"Doing the right thing": Moral conflicts and ethical issues experienced by military nurses during wartime.

INTRODUCTION: The War on Terrorism, which included Operation Enduring Freedom (OEF) in Afghanistan from 2001 to 2014 and the concurrent Operation Iraqi Freedom (OIF) from 2003 to 2011, exposed military nurses to situations and challenges for which many reported feeling unprepared. Clinically, nurses faced multi-trauma injuries and devastating wounds suffered by military troops and civilians alike. Cultural issues and harsh living conditions added further complications to the care environment. The purpose of this study was to address the research question: How do military nurses identify, assess, manage, and personally resolve ethical issues occurring in nursing practice during wartime deployments? DESIGN: Qualitative grounded theory provided the design for this study. METHODS: Using the constant comparative method, data collection, and data analysis occurred simultaneously to build a theory of ethical issues management during wartime. Using a focused interview guide responsive to emerging themes and developing theory, interviews were conducted until theoretical saturation was achieved. Participants represented primarily Army (55%) active duty (83%) female nurses (71%) who had deployed to Iraq (52%), Afghanistan (32%), or both (16%). A sampling grid was used to recruit nurses representative of the demographics deployed in support of OIF and OEF. Data analysis used grounded theory methods to identify a core construct to detail proposed relationships and concepts. Rigor was maintained in study methods and analysis using established tenets to support trustworthiness. RESULTS: The nurses shared stories regarding their experiences during deployment. Many struggled to find internal resolutions regarding the care of detainees, cultural differences, end-of-life decision-making, pain management, and care of civilian casualties. CONCLUSION: The study described the ethical issues military nurses encountered during wartime and the strategies used to mitigate moral conflict. By better understanding how nurses define, assess, and manage ethical situations, we can better prepare our deploying nurses for future conflicts. CLINICAL RELEVANCE: Military nurses returning from wars with unresolved moral conflicts are at risk for moral distress. Moral distress has been associated with burnout, dissatisfaction with and leaving the nursing profession, compassion fatigue, and disinterest in the provision of quality patient care. In the interest of preserving the health of military nurses, steps need to be taken to provide resources for helping them prepare for, encounter, and cope with the ethical situations inherent in wartime nursing care.

Nurse Attrition: Content Analysis of Free-Text Responses From Two Military Nursing Practice Environment Surveys.

INTRODUCTION: Staff nurse attrition negatively impacts readiness of the warfighter and the health and wellbeing of all beneficiaries of the Military Health System (MHS). To promote the retention of a robust nursing workforce, a complete understanding of nurses' perceptions regarding their intent to leave is necessary. The purpose of this study was to explore the free-text responses of 1,438 nurses working among military medical treatment facilities for factors influencing their intent to leave, as an indicator of potential turnover, or attrition. MATERIALS AND METHODS: This study employed thematic analysis to investigate the qualitative responses from the 2016 and 2018 Military Nursing Practice Environment Surveys. The study was determined to be exempt from Institutional Review Board review through the Womack Army Medical Center's Human Research Protection Program. RESULTS: Findings indicate that leadership and management (n = 647), staffing (n = 353), career opportunities (n = 345), staff outcomes (n = 247), culture (n = 153), quality of care (n = 99), patient care barriers (n = 86), non-patient care activities (n = 79), lack of formal professional development (n = 75), and area or care environment (n = 67) were among the top factors influencing staff nurse intent to leave, respectively. CONCLUSIONS: Our findings support the evaluation of retention strategies using implementation science for nurses and nurse resource personnel (e.g., nursing assistants, technicians, medics, and corpsman) to ensure a robust nursing work force throughout the MHS. Staff nurses and resource personnel working among military treatment facilities and embedded in units supporting combat and humanitarian missions ensure access to care and health promotion of the warfighter and all MHS beneficiaries.

An international panel perspective: Exploring nursing scholarship in academia.

