Thursday September 18th 2014

Nurse to nurse

Creating ways to ensure better care for military service members, veterans

“Joining Forces” is not a campaign in name only. It’s a meaningful effort by many stakeholders — including nurses — to ensure veterans, military men and women, and their families get the full range of services they need.

In April 2012, the American Nurses Association (ANA) and the greater nursing community committed to do their part to help advance this national, multipronged campaign, created by First Lady Michelle Obama and Jill Biden. The following is a brief overview of two projects aimed at achieving this crucial goal.

A simple question

Nurses ask patients questions every day. They ask about tobacco and alcohol use, the existence of pain, and whether heart disease runs in their families — all with the goal of getting an accurate picture of a patient’s health history and current condition.

But most nurses don’t automatically ask patients about their military background.  That is about to change as a campaign developed through the American Academy of Nursing continues to expand.

The campaign is aptly called “Have you ever served in the military?” and it got its start in September 2013 in 10 states with the assistance of Veterans Affairs commissioners in each of those states and widespread support of the National Association of State Directors of Veterans Affairs.

One of the commissioners is Linda Schwartz, PhD, RN, FAAN, of the Connecticut VA. A member of the Academy’s Military and Veterans Health Expert Panel, she was behind the idea of routinely asking patients about their military service and helped develop the group’s campaign materials.

Asking that simple question can lead to better assessment, diagnosis and treatment of conditions and illnesses that may be linked to a patient’s service, according to Schwartz, a retired U.S. Air Force nurse, past president of the Connecticut Nurses Association and past member of the ANA Board of Directors. She recently was nominated by President Obama for the position of assistant secretary for the Department of Veterans Affairs Office of Policy and Planning.

Those who serve in the military can experience a range of stressors and be exposed to toxic substances, hazards and other generally uncommon safety risks, noted Schwartz and other panel members in a September 2013 article in Nursing Outlook.

For example, veterans returning from Iraq and Afghanistan who worked or slept near open-air burn pits may have been exposed to multiple toxins, which put them at increased risk for respiratory illness and many cancers, including leukemia.

Schwartz herself has witnessed patients and health care providers being perplexed by symptoms because they do not consider hazards connected with military service.  In one instance, she was asked to consult on a case involving a patient who was deathly ill in an ICU at a local, community hospital.

“Physicians were stumped over what was wrong with him, although they were considering non-Hodgkins lymphoma,” she said.  Schwartz discovered that the patient had served in Vietnam, where the herbicide Agent Orange was regularly sprayed.

“There’s a long list of diseases associated with Agent Orange, and one of them is non-Hodgkins lymphoma,” she explained. The patient subsequently received the appropriate treatment and his health improved.

Less than 22 percent of veterans and active service members receive care through the VA system, said Cheryl Sullivan, chief executive officer of the Academy, an organization that is part of the American Nurses Association (ANA) enterprise. So it’s important for all nurses and other health care providers to ascertain someone’s military background so they can consider associated risks and provide appropriate care.

Schwartz also pointed to a survey of 33 hospitals in Connecticut, which revealed that providers don’t ask patients whether they ever served in the military and don’t know how to refer patients to the VA system for specialized care.

The “Have you ever served?” campaign tackles those issues. One of the Academy’s campaign tools is designed to be used during patient intake and assessment. It provides specific questions nurses and other providers can ask about a patient’s military history. It also gives information on general areas of concern for all veterans, suicide risk cues and common military health risks.

The website includes materials for health care providers and veterans, and has links to national and state VA facilities.

“During the upcoming year, the Academy will distribute campaign materials to nurses in federally qualified health centers, mental health centers and health systems, and to veterans groups, as well as amplify the message to the general public using other tools,” Sullivan said. “The systems goal is to have the military service question become part of the electronic health record for all individuals in all settings.”

Said Schwartz, “With the directors of state departments of Veterans Affairs joining with the Academy, we literally are going to transform the terrain of care to veterans, service members and their families.”

An unfortunate, but common, problem

An issue that had been getting a lot of media attention — but something that nurses may feel less equipped to handle is post-traumatic stress disorder (PTSD). Further, an estimated 500,000 veterans and military service members suffer from it.

PTSD is a cluster of symptoms that some people experience when they witness a threat of injury or death. Irritability, depression, anxiety, nightmares, flashbacks, difficulty sleeping, and simply having a hard time relating to and getting along with family, partners or friends are common experiences of PTSD. Treatment for PTSD, however, is available and effective.

“It is a significant public health issue with a long-standing effect on individuals, families and communities,” said Nancy Hanrahan, PhD, RN, FAAN, who is leading the project at the University of Pennsylvania School of Nursing to improve care to service members with PTSD. “It’s been widely reported that many service members returning from Middle Eastern conflicts have difficult transitions to civilian life. It’s also been reported that every 65 minutes, a veteran commits suicide. We must and can do better, and nurses can help.”

There is a desperate need for resources to help veterans and service members, said Katherine Gatewood, director of development at the American Nurses Foundation, the philanthropic arm of ANA. In most instances, nurses represent the first point of contact for patients and their families when they seek care, making them uniquely positioned to address the crisis.

To that end, the Foundation provided a grant to Hanrahan and her team at Penn Nursing to develop an interactive PTSD website, an e-learning module based on advanced gaming techniques, and a downloadable smartphone app that will provide access to materials allowing nurses to assess, intervene and refer military members and veterans who are experiencing PTSD symptoms.

The PTSD Toolkit was developed to fit the busy lives of nurses, noted Hanrahan, a Pennsylvania State Nurses Association member.

“We’re not asking nurses to dig into what is traumatizing an individual, but to be able to assess patients who may have PTSD, communicate therapeutically, help patients determine their next step and refer them appropriately to mental health experts,” Hanrahan said.

And that’s what the interactive learning tools are designed to do; nurses work through three case simulations where they practice and hone their skills. The PTSD Toolkit will be released in the near future as a place for nurses to also receive continuing education credit.

“There are 3.1 million nurses who are working in rural and urban areas and in every type of setting,” Hanrahan said. “This novel technology will help leverage nurses’ knowledge and access in the community to improve care to returning service members and veterans.”

— Susan Trossman is the senior reporter for The American Nurse.

Resources

Read about and support ANA’s Joining Forces efforts: www.nursingworld.org/ANA-Supports-Joining-Forces

Access materials on the Academy’s “Have you served in the military?” campaign: www.haveyoueverserved.com

Learn more about Nancy Hanrahan’s project at Penn Nursing: www.nursing.upenn.edu/innovation/health-technology-lab/Pages/Our-Projects.aspx?itemID=3

Learn more about the American Nurses Foundation: www.anfonline.org

Read more about the contributions of nursing and other organizations to advance the mission of the “Joining Forces” campaign: www.whitehouse.gov/joiningforces

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