The Influence of Time and Place on the Experiences of US Military Nurses in Vietnam.

BACKGROUND: Although the conflict in Vietnam (usually referred to as the Vietnam War) ended almost 50 years ago, few research-based publications of nurses' experiences in Vietnam exist. PURPOSE: The purpose of this study was to expand what is known about the experiences of US military nurses who served in Vietnam. METHODS: This secondary analysis used qualitative description to examine interview data from 15 nurses who served in-country (within Vietnam) and in-theater supporting Vietnam (e.g., Guam, the Philippines) between 1965 and 1972. FINDINGS: We found that nurses' experiences varied based on time deployed and place deployed (land, sea, or air; in-country or in-theater). The influence of time and place on US military nurses' experiences in Vietnam are illustrated through findings pertaining to danger, daily life, and work. The most prominent differences were between nurses assigned in-country and those assigned in-theater. DISCUSSION: The findings illustrate ways research of more recent and future conflicts might be strengthened.

Exploring the turbulent nature of nurses' workflow.

Turbulence is a central feature of nurses' workflow, yet it has received insufficient attention regarding how it affects nurses' work conditions. To enhance understanding of turbulence, we expanded upon and added refinements to an early conceptualization that included communication and workload as major sources of turbulence. For communication, the contributions of interruptions and handoffs are further explored. For workload, patient turnover and supplies/equipment are further explored; human resources and the built environment were added. Potential consequences of turbulence are also identified including increased cognitive work, increased workarounds, and diminished nurse well-being. Actions to address turbulent workflow include teaching students and nurses strategies to manage turbulence; attending to the practice environment such as staffing composition, remedying longstanding issues with supplies and equipment, and developing technology platforms with nurse input; and suggesting investigations to advance understanding of how turbulence influences nurses and to devise effective interventions.

Nurse Leader Expertise for Pandemic Management: Highlighting the Essentials.

The COVID-19 pandemic requires military nurse leaders in various patient care settings to engage in disaster response. Evidence supports essential leadership attributes for nurses that include skilled communication, organizational influence, and personnel management. Yet, nursing expertise that shapes nurse leader responsibilities during disaster management remains unclear. A description of how military nurse leaders contributed their nursing expertise during the COVID-19 pandemic response at one U.S. Military health care facility is provided to begin to delineate disaster management responsibilities.

Developing an instrument to assess empowering nurse leader communication behaviours.

AIM: The overall purpose of the study was to develop an instrument to assess empowering nurse leader communication behaviours. BACKGROUND: Effective communication by nurse leaders promotes empowerment, yet communication assessments are often broad in nature without specifying precise behaviours. METHODS: An instrument development process was used to identify empowering nurse leader communication behaviours. Nurses working in United States military health care facilities (n = 240) provided responses to 47 pilot items, along with a 12-item psychological empowerment instrument to test for concurrent criterion validity. RESULTS: After review of item performance, 12 items were deleted. An exploratory factor analysis supported either a 2- or 3-factor model, with confirmatory factor analyses conducted to validate the underlying latent variables of empowering and limiting behaviours. The final nurse leader communication assessment consists of 2 factors consisting of 20 positive items (empowering subscale) and 15 negative items (limiting subscale). CONCLUSION: The final 2-factor assessment supports the theoretical premise of the empowering and limiting behaviours. Further testing may provide further dimensional clarity. IMPLICATIONS FOR NURSING MANAGEMENT: Use of the assessment can provide a basis for the development of training for individual nurse leaders or for facility nurse leaders as a collective.

A multi-center study of horizontal violence in United States military nursing.

Horizontal violence refers to repeated behaviors over time that intimidate or demean another. These behaviors may negatively impact the nursing workplace. The purpose of this study was to describe horizontal violence occurrence in the United States military nursing workplace and to determine the effectiveness of an educational intervention. Using a one group before-after design, survey data on horizontal violence behaviors, personal effects, perpetrators, job satisfaction and intention to leave were collected before and after a 30-min educational intervention. Reported horizontal violence behaviors and personal effects from horizontal violence averaged once to twice in a three month period. Staff nurses (peers) were the most frequent perpetrators. Job satisfaction and intent to leave significantly correlated with horizontal violence. There were no significant differences in overall horizontal violence before and after the intervention. Within the United States military nursing workplace horizontal violence does occur, although less frequently than in the United States civilian nursing population. Education on horizontal violence may not be sufficient as a sole intervention.

Short Peripheral Catheter Dwell Time and Associated Complications: A Systematic Review.