BACKGROUND: Boyer's framework of scholarship, the basis of many academic models for faculty promotion, is comprised of the components of discovery, teaching, integration, application, and engagement. Yet, the scholarship component of application (containing goal-based clinical practice) is undervalued by many academic models. PURPOSE: This study explores the nursing activities currently qualifying as scholarship in several international academic models. METHODS: Using the Delphi approach, an international nine-member panel from seven countries participated in a six-question, structured brainstorming session to explore the nursing activities qualifying as scholarship by academic models. Follow-up sessions were attended by six panel members. RESULTS: Panel members reported that the nursing activities, which most often were recognized as scholarship, fit the scholarship components of discovery, teaching and integration but few fit the components of application or engagement. Although this project originally focused on clinical practice, far more recommendations for an academic model targeted the scholarship component of engagement. CONCLUSION: Academic models' lack of appreciation for the scholarship components of application (goal-based clinical practice) and engagement (partnering with community groups) discourages faculty from participating in these activities. Yet, these nursing activities demonstrate scholarship and are essential for the continued development of the nursing profession and discipline.

"Life is Bitter and Sweet": The Lived Experience of Ethnic Minority Elders with Type 2 Diabetes Mellitus in Rural, Thailand.

PURPOSE: The purpose of this study was to describe the lived experience of ethnic minority elders (EME) with type 2 diabetes mellitus (T2DM) to understand an individual's experience, perception, and behaviors connected to T2DM in rural areas where support is limited. METHOD: The hermeneutic phenomenological methodology was used to explore the lived experience of EME with T2DM by using conversational interviews. Twenty EME were interviewed. The data analysis and interpretation followed the thematic analysis by van Manen. RESULTS: Analysis highlighted an overarching theme of "Life is Bitter and Sweet" and three main themes: (1) the struggle of living with diabetes, (2) living with inequalities, and (3) dealing with diabetes that reflects the experiences of EME with T2DM living in underserved areas based on the cultures, beliefs, and spirits. CONCLUSIONS: The finding led to recommendations to strengthen interventions by family members, improve supportive systems and services to improve knowledge, self-management, and maintain physical well-being in order to increase the quality of life for the EME with T2DM.

Creating Interdisciplinary Engagement Through a Hospital-Based Endowed Chair in Nursing Research: The "Conway Chair Conversations".

Although clinical nurses' involvement in research is a role expectation, efforts to engage clinical nurses in nurse-led research have had notably mixed results. These efforts have most typically been single discipline-focused (nursing), although nursing care is a collaborative, interdisciplinary practice. Adding an interdisciplinary strategy to multiple other efforts to engage clinical nurses in research may contribute to more nurse involvement. Here, we describe the use of a hospital-based endowed chair in nursing research to simultaneously engage nursing and other disciplines in a monthly dialogue about clinically relevant, research-related challenges and solutions. Outcomes indicate that the research-related dialogue among nurses and interprofessional colleagues would likely not have taken place without this approach.

Just-in-Time Qualitative Research: Methodological Guidelines Based on the COVID-19 Pandemic Experience.

BACKGROUND: Methodological guidelines are required to ensure both the rigor and feasibility of just-in-time, qualitative research addressing the human experience and response to the COVID-19 pandemic and major public health crises. OBJECTIVES: This article presents methodological guidelines for just-in-time qualitative research based on our current, pandemic-relevant research. METHODS: The processes followed while conducting two longitudinal, online qualitative studies addressing the lived experience and response to the COVID-19 pandemic were analyzed. Methodological challenges faced were then identified, and specific design and implementation guidelines were developed. The ways in which these guidelines can be applied to conduct just-in-time research during the COVID-19 pandemic and future public health crises were further delineated using examples from our pandemic-relevant research. RESULTS: Six guidelines were identified: (a) capitalize on fast track review and reporting processes; (b) prioritize accessibility during sample specification and selection; (c) optimize recruitment and retention strategies; (d) maximize current and future data use through strategic research design; (e) tailor data collection to participants' characteristics, preferences, and priorities; and (f) incorporate timeline mapping of personal and contemporaneous phenomena. DISCUSSION: Public health measures taken to slow disease spread during the current COVID-19 pandemic and future public health crises may slow the pace of research and make its implementation all the more challenging. However, just-in-time qualitative research advances our understanding of the human experience and response to the COVID-19 and major public health crises. It also complements existing behavioral theory and research. The guidelines presented may assist researchers to initiate necessary qualitative research more rapidly, with fewer logistic challenges, and with methodological rigor. They may also help expand research on groups experiencing collateral effects of the pandemic and major public health crisis. Lastly, the guidelines may support the development of more robust data for alternate analysis at a later date.

