Master resilience trainer course quality improvement evaluation.

The Master Resilience Training (MRT) course is the U.S. Army's resilience program of record to develop soldiers as resilience trainers within their home units. The Walter Reed Army Institute of Research (WRAIR) recently conducted an MRT Quality Improvement Evaluation (QIE) to understand perceptions of the MRT course, determine the effectiveness of the course, and provide revision recommendations for the next iteration of the course. Soldiers who were completing the MRT course were invited to take surveys and participate in interviews. Results from quantitative and qualitative data suggest that most participants felt satisfied with the training and that it was relevant for soldiers. Most participants also agreed that the training would help them become better soldiers and leaders. Along with positive feedback about the course, participants also identified areas that could be improved. Soldier feedback along with program evaluators' observation informed recommendations for improving the overall MRT course and its implementation. Program evaluators recommend MRT participants learn fewer and less complex skills, focus on coach education throughout the course, and highlight leader development by promoting motivation and enhancing effective communication. Program evaluators recommendations for ways to improve buy-in from leaders and graduated MRTs are also discussed.

Systematic Improvements to the Army's Deployment Cycle Resilience Training Using a Comprehensive, Iterative Process.

INTRODUCTION: To support soldier readiness and mitigate the mental health consequences of deployments, Army regulation mandates soldiers to receive Deployment Cycle Resilience Training (DCRT) throughout their deployment cycle. A recent evaluation revealed several issues with the existing version that threatened the relevancy and usefulness of the training. The present article details the systematic approach taken by the Research Transition Office at the Walter Reed Army Institute of Research to revise the DCRT curriculum and presents the revision updates that are now included in DCRT version 3. METHOD: Curriculum developers (n = 2) with subject matter expertise relevant to the project followed an iterative process that was critical to the efficacy of the revisions. Developers used the existing DCRT modules as the curriculum framework and utilized several materials to inform the revisions to include Army doctrine, data from the quality improvement evaluation conducted by the Walter Reed Army Institute of Research, and the current research related to the deployment cycle, resilience, and behavior change. Internal and external stakeholders (n = 31) provided iterative feedback to ensure each of the six modules met DCRT revision objectives. RESULTS: The revised DCRT curriculum was implemented in August 2021. The resulting revisions included an increase in inclusivity, an emphasis on growth opportunities, an integrative approach to the deployment cycle phases, and greater practical application. Additionally, the curriculum incorporates best practices found to enhance the delivery of resilience-based psychoeducational interventions, specifically within high-risk occupational settings like the military. CONCLUSIONS: The revisions outlined in this article enhance the training quality and potential effectiveness of DCRT, which can positively influence soldier and family readiness and mission success. Furthermore, the deliberate and iterative curriculum revision process can serve as a guide to other curriculum development projects, specifically within the military context. Implementation considerations and potential limitations are provided, and future directions are discussed to include the ongoing evaluation.

Cohesion Assessment Team: A Multidisciplinary Unit Assessment Grounded in Army Doctrine.

INTRODUCTION: The Cohesion Assessment Team (CAT) provides battalion and brigade command teams with actionable insight into the climate of their unit and the presence of certain harmful behaviors. This assessment, initiated by the Vice Chief of Staff of the Army and initially managed by the Headquarters Department of the Army's People First Task Force, employs a framework from the Center for Army Professional Leadership to structure data and findings. MATERIALS AND METHODS: This manuscript describes how to conduct a CAT assessment. To start, two battalions within the same brigade are selected or volunteer for observation based on various metrics. Data are collected from multiple sources including (1) army metrics, such as promotion rates and Uniformed Code of Military Justice actions, (2) subject matter expert in-person observations and interactions, (3) discussions with battalion and brigade staff, (4) survey data from approximately 90% of the soldiers in participating units, and (5) targeted interviews, focus groups, and listening sessions. Onsite data are collected and synthesized with the survey results within a week. Results are presented to battalion and brigade command teams. Briefs highlight key elements of the unit climate that should be maintained or improved. In addition, summarized results are presented to progressively higher echelons of leadership, culminating with the Vice Chief of Staff of the Army for consideration of army-wide changes. RESULTS AND CONCLUSIONS: The CAT focuses on providing leaders at brigade and below with relevant and actionable information to help inform their internal decision-making to improve their unit's climate. This capability is distinct in many ways, including its non-attributional systems focus and its methodical approach to quickly collecting and triangulating multiple data points. Additionally, the CAT helps leaders identify areas under their control that will impact unit climate, similar to the feedback that training events provide on unit readiness. Army leadership deemed the CAT pilot a success, and responsibility for future CATs was transferred to the Training and Doctrine Command (TRADOC) in October 2022.

