland, eyelash, and eyelid redness, irritation, and appearance in comparison as well as were better tolerated in comparison to traditional recommendations of eyelid compresses and wash (tea tree oil, diluted baby shampoo, and topical antibiotics).⁸ In children with moderate to severe atopic dermatitis, Majewski et al compared a traditional bleach bath with a body wash containing hypochlorite (NaOCl; hypochlorous acid in alkaline aqueous solution). The body wash proved to be more convenient (showering vs 10-minute bath) and significantly improved symptoms while reducing the need for topical corticosteroids (common treatment modality for atopic dermatitis).⁹ 

The skin is the body’s primary defense against both dermatologic and respiratory infections. The face is especially vulnerable to microbes via airborne or environmental transmission, mechanical irritation, and touch. In the military environment, personal protective equipment (PPE) or uniform items may increase the risk of dermatologic conditions such as allergic or irritant dermatitis, infection, and friction blisters. 

In a literature review of 312 dermatologic articles published between 2002 and 2022, Singal and Lipner found that among deployed soldiers serving in hot and dry climates, dermatitis and eczematous conditions were the most common, whereas bacterial and fungal conditions were most common in hot and humid settings. In the nondeployed setting, dermatitis and eczematous, acne, and fungal infections were the most common skin conditions. This is reflected by the unique circumstances that service members face at home and while deployed, when they may be more vulnerable to developing new or worsening chronic skin conditions depending on the environment (access to shelter, humid vs dry environments), and decreased access or time for hygiene (shared quarters at home in barracks or on deployment). Occupation-related conditions also play a large role in military dermatologic conditions.¹⁰ 

Dever et al noted the unique risks and exposures in the environment itself (plants, arthropods) as well as uniform items (protective gear) that carry an increased risk of friction irritation and dermatitis. Occupational exposures commonly associated with irritant contact dermatitis include alcohols, oils, fuel, disinfectants, and solvents. Chemicals in military uniforms themselves (eg, formaldehyde resins, disperse dyes, and chromate-containing dyes) also have the potential to cause allergic contact dermatitis, which can be challenging to address given the emphasis on uniformity and standards.¹¹ PPE also may exacerbate rosacea and acne. 

Some pathologies are associated specifically with bacteria, such as Cutibacterium acnes, as seen in acne vulgaris. Colonization of bacteria on the face may create biofilms that are difficult to detect, may be resistant to antibiotic therapy, and are implicated in other dermatologic conditions, such as persistent wounds, atopic dermatitis, and candidiasis.¹² 

Biofilm and antibiotic resistance already pose a risk to patient care, but the unique environmental conditions and exposures of military settings can amplify this risk in the military population.¹³ Using HOCl in austere environments or the field for wound care may help reduce microbial load and the subsequent need for systemic antibiotics which carry the risk of gastrointestinal AEs and resistance.¹ 

An optimized healing rate would support operational objectives by enabling service members to remain on full duty and avoid medications, which may prevent them from special duty, such as aviation. Sakarya et al found that HOCl solution enhanced wound healing in contrast with povidone-iodine (PI), while a study by Dharap et al discussed how HOCl provided major improvement in ulcer wound size (and infection), as well as significant reduction of inflammation.¹³ 

Anagnostopoulos et al studied the efficacy of 0.01% HOCl vs other disinfectants (5% PI, 4% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA]) against common skin organisms, including methicillin-susceptible Staphylococcus aureus and methicillin-susceptible Staphylococcus epidermidis. The study found that HOCl had at least equal if not greater efficacy to PI, CHG, and IPA depending on the bacterial strain, demonstrating immediate bactericidal effects.¹⁴ 

Furthermore, HOCl has been shown to be useful in suturing and wound closure by reducing microbial load when soaked gauze is placed in wound beds prior to closure, while not harming surrounding tissue.¹⁵ This would be especially advantageous for military health care when specialist follow-up would be delayed or to prevent infection risk while en route to higher care. Aside from its disinfectant strength, it’s also well tolerated. HOCl studies on human tissue demonstrate its efficacy to prevent irritation and AEs while also preventing infection and promoting wound healing. 

Gozukucuk and Cakiroglu studied the use of HOCl as a skin disinfectant before neonatal circumcision and demonstrated fewer adverse effects compared with the more commonly used PI. Neonates treated with PI prior to circumcision resulted in greater postoperative edema and increased duration of wound healing compared with infants treated with HOCl.¹⁶ Furthermore, studies have shown that PI can lead to irritant dermatitis or chemical burns if not properly dried or if it becomes pooled because of occlusion dressings.¹⁷ 