Military parents' perceptions of separation for their younger children.

ABSTRACT: Many studies are available in the literature considering effects of deployment on older school age and adolescent children, but less is known about the effects on younger children. The purpose of this study was to describe the experience of deployment/separation for military children aged 4-10 years from both the deployed parent and stay-at-home parent's experiences. Parents completed demographics followed by an interview to describe the child's reaction to separation. Thematic analysis was used to identify children's reactions and intervention strategies. Thirty-eight families, encompassing 57 children aged 4-10 who experienced a separation or deployment within the past 2 years participated. Interviews included 24 military members and 34 spouses (most frequently the mothers) completed the interview and research instruments. Interview data revealed a turbulent experience for families resulting from frequent and repeated separations. Parents actively employed strategies garnered from military-provided materials and informal interaction with other military parents. The different perspectives provided new insights as to the strategies military families find successful during separations and will be useful in providing anticipatory guidance.

Finding the evidence: Screening of Military Family Research, 2014-2017.

Of 1.3 million active duty service members, the majority have family responsibilities; 54.3% are married, and 41.2% have at least one child. The authors sought to determine existing areas of focus in military family research and to identify areas that are currently understudied. The authors queried four literature databases from January 2014 to May 2017, and 2,502 articles were identified in the initial catchment. All 595 article abstracts that met inclusion criteria were sorted into one or more of 12 topics. Topics with the highest number of articles included Mental Health and Care (n = 276), Adult/Couple Partner Relationships (n = 247), and Deployment Issues (n = 244). Topics with sparse articles included Maternal/Child & Newborn Health (n = 27), Health Promotion (n = 10), and Special Heath Care Needs (n = 4). The three topics with the highest number of articles reflect interdependent and overlapping themes and showcase the importance of family relationships to the operational readiness of active duty members. The topics with fewer numbers of articles highlight areas where more evidence is needed. Understanding the current evidence allows nurse practitioners to support military families appropriately in real time.

Making the hard decisions: Ethical care decisions in wartime nursing practice.

BACKGROUND: Codes of ethics set forth standards of ethical conduct for nurses. However, nurses involved in wartime operations, or disasters, may often have their moral compass challenged by the patient care decisions necessary under adverse conditions. Reverse triage, resource allocation, and promotion of patient autonomy present multiple challenges to meeting commonly applied ethical principles. PURPOSE: The purpose of this study was to use the International Council of Nursing code of ethics as a framework to organize the ethical issues emerging from wartime nursing. METHODS: This article represents a secondary analysis of two studies using thematic analysis to identify ethical issues encountered by military nurses during the recent conflicts in Iraq and Afghanistan. Data were collected from nurses deployed from 2002 to 2015 and from 111 military nurses during focused interviews. DISCUSSION: Across both studies, issues such as resource allocation, patient triage, cultural differences, and equitable treatment for all emerged as challenges within the wartime environment. Nurses were at a loss at times as to how best to manage the situations and recommended that more education is needed in ethical decision making before, during, and after deployment as a debriefing strategy. Similar issues have been documented in military and disaster literature indicating that such challenges are not limited to the recent conflicts but cross time and location. CONCLUSION: By better understanding how nurses define, assess, and manage the ethical situations they encounter in wartime nursing practice, military nurses can better prepare for future conflicts, provide mentorship and targeted education to hopefully reducing any feelings of moral distress, and promote ethical decision making that will best promote outcomes in accordance with nursing's ethical codes.

