Developing nursing curriculum to facilitate the delivery of holistic care to the military veteran

doi:10.4236/ojn.2013.35054

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Open Journal of Nursing, 2013, 3, 400-403 OJN

http://dx.doi.org/10.4236/ojn.2013.35054 Published Online September 2013 (http://www.scirp.org/journal/ojn/)

Developing nursing curriculum to facilitate the delivery of

holistic care to the military veteran

Michelle Beckford, Corinne Ellis

Saint Peter’s University, Jersey City, USA

Email: [email protected], [email protected]

Received 16 April 2013; revised 17 May 2013; accepted 10 June 2013

tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly

cited.

ABSTRACT

Daily media coverage tells the story of challenges

facing returning members of the United States Mili-

tary. H igh rates of suicide, more than twen ty per day,

horrific traumatic injuries necessitating challenging

physical and emotional healing, and lingering post-

traumatic stress disorders warranting the most ad-

vanced methods of treatment are reported daily. As

America recoils from two prolonged oversea wars,

the need for prepared healthcare providers is essen-

tial not only for the Veterans Administration (VA),

but also for civilian based healthcare systems. The

bulk of nursing education literature seems to evidence

a void regardi n g thi s se gment of the population. Wha t

seems like a prime education focus remains yet to be

enacted in most nursing programs. The authors have

responded to this challenge, by creating curricula

developed to increase nursing student awareness of

veterans’ unique needs, and to prepare undergradu-

ate nursing students to provide quality care to veter-

ans. Through the creation of a laboratory simulation

scenario, students learned how to holistically view

and respond to the needs of a veteran client. Debrief-

ing allowed for reviewing the experience and discuss-

ing concerns. Outcomes measured via pre- and post-

testing survey reflected the complexity of patient care

needs. Students were asked to rate their ability to

identify and prioritize appropriate nursing interven-

tions. Anecdotal feedback was positive in that stu-

dents consistently expressed a need to have additional

simulation experiences.

Keywords: Military; Suicide; Spinal Cord Injury;

Simulation

1. INTRODUCTION

Nurse Educators are being challenged to evolve with the

changing times; the needs of new graduates are rigorous

and compelling. Curriculum must extend beyond the

didactic to facilitate psychomotor skills and application

to clinical care of patients. C. Rauen [1] suggests a

paradigm shift from an instructor-centered model to a

learning centered model. Simulation can be the means to

this end. In a previous study conducted by the authors,

simulation was found to improve student outcomes.

Attrition rates dropped 14.6% with an added low fidelity

simulation component as compared to cohorts that were

not exposed to simulation in the curriculum. The study

was local and limited in sample size. The purpose of the

current study was to expand upon the use of simulation

by utilizing high fidelity simulation to prepare undergra-

duate nursing students to respond to the unique and

urgent healthcare needs of military veterans.

Current statistics delineate the alarming crisis facing

US veterans returning from Afghanistan and Iraq. For

every veteran killed by enemy combatants, 25 veterans

take their own lives ([2]. A recently established crisis

hotline created by the Department of Veteran’s Affairs

(VA), has documented more than 26,000 calls from

actively suicidal military vets. These data are frighten ing

given the tendency toward underreporting of suicidal

ideation [3]. Veterans with mental illness and substance

use disorders accounted for 32.9 percent of all Veterans

Health Administration (VHA) costs $12 billion [4].

According to the National Alliance for Mental Health

(NAMI), rates of PTSD in veterans of the Iraq and

Afghanistan wars range from 5 to 37 percent, while rates

of depression were found to be as high as 27 percent. The

Veterans’ Administrationhas treated more than 400,000

post 9/11 veterans for mental health problems [5].

To help meet the mental health and recovery needs of

US vets, services and pr ograms geared especially to their

unique needs are going to be required [6]. Senators have

told officials of the VA that they must speed up services

for vets with Post-Traumatic Stress Disorder and other

OPEN ACCESS

M. Beckford, C. Ellis / Open Journal of Nursing 3 (2013) 400-403 401

mental health cond itions [7 ]. A report released in January

2013 by the VA identifies report also identified female

veterans and Vietnam-era veterans as two demographic

groups that require extra consideration when it comes to

suicidal behaviors [8]. Keavney [9] notes that there are

22 million vets in the US, a mix of older vets exposed to

Agent Orange during the Vietnam war, vets exposed to

Malaria and Tuberculosis during conflicts in the Middle

East, veterans suffering from traumatic brain injury after

encountering improvised explosive devices, and todays

vets who are living with very serious injuries.