Aside from its indicated use for infection or wound care, anti-inflammatory properties of HOCl also may be beneficial for off-label use in preventing flareups of chronic conditions as well as for treating symptoms while awaiting specialist evaluation. This might be the case during US-based training exercises, in remote locations without nearby dermatologists, or during virtual care because of internet constraints. For chronic conditions such as rosacea or atopic dermatitis, which research has shown are related to mast cell activation and degranulation and cytokine release, HOCl has been shown to reduce histamine, neutrophil-generated leukotrienes, in addition to interleukin-6 and interleukin-2 to improve symptoms by reducing inflammation.¹⁸ 

Limitations of HOCl to explore would be extending its shelf life, exploring its various forms (eg, spray, topical) and storage limitations, and training of the machine and materials needed to be made in-house if not purchased. There are also no official guidelines for clinicians to recommend HOCl to patients, and research should be expanded on its use in humans, though it generally is well tolerated without AEs. HOCl has the potential to be a potent, nontoxic, inexpensive tool in med bags or at austere clinics to help maintain a sterile space for procedures, prevent infection while rendering care, and help with exacerbations or prevent flare-ups of chronic conditions such as psoriasis, acne, and atopic dermatitis while specialist care is pending. 

Exogenously, hypochlorous acid (HOCl) is a powerful oxidizing agent formed from chlorine dissolved in water. Within the body, it is part of the immune response, created by activated leukocytes, which form HOCl from hydrogen peroxide and chloride. HOCl has been used as a disinfectant in wound care due to its antimicrobial properties via inhibition of DNA synthesis, protein synthesis, and decreased adenosine triphosphate production. It specifically targets bacteria by blocking bacterial cell wall synthesis and decreasing DNA replication.¹ 

During the COVID-19 pandemic, HOCl was recommended by the US Environmental Protection Agency as a disinfectant.² HOCl can be purchased from a supplier, though its major limitation is its shelf life. The main environmental factors affecting its stability are sunlight exposure, temperatures > 25 °C, and air exposure. HOCl is stable and most potent when the pH falls between 3.5 and 5.5.³ It is best stored in a cool, dark environment to maintain efficacy for 2 weeks. Rossi-Fedele et al found that when exposed to sunlight, chlorine reduction starts on day 4, whereas solutions kept in dark storage remained more stable, with this process starting after day 14.⁴ 

HOCl can also be made on-site via a machine, which ranges in price from a portable version costing < $200 to a large commercial option that can cost $7000 to $25,000. HOCl is produced by mixing noniodinated salt and water, and using electrolysis, which generally takes less than 10 minutes before it is ready for use.² Given the cost and nonreusable nature of disinfecting wipes, HOCl may be more worthwhile for economic and disposal purposes in the long term. 

Different concentrations of HOCl are readily available commercially. Because topical application of 1% HOCl may cause skin irritation, solutions with lower concentrations have been developed including Vashe (0.03% HOCl; SteadMed), PhaseOne (0.025% HOCl solution; IHT), OCuSOFT (0.02% HOCl; OCuSOFT), Bruder (0.02% HOCl; Bruder Healthcare), Acuicyn (0.01% HOCl solution in dilute saline; Sonoma Pharmaceuticals), and Avenova (0.01% HOCl solution; NovaBay Pharmaceuticals).⁵ 

Aside from its surface utility, HOCl has been researched for its beneficial effects on skin. HOCl has been shown to be helpful intraoperatively and postoperatively in improving adverse effects (AEs) after hair restoration, including erythema and pruritus, and in optimizing healing by reducing inflammation, likely due to its antimicrobial properties and ability to promote oxygenation.⁶ Bucko et al demonstrated that Microcyn scar gel (with HOCl) was a superior nonirritating, nontoxic method of not only improving scar appearance (vascularity, scar height, and pliability) but also reducing scar symptoms of pain and pruritus in comparison to 100% silicone scar gel (traditional application used to improve scarring).⁷ Zhang et al demonstrated that HOCl consistently improved symptom relief of blepharitis, including meibomian gland, eyelash, and eyelid redness, irritation, and appearance in comparison as well as were better tolerated in comparison to traditional recommendations of eyelid compresses and wash (tea tree oil, diluted baby shampoo, and topical antibiotics).⁸ In children with moderate to severe atopic dermatitis, Majewski et al compared a traditional bleach bath with a body wash containing hypochlorite (NaOCl; hypochlorous acid in alkaline aqueous solution). The body wash proved to be more convenient (showering vs 10-minute bath) and significantly improved symptoms while reducing the need for topical corticosteroids (common treatment modality for atopic dermatitis).⁹ 

The skin is the body’s primary defense against both dermatologic and respiratory infections. The face is especially vulnerable to microbes via airborne or environmental transmission, mechanical irritation, and touch. In the military environment, personal protective equipment (PPE) or uniform items may increase the risk of dermatologic conditions such as allergic or irritant dermatitis, infection, and friction blisters. 