Ethical Issues Encountered by Military Nurses During Wartime.

Military nurses encounter similar issues as civilian nurses in daily practice situations; however, wartime and humanitarian missions may bring unique and difficult ethical dilemmas. While nursing has the American Nurses Association code of ethics to provide a framework to guide ethical practice decisions, conflicts may arise from the unique aspects of nursing within a wartime environment. Understanding those conflicts occuring within the military wartime scenario can provide nurses with experiential examples from which to derive strategies for personal coping and professional behavior and decision making. This chapter describes the research that has focused upon the identification of these issues, the effects from uresolved issues, and those directions for future research to better prepare miltiary nurses before and during deployment.

Cultural Awareness: Nursing Care of Iraqi Patients.

PURPOSE: The aim of this study was to describe the cultural factors that have an impact on military nursing care for Iraqi patients. The results were part of a larger study in which the purpose was to understand nurses' experiences of delivery of care for Iraqi patients. METHOD: Three focus groups, consisting of military registered nurses and licensed practical nurses, were used to generate rich descriptions of experiences in a military combat support hospital in Iraq. Data were analyzed using thematic analysis methods. FINDINGS: Culturally, the differences between the Iraqi patients and the nurses included variations in communication, diet, and beliefs and values in reference to gender and patient dependency. CONCLUSION: The findings indicated that the nurses need language skills and cultural customs and beliefs training to provide care to culturally diverse patients. In addition, support services, such as dieticians, need to be involved in the plan of care to address applicable cultural issues. IMPLICATIONS: Implementation of learning to provide nurses language skills and cultural awareness of the diet, customs and beliefs of Iraqi people as well as the economic, political, and social factors that have an impact on their lives will promote quality nursing care and optimal health outcomes.

Chapter 6 impact of deployment on military families.

To date, approximately 300,000 families including 700,000 children have been affected by the increased and repeated number of deployments in support of the Global War on Terror in Iraq and Afghanistan since 2001. The purpose of this review is to discuss the impact of these deployments on family members of active duty and reserve/guard personnel. A search of literature across the years of military conflicts reveals waves of studies emerging after World War II, the Vietnam conflict, Desert Storm/Shield, and now the most recent wars. Study designs most frequently include qualitative exploratory, survey methods, and program evaluations. The field is limited by small scale projects, service- and facility-specific samples, and knowledge extracted from related topics. More research is needed to achieve a more comprehensive understanding across the trajectory of the deployment experience for both service personnel and family members as well as long-term outcomes.

Mothers going to war: the role of nurse practitioners in the care of military mothers and families during deployment.

PURPOSE: Many military women are being called to separate from their children to go to war. Most previous research has focused upon paternal, rather than, maternal, separation. The purpose of this article is to describe the experience of military mothers and their children during wartime deployments with clinical implications for nurse practitioners (NPs) in military or community settings. DATA SOURCES: Using grounded theory methods, 37 active duty and reserve component military women participated in a one-time interview. Included were women who deployed for at least 4 months to Iraq or Afghanistan and had at least one child under the age of 12 during the separation. CONCLUSIONS: Military families present unique challenges for NPs. Mother deployments offer opportunities for intervention and anticipatory guidance across the trajectory of the separation. Military women's emotional and physical health must be supported before, during, and following deployment. IMPLICATIONS FOR PRACTICE: NPs are ideally positioned to support military families. During deployment, the NP's focus may shift to care of the children and their caregiver. Before and at reintegration, NPs are in a key position to intervene early for posttraumatic stress and support family readjustment.

Military nursing care of Iraqi patients.