Optimizing Performance and Mental Skills With Mindfulness-Based Attention Training: Two Field Studies With Operational Units.

INTRODUCTION: Mental skills such as focusing attention and managing emotions are essential for optimal performance in high-stress occupations. Studies with military samples have demonstrated that mindfulness training (MT) led to improved computer-based cognitive performance. MATERIALS AND METHODS: To examine the impact of MT on operational performance, mental skills, and psychological health, a short-form program, Mindfulness-Based Attention Training (MBAT), was delivered to active duty soldiers as part of two randomized trials. Participants in study 1 (n = 121) and study 2 (n = 77) were randomized to one of three conditions: MT with proctored practice, MT with unproctored practice, or a waitlist control. Weekly 2-hour MBAT sessions were offered to participants in both MT conditions for 4 weeks. Beyond these sessions, participants also engaged in mindfulness practice that was proctored (within the occupational context) or unproctored (left up to the individual) for four subsequent weeks. RESULTS: Overall, the frequency of mindfulness practice was generally associated with better performance and improvements in mental skills. In study 1, those who practiced 3 or more days per week performed better on marksmanship under physical stress and reported fewer attentional lapses, less emotion regulation difficulties, greater mental toughness, and higher self-reported mindfulness compared to those who did not practice. In study 2, the frequency of mindfulness practice was associated with fewer attentional lapses and emotion regulation difficulties. CONCLUSIONS: Consistent with prior findings, results suggest that regular engagement in MT practice may help to optimize operational performance and improve mental skills in military cohorts.

Sleep problems and functioning during initial training for a high-risk occupation.

OBJECTIVES: The current study sought to characterize the sleep problems of soldiers entering Basic Combat Training and to identify the link between sleep problems and subsequent performance, psychological distress, anger reactions, and attention. DESIGN: Soldiers were surveyed at 4 time points throughout the standard 10 weeks of Basic Combat Training. Surveys were administered at weeks 1, 3, 6, and 9. Sleep problems were identified as either present or absent at each time point using a sleep problem screening questionnaire. Four sleep patterns were identified and then used to evaluate outcomes throughout training (n = 1577). RESULTS: When compared to those who never had a sleep problem ("healthy "; 60.6%), those who recovered from their initial sleep problem ("recovered"; 12.8%) started training with higher psychological distress and anger reactions and lower attention but steadily improved throughout training. Those who developed a sleep problem during training ("new onset"; 20.0%) and those who had a sleep problem throughout training ("chronic"; 6.6%) also started off significantly worse than the healthy group. The new-onset and chronic groups saw slower psychological distress improvement and a decline in attention throughout the course compared to the healthy group. The chronic group also significantly increased their anger reactions throughout training compared to the healthy group. CONCLUSION: Sleep problems during Basic Combat Training may be an indicator for difficulties managing entry into the military. These findings highlight the importance of improving sleep health for soldiers throughout Basic Combat Training and for others with similar training in high-risk occupations.

Energy Drink Use in U.S. Service Members After Deployment: Associations With Mental Health Problems, Aggression, and Fatigue.

Introduction: Energy drink use has become widespread, particularly by service members, but its association with mental health problems and other behavioral and health problems such as aggression and fatigue is unclear. The present study examines the association between energy drink use and mental health problems, aggressive behaviors, and fatigue in a military population. Materials and Methods: At 7 months following a combat deployment, 627 male infantry soldiers were surveyed. Prevalence rates were examined for the frequency (defined as the number of energy drinks consumed per day) and volume of energy drink use (defined as the number of ounces of energy drink consumed per day). Regression models examined the associations between energy drink use and mental health problems (i.e., sleep problems, depression, anxiety, post-traumatic stress disorder, alcohol misuse), aggressive behaviors, and fatigue. This study was approved by the Walter Reed Army Institute of Research Institutional Review Board. Results: Past month energy drink use was reported by 75.7% of soldiers with 16.1% consuming high levels (2+ energy drinks/day). High energy drink use, when examined by frequency, was associated with mental health problems (adjusted odds ratios from 2.0 to 2.7), aggressive behaviors (adjusted odds ratios from 2.3 to 3.5), and fatigue (ß = 0.143, p = <0.001) relative to those drinking none or less than one per week. These patterns were consistent when examining volume of energy drink consumption (high levels = 24 ounces or more/day). Conclusion: High energy drink use was reported by one in six soldiers and was significantly related to mental health problems, aggressive behaviors, and fatigue in a military population following a combat deployment. Messaging regarding energy drinks should encourage moderation and highlight the association with negative health outcomes and paradoxical association with fatigue. Future studies should examine these relationships in a longitudinal design to understand how high energy drink use may impact or be impacted by these health-related variables.