There is evidence that the risk of complications caused by short peripheral catheters (SPCs) does not increase when SPCs are replaced due to clinical indication versus at a specific time frame. In the studies, however, the dwell time does not typically exceed an average of 3.5 days. It is uncertain how long SPCs may stay in place before there is an increased risk for complications or if there is an increased risk. This systematic review was conducted to explore the current state of the science regarding SPC dwell time as a predictor of SPC complications in adult inpatients.

Improving the Efficiency of a Military Treatment Facility Transfer Center Process.

INTRODUCTION: A performance improvement project was initiated at Tripler Army Medical Center (TAMC) to decrease the amount of inpatient stays by military beneficiaries at civilian hospitals. Before the start of the project, the transfer process from external emergency rooms was completed by patient administration personnel and residents. This process had a median time to disposition decision of 40 minutes and led to missed opportunities for TAMC to care for military beneficiaries. The goals for the project were to have the median transfer process at less than 30 minutes from first call to time of disposition, to minimize unnecessary transfer denials, and to improve the perception of TAMC transfer process. MATERIALS AND METHODS: The team implemented multiple countermeasures as a performance improvement project to improve the transfer process. These included enhancing technological capabilities, providing clinically trained personnel to answer initial telephone calls, establishing rapid attending physician contact for acceptance, and standardizing data collection. Descriptive data were used to describe the progress toward project goals to include median time to disposition, number of monthly calls, and reasons for denials of patient transfers. RESULTS: The project met all proposed goals. The median time to disposition decision was reduced to 22 minutes. The primary reasons for denials included that the transfer was considered medically unnecessary (40.6%), no beds were available (18.9%), and the patient was unstable for transport (14.9%). As a reflection of improved customer service, there was an overall increase in transfer requests and positive feedback from the referring physicians at the local civilian hospitals. CONCLUSION: The improved transfer process at TAMC resulted in a decreased median time of transfer request process, increased total transfer requests, and improved relationships with local civilian hospitals. While we acknowledge that each MTF has facility and regional characteristics (such as capability, capacity, military staffing, and degree of availability of civilian healthcare resources) that may contribute to variation from TAMC, the concepts and changes made in the transfer process may be considered a best practice to be adopted by other military facilities to promote the recapture of beneficiaries into the Defense Health Agency system.

Dysphoric Milk Ejection Reflex: A Descriptive Study.

Introduction: Dysphoric milk ejection reflex (D-MER) is emerging as a recognized phenomenon to describe an abrupt dysphoria, or undesirable feeling that occurs with the milk ejection reflex (MER) and then goes away after a few minutes. The purpose of this study was to determine the prevalence of D-MER among breastfeeding women and to describe the experience of symptoms associated with D-MER. Materials and Methods: To determine the prevalence of D-MER, a retrospective chart review was conducted over a 12-month period on women presenting for their 6- to 8-week postpartum visit. To describe the experience of D-MER, an anonymous cross-sectional survey consisting of 36 items was made accessible through a link to an online survey management platform. Participants were recruited through both paper and electronic posters at a variety of venues. Results: A prevalence rate of 9.1% was found. The respondents described similarities in their experiences with D-MER, to include feelings coming on suddenly and lasting for <5 minutes. The respondents described feeling anxious, sad, irritable, panicky, agitated, oversensitive, and tearful most often. Conclusion: This is the first study to quantify a prevalence rate and describe suspected experiences of D-MER. It provides the groundwork for future research to explore other contributing factors or relationships that may be relevant to D-MER. The findings support that the experience of D-MER is different from that of postpartum depression. Future research exploring the behavior of hormones and neurotransmitters within the context of lactation could contribute to the knowledge regarding D-MER.

The 3'UTR of the α6 integrin message regulates localization of α6ß4 integrin heterodimers.

The α6ß4 integrin heterodimer is an essential component of hemidesmosomes (HDs) and HD-related structures, which adhere epithelial cells to the underlying extracellular matrix. In this study, we focused on the importance of the α6 integrin 3' untranslated region (UTR) in α6ß4 integrin localization. To do so, A549 cells (a type II lung alveolar cell line) and immortalized human epidermal keratinocytes (iHEK) were infected with adenovirus encoding the entire α6 integrin protein with or without portions of its 3'UTR. In infected A549 cells, we detected α6ß4 integrin heterodimers containing the product of the adenovirus, regardless of whether the α6 integrin 3'UTR was present. However, only those α6 integrin proteins whose messages contained bases 4770-5633 of the α6 integrin 3'UTR were targeted to matrix adhesion sites. Moreover, overexpression of the full length α6 integrin 3'UTR, minus the coding sequence, in A549 cells disrupts the localization of endogenous α6ß4 integrin heterodimers. Following infection of iHEKs with the same adenovirus, the induced α6 integrin protein localizes to HDs regardless of whether its message possessed a 3'UTR. In sharp contrast, in α6 integrin depleted iHEKs, restoring α6 integrin expression using the coding sequence alone via adenoviral transduction resulted in α6 integrin preferentially forming α6ß1 rather than α6ß4 integrin heterodimers. α6ß4 integrin was only observed in knocked down cells following infection of adenovirus encoding the α6 integrin coding sequence with its 3'UTR. In summary, our data indicate that the α6 integrin 3'UTR is a key regulator of α6ß4 integrin heterodimer assembly and incorporation at sites of cell-matrix adhesion.