In a literature review of 312 dermatologic articles published between 2002 and 2022, Singal and Lipner found that among deployed soldiers serving in hot and dry climates, dermatitis and eczematous conditions were the most common, whereas bacterial and fungal conditions were most common in hot and humid settings. In the nondeployed setting, dermatitis and eczematous, acne, and fungal infections were the most common skin conditions. This is reflected by the unique circumstances that service members face at home and while deployed, when they may be more vulnerable to developing new or worsening chronic skin conditions depending on the environment (access to shelter, humid vs dry environments), and decreased access or time for hygiene (shared quarters at home in barracks or on deployment). Occupation-related conditions also play a large role in military dermatologic conditions.¹⁰ 

Dever et al noted the unique risks and exposures in the environment itself (plants, arthropods) as well as uniform items (protective gear) that carry an increased risk of friction irritation and dermatitis. Occupational exposures commonly associated with irritant contact dermatitis include alcohols, oils, fuel, disinfectants, and solvents. Chemicals in military uniforms themselves (eg, formaldehyde resins, disperse dyes, and chromate-containing dyes) also have the potential to cause allergic contact dermatitis, which can be challenging to address given the emphasis on uniformity and standards.¹¹ PPE also may exacerbate rosacea and acne. 

Some pathologies are associated specifically with bacteria, such as Cutibacterium acnes, as seen in acne vulgaris. Colonization of bacteria on the face may create biofilms that are difficult to detect, may be resistant to antibiotic therapy, and are implicated in other dermatologic conditions, such as persistent wounds, atopic dermatitis, and candidiasis.¹² 

Biofilm and antibiotic resistance already pose a risk to patient care, but the unique environmental conditions and exposures of military settings can amplify this risk in the military population.¹³ Using HOCl in austere environments or the field for wound care may help reduce microbial load and the subsequent need for systemic antibiotics which carry the risk of gastrointestinal AEs and resistance.¹ 

An optimized healing rate would support operational objectives by enabling service members to remain on full duty and avoid medications, which may prevent them from special duty, such as aviation. Sakarya et al found that HOCl solution enhanced wound healing in contrast with povidone-iodine (PI), while a study by Dharap et al discussed how HOCl provided major improvement in ulcer wound size (and infection), as well as significant reduction of inflammation.¹³ 

Anagnostopoulos et al studied the efficacy of 0.01% HOCl vs other disinfectants (5% PI, 4% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA]) against common skin organisms, including methicillin-susceptible Staphylococcus aureus and methicillin-susceptible Staphylococcus epidermidis. The study found that HOCl had at least equal if not greater efficacy to PI, CHG, and IPA depending on the bacterial strain, demonstrating immediate bactericidal effects.¹⁴ 

Furthermore, HOCl has been shown to be useful in suturing and wound closure by reducing microbial load when soaked gauze is placed in wound beds prior to closure, while not harming surrounding tissue.¹⁵ This would be especially advantageous for military health care when specialist follow-up would be delayed or to prevent infection risk while en route to higher care. Aside from its disinfectant strength, it’s also well tolerated. HOCl studies on human tissue demonstrate its efficacy to prevent irritation and AEs while also preventing infection and promoting wound healing. 

Gozukucuk and Cakiroglu studied the use of HOCl as a skin disinfectant before neonatal circumcision and demonstrated fewer adverse effects compared with the more commonly used PI. Neonates treated with PI prior to circumcision resulted in greater postoperative edema and increased duration of wound healing compared with infants treated with HOCl.¹⁶ Furthermore, studies have shown that PI can lead to irritant dermatitis or chemical burns if not properly dried or if it becomes pooled because of occlusion dressings.¹⁷ 

Aside from its indicated use for infection or wound care, anti-inflammatory properties of HOCl also may be beneficial for off-label use in preventing flareups of chronic conditions as well as for treating symptoms while awaiting specialist evaluation. This might be the case during US-based training exercises, in remote locations without nearby dermatologists, or during virtual care because of internet constraints. For chronic conditions such as rosacea or atopic dermatitis, which research has shown are related to mast cell activation and degranulation and cytokine release, HOCl has been shown to reduce histamine, neutrophil-generated leukotrienes, in addition to interleukin-6 and interleukin-2 to improve symptoms by reducing inflammation.¹⁸ 

Limitations of HOCl to explore would be extending its shelf life, exploring its various forms (eg, spray, topical) and storage limitations, and training of the machine and materials needed to be made in-house if not purchased. There are also no official guidelines for clinicians to recommend HOCl to patients, and research should be expanded on its use in humans, though it generally is well tolerated without AEs. HOCl has the potential to be a potent, nontoxic, inexpensive tool in med bags or at austere clinics to help maintain a sterile space for procedures, prevent infection while rendering care, and help with exacerbations or prevent flare-ups of chronic conditions such as psoriasis, acne, and atopic dermatitis while specialist care is pending. 

