Research interest groups: Creating the foundation for professional nursing education, mentorship, and collaboration.

BACKGROUND: Research Interest Groups have been used to enhance collaboration within specialty health care areas. PURPOSE: This article was to demonstrate the impact of an organic model created by the TriService Nursing Research Program which became a conduit for collaboration across the three branches of Military Nursing Services to answer relevant research questions and support evidence-based practice. METHODS: Groups were organized around different specialty topics with a focus on education, mentorship, and collaboration. Modest funding, together with the development of an annual plan and report of scholarly activities allowed the groups to capture their impact and to strategically align efforts to support the National Defense Strategy and excellence in Military Nursing. FINDINGS: From 2018 to 2021, overall publications and funded grants for these groups increased each year despite multiple competing priorities. DISCUSSION: TriService Nursing Research Program Research Interest Groups demonstrate a successful, and easily replicable model to generate and disseminate research to inform clinical practice and health policy, both in the public and private sectors.

Top 10 Research Priorities for U.S. Military En Route Combat Casualty Care.

INTRODUCTION: Within the Military Health System, the process of transporting patients from an initial point of injury and throughout the entire continuum of care is called "en route care." A Committee on En Route Combat Casualty Care was established in 2016 as part of the DoD Joint Trauma System to create practice guidelines, recommend training standards, and identify research priorities within the military en route care system. MATERIALS AND METHODS: Following an analysis of currently funded research, future capabilities, and findings from a comprehensive scoping study, members of a sub-working group for research identified the top research priorities that were needed to better guide evidence-based decisions for practice and policy, as well as the future state of en route care. RESULTS: Based on the input from the entire committee, 10 en route care research topics were rank-ordered in the following manner: (1) medical documentation, (2) clinical decision support, (3) patient monitoring, (4) transport physiology, (5) transfer of care, (6) maintaining normothermia, (7) transport timing following damage control resuscitation or surgery, (8) intelligent tasking, (9) commander's risk assessment, and (10) unmanned transport. Specific research questions and technological development needs were further developed by committee members in an effort to guide future research and development initiatives that can directly support operational en route care needs. The research priorities reflect three common themes, which include efforts to enhance or increase care provider capability and capacity; understand the impact of transportation on patient physiology; and increase the ability to coordinate, communicate, and facilitate patient movement. Technology needs for en route care must support interoperability of medical information, equipment, and supplies across the global military health system in addition to adjusting to a dynamic transport environment with the smallest possible weight, space, and power requirements. CONCLUSIONS: To ensure an evidence-based approach to future military conflicts and other medical challenges, focused research and technological development to address these 10 en route care research gaps are urgently needed.

Nursing's Role in Preventing and Managing Back Pain in Military Members: Proceedings of the First Back Pain Summit.

This is a review of the proceedings of the first Military Nursing Back Pain Summit focusing on nursing's role in preventing and managing back pain. The purpose of the summit was to present the state of the science in back pain and to identify key gaps in research, policy, education, and treatment that could be undertaken by military nurses, nurse leaders, nurse practitioners, and nurse scientists. Several key points were highlighted during the summit: (1) back pain is multifactorial and preventable; (2) military service members have unique risk factors for developing back pain; (3) both acute and chronic back pain impact readiness and sustaining readiness is the primary mission of military medicine; (4) back pain is most effectively managed with multiple treatment approaches; (5) military culture must pivot away from an attitude of ignoring persistent pain or "toughing it out" to prevent acute back pain from becoming chronic; (6) integrating military nurses within operational units will be important for effective prevention, education, screening, and treatment within dispersed Multi-Domain Operations; and (7) early self-management is an important area for nursing research and intervention to empower service members to maintain and sustain their back health. The various presentations and panels from the meeting are summarized.

Implementing Evidence-Based Practice Facilitators: A Case Series.

