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80% OF NURSES SHOULD HAVE A BACHELOR’S DEGREE BY 2020

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Unlock your career potential in nursing with the CCNE-accredited RN-to-BSN2 program at University of Maryland University College. Developed with input from industry experts, our program can help equip you to take on more responsibility and provide exceptional evidence-based care in challenging settings. Our dedicated military and veteran advisors can help you navigate a degree plan that is right for you and explain how you may be able to earn up to 90 credits for your registered nurse license, associate’s degree and prior college coursework. The baccalaureate degree in nursing at UMUC is accredited by the Commission on Collegiate Nursing Education, 655 K Street, NW, Suite 750, Washington, DC 20001, 202-887-6791. CCNE is a specialized accrediting agency recognized by the U.S. Department of Education.

Enroll in our CCNE-accredited RN-to-BSN program.

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“Employment of New Nurse Graduates and Employer Preferences for Baccalaureate-Prepared Nurses,” American Association of Colleges of Nursing, 2013.

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This degree is only open to students with an associate’s degree in nursing or a diploma from a registered nursing education program that is recognized by the appropriate State Board of Nursing. Students must reside and have an active unencumbered nursing license in an approved state at the time of admission and throughout completion of the program. For a list of approved states, visit umuc.edu/nursing.

MADE FOR YOU Call 844-404-UMUC or visit UMUC.EDU

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INTERVIEW

MAJ. GEN. BARBARA R. HOLCOMB

n MAJ. GEN. BARBARA R. HOLCOMB is a 1987 distinguished military graduate of Seattle University Army ROTC, where she earned a Bachelor of Science degree in nursing. She earned a master’s in nursing administration from the University of Kansas, a master’s-level certification in emergency and disaster management from American Military University, and a master’s in military strategic studies from the U.S. Army War College, in Carlisle, Pennsylvania. Holcomb’s military education includes the U.S. Army Medical Department (AMEDD) Officer Basic Course, AMEDD Officer Advanced Course, Faculty Development Course, Combined Arms Services and Staff School, resident Command and General Staff College, AMEDD Executive Skills Course, Interagency Institute for Federal Health Care Executives, Medical Strategic Leadership Program, Army War College, Army Strategic Leader Basic, Intermediate, and Advanced courses, and CAPSTONE. Her previous assignments include clinical staff nurse, Post-anesthesia Care Unit and Department of Emergency Medicine, Madigan Army Medical Center; EMT Section, 47th Combat Support Hospital, Fort Lewis, Washington, and deployment to Desert Shield/Desert Storm; staff nurse and clinical head nurse, mixed medical/ surgical ward and head nurse, Troop Medical Clinic and 111th MI Brigade Family Clinic, Fort Huachuca, Arizona; Officer Basic Course nurse adviser, Department of Nursing Science; and commander, A/187th Medical Battalion, Fort Sam Houston, Texas; chief nurse, Department of Outlying Health Clinics, 67th Combat Support Hospital (CSH)/ Würzburg U.S. Army Medical Department

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Activity, Germany; Medical Detachment commander (provisional), Camp Able Sentry, Macedonia; chief nurse/executive officer, 14th CSH, Fort Benning, Georgia; commander, Special Troops Battalion; chief, Base Transformation Office, U.S. Army Garrison, Fort Sam Houston, Texas; chief, ambulatory nursing, Brooke Army Medical Center; chief, nursing administration, Carl R. Darnall Army Medical Center and commander, 21st CSH, Fort Hood, Texas; commander, Medical Task Force 21, operations Iraqi Freedom and New Dawn; chief, Army Nurse Corps Branch at Human Resources Command, Fort Knox, Kentucky; commander, Landstuhl Regional Medical Center, Landstuhl, Germany; command surgeon, U.S. Army Forces Command, Headquarters, Fort Bragg, North Carolina; Army action officer for the Military Health System Review; commanding general, Regional Health Command-Central (provisional), Fort Sam Houston, Texas. Prior to becoming

commanding general, Medical Research Materiel Command and Fort Detrick, she served as the deputy commanding general for operations, U.S. Army Medical Command. She was designated as chief, Army Nurse Corps on Nov. 2, 2015. Holcomb’s awards and decorations include the Distinguished Service Medal (1 oak leaf cluster), Legion of Merit (2 oak leaf clusters), Bronze Star, Meritorious Service Medal (5 oak leaf clusters), Army Commendation Medal (3 oak leaf clusters), Army Achievement Medal (1 oak leaf cluster), National Defense Service Ribbon, Iraq Campaign Medal (2 campaign stars), Kosovo Campaign Medal, NATO Service Ribbon (Kosovo), Southwest Asia Service Medal (3 campaign stars), Kuwait Liberation Medal (Saudi Arabia and Kuwait), the Meritorious Unit Commendation Ribbon (1 oak leaf cluster), and the Expert Field Medical Badge. She is a member of the Order of Military Medical Merit.

Maj. Gen. Barbara R. Holcomb.

Veterans Affairs & Military Medicine Outlook: What motivated you to begin a career in Army Medicine? Maj. Gen. Barbara R. Holcomb: I realized at the end of my first year of nursing school that I couldn’t afford the next three years. I had a workstudy job as a clerk typist in the Army Reserve Officer Training Corps [ROTC]/ military science department. During the summer, a three-year scholarship opportunity opened up. I applied, was accepted, and joined ROTC. I planned to do my four-year commitment and then get out. About two years in, I realized I liked what I was doing, and I’ve been here ever since.

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U.S. ARMY

Commanding General, U.S. Army Medical Research and Materiel Command and Fort Detrick, Maryland; Chief, U.S. Army Nurse Corps


V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

PHOTO BY JAMES CAMILLOCCI

How many different specialties are there within Army nursing? We currently have nine specialty nursing areas beyond medical-surgical nursing: public health, psychiatric, peri-operative, certified registered nurse anesthetist [CRNA], emergency/trauma, critical care, family nurse practitioner [FNP], psychiatric nurse practitioner [PNP], and nurse midwife [NMW]. We have some sub-specialties, called additional skill identifiers, that any of the specialties can earn. These include en route critical-care nurse, nursing informatics, nurse methods analyst, infection control, research, and case management. Are there any particular specialty areas experiencing nursing shortages? We have a shortage of CRNAs and PNPs in the active component. The Reserve component also has these shortages as well as critical care and emergency/ trauma. While we have many specialties, we also have to be generalists so we can

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Maj. Gen. Barbara R. Holcomb, chief of the U.S. Army Nurse Corps, speaks to medical personnel during a celebration of the 116th birthday of the Army Nurse Corps at Brooke Army Medical Center, Joint Base San Antonio-Fort Sam Houston, Feb. 2, 2017.Â

assist in areas where there are shortages or if a specific area in the hospital has a high volume of work. Do you find you are sometimes competing with the Department of Veterans Affairs (VA) and civilian hospitals when seeking new nurses for Army Medicine? Not really for our military nurses. We bring new nurse officers in through either ROTC, OCS [(Officer Candidate School) (through the Army Enlisted Commissioning Program)], or through a direct appointment. Nurses coming in with a direct appointment work through a recruiter and need to have a year of experience in nursing or already have a

specialty as mentioned above. Where we compete with the VA and civilian hospitals is with our Department of the Army civilian nurses. Nearly 60 percent of our nursing staff is civilian. Although we are both federal nursing entities, the VA has a different pay scale than the DOD [Department of Defense] and has not faced sequestration. We are challenged in some parts of the country to retain our civilian nurses especially if there is a VA or a large civilian hospital nearby. On the other hand, many Army nurses and other medical professionals transition to the VA at the end of their military career. It provides an opportunity for them to continue to serve. We have many great partnerships with the VA and are continuously developing partnerships with our civilian counterparts as well. How does the Army incentivize prospective nurses to choose a nursing career in the service?

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PHOTO BY ASHLEY FORCE, USAMMDA PUBLIC AFFAIRS

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

ROTC scholarships, recruiting and retention bonuses, specialty pay for advanced practice nurses [CRNAs, PNPs, FNPs, and NMWs]. We offer a program to pay for an advanced degree at the master’s and doctorate levels. Other incentives include leadership opportunities, medical and dental care, housing and food allowances, along with salary and promotion opportunities. What sort of balance does the Army maintain between military nurses, civilian nurses, and contractors? We rely heavily on our civilian and contract staff; they are essential to our success as a health care system. Our military nurses must maintain specific skills to provide essential nursing care in an operational field environment, so they have certain training requirements. Our

Lt. Col. Kara Schmid (center), project manager of the U.S. Army Medical Materiel Development Activity’s (AMMDA) Neurotrauma and Psychological Health Project Management Office, briefs Maj. Gen. Barbara R. Holcomb (right), commander of the U.S. Army Medical Research and Materiel Command and Fort Detrick, Maryland, on her office’s products and accomplishments, April 23, 2018.

military nurses also relocate every two to four years to gain experience. Our civilians provide continuity for our patients. Many of our civilians are military spouses, so they also relocate. During high periods of transition, we use contracted nursing staff to help fill our gaps. What are some of the key medical technologies that have been developed during your career, and how have they changed Army

Medicine, both on the battlefield and in care facilities? There have been many changes in technology over the past 30-plus years. To start with, health care itself has changed from an inpatient-based practice to outpatient with many surgical procedures changing to laparoscopic as opposed to open incisions. Radiologic diagnostic tools such as the digital X-ray, CT scan, PET scan, and MRI as well as diagnostic ultrasound have improved immensely. Other medical devices such as IV pumps, pain injection pumps, diabetic monitors, instant lab results with pointof-care testing, needleless IVs, infrared vein scanners to help insert IVs are new during my career. Patient documentation has also changed, from paper-charting to electronic-charting, and we are experiencing advances in telemedicine

In addition to changing the response procedures to trauma, we’ve developed blood products, burn treatments, regenerative tissue, extremity prosthetics, and many other products – many of which are now also in use in civilian health care settings. www.defensemedianetwork.com

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Battlefields in the future “may not allow us to have rapid air evacuation. We’ve trained our medics to treat a casualty and get them evacuated within a ‘golden hour.’ We have to teach them how to provide care beyond that hour. It may be 24, 72, or 96 hours before they can evacuate casualties.