Exogenously, hypochlorous acid (HOCl) is a powerful oxidizing agent formed from chlorine dissolved in water. Within the body, it is part of the immune response, created by activated leukocytes, which form HOCl from hydrogen peroxide and chloride. HOCl has been used as a disinfectant in wound care due to its antimicrobial properties via inhibition of DNA synthesis, protein synthesis, and decreased adenosine triphosphate production. It specifically targets bacteria by blocking bacterial cell wall synthesis and decreasing DNA replication.¹ 

During the COVID-19 pandemic, HOCl was recommended by the US Environmental Protection Agency as a disinfectant.² HOCl can be purchased from a supplier, though its major limitation is its shelf life. The main environmental factors affecting its stability are sunlight exposure, temperatures > 25 °C, and air exposure. HOCl is stable and most potent when the pH falls between 3.5 and 5.5.³ It is best stored in a cool, dark environment to maintain efficacy for 2 weeks. Rossi-Fedele et al found that when exposed to sunlight, chlorine reduction starts on day 4, whereas solutions kept in dark storage remained more stable, with this process starting after day 14.⁴ 

HOCl can also be made on-site via a machine, which ranges in price from a portable version costing < $200 to a large commercial option that can cost $7000 to $25,000. HOCl is produced by mixing noniodinated salt and water, and using electrolysis, which generally takes less than 10 minutes before it is ready for use.² Given the cost and nonreusable nature of disinfecting wipes, HOCl may be more worthwhile for economic and disposal purposes in the long term. 

Different concentrations of HOCl are readily available commercially. Because topical application of 1% HOCl may cause skin irritation, solutions with lower concentrations have been developed including Vashe (0.03% HOCl; SteadMed), PhaseOne (0.025% HOCl solution; IHT), OCuSOFT (0.02% HOCl; OCuSOFT), Bruder (0.02% HOCl; Bruder Healthcare), Acuicyn (0.01% HOCl solution in dilute saline; Sonoma Pharmaceuticals), and Avenova (0.01% HOCl solution; NovaBay Pharmaceuticals).⁵ 

Aside from its surface utility, HOCl has been researched for its beneficial effects on skin. HOCl has been shown to be helpful intraoperatively and postoperatively in improving adverse effects (AEs) after hair restoration, including erythema and pruritus, and in optimizing healing by reducing inflammation, likely due to its antimicrobial properties and ability to promote oxygenation.⁶ Bucko et al demonstrated that Microcyn scar gel (with HOCl) was a superior nonirritating, nontoxic method of not only improving scar appearance (vascularity, scar height, and pliability) but also reducing scar symptoms of pain and pruritus in comparison to 100% silicone scar gel (traditional application used to improve scarring).⁷ Zhang et al demonstrated that HOCl consistently improved symptom relief of blepharitis, including meibomian gland, eyelash, and eyelid redness, irritation, and appearance in comparison as well as were better tolerated in comparison to traditional recommendations of eyelid compresses and wash (tea tree oil, diluted baby shampoo, and topical antibiotics).⁸ In children with moderate to severe atopic dermatitis, Majewski et al compared a traditional bleach bath with a body wash containing hypochlorite (NaOCl; hypochlorous acid in alkaline aqueous solution). The body wash proved to be more convenient (showering vs 10-minute bath) and significantly improved symptoms while reducing the need for topical corticosteroids (common treatment modality for atopic dermatitis).⁹ 

The skin is the body’s primary defense against both dermatologic and respiratory infections. The face is especially vulnerable to microbes via airborne or environmental transmission, mechanical irritation, and touch. In the military environment, personal protective equipment (PPE) or uniform items may increase the risk of dermatologic conditions such as allergic or irritant dermatitis, infection, and friction blisters. 

In a literature review of 312 dermatologic articles published between 2002 and 2022, Singal and Lipner found that among deployed soldiers serving in hot and dry climates, dermatitis and eczematous conditions were the most common, whereas bacterial and fungal conditions were most common in hot and humid settings. In the nondeployed setting, dermatitis and eczematous, acne, and fungal infections were the most common skin conditions. This is reflected by the unique circumstances that service members face at home and while deployed, when they may be more vulnerable to developing new or worsening chronic skin conditions depending on the environment (access to shelter, humid vs dry environments), and decreased access or time for hygiene (shared quarters at home in barracks or on deployment). Occupation-related conditions also play a large role in military dermatologic conditions.¹⁰ 

Dever et al noted the unique risks and exposures in the environment itself (plants, arthropods) as well as uniform items (protective gear) that carry an increased risk of friction irritation and dermatitis. Occupational exposures commonly associated with irritant contact dermatitis include alcohols, oils, fuel, disinfectants, and solvents. Chemicals in military uniforms themselves (eg, formaldehyde resins, disperse dyes, and chromate-containing dyes) also have the potential to cause allergic contact dermatitis, which can be challenging to address given the emphasis on uniformity and standards.¹¹ PPE also may exacerbate rosacea and acne. 