Usability of and Satisfaction With Vocera Wireless Communication.

Qualitative reports of hands-free communication devices highlight numerous improvements in communication. The purpose of this study was to assess both usability and satisfaction scores at approximately 1 year after the implementation of a hands-free communication device at two different large military facilities. To do this, a survey that included the System Usability Scale and questions to assess satisfaction with regard to use, quality, and user satisfaction was provided to staff at both of these facilities. System usability scores indicated moderate satisfaction (61.7 at facility A, 63.8 at facility B). User satisfaction rated highest levels of agreement with the hands-free devices as an important system and being useful (35%-37% at facility A, 46% at facility B). Scores regarding improving the quality of work (A = 12%, B = 16%); safety of patients (A = 23%, B = 29%); and ability to do their job in a timely manner (A = 23%, B = 29%) were the lowest. The results highlight the potential benefits of Vocera for improving communication within the healthcare team. Given the large percentage of staff turnover at both of these facilities, the sustained benefit of hands-free devices will require ongoing training and continued evaluation of workflow processes.

Identifying the constructs of empowering nurse leader communication through an instrument development process.

AIM: The purpose of this article was to describe the constructs of empowering front-line nurse leader communication behaviours. BACKGROUND: Leaders' communication behaviours are instrumental in establishing a positive work environment. Nurse empowerment, a characteristic of a positive work environment, is influenced by communication behaviours. However, characteristics of empowering nurse leader communication behaviours have not been well-defined. METHODS: The constructs of empowering nurse leader communication behaviours were identified and refined during the instrument development process. A priori constructs were identified through a literature search, presented to focus groups of military nurses (N = 16), and refined during the procedures of item development. RESULTS: Eight final constructs emerged as a result of the iterative methods of item development: comprehensibility, listening, openness, feedback, empathy, nonverbal, paralanguage and manner. CONCLUSION: The constructs that describe empowering nurse leader communication behaviours are based on theoretical tenets of empowering communication and leadership, as well as the perspectives of military nurses. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers can use the findings to implement innovative leadership assessments and training that focuses on Nurse Leader communication to enhance the nursing workplace environment.

Auricular Acupuncture for Chronic Pain and Insomnia: A Randomized Clinical Trial.

Objective: In the United States, ∼1.6 million adults use complementary and alternative or integrative medicine for treating pain and insomnia. However, very few studies have tested the use of auricular acupuncture using a standard protocol for chronic pain and insomnia. The aims of this research were to assess the feasibility and credibility of auricular acupuncture, and to evaluate the effects of auricular acupuncture on pain severity and interference scores, and on insomnia severity over an 8-day study period. Materials and Methods: Forty-five participants were randomized to either an auricular acupuncture group (AAG) or a usual care group (CG) on study day 4. A standard auricular acupuncture protocol was administered, with penetrating semipermanent acupuncture needles in place for up to 4 days. The main outcome measures were feasibility of conducting the study, credibility of auricular acupuncture as a treatment modality, Brief Pain Inventory pain severity and interference scores, and Insomnia Severity Index (ISI) scores. Results: There was high interest in the study and the retention was 96%. Credibility of auricular acupuncture as a treatment was high in both groups. The use of the standard auricular acupuncture protocol in the AAG led to significant within- and between-group reduced pain severity and interference scores, compared to the CG. Both groups showed within-group decreased ISI scores. However, the AAG showed significant between-group reduced ISI severity scores compared to the CG. Conclusions: With the heightened focus on the opioid crisis in the United States, this easy-to-administer protocol may be an option for treating military beneficiaries who have chronic pain and insomnia.

Workplace victimization risk and protective factors for suicidal behavior among active duty military personnel.