Soldiers and Leaders With Combat Experience: Unit Health and Climate.

Objective: The present study investigated the association between previous deployment experience and somatic symptoms, mental health, unit climate perceptions, anger, and risk taking among junior-enlisted soldiers who were preparing to deploy or who were in garrison, or home duty station. The study also investigated potential differences in these variables based on unit leader deployment history. Method: Soldiers in a combat unit were surveyed either in a predeployment (n = 1,554; one week before deployment) or garrison setting (n = 1,326). Surveys addressed deployment history, health, unit climate, and leader deployment history. Results: Those in the predeployment sample with deployment history had significantly more somatic symptoms, posttraumatic stress disorder (PTSD), sleep problems, and anger reactions, and significantly less favorable unit climate perceptions, compared to those without deployment history. Higher rates of sleep problems, anger reactions, and endorsement of a risk-taking item, along with less favorable unit climate perceptions, were also reported by experienced soldiers in the garrison sample. In both samples, soldiers with experienced leaders endorsed more risk-taking behaviors than those with inexperienced leaders. Predeployment soldiers with experienced leaders also reported higher unit cohesion than those with inexperienced leaders. Conclusions: Previous deployments appear to increase the risk for a range of outcomes reported by soldiers at predeployment and in garrison. Findings suggest the impact of deployment should be considered well beyond the traditional deployment phases. Future research should examine what experienced leaders bring to units, in terms of boosting cohesion and potentially increasing the willingness of unit members to engage in risk-taking behaviors.

Professional Stress and Burnout in U.S. Military Medical Personnel Deployed to Afghanistan.

BACKGROUND: Studies of medical staff members have consistently documented high levels of burnout compared to those in other professions. Although there are studies of burnout in military medical staff, there are gaps in understanding the experience of medical staff while they are deployed and few occupationally-related factors associated with decreased burnout have been identified in this population. PURPOSE: To assess work-related variables accounting for burnout over and above rank, post-traumatic stress disorder (PTSD) symptoms, and professional stressors in the deployed environment. METHODS: U.S. military medical staff members were surveyed in Afghanistan. The survey assessed burnout (emotional exhaustion and depersonalization), PTSD symptoms, perception of professional stressors, self-care behaviors, taking care of team members (team care), general leadership, and health-promoting leadership. Participants provided informed consent under a protocol approved by the institutional review board at Walter Reed Army Institute of Research, and coordinated through the Washington Headquarters Service and the Joint Casualty Care Research Team located in Afghanistan. A total of 344 individuals provided their consent (83.3%) and completed the survey. RESULTS: Correlations found significant positive relationships between perception of professional stressors and levels of burnout. Significant negative correlations were found between burnout and self-care, team care, general leadership, and health-promoting leadership. Regression analyses found self-care and team care accounted for less burnout even after controlling for rank, PTSD symptoms, and professional stressors. Health-promoting leadership accounted for less burnout even after controlling for these same covariates and general leadership as well. CONCLUSION: Although a cross-sectional survey, results provide three specific directions for reducing burnout in deployed medical staff. By emphasizing self-care, team care, and health-promoting leadership, policy makers, researchers, and leaders can address factors that influence burnout in this, and other occupational contexts. In addition, the constructs of team care and leadership offer novel contributions to the study of burnout in medical personnel.

Feelings of energy are associated with physical activity and sleep quality, but not adiposity, in middle-aged postmenopausal women.