Some pathologies are associated specifically with bacteria, such as Cutibacterium acnes, as seen in acne vulgaris. Colonization of bacteria on the face may create biofilms that are difficult to detect, may be resistant to antibiotic therapy, and are implicated in other dermatologic conditions, such as persistent wounds, atopic dermatitis, and candidiasis.¹² 

Biofilm and antibiotic resistance already pose a risk to patient care, but the unique environmental conditions and exposures of military settings can amplify this risk in the military population.¹³ Using HOCl in austere environments or the field for wound care may help reduce microbial load and the subsequent need for systemic antibiotics which carry the risk of gastrointestinal AEs and resistance.¹ 

An optimized healing rate would support operational objectives by enabling service members to remain on full duty and avoid medications, which may prevent them from special duty, such as aviation. Sakarya et al found that HOCl solution enhanced wound healing in contrast with povidone-iodine (PI), while a study by Dharap et al discussed how HOCl provided major improvement in ulcer wound size (and infection), as well as significant reduction of inflammation.¹³ 

Anagnostopoulos et al studied the efficacy of 0.01% HOCl vs other disinfectants (5% PI, 4% chlorhexidine gluconate [CHG] and 70% isopropyl alcohol [IPA]) against common skin organisms, including methicillin-susceptible Staphylococcus aureus and methicillin-susceptible Staphylococcus epidermidis. The study found that HOCl had at least equal if not greater efficacy to PI, CHG, and IPA depending on the bacterial strain, demonstrating immediate bactericidal effects.¹⁴ 

Furthermore, HOCl has been shown to be useful in suturing and wound closure by reducing microbial load when soaked gauze is placed in wound beds prior to closure, while not harming surrounding tissue.¹⁵ This would be especially advantageous for military health care when specialist follow-up would be delayed or to prevent infection risk while en route to higher care. Aside from its disinfectant strength, it’s also well tolerated. HOCl studies on human tissue demonstrate its efficacy to prevent irritation and AEs while also preventing infection and promoting wound healing. 

Gozukucuk and Cakiroglu studied the use of HOCl as a skin disinfectant before neonatal circumcision and demonstrated fewer adverse effects compared with the more commonly used PI. Neonates treated with PI prior to circumcision resulted in greater postoperative edema and increased duration of wound healing compared with infants treated with HOCl.¹⁶ Furthermore, studies have shown that PI can lead to irritant dermatitis or chemical burns if not properly dried or if it becomes pooled because of occlusion dressings.¹⁷ 

Aside from its indicated use for infection or wound care, anti-inflammatory properties of HOCl also may be beneficial for off-label use in preventing flareups of chronic conditions as well as for treating symptoms while awaiting specialist evaluation. This might be the case during US-based training exercises, in remote locations without nearby dermatologists, or during virtual care because of internet constraints. For chronic conditions such as rosacea or atopic dermatitis, which research has shown are related to mast cell activation and degranulation and cytokine release, HOCl has been shown to reduce histamine, neutrophil-generated leukotrienes, in addition to interleukin-6 and interleukin-2 to improve symptoms by reducing inflammation.¹⁸ 

Limitations of HOCl to explore would be extending its shelf life, exploring its various forms (eg, spray, topical) and storage limitations, and training of the machine and materials needed to be made in-house if not purchased. There are also no official guidelines for clinicians to recommend HOCl to patients, and research should be expanded on its use in humans, though it generally is well tolerated without AEs. HOCl has the potential to be a potent, nontoxic, inexpensive tool in med bags or at austere clinics to help maintain a sterile space for procedures, prevent infection while rendering care, and help with exacerbations or prevent flare-ups of chronic conditions such as psoriasis, acne, and atopic dermatitis while specialist care is pending. 

Render unto Caesar the things that are Caesar’s, and to God the things that are God’s.
Matthew 22:21

While in my 20s, I taught religious education at a church on the Army base where I was born and had the honor of working with military chaplains. During my US Department of Veterans Affairs career, I closely collaborated with chaplains—many of whom were veterans—on patient care and ethics consultations. Some were quite proud of their rank and interested in climbing the ladder of promotion. A few made sure you knew what they wore or had worn on their uniform, while most were incredibly humble and sheepish when soldiers saluted them. Those visible responses to rank may be hidden if chaplains will no longer be permitted to wear insignia indicating their grade. 