PHOTO BY MELISSA MYERS, USAMRMC PUBLIC AFFAIRS

surgical teams through those facilities before deployment to ensure they have the highest possible skill set to take care of wounded warfighters.

U.S. Army Medical Research and Materiel Command Commanding General Maj. Gen. Barbara R. Holcomb delivers opening remarks at the 2017 Military Medicine Partnership Conference and Expo. and virtual health care. During the last 18 years of war in Iraq and Afghanistan, we’ve developed many medical devices and products to stop extremity, axillary, and intra-abdominal bleeding. In addition to changing the response procedures to trauma, we’ve developed blood products, burn treatments, regenerative tissue, extremity prosthetics, and many other products – many of which are now also in use in civilian health care settings. Do you ever have concerns that, because of the tremendous advances in such technologies, nurses and other health care professionals might become too dependent upon them? Yes. My concern is that we may not maintain the sensing skills we need such as listening, seeing, smelling, touching, and be able to assess a casualty to determine a plan because we rely on machines to do the work for us. If we are in an environment where we don’t have

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electricity, communication networks, or high-tech equipment, we will need to rely on basic skills, our senses, professional knowledge, and experience to get through difficult situations. What are some of the opportunities available to Army nurses for them to continue their education and growth in their careers? As I mentioned earlier, as part of the incentives, there are opportunities for advanced degrees. Additionally, Army nurses take national certification exams to demonstrate their specialty expertise. There are other opportunities for nurses to develop their leadership skills. They attend the same military courses as all other Army officers. There are opportunities to work in both field and garrison clinical settings, serve in roles to recruit nurses, support ROTC, command units, and work as staff officers at headquarters levels, among other opportunities such as congressional fellows and training with industry. We have just started a program to assign Army nurses and doctors to civilian trauma centers to help them develop their skills and to serve as a conduit to rotate

What do you see as the greatest future challenges in ensuring the health and safety of Army soldiers? We have become accustomed to being able to evacuate casualties from the point of injury to surgical care very rapidly. Battlefields in the future may not allow us to have rapid air evacuation. We’ve trained our medics to treat a casualty and get them evacuated within a ‘golden hour.’ We have to teach them how to provide care beyond that hour. It may be 24, 72, or 96 hours before they can evacuate casualties. They need to have the nursing skills to manage pain, minimize infections, toilet, feed, and position casualties. We can look to the past, to the lessons available from World War I and World War II and learn from those lessons to prepare for the future. We are also working efforts on how to maximize soldier fitness, so they are fighting at their optimal level, regardless of climate or elevation. The most important thing is helping soldiers understand why they are doing whatever skill they are learning, so they can troubleshoot if it doesn’t work. We have to grow from a mind-set of ‘do as you’re told’ to ‘this is the objective and these are ways you can achieve the objective.’ Soldiers must understand the intent of the task or mission.

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MILITARY AND VA NURSING HISTORY Caring Across the Years for Those Who Serve By Craig Collins

n U.S. NURSES (mostly males in the first century-and-a-half) have aided sick and wounded warfighters on the battlefield since the Revolutionary War – although not officially part of the military until the 20th century. The Continental Congress, at the request of Gen. George Washington, on July 27, 1775, approved hiring one nurse for every 10 patients in Army hospitals at a pay of $2 per month, $4 for nurse supervisors. The pay per nurse was raised to $4 when the Revolutionary War began a year later and their duties increased with combat casualties. In addition to the care they gave the soldiers, having a female nurse replace a male freed that man to join the fight. Those first nurses were untrained and many the wives of soldiers, who had no way to support themselves and had begun following the Army, doing odd jobs, for food and lodging. When the war ended, female nurses were dismissed. Despite fighting two more wars – the War of 1812 and the Mexican-American War (1846-1848) – female nurses were not employed by the Army again until the Civil War. Still working with no training, more than 6,000 served in both Union and Confederate hospitals and closer to the battle lines. A major step forward was made on June 10, 1861, when the Union named Dorothea Lynde Dix “superintendent of women nurses,” creating the first organized unit of U.S. nurses. As with the Revolution, however, they were civilian hires, not members of the military in either army. As before, the end of that war meant the end of the Army’s perceived need for such support, returning instead to only a small cadre of male nurses. Female nurses were not employed again until the Spanish-American War (1898), when the first contract hires were made to deal primarily with outbreaks of yellow fever, malaria, and other tropical diseases. Although that conflict only lasted four months, 21 of the more than 1,500 nurses who served died, largely from tropical diseases contracted from their patients. Once again, most of the women who applied were untrained, and the War Department had no resources to see if they were medically qualified. The Daughters of the American Revolution offered to serve as an examining board for potential nurses and,

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for the first time, an acceptable applicant had to have graduated from a training school and provide suitable recommendations. Recognizing the value nurses provided – and the need for more than the few male nurses the Army normally employed – the U.S. surgeon general laid out the criteria for a reserve force of nurses in 1899. Two years later, Congress made nurses a full part of the military by creating the Army Nurse Corps (ANC). The Navy Nurse Corps was established seven years later. The Army Reorganization Act of 1901 also created the first Reserve Corps of female nurses, most of whom previously had served at least six months in the Army. For the first time, the U.S. military had an organic corps of military nurses, trained to work close to the battle lines, which proved vital when America entered World War I in 1917. Although there were only 403 Army and 160 Navy nurses on duty at the time, by the end of the war in 1918, more than 22,000 had served, several decorated for their actions, including the Distinguished Service Cross and Medal of Honor. Several hundred of those also died in service, many victims of the 1918 Spanish Flu epidemic, according to the American Society of Registered Nurses®. World War I also saw the creation of the Army School of Nursing, which began courses specific to Army nursing at several military hospitals in 1918.

View of nursing nuns seated in front of tents of the U.S. Army 3rd Division Hospital, 7th Army Corps during the Spanish-American War, 1898.

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NATIONAL LIBRARY OF MEDICINE

Military Nursing History


V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

NATIONAL ARCHIVES

Left: “Nurses Are Needed Now!” World War II poster. Below left: On Aug. 1, 1956, Capt. Norma Parsons became the first woman to join the Air National Guard when she was sworn in as a nurse in the 106th Tactical Hospital, New York Air National Guard. Two days earlier, Congress had enacted Public Law 845 allowing the participation of women in the Guard, albeit only as officers serving in nursing and other medical fields; women were not allowed to enlist until 1967. Bottom: A Mobile Army Surgical Hospital (MASH) during the Korean War: The H-13 helicopter (left) that frequently ferried the wounded to medical care (the use of helicopters for transporting the wounded was first widely used during the Korean War); surgeons, nurses, and medics prepping a patient for surgery (center); and sterilizing surgical instruments (right).

U.S. ARMY MEDICAL COMMAND

AIR NATIONAL GUARD

After World War I, the military realized there was a problem with medics and others too often ignoring the authority of nurses because they were not commissioned. As a result, in 1920, military nurses were assigned “relative ranks” as lieutenants, captains, and majors, although the surgeon general ordered that they be addressed as “Miss” rather than by their ranks. Their pay was half that of male officers of the same rank, but the support of line generals and nursing organizations led to legislative changes in status and retirement. By the 1930s, military nurses, for the first time, were given full pay and allowances while attending advanced educational courses, especially in anesthesia and psychiatry, at universities across the nation. Those post-graduate courses served them and the military well in the conflict to come.

Nurses became a significant part of the military after the United States entered World War II in December 1941, facing combat across the globe against the two strongest militaries of the time: Nazi Germany in Europe, Africa, and western Asia, and Imperial Japan in the Asia Pacific. The American National Red Cross issued an urgent appeal for 50,000 nurses to join the Army and Navy nurse corps. In a 1942 editorial in the American Journal of Nursing, first lady Eleanor Roosevelt added her plea for women to join. Citing her four military sons, she wrote: I ask for my boys what every mother has the right to ask – that they be given full and adequate nursing care should the time come when they need it. Only you nurses who have not yet volunteered can give it. … You must not forget that you have it in your power to bring back some who otherwise surely will not return. Overall, more than 70,000 nurses joined the two corps, dozens of whom became Japanese prisoners of war, and many others who were trapped behind enemy lines in the middle of combat on both sides of the world. Their actions led to the lowest death-after-wounding rate in the history of war, with fewer than 4 percent of warfighters treated by nurses in the field dying from wounds or disease. It was not until 1947 that Army and Navy nurses were granted true permanent commissioned officer status, giving them the full rights, privileges, authority, and pay to which their ranks entitled them.

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PHOTO BY SGT. 1ST CLASS RANDALL JACKSON

As depicted in the TV show M*A*S*H* (Mobile Army Surgical Hospital), Army nurses served close to the front lines during the Korean War (1950-53) – the only women allowed in the combat zone. They also were present in field hospitals and on Army transport ships and hospital trains. Air Force nurses served in Japan and as flight nurses in the Korean theater. Navy nurses served on hospital ships in theater, the first time women were assigned to Military Sea Transportation Service ships. Several nurses from all services died during the war, most in plane crashes en route to Korea. As that war drew to a close, the first woman physician was commissioned in the Army. That conflict also saw the first woman enter the Air National Guard – Capt. Norma Parsons – who served as a nurse in the China-Burma-India theater. The Vietnam War (1965-72) saw a bit of a reversal in history as the first male nurses served in that war, their first major deployment since having been allowed into the Army and Air Force nurse corps and the Army Medical Specialist Corps in 1955 (it would be another 10 years before they were accepted into the Navy Nurse Corps). Male Army nurses were sent into areas considered too dangerous for female nurses, but Vietnam was America’s first war without clearly defined fronts, placing all nurses in the greatest danger in military nursing history and leading to a number of deaths and wounded among the thousands who served in theater.