BACKGROUND: In 2017, the TriService Nursing Research Program completed a strategic planning session, which identified key barriers to implementing evidence-based practice (EBP) within the U.S. Military Health System (MHS) including a focus on readiness training and deployments, frequent staff moves for military members, and relatively junior nurses in clinical roles. To facilitate EBP at individual military treatment facilities (MTFs), an EPB Facilitator role was developed using an evidence-based model and based on validated EBP competencies. METHODS: This new role was implemented at four MTFs in 2018: Naval Medical Center Portsmouth, 59th Medical Wing at Joint Base San Antonio Lackland, Naval Medical Center San Diego, and David Grant USAF Medical Center at Travis Air Force Base. This case series provides a description of the initial implementation of this role. RESULTS: Common enablers and challenges were identified from the experiences at all four sites. These included the importance of incorporating efforts into existing organizational efforts and infrastructure; the value of nurse leaders inviting EBP facilitators to participate and engage in scheduled meetings and committees; the significance of engaging with existing quality, process improvement, and training initiatives; and the benefit of collaborating with advanced practice nurses within the organization. The common challenges for all EBP facilitators were the frequent staff turnover at all levels and a lack of standardization to review and approve EBP initiatives, which makes it difficult to navigate the complete process of project implementation and collaboration across sites. Another challenge has been the difficulty to measure the impact of this role at the MTF and MHS levels. CONCLUSIONS: As EBP efforts continue and the program matures, it is anticipated that the outcomes from the individually completed projects, to include decreases in safety events, fiscal savings, and other improvements in organizational metrics, can be compiled to demonstrate the collective impact of these roles within the MHS.

Relation of post-traumatic stress disorder symptom severity to the efficacy of an animal-assisted intervention for stress reduction after military aeromedical evacuation.

Animal-assisted interventions (AAIs) have been found to decrease stress in some settings, but it is not known if AAI is feasible in an aeromedical staging facility or effective in reducing stress following aeromedical evacuation (AE) of military personnel. An experimental design was used to evaluate the efficacy of AAI at reducing stress in AE military patients (N = 120). Patients participated in a 20-min AAI (n = 60) or 20-min informational session about assistance dogs as an attention-control group (n = 60). Demographics, post-traumatic stress symptom severity (PTSSS), and stress biomarkers (cortisol, alpha-amylase, and immunoglobulin A) were collected regular intervals. AAI was found feasible and efficacious at reducing stress. Cortisol decreased significantly (p < .05) in the AAI group compared with the attention-control group. PTSSS moderated the immunoglobulin A responses to AAI as demonstrated by the interaction of PTSD Checklist-Military Version score, group, and time, F(1, 111.23) = 4.15 p = .044; effect size: d = 0.31. This research supports AAI as a stress-reducing modality in AE patients, particularly those who report higher PTSSS. Implications for future research are discussed.

Factors That Affect Pain Management in Aeromedical Evacuation: An Ethnographic Approach.

BACKGROUND: Pain management is a challenge in the transport setting, but actual factors that influence pain have not been assessed systematically. OBJECTIVE: To describe the environmental factors and social context that affect pain management in military aeromedical evacuation. METHODS: Field notes were taken throughout flight, including observational measures of pain, environmental factors, and interactions between the patient and crew. Data collection was completed on 8 missions and 16 patients; common themes were identified that should be considered in the management of pain in aeromedical evacuation. RESULTS: Communication was a key problem primarily to aircraft noise, the reluctance of patients to speak with crew members while they were wearing headsets, and limited time to assess for pain and provide patient education. Seating and litters appeared to be uncomfortable for ambulatory and litter patients, and preparatory guidance on pain management did not address the stressors of flight or transportation phases. Another compounding factor was the psychological distress, particularly among those leaving a combat zone before the anticipated end of a deployment. Throughout the flight, the military culture of independence, stoicism, and camaraderie also was clearly evident. CONCLUSIONS: Barriers to communication, comfort, and patient education are well known to transport nurses, but it is important to understand the overall effect they have on the management of pain. Developing solutions to address these factors should be a priority to ensure pain is adequately managed throughout transport.

Understanding Post-Deployment Reintegration Concerns Among En Route Care Nurses: A Mixed-Methods Approach.