Department of War Secretary Peter Hegseth, a combat veteran who has championed a “combative” form of Christianity, announced in April 2026 that chaplains would no longer wear their rank on their uniform.¹ Details of how this shift will be translated into regulation, policy, and actions were not provided. Secretary Hegseth did not remove the actual rank of members of the chaplain corps and they would retain their rank, attendant pay, benefits, responsibilities, and privileges. However, instead of bearing the insignia of their military station, under this new policy only the symbol of their religious profession would identify them. Currently, both a military officer’s rank and religious symbol are displayed.² 

Useful insight can be gained from an historical perspective, which demonstrates that the concerns and contention about the issue of chaplain’s wearing rank are not new. There have been chaplains in the US Army since 1775.³ Army chaplains initially wore only a religious symbol on their clothing. In April 1914, chaplain leaders successful argued that chaplains deserved the privileges, respect, and prospect for promotion that rank symbolized and where authorized to display their position. Four years later, General Jack Pershing cabled the then Secretary of War opposing the new policy: “Believe the work of chaplains would be facilitated if they were not given military rank ... Many of our principal ministers believe that their relations would be closer if they did not have military titles and did not wear insignia.”4 Interestingly, Secretary Hegseth articulated the same concern: “A chaplain is first and foremost a chaplain and an officer second. This change is a visual representation of that fact.”⁵ 

Hegseth has stated that in recent years the military chaplain corps had drifted too far in the direction of providing spiritual counseling and psychological support. This contravenes the current competencies especially for company-grade military chaplains who primarily minister to the moral distress and spiritual needs of service members.⁴ The removal of rank is thus best understood as part of Secretary Hegseth’s broader plan to remake the chaplain corps into his vision of religious ministry in the military.⁵ 

Secretary Hegseth proffered several arguments for the necessity of removing rank in part to reorient the chaplain corps to what he calls a more fundamental mission. The first was theological: chaplains need to prioritize their “divine calling” rather than any human distinction. Chaplain theologians and ethicists have expressed similar concerns that in wearing rank, military chaplains become servants of the state and not of God. Adam Tietje articulates the corruptive influence this shift in the source of legitimacy has on the military chaplain’s spiritual mission: 

This undermines the ability of chaplains to provide care and counsel to both soldiers and leaders that is not muddied with the interests of the military. Chaplains without rank are better positioned to hear and advocate for their soldier’s matters of conscience as well as bear witness to the moral claims of their respective religious communities especially about war itself.³ 

The second argument is pastoral. Hegseth contends that service members of lower rank would feel more comfortable and secure approaching chaplains with no outward sign of their higher position. Chaplain interactions with military personnel carry a degree of confidentiality higher than that of either doctors or lawyers. Chaplains, as they were in the past, remain divided on this important consideration.^4,5 

The third argument is ethical in nature. Secretary Hegseth contends that excluding any manifestation of military rank, “speaks to the difficult balance of the duality” of the role.⁶ It seems he is proposing that chaplains displaying only the image of their faith commitment symbolically resolves the inherent moral conflict between serving human masters as a military officer, and the divine as a minister.⁷ Military chaplains and health care professionals are all too familiar with the dilemma of having 2 masters and the challenge of negotiating legally and ethically overlapping roles.^8-10 

This may seem to some like a minor change in chaplain etiquette to some, but to others it signals a significant ethical and political change with potential import beyond chaplaincy. One military commentator has suggested the move sets a dangerous precedent that could eventually be applied to both health care professionals and the judge advocate corps.¹¹ At this point this is only speculation and its slippery slope arguments are logically suspect without evidence. Yet at least 1 study suggests that the influence of military physician’s rank on patient care may lead to inequities in the care delivered to patients with lower grade.¹² 

It is commanders who are the decision-makers in the military. Chaplains who are field grade officers serve as trusted staff advisors in moral, ethical, and spiritual matters.⁴ Some chaplains fear that without rank leaders at all levels will not have adequate trust and sufficient respect to heed their crucial counsel especially regarding high-stakes strategic decisions in wartime.⁸ The more serious concern is with a major shift in the locus of authority to determine the professional identity of chaplains, that could in theory be expanded to impact military health care practitioners, and attorneys. The independent expert judgment of these professionals regarding what is necessary to fulfil their respective roles in providing spiritual ministry, medical care, and legal is critical to uphold the highest values of the US military.¹¹ Chaplains have long struggled with what they owe to the Caesar and to God: how the Secretary’s recent decision will shape that rendering is uncertain. What is certain is that military chaplains of all faiths and in every branch of the armed services will continue to minister to their brothers and sisters in arms with courage and compassion. 

Render unto Caesar the things that are Caesar’s, and to God the things that are God’s.
Matthew 22:21

While in my 20s, I taught religious education at a church on the Army base where I was born and had the honor of working with military chaplains. During my US Department of Veterans Affairs career, I closely collaborated with chaplains—many of whom were veterans—on patient care and ethics consultations. Some were quite proud of their rank and interested in climbing the ladder of promotion. A few made sure you knew what they wore or had worn on their uniform, while most were incredibly humble and sheepish when soldiers saluted them. Those visible responses to rank may be hidden if chaplains will no longer be permitted to wear insignia indicating their grade. 