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Left: Lt. j.g. Shiju SantaNivas, an intensive care nurse assigned to Walter Reed National Military Medical Center, treats a patient aboard the Military Sealift Command hospital ship USNS Comfort after a medical evacuation, Oct. 4, 2017. Comfort was in Puerto Rico to provide humanitarian assistance throughout the area. The Department of Defense was supporting the Federal Emergency Management Agency, the lead federal agency, in helping those affected by Hurricane Maria to minimize suffering and was one component of the overall whole-ofgovernment response effort. Right: Doctors and nurses from Landstuhl Regional Medical Center, Germany, and San Antonio Military Medical Center, Texas, attend to their patient July 10, 2013, prior to take off in the back of a C-17 transport plane. The patient, an Army wife, was the first patient to be flown across the Atlantic while on a specialized lung bypass machine called ECMO.

The ratio of male-to-female nurses changed significantly in the latter half of the 20th century, according to Col. Michael Ludwig, chief nursing officer at Brooke Army Medical Center, in San Antonio, Texas: “There are more male nurses in the Army than in the civilian world, although there are more women than men in military nursing.” Vietnam also saw a number of changes for the ANC, including the removal of all restrictions on the careers of female officers in 1967. As a result, in 1970, the chief of the Army Nurse Corps and the Women’s Army Corps director became the first women promoted to brigadier general. In 1971, the first woman was assigned as a flight surgeon in the Air Force and the Air Force

Reserve. In 1972, the hospital ship USS Sanctuary became the first naval vessel to sail with a male/female crew, and the Navy promoted the director of the Navy Nurse Corps to that service’s first female rear admiral. In 1979, an Army Nurse Corps officer became the first black female brigadier general in the history of the U.S. military. The first Air Force Reserve nurse was promoted to brigadier general in 1985. Military nurses were deployed to the brief first Gulf War (1991), but served in the largest numbers since Korea during the second Gulf War (2001- ), the longest sustained armed conflict in U.S. history. They helped contribute to the lowest U.S. killed-in-action rate in the history of warfare in both Iraq and Afghanistan, where, due to the asymmetrical nature of that war, they once again were subject to hostile fire. They also frequently found themselves treating more locals – including enemy soldiers – than U.S. or coalition casualties. The Muslim culture, especially in Saudi Arabia during Operation Desert Storm and later in Afghanistan, was at times, difficult for American female nurses, who worked in their regular uniforms alongside men, some under their command, which was alien to the local males, who sometimes criticized their dress and actions. But a 2008 study by the Brigham Young University College of Nursing found a common theme among the nurses who served – and continue to serve – in Southwest Asia:

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U.S. NAVY PHOTO BY MASS COMMUNICATION SPECIALIST 2ND CLASS STEPHANE BELCHER

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K


PHOTO BY DAVID KAMM, U.S. ARMY

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

“We did what we had to do. It’s what we’re here for.” Today, Army, Navy, and Air Force nurses of all ranks and specialties serve around the world, in permanent U.S. military hospitals in the States and overseas, such as the Landstuhl Regional Medical Center in Germany, the largest U.S. military hospital outside the country; aboard Navy hospital ships and Air Force medical transport aircraft; and deployed to both combat zones and natural disaster aid sites. In their nearly 250 years of service, from the untrained women hired for $2 a month by the Continental Army to today’s highly trained commissioned officers, military nurses – especially female – have made unprecedented progress and saved untold numbers of soldiers, sailors, airmen, and Marines in nearly every war the nation has fought, as well as peacetime duty caring for the sick and injured.

LIBRARY OF CONGRESS

VA Nursing History The foundation of today’s VA Nursing Service took shape in 1930, when three federal agencies responsible for veterans’ programs consolidated into the new Veterans Administration (VA). Approximately 2,500 registered nurses who had been assigned to the U.S. Civil Service went to work for the new VA. Although classified as “sub-professional” at the time, graduation from a state-approved school of nursing was required for VA employment, according to Alan Bernstein, deputy chief of the VA’s Nursing Office. The history of providing care for America’s veterans, however, stretches back to early colonial times. In 1636, a law passed by the Pilgrims of Plymouth Colony stated that disabled soldiers – primarily from the war with the Pequot Indians – would be supported by the colony. In 1776, the Continental Congress sought to improve enlistments during the Revolutionary War by providing pensions to disabled soldiers. For the first three decades following the Revolution, individual states and communities provided direct medical and hospital care to veterans. It wasn’t until 1811, just prior to the second war against the British, that the federal government established the first home and medical facility for veterans. Later in the 19th century, veterans’ assistance programs were expanded to include widows and dependents. The Veterans Health Administration (VHA) traces its history back to the closing days of the Civil War, when President Abraham Lincoln signed a law establishing a national soldiers and sailors asylum for that war’s veterans, the nation’s first federal soldiers’ facility. The first of the new national homes – aka soldiers’ homes or military homes – opened in August 1866 near Augusta, Maine. They were restricted to Union Army veterans, including U.S. black troops. By 1929, there were 11 of those homes across the nation, accepting veterans of all wars. A number of veterans’ homes that included medical and hospital treatment also was established by the individual states

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Top: VA Medical Center, Aspinwall Division, Attendant’s Quarters Annex, Aspinwall, Pennsylvania. The Attendant’s Quarters Annex was associated with an early program of expansion at the Aspinwall Veteran’s Hospital facility. The construction of new quarters for attendants in 1932 was indicative of the increased demand placed upon the hospital during the late 1920s. Above: The former Western Branch of the National Home for Disabled Volunteer Soldiers was founded in 1885. It was the fifth in a series of 11 branch institutions established between 1867 and 1929.

following the Civil War. Those homes provided such care to indigent and disabled veterans of the Civil War, Indian wars, Spanish-American War, and Mexican border skirmishes, along with discharged regular members of the armed forces. “Men were the primary nurses at our earliest facilities – the National Home for Disabled Volunteer Soldiers – until 1890, when the first women nurses were hired,” according to the VA historian. “They were called stewards at the time. Overall, nursing was a male-dominated field in the U.S. until after the Civil War.” With America’s entry into World War I, the federal government established a new system of benefits for veterans, including vocational rehabilitation. After the war, administration of benefits to veterans was handled by three separate federal agencies: the Veterans Bureau, the Bureau of Pensions of the Interior Department, and the National Home for Disabled Volunteer Soldiers (NHDVS).

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Hundreds of private hospitals and hotels were leased by the Bureau of War Risk Insurance and the Public Health Service in 1918, creating the secondlargest VA hospital system, specifically to deal with returning World War I veterans. They also began building new dedicated veterans hospitals. The Veterans Bureau was created in August 1921 to bring all World War I veterans programs under a single agency. Veterans hospitals run by the Public Health Service were transferred to the bureau in 1922, along with 1,400 nurses, and construction began on a number of new hospitals for veterans across the nation. In 1928, admission to NHDVS homes was extended to women, National Guard, and militia veterans. A majority of today’s VA hospitals and medical centers came from the facilities operated by the three agencies. The Veterans Administration was created on July 21, 1930, by elevating the Veterans Bureau to a federal administration and merging the National Homes and Pension Bureau into the new VA. Approximately 2,500 registered nurses were employed in the new VA Nursing Service. In 1946, the VA’s Department of Medicine and Surgery was created, later re-designated as the Veterans Health Services

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and Research Administration. That became the VHA in 1991. “Public Law 293 [Title 38 U.S.C.] was passed in 1946 to reorganize and modernize the VA health-care system. It removed VA nurses, physicians and dentists from Civil Service, placing them in their own ‘Title 38’ personnel system under unique and specific personnel policies. Under this system, VA nurses were compensated according to experience, education and competencies, regardless of position assignments [i.e., clinical or administrative],” according to information Bernstein provided for this publication. “The first VA nurses mainly came from the armed forces. However, after local and regional experience with recruitment advertising during the late 1980s, VA launched its first national nurse recruitment advertising campaign in February 1990. Today, most VA nurses come from the civilian sector and students from accredited schools of nursing.” Since World War II, VA nurses, many of whom are reservists, have been called into active service to provide care for warfighters in combat zones and military hospitals. The demand for such nurses during World War II and the Korean War caused nursing shortages at VA hospitals back home. That service continues

today, with many VA nurses having been deployed with their Reserve units to Iraq and Afghanistan. Today, the VHA has become one of the largest health care systems in the world, providing training for a majority of the nation’s medical, nursing, and allied health professionals. According to the VA’s history website, some 60 percent of all medical residents receive at least part of their training at a VA hospital. The VA operates 1,600 health care facilities, including 144 VA Medical Centers and 1,232 outpatient sites, up from only 54 hospitals in 1930. The VHA’s medical facilities have expanded to cover a wide range of veteran conditions, including traumatic brain injuries, post-traumatic stress, suicide prevention, and more, as well as establishing telemedicine and other services to accommodate today’s diverse veteran population and incorporate the latest technologies. “The number of nurses employed by VA has increased with the increase in number of veterans seeking care at VA facilities,“ Bernstein said. “In 1921, about 1,400 hospital nurses from the Public Health Service were transferred to the new Veterans’ Bureau, the forerunner of VA. In 1930, when three federal agencies responsible for veterans’ programs consolidated into the new Veterans Administration, approximately 2,500 registered nurses then assigned to the U.S. Civil Service went to work for VA. As of January 2019, the VA employs over 100,000 total nursing staff members.” Bernstein said that number includes 71,286 RNs (15 percent of whom are military veterans), 15,001 LPNs (18 percent veterans), 13,234 nursing assistants (14 percent veterans), and 1,023 nurse anesthetists (28 percent veterans). “Taken together as a combined population, approximately 19 percent of VA nurses are veterans,” noted Karen Ott, the VA’s director for Policy and Legislation.