BACKGROUND: Workplace victimization is a potential risk factor for suicidal behaviors (SB) among military personnel that has been largely overlooked. This paper examines both the impact of workplace victimization on reported SB and several potential protective factors associated with such suicidal behaviors in a large sample of active duty soldiers. METHODS: A case-control study was conducted with 71 soldiers who reported SB in the past 12 months, each matched on sociodemographic characteristics to two others without reported suicidal behaviors. A multiple regression model was estimated to assess the effects of risk and protective factors while controlling for other variables. RESULTS: SB was associated with several aspects of victimization, mental health and substance abuse conditions, pain, impulsivity, stressors, negative life events, work-family conflict, active coping behaviors and positive military-related factors. Controlling for other variables, those with SB were more likely to have sought mental health or substance abuse services, to be depressed, anxious, impulsive, and less resilient than non-SB personnel. LIMITATIONS: Study limitations included the use of retrospective self-report data, absence of some known SB predictors, and a population restricted to active duty Army personnel. CONCLUSIONS: SB among active duty personnel is associated with victimization since joining the military and is protected by resiliency. These findings suggest that in addition to the usual mental health factors, these additional predictors should be accounted for in SB intervention and prevention planning for active duty personnel.

Dysphoric Milk Ejection Reflex: A Case Series.

BACKGROUND: Dysphoric milk ejection reflex (D-MER) is characterized by an abrupt dysphoria, or undesirable feeling that occurs with the MER and continues for no more than a few minutes. After milk ejection, the dysphoria vanishes. CASE SERIES: This case series provides a report of three women who have experienced D-MER. All three women described the sudden onset of negative feelings at the initiation of each breastfeeding session. The dysphoria vanished after each milk ejection. DISCUSSION: Literature on D-MER is limited to one published qualitative research study and two published case reports. As a result, lactation professionals and other providers in the healthcare setting rarely recognize this condition. CONCLUSIONS: The case studies presented here provide evidence for the presence of D-MER. Research is needed to better understand its pathophysiology, incidence, and treatment options.

The culture contributing to interruptions in the nursing work environment: An ethnography.

AIMS AND OBJECTIVES: To understand the occurrence of interruptions within the culture of the medical nursing unit work environment. BACKGROUND: Interruptions may lead to errors in nursing work. Little is known about how the culture of the nursing work environment contributes to interruptions. DESIGN: A micro-focused ethnographic study was conducted. METHOD: Data collection involved extensive observation of a nursing unit, 1:1 observations of nurses and follow-up interviews with the nurses. Data were analysed from unstructured field notes and interview transcripts. The definitions of interruption and culture guided coding, categorising and identification of themes. RESULTS: A framework was developed that describes the medical nursing unit as a complex culture full of unpredictable, nonlinear changes that affect the entire interconnected system, often in the form of an interruption. The cultural elements contributing to interruptions included (i) the value placed on excellence in patient care and meeting personal needs, (ii) the beliefs that the nurses had to do everything by themselves and that every phone call was important, (iii) the patterns of changing patients, patient transport and coordination of resources and (iv) the normative practices of communicating and adapting. CONCLUSIONS: Interruptions are an integral part of the culture of a medical nursing unit. Uniformly decreasing interruptions may disrupt current practices, such as communication to coordinate care, that are central to nursing work. In future research, the nursing work environment must be looked at through the lens of a complex system. RELEVANCE TO CLINICAL PRACTICE: Interventions to minimise the negative impact of interruptions must take into account the culture of the nursing as a complex adaptive system. Nurses should be educated on their own contribution to interruptions and issues addressed at a system level, rather than isolating the interruption as the central issue.

Loss of ß-PIX inhibits focal adhesion disassembly and promotes keratinocyte motility via myosin light chain activation.

During healing of the skin, the cytoskeleton of keratinocytes and their matrix adhesions, including focal adhesions (FAs), undergo reorganization. These changes are coordinated by small GTPases and their regulators, including the guanine nucleotide exchange factor ß-PIX (also known as ARHGEF7). In fibroblasts, ß-PIX activates small GTPases, thereby enhancing migration. In keratinocytes in vitro, ß-PIX localizes to FAs. To study ß-PIX functions, we generated ß-PIX knockdown keratinocytes. During wound closure of ß-PIX knockdown cell monolayers, disassembly of FAs is impaired, and their number and size are increased. In addition, in the ß-PIX knockdown cells, phosphorylated myosin light chain (MLC; also known as MYL2) is present not only in the leading edge of cells at the wound front, but also in the cells following the front, while p21-activated kinase 2 (PAK2), a regulator of MLC kinase (MYLK), is mislocalized. Inhibition or depletion of MYLK restores FA distribution in ß-PIX knockdown cells. Traction forces generated by ß-PIX knockdown cells are increased relative to those in control cells, a result consistent with an unexpected enhancement in the migration of single ß-PIX knockdown cells and monolayers of such cells. We propose that targeting ß-PIX might be a means of promoting epithelialization of wounds in vivo.