Department of War Secretary Peter Hegseth, a combat veteran who has championed a “combative” form of Christianity, announced in April 2026 that chaplains would no longer wear their rank on their uniform.¹ Details of how this shift will be translated into regulation, policy, and actions were not provided. Secretary Hegseth did not remove the actual rank of members of the chaplain corps and they would retain their rank, attendant pay, benefits, responsibilities, and privileges. However, instead of bearing the insignia of their military station, under this new policy only the symbol of their religious profession would identify them. Currently, both a military officer’s rank and religious symbol are displayed.² 

Useful insight can be gained from an historical perspective, which demonstrates that the concerns and contention about the issue of chaplain’s wearing rank are not new. There have been chaplains in the US Army since 1775.³ Army chaplains initially wore only a religious symbol on their clothing. In April 1914, chaplain leaders successful argued that chaplains deserved the privileges, respect, and prospect for promotion that rank symbolized and where authorized to display their position. Four years later, General Jack Pershing cabled the then Secretary of War opposing the new policy: “Believe the work of chaplains would be facilitated if they were not given military rank ... Many of our principal ministers believe that their relations would be closer if they did not have military titles and did not wear insignia.”4 Interestingly, Secretary Hegseth articulated the same concern: “A chaplain is first and foremost a chaplain and an officer second. This change is a visual representation of that fact.”⁵ 

Hegseth has stated that in recent years the military chaplain corps had drifted too far in the direction of providing spiritual counseling and psychological support. This contravenes the current competencies especially for company-grade military chaplains who primarily minister to the moral distress and spiritual needs of service members.⁴ The removal of rank is thus best understood as part of Secretary Hegseth’s broader plan to remake the chaplain corps into his vision of religious ministry in the military.⁵ 

Secretary Hegseth proffered several arguments for the necessity of removing rank in part to reorient the chaplain corps to what he calls a more fundamental mission. The first was theological: chaplains need to prioritize their “divine calling” rather than any human distinction. Chaplain theologians and ethicists have expressed similar concerns that in wearing rank, military chaplains become servants of the state and not of God. Adam Tietje articulates the corruptive influence this shift in the source of legitimacy has on the military chaplain’s spiritual mission: 

This undermines the ability of chaplains to provide care and counsel to both soldiers and leaders that is not muddied with the interests of the military. Chaplains without rank are better positioned to hear and advocate for their soldier’s matters of conscience as well as bear witness to the moral claims of their respective religious communities especially about war itself.³ 

The second argument is pastoral. Hegseth contends that service members of lower rank would feel more comfortable and secure approaching chaplains with no outward sign of their higher position. Chaplain interactions with military personnel carry a degree of confidentiality higher than that of either doctors or lawyers. Chaplains, as they were in the past, remain divided on this important consideration.^4,5 

The third argument is ethical in nature. Secretary Hegseth contends that excluding any manifestation of military rank, “speaks to the difficult balance of the duality” of the role.⁶ It seems he is proposing that chaplains displaying only the image of their faith commitment symbolically resolves the inherent moral conflict between serving human masters as a military officer, and the divine as a minister.⁷ Military chaplains and health care professionals are all too familiar with the dilemma of having 2 masters and the challenge of negotiating legally and ethically overlapping roles.^8-10 

This may seem to some like a minor change in chaplain etiquette to some, but to others it signals a significant ethical and political change with potential import beyond chaplaincy. One military commentator has suggested the move sets a dangerous precedent that could eventually be applied to both health care professionals and the judge advocate corps.¹¹ At this point this is only speculation and its slippery slope arguments are logically suspect without evidence. Yet at least 1 study suggests that the influence of military physician’s rank on patient care may lead to inequities in the care delivered to patients with lower grade.¹² 

It is commanders who are the decision-makers in the military. Chaplains who are field grade officers serve as trusted staff advisors in moral, ethical, and spiritual matters.⁴ Some chaplains fear that without rank leaders at all levels will not have adequate trust and sufficient respect to heed their crucial counsel especially regarding high-stakes strategic decisions in wartime.⁸ The more serious concern is with a major shift in the locus of authority to determine the professional identity of chaplains, that could in theory be expanded to impact military health care practitioners, and attorneys. The independent expert judgment of these professionals regarding what is necessary to fulfil their respective roles in providing spiritual ministry, medical care, and legal is critical to uphold the highest values of the US military.¹¹ Chaplains have long struggled with what they owe to the Caesar and to God: how the Secretary’s recent decision will shape that rendering is uncertain. What is certain is that military chaplains of all faiths and in every branch of the armed services will continue to minister to their brothers and sisters in arms with courage and compassion. 

Render unto Caesar the things that are Caesar’s, and to God the things that are God’s.
Matthew 22:21

While in my 20s, I taught religious education at a church on the Army base where I was born and had the honor of working with military chaplains. During my US Department of Veterans Affairs career, I closely collaborated with chaplains—many of whom were veterans—on patient care and ethics consultations. Some were quite proud of their rank and interested in climbing the ladder of promotion. A few made sure you knew what they wore or had worn on their uniform, while most were incredibly humble and sheepish when soldiers saluted them. Those visible responses to rank may be hidden if chaplains will no longer be permitted to wear insignia indicating their grade. 