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VA.GOV VANTAGE

Former airman and nurse practitioner Richard Stiles now serves his fellow veterans as a VA nurse, working in palliative care.


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U.S. AIR FORCE PHOTO BY HEIDE COUCH

Left: Nursing staff members at Hunter Holmes McGuire VA Medical Center, in Richmond, Virginia. Below: Medical staff at David Grant USAF Medical Center perform thoracoscopic surgery to remove the upper left lobe in a lung cancer patient Feb. 26, 2019, at the Heart, Lung and Vascular Center (HLVC), Travis Air Force Base, California. Because of its partnership with the VA Northern California Health Care System, the HLVC provides one-stop care for patients with diseases of the heart, lungs, and circulation.

Since the 1960s, advances in medicine have required specialized training programs and expanded the need for advanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) in a number of areas. Education and research thus became increasingly integral components of the VA Nursing Service. Today, VA nursing has become the largest clinical training and cooperative education system, working with undergraduate and graduate programs at numerous colleges and universities. Several people within the VNS estimate 1 out of every 4 professional nursing students in the country receives some training from the VA. In addition to clinical care, VA nurses also are heavily involved in advancing medical research and helping the VHA keep up with the latest technological innovations. Nurse researchers help promote inclusion of evidence into practice to provide quality care for veterans. The VA nurse corps also plays a significant role in VA emergency planning, preparedness, response, and recovery. The types of care VA nurses are required to provide veterans began to change significantly in the 1960s, as the Vietnam War saw more and more veterans seeking help with a variety of ailments. Greater efficiencies in evacuating wounded warfighters from the battlefield and providing immediate care led to a

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dramatic increase in survival rates and, subsequently, in the number of disabled veterans seeking care from the VA. New diagnostic techniques led to other changes resulting from the wars in Southeast – and later Southwest – Asia, with new types of poly-trauma injuries requiring specialized expertise. Longer life expectancies also increased the need for geriatric and long-term care for veterans of earlier conflicts. By the 1970s, nurse practitioners had become the primary providers of VA patient care and the use of clinical nurse specialists was expanded. In the 21st century, VA nurses are constantly training and involved in continuing

education to ensure state-of-the-art care to more than 9 million veterans, ranging from the last survivors of World War II to those who recently left active service. That covers a wide range of services, comprising not only patient care but also clinical practice, education, research, and administration. In addition to medical, surgical, and psychiatric units, VA nurses work in intensive care, spinal cord injury, geriatric, dialysis, blind rehabilitation, specialty care (e.g., diabetes clinics) and hospice, domiciliary, oncology, and organ transplant units, providing primary, ambulatory, acute, rehabilitative, and extended care. “We see nurses continuing to be the largest group of care providers in the VA system, with expanded scopes of practice for all nurses and full practice authority for the advanced nurse practitioners. In addition, we see continued growth in care in the community and virtual health care,” Bernstein said.

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DOD AND VA NURSING Expanding Techniques and Technologies for 21st Century Care

n IN ANSWERING THE QUESTION “What is Nursing?” on the American Nurses Association website, it states: “21st Century nursing is the glue that holds a patient’s health care journey together. Across the entire patient experience, and wherever there is someone in need of care, nurses work tirelessly to identify and protect the needs of the individual.” That description is clearly evident throughout the multitude of nursing roles and venues in the Department of Defense (DOD) and the Department of Veterans Affairs (VA). While nurses’ commitment to highly skilled and compassionate care never waivers, the techniques and technologies utilized to deliver that care are continuously evolving. DOD TRAUMA DOCUMENTATION STUDY: FROM PAPER TO ELECTRONIC In one example of an evolving technology, trauma staff at Brooke Army Medical Center (BAMC) in San Antonio, Texas, have been conducting a performance improvement study since August 2018 using T6, an electronic trauma documentation application created by T6 Health Systems. U.S. Air Force (USAF) Lt. Col. (Dr.) Valerie Sams, trauma critical care surgeon at BAMC and the T6 study lead, explained the reason for the study, based on her observations and experience during deployment to Afghanistan a few years ago. Sams said that standard trauma documentation in the United States is still predominantly a paper process. The problem she noted while deployed, “with military health care being a continuum of care, from the point of injury through the Role 4, Role 5 level of care both in Germany and in the States, is that that paper documentation becomes very cumbersome in terms of data capture,” she said. “This is a process that follows people from the battlefield to wherever they’re going for their definitive care. A lot of the documentation was pretty poor, given the fog of war and difficult operational environments.” Sams continued, “In order for us to make decisions about resources, practice guidelines, and casualty care, we really rely on accurate data.” In an effort to improve data capture along the continuum of military trauma care, Sams worked with company representatives to explore an “electronic version of what we’ve been

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doing on paper for a very long time.” With improved efficiency and accuracy of data capture, she said, “combat casualty care is only going to get better.” Sams categorized the T6 as a nursing documentation tool, with the application extending “beyond documentation into things like clinical support, clinical practice guideline compliance, supply and logistics chain management, personnel management, coding and billing, and registry data capture,” she said. While those T6 capabilities exist, this yearlong, off-line study focuses solely on the documentation aspect. Because the trauma nursing community is passionate about ensuring accurate and complete documentation, Sams said, “finding an application that they can use and feel confident in was huge.” To evaluate the T6 application as a pilot at BAMC, nursing staff are documenting trauma care both electronically and with the paper method in a head-to-head comparison. Recently, the study has been extended to trauma care in Afghanistan, where Sams was again deployed. In use, Sams said the T6 application is loaded on Apple Inc. iPads® that are mounted to stands in the trauma bays, but are removeable for continuing documentation as patients are transported to other locations for diagnostic studies, such as X-rays. Large monitors also display the documentation in the trauma bay, including checklists, algorithms, warnings, and decisions, so everyone involved “can be on the same page with what is going on with that patient.” “The systematic approach to the T6 design is ideal for the general nursing environment,” said USAF Capt. Seana L. Gerald-Ellsworth, NC, BSN, RN, CEN, emergency/trauma nurse at BAMC. “The wheel set-up allows for head-to-toe guided assessments. It is very user friendly when time allows for the structured flow the T6 provides. The system flags abnormal values in the vital signs flow sheet and also allows for trending of vital signs in a graph format, which adds a visual component to the long-term observation of the patient.” Gerald-Ellsworth also identified challenges in implementing the T6 into their trauma practice. For example, she noted that it does not allow for easy navigation if a patient’s condition requires parts of the assessment to be done out of order, adding, “This also is partially attributed to the comfort or

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PTRUMP16 VIA WIKIMEDIA COMMONS

By Gail Gourley


U.S. AIR FORCE PHOTO BY CAPT. ANNA-MARIE WYANT

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

experience level of the nursing staff with the program. We have only been utilizing this system on a trial basis, which has been staffing dependent on how frequently we are able to use it in live trauma situations.” Gerald-Ellsworth observed that T6 utilization “follows a very structured layout that requires flipping through multiple pages at times to obtain certain categories for documentation. In some sections, there are not adequate options available and minimal ability to free text; for example, lab tests or radiology exams

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Capt. Katie Barnack (left), an emergency room nurse, and Lt. Col. Valerie Sams, a trauma surgeon, both deployed with the 455th Expeditionary Medical Group, demonstrate the T6 Health System, which is in trial phase at the Craig Joint Theater Hospital at Bagram Airfield, Afghanistan, March 30, 2019. The T6 mobile device application is a high-resolution, digital documentation system that may be used to replace some paper records and streamline patient care processes. can only be charted as ‘ordered/not ordered’ and ‘results.’ This is not useful in our trauma environment given that we need to chart the times the blood was

obtained or not obtained. Also, there is not an option for ‘unable to obtain’ or ‘deferred’ in the vital sign categories, which creates difficulties when closing out the charts that require vital signs to be entered.” However, she continued, “These may be [factors] that have potential to be tailored through the developers of the program to whom we have provided feedback when they have returned for follow-up visits. “As with any change to standard practice, there are always difficulties

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trying to look over a paper chart where you have to figure out everybody’s handwriting. I think it improves the process of caring for patients and getting the clear story from one location to another.” Looking to the future, Sams said the study also investigates whether the system could be used at earlier roles of care, beginning with point of injury, air medical evacuation, and other pre-hospital environments.

Mobile medic Spc. Amanda Knight prepares for a video conference with a medical provider while mobile medic Spc. Joshua Rath checks Spc. Joao Dos Santos Faustino’s vitals during an early morning “sick call” at the 232nd Medical Battalion, Sept. 25, 2017. A team of mobile medics used a combination of virtual and hands-on health care to triage the soldiers who reported to morning sick call.