75% of military vets are cared for through the

Department of Veteran’s Affairs, which employs about

45,000 registered nurses. The VA is projecting the need

for even more RNs to address the best care for veterans’

special needs, including post-traumatic stress disorder,

mental-health issues and traumatic brain injuries [10].

Many military personnel will ultimately be treated by

primary care providers in the community and/or in local

hospitals [11]. The VA, the National League of Nursing,

the American Association of Colleges of Nursing and

other industry groups are calling on nursing schools to

take a pledge to do more to educate students on how to

care for veterans and their families [12]. Schools of

nursing are being challenged to provide relevant,

evidence-based content in their curricula. The American

Association of Colleges of Nursing (AACN) has

sponsored Joining Forces, which is a collaboration of

more than 500 nursing schools that are striving to

educate nursing students on best practice methods in

caring for military veterans. As part of this initiative,

educators are encouraged to prepare students to care for

those suffering post-traumatic stress disorder, traumatic

brain injury, depression, and other clinical issues [13].

The lay literature has clearly established the plight of

the military vet. However, there remains a gap in

scholarly nursing journals with regard to how educators

are responding. Therefore the authors have developed

and implemented a curriculum designed to address the

needs of this vulnerable population. Ultimately the

curriculum is intended to prepare undergraduate nursing

students as they enter into practice and to promote safe

practices. The curriculum incor porates concepts of holistic

care, meaning that care addresses physical, mental, emo-

tional, sexual, cultural, social and spiritual needs [14].

Holistic care as it applies to the military veteran, recog-

nizes the need to shift from traditional problem-based

disease care, to person-centered health care [15]. In

accordance with the philosophy of Holistic Enrichment

of Adult Living (HEAL), the aim of this program has

been to improve the preparation of nursing students by

including the use of relevant clinical assessment tools,

addressing the status of client support systems, and

improving communication [16].

This scenario was part of a larger set of simulation

scenarios designed to decentralize mental health concepts.

Decentralization is proposed, not for the purpose of

diluting the importance of mental health, but on the

contrary, to emphasize the need for all nurses to utilize

appropriate psychosocial interventions. In terms of

holistic care, psychological well-being is relevant to all

realms of nursing practice. Mental health assessment and

intervention need to be threaded across all areas of the

nursing curriculum.

The purpose of this project was to create a BSN

curriculum that reflected the mental health needs of

patients not only in acute care psychiatric facilities but

also in medical-surgical disciplines, maternity units, and

community settings. The larger curricu lum was designed

to also cover mental health throughout the lifespan. The

learning objectives were for undergraduate nursing

students to initiate and implement an appropriate mental

status assessment using therapeutic communication, and

also to provide safe care by identifying risk factors and

using critical thinking to establish requisite nursing

interventions. Therapeutic communication is a concept

introduced during the initial theory and clinical courses,

therefore the simulation also served to reinforce those

skills. Simulation of this type discouraged students from

hiding behind clinical tasks in the provision of holistic

care. Most importantly, this simulation was designed to

help students identify and respond to the individual

needs of military veterans. Students were provided

appropriate assessment tools including VA/DoD Essen-

tials for Depression Screening and Assessment in Pri-

mary Care [17].

2. METHODOLOGY

Students were provided with related didactic lecture

material prior to their scheduled simulation experience.

They were also assigned readings relevant to nursing

research that supported evidenced based practice.

Simulation was a mandatory assigned experience.

Students were placed in pairs to provide care for the

simulated patient. Two faculty members supervised the

simulation, one as a facilitator and one serving behind

the scenes as the voice of the patient. Students were

required to complete a pre-test prior to simulation. The

pretest consisted of a 10 question inventory submitted

anonymously through the survey monkey website.

Questions included 6 true/false questions designed to

measure students understanding of concepts related to

depression, spinal cord injury and care of the military

veteran. One question was dedicated toward dosage

calculation as suggested by QSEN competencies. The

final 3 questions were anecdotal questions in which

students were asked to rate their comfort in prioritizing

care and identifying appropriate nursing interventions.

The exact same questions were formatted into a post-test

M. Beckford, C. Ellis / Open Journal of Nursing 3 (2013) 400-403

402

and administered following the debriefing session of the

simulation.