Department of War Secretary Peter Hegseth, a combat veteran who has championed a “combative” form of Christianity, announced in April 2026 that chaplains would no longer wear their rank on their uniform.¹ Details of how this shift will be translated into regulation, policy, and actions were not provided. Secretary Hegseth did not remove the actual rank of members of the chaplain corps and they would retain their rank, attendant pay, benefits, responsibilities, and privileges. However, instead of bearing the insignia of their military station, under this new policy only the symbol of their religious profession would identify them. Currently, both a military officer’s rank and religious symbol are displayed.² 

Useful insight can be gained from an historical perspective, which demonstrates that the concerns and contention about the issue of chaplain’s wearing rank are not new. There have been chaplains in the US Army since 1775.³ Army chaplains initially wore only a religious symbol on their clothing. In April 1914, chaplain leaders successful argued that chaplains deserved the privileges, respect, and prospect for promotion that rank symbolized and where authorized to display their position. Four years later, General Jack Pershing cabled the then Secretary of War opposing the new policy: “Believe the work of chaplains would be facilitated if they were not given military rank ... Many of our principal ministers believe that their relations would be closer if they did not have military titles and did not wear insignia.”4 Interestingly, Secretary Hegseth articulated the same concern: “A chaplain is first and foremost a chaplain and an officer second. This change is a visual representation of that fact.”⁵ 

Hegseth has stated that in recent years the military chaplain corps had drifted too far in the direction of providing spiritual counseling and psychological support. This contravenes the current competencies especially for company-grade military chaplains who primarily minister to the moral distress and spiritual needs of service members.⁴ The removal of rank is thus best understood as part of Secretary Hegseth’s broader plan to remake the chaplain corps into his vision of religious ministry in the military.⁵ 

Secretary Hegseth proffered several arguments for the necessity of removing rank in part to reorient the chaplain corps to what he calls a more fundamental mission. The first was theological: chaplains need to prioritize their “divine calling” rather than any human distinction. Chaplain theologians and ethicists have expressed similar concerns that in wearing rank, military chaplains become servants of the state and not of God. Adam Tietje articulates the corruptive influence this shift in the source of legitimacy has on the military chaplain’s spiritual mission: 

This undermines the ability of chaplains to provide care and counsel to both soldiers and leaders that is not muddied with the interests of the military. Chaplains without rank are better positioned to hear and advocate for their soldier’s matters of conscience as well as bear witness to the moral claims of their respective religious communities especially about war itself.³ 

The second argument is pastoral. Hegseth contends that service members of lower rank would feel more comfortable and secure approaching chaplains with no outward sign of their higher position. Chaplain interactions with military personnel carry a degree of confidentiality higher than that of either doctors or lawyers. Chaplains, as they were in the past, remain divided on this important consideration.^4,5 

The third argument is ethical in nature. Secretary Hegseth contends that excluding any manifestation of military rank, “speaks to the difficult balance of the duality” of the role.⁶ It seems he is proposing that chaplains displaying only the image of their faith commitment symbolically resolves the inherent moral conflict between serving human masters as a military officer, and the divine as a minister.⁷ Military chaplains and health care professionals are all too familiar with the dilemma of having 2 masters and the challenge of negotiating legally and ethically overlapping roles.^8-10 

This may seem to some like a minor change in chaplain etiquette to some, but to others it signals a significant ethical and political change with potential import beyond chaplaincy. One military commentator has suggested the move sets a dangerous precedent that could eventually be applied to both health care professionals and the judge advocate corps.¹¹ At this point this is only speculation and its slippery slope arguments are logically suspect without evidence. Yet at least 1 study suggests that the influence of military physician’s rank on patient care may lead to inequities in the care delivered to patients with lower grade.¹² 

It is commanders who are the decision-makers in the military. Chaplains who are field grade officers serve as trusted staff advisors in moral, ethical, and spiritual matters.⁴ Some chaplains fear that without rank leaders at all levels will not have adequate trust and sufficient respect to heed their crucial counsel especially regarding high-stakes strategic decisions in wartime.⁸ The more serious concern is with a major shift in the locus of authority to determine the professional identity of chaplains, that could in theory be expanded to impact military health care practitioners, and attorneys. The independent expert judgment of these professionals regarding what is necessary to fulfil their respective roles in providing spiritual ministry, medical care, and legal is critical to uphold the highest values of the US military.¹¹ Chaplains have long struggled with what they owe to the Caesar and to God: how the Secretary’s recent decision will shape that rendering is uncertain. What is certain is that military chaplains of all faiths and in every branch of the armed services will continue to minister to their brothers and sisters in arms with courage and compassion.