VA TELEHEALTH: USING TECHNOLOGY TO EXPAND ACCESS In another example of broadening technology, the VA is recognized as a world leader in the development of telehealth services that are now missioncritical to the future direction of VA health care, according to John Peters, M.G., VA deputy director for telehealth services. Goals of utilizing telehealth technologies include enhancing accessibility, capacity, and quality of VA health care for veterans, their families, and their caregivers anywhere in the country. “VA’s history with telehealth goes back more than 50 years, when closed-circuit television was used to connect specialist providers at the University of Nebraska Medical Center in Omaha with veterans at three VA hospitals in Grand Island, Lincoln, and Omaha, Nebraska,” Peters

U.S. ARMY PHOTO BY ROBERT SHIELDS

with comfort and ease of implementation that can only be improved upon with familiarity with the program,” she concluded. “This is an ongoing process that we are trying to incorporate into our practice as staffing and availability allows.” Acknowledging the challenges and discomfort inherent in a new process, USAF Maj. (Dr.) Remealle How, trauma surgeon at BAMC and who is also involved with the T6 study, added that the electronic documentation system benefits patients by improving continuity of care. “Whenever you transfer a patient from one location to another, you’re relying mainly on verbal sign-out and paper charts,” she said. “From a clinician standpoint, it’s helpful to have all that information available in one location versus trying to piece it together from what people are telling you, and then

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noted. “Modern VA telehealth services, as integrated into VA’s national health care delivery, quality, and staff training systems, began almost 20 years ago. Today, VA telehealth services are available from more than 900 VA locations, and most recently to veterans at home or other non-VA locations. Last fiscal year, VA served more than 782,000 veterans in over 50 specialty areas of care through telehealth.” VA telehealth services function in three overlapping categories: remote patient monitoring/home telehealth; asynchronous telehealth; and synchronous telehealth. Remote patient monitoring/home telehealth applies care and case management principles to coordinate care using health informatics, chronic disease management, and technologies such as in-home mobile monitoring, messaging, and/or video technologies. Asynchronous telehealth uses technologies to acquire and store clinical information – such as data, images, or sounds – that is later reviewed, assessed, and evaluated by a VA provider at another location. Synchronous telehealth uses real-time interactive video conferencing, sometimes with supportive peripheral equipment, to assess, treat, and provide care to a veteran in a separate clinical location, increasingly at home or another non-VA location. As with VA health care services delivered in person, nurses serve at all levels of VA telehealth services, making a significant and sustainable impact on the care of veterans, according to Rita Kobb, APRN-BC, telehealth training team lead. Clinically, nurses utilize telehealth technologies along a continuum, from licensed practical nurses providing health coaching, to registered nurses serving as case managers, to nurse practitioners managing complex care for

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VA IMAGE

The VA’s Video Connect mobile app enables “anywhere to anywhere” synchronous video telehealth service.

veterans in primary and specialty care. Additionally, Kobb expanded, “VA registered nurses and advanced practice nurses have meaningful roles in research to shape telehealth practice; roles in education to ensure telehealth competency for VA staff; as well as roles in administration to provide vision and collaboration for enhancing veterans’ care through telehealth expansion and innovation. Nurses are involved in identifying patient outcomes and measures for telehealth services, establishing disease management standards and protocols, and developing tools to support staff performance.” VA telehealth services augment the in-person care veterans receive from their local VA, Peters explained, and offer many benefits. Veterans can utilize telehealth to access care that may not otherwise have been as easily accessible, due to factors such as travel time,

VA telehealth enhances “the quality of care for

veterans living in remote or rural areas who can access nationally recognized VA specialists in several specialty clinical areas such as post-traumatic stress disorder, bipolar disease, and genomics, for example.

distance, and cost; traffic; loss of work; daycare; inclement weather; or social stigma seeking care. Veterans also benefit when VA uses telehealth to better match supply and demand. “VA can hire providers at larger, often urban and academic, VA medical centers to provide interim vacancy coverage at smaller, often rural, VA facilities where there is relatively less recruitment potential,” Peters noted. “VA telehealth enhances the quality of care for veterans living in remote or rural areas who can access nationally recognized VA specialists in several specialty clinical areas such as post-traumatic stress disorder, bipolar disease, and genomics, for example.” Peters described several ways in which the VA plans to expand its use and definition of telehealth services, including: further development of its VA clinical telehealth resource hubs to provide mental health, primary care, and other core clinical providers’ services; strategic partnerships with public community centers and commercial retailers to establish telehealth access stations for veterans without video capability or internet at home; VA provider and veteran adoption of VA Video Connect, VA’s mobile app enabling “anywhere to anywhere” synchronous video telehealth; expansion of asynchronous telehealth services from the VA clinic to the veteran’s home and mobile device; and growth of VA’s remote patient monitoring/home telehealth and the use of artificial intelligence.

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VA PATIENT-ALIGNED CARE TEAMS: VETERAN-FOCUSED PRIMARY CARE Nurses also have a pivotal role in the Veterans Health Administration’s (VHA) Patient Aligned Care Team (PACT) model of care, a team-based approach launched in 2009 that built on previous team-based strategies for providing comprehensive primary care to veterans. VHA adopted and customized principles of the patient-centered medical home model that features patientcentered care, coordination of care, and access to care. Individual PACTs consist of a primary care provider (PCP), registered nurse care manager (RNCM), clinical associate (CA), and administrative associate, explained Karey Johnson, DNP, RN,

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Nurses participate in a video conference at the VA Sierra Nevada Health Care System (VASNHCS) Medical Center. VASNHCS’ telehealth services include primary care, nutrition, mental health, women’s care, urology, wound care, and more.

director of clinical learning, VHA Office of Primary Care. They are also supported by extended team members in the roles of clinical pharmacy specialist, registered dietitian, social worker, and integrated mental health partners. Each PACT cares for a dedicated group of patients and serves as the central point of coordinating and managing care for the assigned veterans. This includes not only providing primary care, but also coordinating with other services such as specialists and community organizations to provide comprehensive health care for veterans.

The original goal of the PACT model was two-fold. For the overall model, the goal was to address the anticipated primary care provider shortage combined with the increasing number and aging population of veterans by moving away from the “lone provider” model to one that was proactive, personalized, and “included a team that could share the workload for the panel of patients,” Johnson said. For the individual PACTs, she continued, “the goal is to be responsible in a continuity-type relationship for a core group of patients, to develop relationships with those patients, to really understand who they are, what their story is, and then understand through their story and their life how we can help them achieve whatever they want for that life. And you can really only do that best through that

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VANTAGE POINT, VA BLOG

At the VA Southern Nevada Healthcare System Medical Center, 12 rooms, like the one pictured, are equipped with Tele-ICU capability.

relationship. Having a dedicated group of providers – including doctors, nurses, and extended providers who can develop that relationship – was key.” Nurses function in a variety of roles within PACTs. For example, advanced practice nurses, such as certified nurse practitioners, can function as the team’s PCP. The RNCM provides comprehensive and coordinated nursing care, collaborating with both VA and community services to meet the health promotion or disease prevention, acute, chronic, and long-term needs based on the veteran’s goals and plan of care, with a focus on self-management. On a typical day, Johnson said, the RNCM provides overall coordination regarding that day’s patients, discussing patients’ needs with the PCP and other team members, and triaging veterans who present with acute needs. “Nurses have their own schedule grids,” she said, “so if patients need follow-up visits that are within the purview and scope of an RN, they’ll see patients for that follow-up care.” Additionally, “they may have had alerts come in from a call center – if a veteran called in and needs something, they’ll check back with those veterans.

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They’ll also look at the list of patients who’ve been discharged from the hospital or the emergency room,” she said, and, in all instances where possible, contact that patient within 72 hours of an inpatient discharge, ensuring their needs are met for their transition and their follow-up plan. In addition to individual patient care, the RNCM role includes populationbased management, “looking at different cohorts of patients with different risk levels and working to arrange with the provider the right services that are needed to address that cohort of patients,” Johnson said. In the CA role, licensed practical or licensed vocational nurses work closely with the PCP to manage the clinic day and prepare for office visits by gathering veterans’ pertinent information such as vital signs, lab results, and completing basic preventive health questionnaires, and performing routine procedures such as immunizations and screenings as ordered by the PCP. Future trends for the PACT model include increasing use of advancing technologies, including VA Video Connect, for web-based visits, said Johnson. For example, if a veteran has medication questions, “the nurse is

able to say, ‘Why don’t you take your phone and show me your medicine cabinet, show me what you’re seeing,’ as opposed to that veteran having to deal with traffic and parking … Nurses are using this technology to have those visits with patients without requiring them to come into the hospital.” Dr. Leonie Heyworth, VA’s national lead, synchronous telehealth, Office of Connected Care, echoed that point in describing how the technologies of telehealth intersect with the PACT care model. “Currently, VA is undergoing an expansion of video telehealth across PACT with the goal of 100 percent of PACT clinicians capable of offering a video visit by the end of fiscal year 2020,” she noted. “Integration of video visits across PACT using VA Video Connect gives veterans and their caregivers the opportunity to access their VA care from anywhere using any smartphone, tablet, or computer.” Other examples of video visits include interval blood pressure checks with nurses, post-hospital discharge visits, insulin management, and educational opportunities across all PACT services, particularly nutrition, clinical pharmacy, and primary care-integrated mental health services. Heyworth added, “The flexibility of video care from any location enhances continuity of VA care by PACT for traveling veterans, reinforcing the PACTveteran relationship. Engaging veterans, their families, and caregivers through VA Video Connect visits has already demonstrated high veteran satisfaction, travel cost savings, and has the potential to increase access to timely primary care.” Johnson emphasized that within the PACT roles and across the VA, nursing can make a big impact in veterans’ lives. She said, “Regardless of what type of nurse you are, there’s a place for you to be able to serve our veterans, and serve our country, essentially, through service to them.”