OBJECTIVE: Feelings of fatigue and low energy are widespread among middle-aged women and have been shown to negatively affect quality of life. The aim of the present study was to examine the associations among adiposity, physical activity, and feelings of fatigue and energy in postmenopausal women. METHODS: Postmenopausal women (N = 74; mean [SD] age, 58.9 [3.8] y) were assessed for adiposity (via dual-energy x-ray absorptiometry), steps per day, minutes of moderate to vigorous physical activity per day (via an accelerometer), prior week intensity of psychological vigor (via the Profile of Mood States-Short Form), and prior month frequency of energy feelings (via the vitality scale of the 36-item Medical Outcomes Survey--Short Form). Sleep quality was measured using the Pittsburgh Sleep Quality Index, depression was measured using the Beck Depression Inventory-II, and perceived stress was measured using the Perceived Stress Scale. RESULTS: Adiposity was negatively related to steps per day (r = -0.55, P < 0.05) and minutes of moderate to vigorous physical activity per day (r = -0.48, P < 0.05). Adiposity was not significantly related to vigor, vitality, or any other psychological measures. Greater vitality was associated with lower total number of medications (r = -0.31, P < 0.01), more steps per day (r = 0.28, P < 0.05), and higher minutes of moderate to vigorous physical activity per day (r = 0.37, P < 0.01). Prior week feelings of vigor were unrelated to any variable of interest. Regression analyses revealed that minutes of moderate to vigorous physical activity per day independently explained 8% of the variance in vitality, whereas sleep quality was also a significant predictor of vitality (both P < 0.05). CONCLUSIONS: Engaging in recommended amounts of moderate to vigorous physical activity per day is associated with higher monthly frequency of energy feelings, regardless of adiposity status, in middle-aged postmenopausal women.

Physical activity, pain responses to heat stimuli, and conditioned pain modulation in postmenopausal women.

OBJECTIVE: Postmenopausal women (PMW) are at high risk for disabling pain and physical inactivity. This study sought to enhance the understanding of relationships between physical activity (PA) and pain among PMW using heat pain sensitivity test and conditioned pain modulation test. We hypothesized that, compared with active women, (i) inactive women would report higher pain intensity and pain unpleasantness ratings; (ii) inactive women in disabling pain would report higher pain intensity and pain unpleasantness at high, but not low, stimulus intensities; and (iii) inactive women would have less modulation. METHODS: Sixty-eight PMW rated the pain intensity and pain unpleasantness of hot stimuli presented to the thenar eminence of the hand. A subset of 31 women rated the pain intensity of a test stimulus (noxious heat) and a conditioning stimulus (cold water) as part of the conditioned pain modulation task. PA was assessed objectively with accelerometry. RESULTS: Mixed-model analysis of variance (2 × 4 × 2; PA × Temperature × Pain Status) showed that inactive women in disabling pain rated pain unpleasantness higher than active women in disabling pain (F3,192 = 3.526, ∂η = 0.052, P = 0.016). Significantly lower pain unpleasantness ratings were found at the highest stimulus intensity (49°C) only for active women in disabling pain compared with inactive women in disabling pain (t11 = 2.523, P = 0.028). The other hypotheses were not supported. CONCLUSIONS: PA is associated with a reduced sensitivity to the unpleasantness of painful high-intensity heat stimuli among women in disabling pain.

Adiposity, physical activity, and muscle quality are independently related to physical function performance in middle-aged postmenopausal women.

OBJECTIVE: Poor physical function performance is associated with risks for disability in late life; however, determinants of physical function are not well characterized in middle-aged women. The aim of this cross-sectional study was to examine the contributions of body composition, physical activity, muscle capacity, and muscle quality to physical function performance. METHODS: Postmenopausal women (N = 64; mean [SD] age, 58.6 [3.6] y) were assessed for body composition via dual-energy x-ray absorptiometry, for physical activity via accelerometer (steps per day), and for physical function via Timed Up and Go, 30-second chair stand, and 6-minute walk. Leg strength was assessed using isokinetic dynamometry at 60° second. Leg power was assessed with the Nottingham Leg Extensor Power Rig. Muscle quality was calculated as (1) the ratio of leg strength at 60° second to upper leg lean mass and (2) the ratio of leg power to total lower body lean mass. RESULTS: Regression analyses revealed the following: (1) age and muscle quality calculated with leg power are independently related to Timed Up and Go, explaining 12% and 11% of the variance, respectively (P < 0.05); (2) age and muscle quality calculated with leg strength are independently related to 30-second chair stand, explaining 12% and 10% of the variance, respectively (P < 0.05); and (3) number of medical conditions, muscle quality calculated with leg strength, steps per day, and adiposity are independent predictors of 6-minute walk, collectively explaining 51% of the variance. CONCLUSIONS: In postmenopausal women, a more optimal body composition (including lower adiposity and higher lean mass) and higher levels of physical activity are associated with better physical function performance at midlife.