Date

5-20-2026

Department

Helms School of Government

Degree

Doctor of Philosophy in Public Administration (PhD)

Chair

Michael S. Hall

Keywords

Veterans Health Administration, implementation, governance, Institutional Theory, Policy Implementation Theory, Integrated Policy Adaptation Model, non-pharmacological pain management

Disciplines

Public Affairs, Public Policy and Public Administration

Abstract

The Veterans Health Administration (VHA) has invested heavily in non-pharmacological pain management through the Whole Health transformation, the Opioid Safety Initiative, and national CIH expansion efforts. Despite these systemwide priorities, implementation remains uneven across decentralized facilities, revealing barriers that extend beyond logistics or compliance. This study investigated how governance structures, professional norms, and cultural–cognitive logics shape the translation of federal mandates into local clinical practice. Guided by Policy Implementation Theory (PIT) and Institutional Theory (IT), and applying the Integrated Policy Adaptation Model (IPAM), this qualitative inquiry triangulated semi-structured interviews, surveys, and policy document analysis. IPAM’s mechanisms—Leadership Mediation (LM), Frontline Adaptation (FPA), Policy–Context Alignment (PCA), Adaptive Resistance (ADR), and Evaluation–Continuous Improvement (ECI) structured coding and interpretation across data sources. Findings demonstrated that variability in implementation outcomes reflects not only material resource disparities but also the interpretive work clinicians perform as they negotiate, adjust, or resist mandated practices. Leadership mediation emerged as a central determinant of policy fidelity, while adaptive resistance functioned as a patterned, sense-making response to tensions between institutional logics, historical opioid-era norms, and contemporary CIH expectations. Theoretically, the study advances PIT by illustrating how leadership variability influences fidelity in fragmented systems and extends IT by reframing resistance as adaptive meaning-making embedded within cultural–cognitive frameworks. Practically, it offers strategies for strengthening resource equity, leadership development, and clinician support to advance non-pharmacological pain care in the VHA. More broadly, IPAM provides a transferable analytic framework for understanding how federal mandates are interpreted and enacted across decentralized governance contexts, including education, environmental regulation, and human services.

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