The purpose of this phenomenological study was to understand military nurses' experiences of care for Iraqi patients. Analysis yielded three themes-expanding practice, ethical dilemmas, and the cultural divide. "Expanding practice" is the nurses' descriptions of their personal initiative to seek opportunities for learning additional knowledge and skills so that they would be competent to provide care for all ages of patients from newborns to the elderly with a wide variety of complex diagnoses. "Ethical dilemmas" represented the mental distress the nurses experienced when confronted with moral imperatives related to the safe care of the patient. Nurses were faced with feelings of animosity toward provision of care of host nation patients, lack of trust in interpreters, and distressed because of their inability to ensure continuity of care. The "cultural divide" showed the challenges that the nurses confronted when caring for a population with a different language, value system, customs, and traditions. The themes support existing research and extend information about care of host nation patients adding depth and breadth to specific content areas. These nurses developed situated knowledge needed for particular challenges and experienced personal and professional growth.

Deployment of military mothers: supportive and nonsupportive military programs, processes, and policies.

Military mothers and their children cope with unique issues when mothers are deployed. In this article, we present mothers' perspectives on how military resources affected them, their children, and their caregivers during deployment. Mothers described beneficial features of military programs such as family readiness groups and behavioral health care, processes such as unit support, and policies on length and timing of deployments. Aspects that were not supportive included inflexibility in family care plans, using personal leave time and funds for transporting children, denial of release to resolve caretaker issues, and limited time for reintegration. We offer recommendations for enhanced support to these families that the military could provide.

Factors influencing a health promoting lifestyle in spouses of active duty military.

The purpose of this study was to understand the factors influencing the health promoting behaviors (HPBs) of military spouses. Pender's Health Promotion Model provided the theoretical framework guiding this study. One hundred twelve female spouses were surveyed regarding their perceived health status, perceived stress, self-efficacy, social support, and participation in HPBs. Perceived health status, self-efficacy, social support, and HPBs were positively related, whereas perceived stress was negatively related. Hierarchical multiple regression analysis showed perceived stress and social support to be predictive of an overall health promoting lifestyle (HPLPII), with the full model explaining 49.7% of the variance.

Revision of a Parental Stress Scale for use on a pediatric general care unit.

The purpose of this descriptive correlational study was to test and evaluate the psychometric properties of a revised Parental Stressor Scale: Pediatric Intensive Care Unit (PSS:PICU) for use on a pediatric general care unit (PSS:GCU). The sample consisted of 403 parents of hospitalized children in a large military Mid-Atlantic medical center. Reliability and validity were assessed by examining the modified scale using factor analysis, Cronbach's alpha, item analysis, and concurrent validity. Factor analysis supported the subscales on the PSS:PICU. Internal consistency of the PSS:GCU produced a Cronbach's alpha of 0.92 for the total scale similar to the PSS:PICU scale, with the reliabilities for the subscales ranging from 0.70 to 0.92. Significant correlations were found between the total scores of the PSS:GCU and the Family Inventory of Life Events (FILE), a measure of general life stress. The results of psychometric testing suggest that the PSS:GCU is a reliable and valid scale to measure parental stress in general pediatric care units.

Determinants of health-promoting behaviors in military spouses during deployment separation.

The purpose of this research was to describe predictors of participation in health-promoting behaviors among military spouses. A total of 105 female spouses of currently deployed active duty military members were surveyed to determine their perceived stress and participation in the health-promoting behaviors of exercise, diet, checkups, substance use/avoidance, social behaviors, stress management/rest, and safety/environmental behaviors. Demographic and deployment information was also collected. Regression analyses showed perceived stress was predictive of several health behaviors including exercise, social behaviors, stress management/rest, and safety/environmental behaviors. Increased perceived stress was associated with decreased participation in these behaviors. Deployment factors predicted only dietary behaviors and stress management/rest. As the minimum anticipated length of the deployment increased, healthy dietary behavior decreased. Likewise, as the number of deployments experienced increased, stress management and rest decreased. Stress brought on by military deployment may have detrimental effects upon participation in a health-promoting lifestyle.