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VHA’S SPECIALIZED NURSING CARE By Craig Collins n IT’S THE NATION’S LARGEST INTEGRATED health care system, so it’s no surprise that the Veterans Health Administration (VHA) is also the largest employer of nurses in the United States: In January 2019, the most recent published account, more than 100,000 nursing personnel delivered care to veterans at more than 1,250 health care facilities in all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Philippines. Today, more than 9 million veterans are enrolled in the VHA system, and in 2018 alone, the system handled 58 million appointments. The Department of Veterans Affairs (VA) nurses provide stateof-the-art, cost-effective nursing care to patients and families. It’s a common misconception that VA patients are predominantly older veterans, and that VA nurses spend most of their time delivering geriatric care. Older patients represent a significant percentage of the VA’s patient population, and many nurses have built careers in gerontology and geriatric care, but the veteran population receiving VA care is increasingly diverse and dynamic. As younger veterans from the conflicts in Iraq and Afghanistan have enrolled in VA health care, they have introduced unprecedented diversity – in ethnicity, culture, and gender – to the VA patient population, and nursing practice continues to evolve and accommodate these differences. VA nursing services, administered chiefly through the VHA’s Office of Nursing Services (ONS), encompass patient care, clinical practice, education, research, and administration. VA nurses work in every role and setting imaginable: medical, surgical, psychiatric, intensive care, dialysis, oncology, physical therapy, spinal cord injury, hospice, blind rehabilitation, geriatric, cardiology, organ transplant, nephrology, orthopedics, and other units. They provide a full continuum of care, from acute to primary and extended care, and they serve in medical centers, outpatient clinics, nursing homes, and home-based primary care. Registered nurses (RNs) comprise the largest segment of health care employees in the VHA. A registered nurse holds, at minimum, a nursing diploma or Associate Degree in Nursing, has passed the National Council Licensure Examination for Registered Nurses (NCLEX® -RN), and met all other applicable (state) licensing requirements. Most RNs are encouraged to go beyond minimal education requirements to earn a Bachelor of Science in Nursing (BSN) degree as a path

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to licensure, and to lay the groundwork for expanding their expertise after licensure. More than 61,500 RNs serve in the VHA system, leaders or members of health care teams working to provide high-quality care and enable patients to optimize their own health. VHA RNs typically serve in four distinct – though not mutually exclusive – career paths: CLINICAL NURSING While many RNs are generalists, others, particularly in the VHA, become interested in gaining expertise in a nursing specialization. There are literally dozens of clinical specializations available to RNs, knowledge and skills concentrated in a workplace setting (i.e., ambulatory care nurse), body system (pulmonary care nurse), patient population (geriatric nurse), or medical condition (oncology nurse). To gain recognition as a specialized nurse professional, RNs typically need to undergo further experience, clinical practice, and education and training in their specialized fields. The VA typically requires RNs to become certified in their specialty area before they work with patients. When Alan Bernstein, MS, RN, the ONS’ deputy chief nursing officer, was a student nurse in the mid-1990s, for example, his first student nursing experience was spent in the medical-surgical unit of a hospital. After graduating, he began his nursing career with the VA, served two years as a medical-surgical RN, and then applied for a position in the intensive care unit (ICU). He was accepted and underwent a rigorous course of training and education. “We went to ICU classes before we ever went on the floor and touched a patient,” said Bernstein. “We spent almost two months in a classroom in VA, learning all of the nuances of ICU patient care. Then when I came out of that class, there were tests and exams I had to take that were way more intense than what we had in nursing school, concentrating on the intensive care patient.” After passing these exams, Bernstein worked under the supervision of a nurse preceptor – a mentor assigned to help develop new staff nurses – for three or four months before he practiced independently in the ICU. VA RNs often move from one specialty to another, Bernstein said, and the intensity of this professional apprenticeship, or of

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Army Nurse Corps its component parts, varies. “If I’d gone from med-surg to the operating room,” he said, “I would have some classroom instruction that would teach me about all the instrumentation in the process of sterile technique. And I would have to be signed off on those competencies. And then my preceptor experience would probably be longer than it was in ICU.” While VHA nurses practice every area of specialized care found in private-sector facilities, some roles and settings have emerged that are, if not unique to the VHA, areas of unusual emphasis. When a growing number of veterans began returning from Iraq and Afghanistan with polytrauma – multiple injuries, often blastinduced, that affected more than one part of the body – the VA ramped up its Polytrauma/TBI System of Care to help treat and rehabilitate veterans suffering from injuries including traumatic brain injury (TBI), spinal cord injury (SCI), limb loss, fractures, and burns. As the Iraq and Afghanistan conflicts have wound down, the focus among VA’s polytrauma nurses has shifted from acute care to rehabilitation. The ONS’ clinical nurse advisor for Polytrauma and SCI rehabilitation, Susan Pejoro, MSN, RN, GNP-BC, is located at the VA Palo Alto Health Care System. The Palo Alto facility is one of 25 centers in the VA’s Spinal Cord Injuries and Disorders (SCI/D) System of Care, providing a coordinated lifelong continuum of services for veterans with spinal cord injury, from initial injury to death. The Palo Alto center has developed an upperextremity clinic to address an important issue: The fact that for many patients with paraplegia, their arms often receive less attention than other conditions secondary to SCI. Pejoro, a gerontological nurse practitioner, pointed out that pushing oneself around in a wheelchair, often for decades, can be hard on the arms. Patients at the clinic often suffer injuries, misalignments, and pinched nerves and tendons from overuse of their upper limbs, and a Palo Alto team has organized to address these issues. “We work with a hand surgeon and occupational therapist, a physical therapist, a resident, and

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U.S. AIR FORCE PHOTO BY AIRMAN BAILEE A. DARBASIE

Capt. Genevieve Boldin, 99th Inpatient Squadron registered nurse, and Katie Phillips, a VA critical care simulation coordinator/educator, conducts a training class using the VA Tele-ICU system at Mike O’Callaghan Military Medical Center intensive care unit, Nellis Air Force Base, Nevada., Aug. 16, 2018. To contact the VA Tele-ICU nurses for assistance, patients and medical center staff must press the green “eLert” button located on the wall in the room.

other nursing staff,” Pejoro said. Patients who visit the center for a well-check are examined closely for problems in the shoulders, arms, elbows, and hands, and offered either a number of preventive corrections or, if they may be warranted, surgical options to improve function. Because the Palo Alto center serves patients in an integrated service network (VISN) that reaches from Las Vegas to the Philippines, Pejoro often relies on teleconferencing for an initial check-in. “I’ll set up a telemedicine appointment,” she said, “and say: ‘Hey, you’re coming in for your annual checkup, so let’s take a look at your hands and your arms and tell me what’s going on.’ And we can decide whether we need to have the full team involved.” Telemedicine technologies allow VHA providers and nurses to accommodate two circumstances common to all large health care systems – but particularly to

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the nation’s largest. First, the system is mandated to meet the health care needs of 9 million veterans, many of whom live far from the nearest VA facility. Second, the need for expertise throughout the system is dynamic, with lulls and spikes in demand for certain kinds of care and service. An ICU at a VA might find itself suddenly overwhelmed, for example, by an influx of patients needing critical care. To enable a wider reach for VHA’s critical care expertise, the Cincinnati VA Medical Center established the Tele-ICU in 2012. At 15 workstations featuring eight computer screens apiece, critical care nurses and doctors monitor the status of more than 300 patients at 19 Veterans Affairs Medical Centers (VAMCs) and 10 emergency rooms, in an area reaching from Oklahoma to Maine. The screens feature real-time video streams from patient rooms, as well as feeds from equipment monitoring

patients’ vitals, said Michael Torok, RN, the Tele-ICU operations manager. “We’re actually streaming those waveforms here in Cincinnati,” he said. “The patient could be in Charleston, South Carolina, in the medical intensive care unit, and our nurses are seeing in real time that patient’s waveforms here in Cincinnati.” Nurses at the workstations are aided by computer software that performs a kind of triage, sifting through patient records and data and flagging when patients may need special attention. A shift at the Tele-ICU is staffed by about seven to eight nurses – individual nurses at the center average 19 years’ experience in critical care – and a physician, and at night, includes a second provider, often an acute care nurse practitioner. Tele-ICU expertise is meant to augment rather than replace the service of bedside teams, Torok said. For example, if a resident on staff at the ICU in Muskogee, Oklahoma, needs to insert a breathing tube into a patient, a physician and critical care nurse in Cincinnati can assist: The Tele-ICU physician can help guide the insertion of the tube and the ventilator setting, while the Tele-ICU nurse can put in orders for chest X-rays, blood gases, and other lab tests, freeing up the bedside nurse to tend to the patient. “The bedside team could be doing all the hands-on things that need to be done,” said Torok, “while the Tele-ICU critical care team is offloading some of the administrative work, as well as assisting with some of the clinical decision-making going on in the room.” About 40 nurses work shifts at the Tele-ICU in Cincinnati, and the center recently opened a satellite hub in Baltimore, Maryland. Another effort to supplement VHA care, the Interim Staffing Program (ISP),

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n ve

e

PHOTO BY JENNIFER SCALES

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Alexis Carson, nurse case manager for the Wm. Jennings Bryan Dorn VA Medical Center, provides a medical screening at the Stand Down for Homelessness event in Columbia, South Carolina, November 2017. Nurse case managers are RNs who coordinate all aspects of the care of an individual patient, ensuring responsible utilization of services and resources.