Through the creation of a laboratory simulation

scenario, students learned how to holistically view and

respond to the needs of a veteran client. In the scenario, a

young female veteran experienced depression and

suffered a spinal cord injury as a result of an attempted

suicide. It is an inter media te c are settin g, where th e pati ent

is awaiting transfer to a rehabilitative facility. Students

were expected to utilize the nursing process, perform

psychosocial assessments, and recognize signs and

symptoms of depression. Students were also expected to

prioritize their nursing interventions to provide a safe

and supportive environment. Therapeutic communication

was integral to their approach as they prioritize num-

erous patient needs. Furthermore, students were expected

to provide physical care including positioning, turning, ,

and neurological checks. This scenario was different

from typical nursing simulations in that it progressed

based upon the patient’s verbal and psychosocial

presentation rather than according to significant changes

in physiological patterns. The patient was intentionally

created as a female for the purpose of eschewing the

stereotype of males only in the military and also for the

purpose of increasing the awareness that females in the

military are also at high risk for suicide. Debriefing was

conducted with all assigned students and with the

involved faculty members. Students were encouraged to

voice their concerns regarding their progress as the

scenario unfolded. Faculty reiterated that the simulation

lab allows for a safe place to make mistakes. It is im-

portant to note that this particular population of students

was at the junior level in a B.S.N. program and as such

had not had a course in mental health nursing yet.

Retention will be measured at a six-month interval sub-

sequent to this simulation by administering the same

post-test.

3. OUTCOMES

Students entered into each scenario with a high degree of

confidence as evidenced by their pretest ratings. It is

likely that students had no t realized the co mplexity o f the

scenario and/or the psychosocial aspects of care. Students

favorably rated their own ability of identify symptoms

relevant to appropriate assessments for each scenario as

evidenced by pretest questionnaires. In some scenarios

students were more in need of coaching and facilitation

when patients initiated emotionally charged discussions

or self disclosed serious issues such as deliberate attempt

to hurt oneself. Students by and large were able to

accurately provide safety measures related to suicidality,

and were also competent in recognizing presenting

symptoms of depression. Students were noticeably para-

lyzed in respond ing to the hopeless attitude of the p atient.

Not all students recognized that the patient was in fact a

military vet. The authors suspect that the students

misunderstood the patient’s demand for self-reliance,

wanting to be left alone, and overall stoic demeanor as

uncooperativeness rather than the common mind set of a

military vet. Students voiced surprise that the scenario

included a female as a military veteran.

De-briefers emphasized to students that these were

new experiences in which they were not necessarily

expected to know exactly how to respond, thereby a true

opportunity for learning in a safe environment. Students

still rated themselves as not comfortable in providing

holistic care to a patient with a spinal cord injury nor

able to prioritize interventions for safe care with the

same population as evidenced by post-testing. Lower

scores on self assessments in the post-test may reflect the

complexity of learning needs and further substantiates

the need for teaching this content.

Students are rarely engaged in sensitive topics of

discussion during actual clinical rotations. Therefore

simulation affords the opportunity to standardize such

experiences and allows for feedback prior to exposure in

actual clinical settings. Students do not have their

psychiatric nursing rotation until the fall semester of

their senior year and therefore were not expected to

diagnosis as part of the scenario, but were expected to be

able to communicate effectively, to provide safety mea-

sures, and to recognize the need for collaboration and/or

need for referrals. In debriefing sessions, students voiced

appropriate concerns about being caught off guard by

patient concerns and not knowing how to respond. It is

worth noting however that students in the junior class

had back to back scenarios over two consecutive weeks

and those students voiced improvement in their

communication skills and were noticeably more respon-

sive in problem solving with patient. Additionally, the

authors suggest that this simulation will serve as the

perfect segway as students transition into the fall of their

senior year in which they enroll in mental health nursing.

Anecdotally students identified an ability to transfer

knowledge between simulations in lab to patient care in

clinical setting. Students consistently have requested the

opportunity to participate in more simulated scenarios.

4. DISCUSSION

The authors have addressed a gap in the literature with

regard to simulation in psychiatric nursing while simul-

taneously creating a timely curriculum. Simulation in

nursing is not new, however the scenario created in this

simulation is unique. It encompasses a psychosocial

focus along with traditional physical care. The focus is

on therapeutic communication and emotional well-being.

This type of simulation enables students to address the

patient in a more comprehensive manner. Simulation

M. Beckford, C. Ellis / Open Journal of Nursing 3 (2013) 400-403

403

offers standardized clinical experiences for the purpose

of teaching critical concepts that students are unlikely to

encounter. It allows for additional patient care scenarios

of varying acuity in an era when short-term care facilities

have shorter length of stay. Simulation has the added

benefit of debriefing, which allows for reflection and

inquiry. Simulation allows for the introduction of specific

population needs such as the care of military veterans.

Curriculum needs to evolve to meet the changing needs

of society. The VA has a backlog of over 897,000 claims

for disability benefits related to mental health [2]. Nurses

need to be well equipped to provide comprehensive care

in all settings, understanding the unique needs that each

patient may present. There is an imperative to provide

safe care for those who protected the safety of our

country. Future endeavors will be to measure knowledge

retention at a six-month interval following the simu-

lation.

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