The objective of this study was to better understand the post-deployment behavior health symptoms and readjustment/reintegration experienced by military nurses who provided en route care while serving in Operation Enduring Freedom/Operation Iraqi Freedom. Employing an exploratory, concurrent, mixed-methods design with an electronic survey consisting of several valid instruments and single, face-to-face interviews; data were gathered from 119 surveys and 22 interviews. Four qualitative themes aligned with the Post-Deployment Readjustment Inventory items. Findings from interviews support and illuminate the outcomes of the Post-Deployment Readjustment Inventory. Behavioral health usage was high in the quantitative sample. Nearly 74% (n = 88) of respondents indicating they had used Military Behavioral Health services following deployment. Statistically significant differences were noted among all subscales except Intimate Relationship Problems. Combined results indicated en route care nurses encountered difficulties when attempting to return to predeployment roles; behavioral health problems mirrored those of combat warriors. Interventions to assist post-deployment reintegration of en route care nurses should be conducted at the peer, leader, and health care provider levels. Embedding military mental health providers into en route care units is needed. It is imperative to gather lessons learned and identify ways to improve preparation for future conflicts and behavioral health of en route care nurses.

Noninvasive Continuous Hemoglobin Monitoring in Combat Casualties: A Pilot Study.

OBJECTIVE: To describe the accuracy and precision of noninvasive hemoglobin measurement (SpHb) compared with laboratory or point-of-care Hb, and SpHb ability to trend in seriously injured casualties. METHODS: Observational study in a convenience sample of combat casualties undergoing resuscitation at two US military trauma hospitals in Afghanistan. SpHb was obtained using the Masimo Rainbow SET (Probe Rev E/Radical-7 Pulse CO-Oximeter v 7.6.2.1). Clinically indicated Hb was analyzed with a Coulter or iStat and compared with simultaneous SpHb values. RESULTS: Twenty-three patients were studied (ISS 20 ±â€Š9.8; age 29 ±â€Š9 years; male 97%; 100% intubated). Primary injury cause: improvised explosive device (67%) or gunshot (17%). There were 49 SpHb-Hb pairs (median 2 per subject). Bias: 0.3 ±â€Š1.6 g/dL (95% LOA -2.4, 3.4 g/dL). The SpHb-Hb difference < ± 1 g/dL in 37% of pairs. Eighty-six percent of pairs changed in a similar direction. Using an absolute change in Hb of >1 g/dL, a concurrent absolute change in SpHb of >1 g/dL had a sensitivity: 61%, specificity 85%, positive predictive value: 80%, and a negative predictive value: 69%. The SpHb signal was present in 4643 of 6137 min monitored (76%). CONCLUSIONS: This was the first study to describe continuous SpHb in seriously injured combat casualties. Using a threshold of 1 g/dL previously specified in the literature, continuous SpHb is not precise enough to serve as sole transfusion trigger in trauma patients. Further research is needed to determine if it is useful for trending Hb changes or as an early indicator of deterioration in combat casualties.

Perceptions of ICU Diary Utility and Feasibility in a Combat ICU.

Severely injured patients have difficulty recalling their intensive care unit (ICU) experience which may contribute to emotional trauma. An ICU patient journal contains a short summary of key events during the ICU stay, and has been shown to improve emotional well-being. This project evaluated the feasibility and perceptions of ICU journals in a combat ICU. A one-page survey was distributed to ICU nursing staff at Craig Joint Theater Hospital before and after the use of ICU journals as a process improvement initiative. 16 preimplementation and 10 postimplementation surveys were collected to determine the perception of the utility and feasibility of ICU journals, as well as changes to nursing job satisfaction. Overall, nurses had positive perceptions of ICU journaling; after implementation they felt it could also benefit nurses (31% vs. 80%, p = 0.002). ICU nurses that used journals were also more likely to feel their work makes a difference (90%, p = 0.012) and they could connect with their patient on a personal level (50%, p = 0.037). Primary barriers were time to journal and legal concerns. This study demonstrates with the right guidance, ICU journals can be incorporated into an ICU in a deployed environment and nursing staff feel they benefit the patient, family, unit, and staff.

Factors influencing health behaviors among active duty Air Force personnel.