move about. They like the adventure of it. They are adaptable. They are inquisitive, resourceful, and creative. There’s not an area, I believe, within the VA where our nurses have not stood in to assist facilities whenever they have the need.” SUPPORTING AND DIRECTING

was established in 2013. Through the ISP, a pool of talented physicians, nurse practitioners, nurses, and other care providers offer temporary staffing assistance to VA health care facilities. Within the ISP, 97 registered nurses comprise the VA Travel Nurse Corps, meeting the needs of facilities throughout the United States. According to Tyeasa Jones, RN, BSN-MSN, acting nurse director for the corps, VA’s travel nurses have served in nearly every imaginable capacity, including clinical care, home-based primary care, education, management, and quality control. Travel Corps nurses also play a key role in disaster response; in fall 2017, for example, after southeast Texas was devastated by Hurricane Harvey, VA travel nurses served with mobile medical units formed to provide health care in Houston and Beaumont. VA’s travel nurses, said Jones, “love to

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As health care delivery within the VHA has become more complex, technologically advanced, and dynamic, coordination and oversight of nursing care has become a critical role on both the micro and macro levels, even among the most basic units of care. For example, VA primary care nurses, in addition to providing clinical care to patients through interdisciplinary Patient Aligned Care Teams (PACTs), increasingly play a role in care coordination: facilitating the integration of services among team members and with other affiliated providers, including private-sector contractors. Care coordination has become an even more crucial role since last year’s passage of the VA MISSION Act, a law that allows for more VA primary care to be provided outside the VA system. Because a possible consequence of this provision may be the movement of patients between

providers in the private sector and the VA, it’s crucial that both sides are aware of, and coordinating, what’s happening in both settings. RN primary care coordinators are critical in tracking down records, communicating with outside providers, and essentially performing case management to ensure the quality and continuity of veteran care. In the 1990s, a nursing role emerged to involve highly skilled nurses in improving the quality of nursing services: the clinical nurse leader (CNL). A CNL is a master’s-prepared nurse who tracks and documents quality measures in a microsystem – a unit – and educates and guides nursing staff in maintaining or improving them. CNLs communicate, plan, and implement care directly with other clinicians. They are generalists whose roles are highly variable, depending on setting and circumstances. “The ideal scenario is to have one on every patient care unit,” said Bernstein. “And their responsibility on the unit is to oversee the clinical care of all of the patients, to ensure that the front-line nursing staff have the skills and the knowledge to care for the patients as they come in and out of that particular unit.” CNLs may be involved in care

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

VETERANS HEALTH ADMINISTRATION FACEBOOK PAGE

A veteran working on balance and strength at the Maryland Health Care System’s Baltimore VA Medical Center.

planning for a particular patient, or in teaching other nursing staff how to plan care, or in educating staff about a new condition or circumstance. As Bernstein points out, CNLs, like care coordinators, play more of a supportive role than a true supervisory or administrative role. They help other nurses and health care team members do their jobs better, but they don’t have the authority or mandate to do true administrative tasks: directing, hiring, firing, scheduling, and budgeting. “They really are adjuncts to the administrative staff,” he said, “in the sense that they oversee clinical practice and make sure the staff on the unit can care for all the patients that come in and out of that unit.” Bernstein’s own nursing career has been a march through the echelons of what are more commonly recognized as administrative positions – supervisors or managers who provide advanced leadership in resource allocation and evaluation. At the Pittsburgh VA Medical Center, he was nurse manager for a surgical unit. He moved on to become a nursing program leader (known in other facilities as an associate chief nurse), responsible for overseeing nursing services within a section of similar units – behavioral health units and, later, geriatrics and extended care – at the medical center. In 2012, he became nurse executive for the second-largest health care system in the VA, the VA North Texas Health Care System, where he oversaw all the administrative and clinical aspects of nursing care for the entire nursing enterprise: 1,700 nurses and sterile processing personnel. Program leaders and nursing executives must have at least a master’s-level education; Bernstein earned his Master’s in Nursing Administration in 2003. CONSULTATIVE NURSING ROLES Many VA nurses work to improve nursing care by examining processes and sharing knowledge with other personnel. An infection control nurse, for example, develops expertise in

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preventing the spread of infectious agents, such as bacteria and viruses, in VHA environments. These nursing professionals keep other medical staff up to date on proper sanitation practices; analyze infection data, and share findings with other professionals; teach staff how to prevent and control outbreaks; and often work with scientists and doctors to study infectious agents and new treatments for illnesses. Another important consultative role in VHA is the public or community health nurse, who often works beyond the scope of clinical care to guide veteran patients to necessary social or medical services, or to educate veteran communities about ways to reduce the likelihood of certain diseases or disorders. The VHA prides itself on delivering evidence-based clinical care, and the ONS has developed its own curriculum as a resource for those developing or teaching evidence-based practice in clinical settings. VA nurses work to develop and disseminate this evidence in several roles, including: • Nurse education. Nurse educators – RNs with advanced nursing degrees that allow them to teach at colleges and universities – serve as faculty members at both nursing schools and teaching hospitals, transferring their knowledge, experience, and skills to nursing students. Within the VA, this knowledge is often imparted through education programs that use distance-learning technology to provide learning nationwide, to both students and nurses. • Nursing informatics. A rapidly growing field in health care, nursing informatics combines the art and science of nursing with the field of information management and computer analytics. Nurse informaticists develop and evaluate the tools and processes used by nurses and nurse administrators, such as electronic health records and communications systems, and they analyze information systems’ data to improve nursing services and reduce errors. Working behind the scenes, nurse informaticists focus on patient care, enabling nurses to do their tasks with advanced technology that improves patient outcomes. In 2010, the VHA, recognizing the importance of this emerging field, established a new Office of Informatics and Analytics (OIA) to consolidate all nursing informatics activities into a single national program. • Nursing research. With or without the support of VA funding, and often in partnership with academic affiliates, VA nurse researchers study aspects of health, illness, and health care and look for ways to improve health and health care outcomes. Jennifer Ballard-Hernandez, DNP, AG/ACNP-BC, FNP-BC, GNP-BC, CVNP-BC, CCRN, CHFN, AACC, FAHA, FAANP, a nurse practitioner who specializes in cardiology at the Long Beach Healthcare System, has published research in several peer-reviewed journals and has lectured nationally to professional organizations on topics including heart

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PHOTO BY DAVID KAMM, U.S. ARMY

The Honorable Robert Wilkie (right), secretary of the Department of Veterans Affairs (VA), has made implementing the MISSION Act one of his top priorities. The bill consolidates VA community care programs, amends other VA health care programs and facilities’ provisions, and makes appropriations for veterans care.

failure, care transitions, and cardiac stress testing. Like most graduates of nursing doctoral programs, BallardHernandez received extensive training in the conduct of nursing research. “Nursing research is vital to the practice of nursing and one of my passions has been participating in both qualitative and quantitative research,” she said. “Quantitative research allows to precisely measure the effect of a specific intervention: Does it help, harm, or have no effect on a patient? I’ve been involved in those types of clinical trials, and I’m currently involved in one right now, looking at a new medicine for treating heart failure.” She’s also been involved in qualitative research: delivering new training and education programs to nurses themselves and then evaluating their experiences during the process. “First and foremost, I think it’s important for nursing as a profession to have a strong evidence base to support our practice,” said Ballard-Hernandez, “and second, we need to be able to translate that evidence base to those who are practicing at the bedside.” ADVANCED PRACTICE NURSING More than 7,100 RNs in the VA health care system are advanced practice registered nurses (APRNs, holding at least a master’s-level degree, and many ARPNs go on to earn doctorates) and exercising greater professional autonomy. By education and certification, APRNs are prepared to assess, diagnose, and manage patient problems, order tests, and prescribe medications. They may authorize

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or delegate therapeutic methods to supporting personnel, and often confer with outside disciplines and offer referrals to other professionals or agencies. There are four defined APRN roles: 1. Certified nurse midwife (CNM). CNMs handle the gynecologic and primary health care of women from adolescence through menopause. Until recently, because so few U.S. veterans were women of child-bearing age, the VA did not cover their services, but VA care is evolving to accommodate changing demographics. 2. Clinical nurse specialist (CNS). A CNS is an RN with a graduate degree in a specialized area of nursing practice, and occupies an important niche in VA care, though the role is difficult to explain to non-nurses, who often confuse it with a clinical nurse leader. The distinctions between the two are many, though they differ most significantly in expertise (CNLs are generalists; CNSs are specialists) and scope of practice (the CNL’s sphere of influence generally encompasses nursing practice and patients while the CNS sphere can expand to include the entire health care system). CNSs generally work at this systems level to promote nursing excellence in their specialty areas. Christine Engstrom, PhD, CRNP, AOCN, FAANP, the ONS’ director of

clinical practice, was an oncology CNS in VA for 10 years before becoming a nurse practitioner in both primary care and specialty oncology care. She described the CNS as “a more global role. I would do many different things in that sphere of oncology, working across different systems – our VISNs around the country, or even within the Maryland health care system, those hospitals working on policies for chemotherapy safety, standard operating procedures, and education. I also did research.” Engstrom performed data collection for several studies and also conducted her own, as a primary or co-primary investigator; her research expertise led to an appointment to an institutional review board at one of the VA’s university affiliates. The focus of the CNS’ role, then, is to ensure nurses in their specialty area have the knowledge, skills, policies, procedures, and equipment they need to provide optimal care. There are currently just over 300 CNSs at work in the VHA. 3. Certified registered nurse anesthetist (CRNA). CRNAs work in collaboration with surgeons, anesthesiologists, and other professionals to ensure the safe administration of anesthesia in VHA facilities. CRNA responsibilities include administering anesthesia during surgical,

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diagnostic, and therapeutic procedures; providing care before, during, and after anesthesia; monitoring patients during medical procedures; examining patient histories to ensure safe provision of anesthesia or pain management; and discussing any contraindications or side effects with patients. The nearly 1,000 CRNAs who provide care within the VHA system are generally found at hospitals. 4. Certified nurse practitioner (NP). NPs are licensed, autonomous clinicians focused on managing health conditions and preventing disease. NPs comprise the vast