Intermediate Filaments and the Plasma Membrane.

A variety of intermediate filament (IF) types show intricate association with plasma membrane proteins, including receptors and adhesion molecules. The molecular basis of linkage of IFs to desmosomes at sites of cell-cell interaction and hemidesmosomes at sites of cell-matrix adhesion has been elucidated and involves IF-associated proteins. However, IFs also interact with focal adhesions and cell-surface molecules, including dystroglycan. Through such membrane interactions, it is well accepted that IFs play important roles in the establishment and maintenance of tissue integrity. However, by organizing cell-surface complexes, IFs likely regulate, albeit indirectly, signaling pathways that are key to tissue homeostasis and repair.

Using Evidence to Increase Compliance with Therapeutic Stretching for Chronic Low Back Pain.

PURPOSE: In June 2012, a team of nurses at the Army's Landstuhl Regional Medical Center was tasked to generate an evidence-based practice recommendation for patients experiencing chronic low back pain (CLBP). METHODOLOGY: Based on 14 articles, the evidence (a) validated the use of therapeutic stretching for control of CLBP, (b) identified specific modalities to increase patient adherence, and (c) supported military relevance. The team developed a questionnaire to assess previous experience with stretching exercises and preferred learning methods. Based on the responses from 32 patients, the initial goals included an increase in patient reported compliance within 3 months and a decrease in reported pain within 6 months. Long-terms goals targeted a 90% patient compliance in daily stretching regimen and a continued decrease in pain within 1 year. RESULTS: At 3 months, a 96% compliance rate was reported for patients returning for follow-up appointments; however, the average reported pain level did not decrease. IMPLICATIONS: Similar clinics could benefit from methods/tools used in this project, especially where lack of compliance becomes a deterrent to quality of care.

Alpha actinin-1 regulates cell-matrix adhesion organization in keratinocytes: consequences for skin cell motility.

The migration of keratinocytes in wound healing requires coordinated activities of the motility machinery of a cell, the cytoskeleton, and matrix adhesions. In this study, we assessed the role of alpha actinin-1 (ACTN1), one of the two alpha actinin isoforms expressed in keratinocytes, in skin cell migration via a small hairpin RNA-mediated knockdown approach. Keratinocytes deficient in ACTN1 exhibit changes in their actin cytoskeleton organization, a loss in front-rear polarity, and impaired lamellipodial dynamics. They also display aberrant directed motility and move slower compared with their wild-type counterparts. Moreover, they have abnormally arranged matrix adhesion sites. Specifically, the focal adhesions in ACTN1 knockdown keratinocytes are not organized as distinct entities. Rather, focal adhesion proteins are arranged in a circle subjacent to cortical fibers of actin. In the same cells, hemidesmosome proteins arrange in cat paw patterns, more typical of confluent, stationary cells, and ß4 integrin dynamics are reduced in knockdown cells compared with control keratinocytes. In summary, our data suggest a mechanism by which ACTN1 determines the motility of keratinocytes by regulating the organization of the actin cytoskeleton, focal adhesion, and hemidesmosome proteins complexes, thereby modulating cell speed, lamellipodial dynamics, and directed migration.

Lung-specific loss of α3 laminin worsens bleomycin-induced pulmonary fibrosis.

Laminins are heterotrimeric proteins that are secreted by the alveolar epithelium into the basement membrane, and their expression is altered in extracellular matrices from patients with pulmonary fibrosis. In a small number of patients with pulmonary fibrosis, we found that the normal basement membrane distribution of the α3 laminin subunit was lost in fibrotic regions of the lung. To determine if these changes play a causal role in the development of fibrosis, we generated mice lacking the α3 laminin subunit specifically in the lung epithelium by crossing mice expressing Cre recombinase driven by the surfactant protein C promoter (SPC-Cre) with mice expressing floxed alleles encoding the α3 laminin gene (Lama3(fl/fl)). These mice exhibited no developmental abnormalities in the lungs up to 6 months of age, but, compared with control mice, had worsened mortality, increased inflammation, and increased fibrosis after the intratracheal administration of bleomycin. Similarly, the severity of fibrosis induced by an adenovirus encoding an active form of transforming growth factor-ß was worse in mice deficient in α3 laminin in the lung. Taken together, our results suggest that the loss of α3 laminin in the lung epithelium does not affect lung development, but plays a causal role in the development of fibrosis in response to bleomycin or adenovirally delivered transforming growth factor-ß. Thus, we speculate that the loss of the normal basement membrane organization of α3 laminin that we observe in fibrotic regions from the lungs of patients with pulmonary fibrosis contributes to their disease progression.