BACKGROUND: Individual health behaviors affect whether U.S. Air Force (USAF) service members are fit and ready to deploy. PURPOSE: The purpose of this study was to understand health behaviors of USAF members to guide future interventions to reduce cardiovascular risks. METHODS: A qualitative descriptive study was conducted with a purposive sample of 24 active duty USAF participants. Conventional content analysis was used to derive data-driven themes that were compared with the Health Promotion Model (HPM). DISCUSSION: Participants defined health in a multifactorial way that covered physical, emotional, and spiritual dimensions. The three themes that contributed to participants' health behaviors addressed: "who I am," "what works for me," and the USAF culture. There was a poor fit between findings as expressed by these participants and the HPM. CONCLUSION: Although these findings were derived from a sample of USAF participants, the findings have implications for members of other military services. The findings also have relevance for nurses and other providers within the civilian work environments who can promote health and wellness by integrating a client's personal history into a plan for developing and sustaining a healthy lifestyle.

The Fog of War: Delirium Prevalence in a Combat Intensive Care Unit.

INTRODUCTION: Delirium is a fluctuating disturbance in consciousness associated with increased mortality. Injured warriors represent a unique unstudied population. We hypothesized delirium is common because of high injury severity scores and multidrug sedation regimens. METHODS: Mandatory delirium screening using the confusion assessment method (CAM) was initiated at Craig Joint Theater Hospital in Bagram, Afghanistan. Data were collected in July to August 2012 from the first 50 English-speaking trauma patients with CAM for the Intensive Care Unit (ICU) scores. RESULTS: Patients were male with mean age of 27.8 years; 88% of them were U.S. military personnel. Injury mechanisms were blast (68%) and gunshot (26%). Mean injury severity score was 20. Average ICU length of stay was 2.3 days; 64% were ventilated (for mean 1.2 days). Average time from arrival to CAM assessment was 7 hours, and 26 hours from the time of injury. Of patients, 44% were delirious, 36% at first CAM assessment. Fentanyl (62%) and ketamine (16%) were used for pain control (62%) and propofol for sedation (52%). There was no relationship between delirium and mechanism (p = 0.5) or ketamine on first ICU day (p = 0.2262). Delirium increased with vent days (p < .0001) and was associated with admission and mechanical ventilation (p = 0.0025). CONCLUSIONS: This study demonstrates a high rate of delirium in this unique population.

Comparison of a ferret model with an inanimate simulator for training novices in techniques for intubating neonates.

Simulators for neonatal intubation training have improved, prompting us to compare a state-of-the-art simulator with live ferrets for training novice family-medicine residents in this crucial skill. After a scripted didactic presentation, we used a crossover study design and randomly assigned residents to receive simulator or live ferret training, after which they repeated the procedure by using the opposite method. Participants were asked to report their level of confidence and competence before and after each training session and the usefulness of each training method. In addition, residents were videotaped performing the procedure and evaluated by using a modified global rating scale. The 2 methods did not differ in regard to self-reported confidence, competence, or usefulness of each training procedure. A majority of participants indicated that they preferred using the ferrets over the simulator, with realism cited most frequently as the reason for their choice. Videotape scores for time and motion and flow of the procedure were higher when the simulator was used, but higher for instrument handling when ferrets were intubated. Overall scores were higher for videotaped evaluations with the simulator compared with the ferrets. According to these findings, the simulator appears to provide adequate instruction for the initial training of novice learners in neonatal intubation techniques.

Chapter 3 innovations in the en route care of combat casualties.

The en route care environment is dynamic and requires constant innovation to ensure appropriate nursing care for combat casualties. Building on experiences in Iraq and Afghanistan, there have been tremendous innovations in the process of transporting patients, including the movement of patients with spinal injuries. Advances have also been made in pain management and noninvasive monitoring, particularly for trauma and surgical patients requiring close monitoring of their hemodynamic and perfusion status. In addition to institutionalizing these innovations, future efforts are needed to eliminate secondary insults to patients with traumatic brain injuries and technologies to provide closed-loop sedation and ventilation.