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majority – more than 5,800 – of VA’s advanced practice nurses, and about half of them serve in either primary care or women’s health. When she began her nursing career with the VA Salt Lake City Health Care System in the late 1990s, Penny Kaye Jensen, DNP, APRN, FNP-C, FAAN, FAANP, advanced practice registered nurse (APRN) program manager for ONS, was a primary care NP working in what’s now the George E. Wahlen VAMC. Over the years, as the hospital added specialty care services, she and other primary care NPs were moved out to community-based outpatient

clinics and saw veterans in and near their own communities. Many of the VHA’s NPs serve in the Home Based Primary Care (HBPC) program, visiting veterans in their homes to provide diagnosis, care, and treatment. Each one of the 147 regional health care systems in the VHA operates an HBPC program, accounting for a considerable number of NPs. According to the VHA’s Office of Geriatrics and Extended Care Services, VA nurse practitioners dedicated the equivalent of more than 531 NPs working full-time to provide care to veterans in their homes, resulting in a national average cost savings of $7,936 per veteran. NPs are poised to play a critical role in a modernization effort now underway within VHA: the expansion of RN-staffed call centers, which often functioned as referral services, into clinical contact centers where veterans can, to the maximum extent possible, have their health care needs met during their first contact with the VHA system. Storm Morgan, MSN, MBA, RN, ONS’ clinical program manager for Ambulatory and Virtual Care, explained that the goal of transforming these centers is to expand veterans’ access to convenient, highquality care. “We’ve had call centers in VHA,” she said, “but we’ve never had, to any extent, providers who could diagnose and treat on the phone. We would have to determine what the patient needed and send them where they needed to go to get that care.” The new clinical contact centers will be staffed with more providers

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PHOTO BY LANCE CPL. TABITHA BARTLEY

Second Lt. John Bobrousiecki, patient, Spinal Cord Injury and Disorders Center of Excellence, pulls weights during his kinesiotherapy session at the Hunter Holmes VA Medical Center on June 30, 2013. Bobrousiecki also receives therapeutic services in activities for daily living. Physical therapy and spinal cord injury are two areas of nursing services available to veterans through the VA’s Office of Nursing Services.


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– nurse practitioners and physicians who can diagnose, treat, and prescribe – and will combine web, video, chat, and telephone capabilities to enable “first-contact resolution” of veterans’ health issues when possible. “We’re really trying to address patients’ needs when they call in,” said Morgan, “and not send them to other people to have their needs met.” Many nurse practitioners in the VHA specialize or subspecialize. In Palo Alto, Susan Pejoro is a certified gerontological NP. Both she and Ballard-Hernandez, who runs the cardiac clinic at the Long Beach VA, serve as clinical nurse advisors in ONS’ nationwide Clinical Practice Program, developed to support and bring expertise to nursing practice at the point of care – Pejoro for polytrauma; BallardHernandez for cardiovascular care. Today, Ballard-Hernandez divides her time between this role and her oversight of the Long Beach cardiac clinic, where she directs the work of another cardiology NP, a case manager, a licensed vocational nurse, and a scheduler. A lot of work and study went into Ballard-Hernandez’s specialty and her more recent focus on general cardiology and heart failure; while working toward her master’s degree and RN certification, she was able to spend an additional 500 hours of training with a cardiologist beyond her minimum requirements. Afterward, she completed an extensive post-graduate acute care NP program with a clinical focus in cardiology, and went on to earn her Doctor of Nursing Practice degree. “The great thing about the VA,” said Ballard-Hernandez, “is there are a lot of opportunities and options for nurses to excel and have professional growth. And there are a lot of nurses, like me, who practice clinically and also participate in research.” WIDENING THE SCOPE OF PRACTICE FOR APRNS An issue that remains unresolved for many APRNs in the United States is that their scope of practice – the services a qualified health professional is deemed competent to perform and permitted to undertake – varies from state to state. Twentythree states, following the model recommended by the National Academy of Medicine and the National Council of State Boards of Nursing, currently grant “full practice” authority to nurse practitioners, meaning they can provide care and prescribe treatments and medications without requiring the direct supervision of a physician. A considerable number of states, including California, Texas, and Florida, remain “restricted practice” jurisdictions, where state practice and licensure laws constrain the ability of NPs to engage in at least one element of practice, requiring career-long supervision, delegation, or team management in order for a nurse practitioner to provide care. In a nationwide health care system such as the VHA, these inconsistencies resulted in an inefficient use of its resources

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and presented considerable challenges to maintaining veterans’ access to nursing expertise. Requiring a physician’s signature for every NP decision, said Jensen, tended to bog things down. “It was really taking up time,” she said. In some states, NPs were required to attend board-mandated collaboration sessions, which kept them away from patients. “People were cancelling hours in their clinics,” Jensen said, “just to meet their state requirements, and on those days, we weren’t seeing veterans we could have been seeing.” Jensen led a team of nurse practitioners who worked with the U.S. Department of Justice to determine that the VHA, as a federal system, could implement provider regulations that took precedence over those of the states. It took five years of work, in which Jensen was detailed to the ONS, but she and her team wrote the proposed rule change that was eventually adopted – for the most part, after receiving 223,000 public comments – by the VHA: On Dec. 14, 2016, the Department of Veterans Affairs published its rule granting veterans direct access to care by three of the four APRN roles in the VHA: nurse practitioners, certified nurse midwives, and clinical nurse specialists. In a press release accompanying the announcement, the department explained that “we do not have immediate and broad access challenges in the area of anesthesia care across the full VA health care system that require full practice authority for all certified registered nurse anesthetists.” Jensen and other ONS leaders will continue to push for full practice authority for CRNAs within the VHA, but in the meantime, the rule change has meant greater autonomy for other APRNs throughout the country – which translates into more timely, comprehensive, focused care for veteran patients. In California, Ballard-Hernandez is working directly with patients and making administrative decisions about the Long Beach VA’s cardiac clinic. Before adoption of the new rule, she said, “I had to have a physician assigned to the clinic who needed to review and co-sign my work and treatment plan. But really it was a waste of valuable resources, because you’re paying a highly trained cardiologist to sit and oversee something that my education and training have prepared me to do. As NPs, our training focuses on health promotion, disease prevention, and improving health behaviors through patient education.” She now runs the clinic, fully and independently. “Now, that’s not to say we don’t still have a really interdisciplinary team approach,” she said. “If I feel that I need additional resources or a second opinion, our cardiologists are readily available to consult.” The VA’s trust in her professional judgment is one of the many reasons Ballard-Hernandez decided, years ago, to move from the private sector into caring for veterans. For Ballard-Hernandez, whose brother served in the U.S. Marine Corps, VA nursing has always felt more like a calling than a job. “I’ve worked in the private sector for a good number of years,” she said, “and felt that it was time for me to give back. So, when a position opened up, I applied and was fortunate enough to be accepted. I’ve never looked back, and it’s been one of the best career decisions I’ve ever made. I’m very, very lucky to work and care for veterans.”

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EDUCATIONAL PROGRAMS Training Opportunities for VA and Military Nurses By J.R. Wilson

Educational Programs and Support for VA Nurses n THE DEPARTMENT OF VETERANS AFFAIRS (VA) has a long and extensive list of educational programs and support for nurses who serve in VA hospitals throughout the nation. “A brand-new nurse comes into the VA from nursing school as a Nurse 1; although with a bachelor’s degree, they may come in as an N2. They can progress all the way to a Nurse 5,” according to Karen Ott, D.N.P., R.N., director for Policy and Education in the VA Office of Nursing Services. “The career track that allows that, by virtue of education, experience, and other practice qualifications, is based on their abilities to function at the high grades. Nurse 1-3 is based on the individual’s qualifications; for N4-5, the qualification is in the position, not the person. They are generally the supervisors, N1-2 are staffers, N3 are generally mid-level managers. Every registered nurse in the military is an officer; every nurse in the VA is Title 38 civil service, which is not the same as Title 5.” Promotion through those ranks depends on a nurse continuing his or her education after joining the VA. “Senior nurses have to have advanced degrees,” Ott added. “Nurses can have a diploma from a nursing school, an associate degree from a community college, a bachelor’s in nursing, a master’s in nursing, or a doctorate in nursing practice.” The VA also now requires the accreditation for those schools to be Commission on Collegiate Nursing Education (CCNE) and the National League for Nursing (NLN). Nurses also are required to have a “full and unrestricted” license from a U.S. state or territory. “In FY 1999, VA proposed new nurse qualifications standards and launched a new education assistance initiative to support it. VA committed $50 million to assist VA nurses seeking baccalaureate degrees in nursing and adopted new performance standards requiring a four-year degree for

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registered nurses by 2005,” added Alan Bernstein, M.S., R.N., deputy chief nursing officer. “Although VA employs all education levels of registered nurses from diploma to doctoral graduates, it strongly supports and encourages higher levels of education.” A significant percentage of VA nurses joins the civilian organization after serving in the military, which Ott said has a different view of nursing. For the VA, the focus is quality of life; for the military, it’s fitness for duty. “The group of nurses who most often sign up with the VA after leaving the military are the certified registered nurse anesthetists [CRNAs]; 28 percent of our CRNAs are veterans, which is the largest group out of 1,023 total,” she said. “Overall, we have 71,286 registered nurses, nurse practitioners, and clinical nurse specialists in the VA; of those, 15 percent are veterans. We also have 15,000 licensed practical nurses [LPNs], of whom 18 percent are vets. So, overall, including LPNs,19 percent of VA nurses are veterans. “The VA and DOD [Department of Defense] are separate agencies with separate missions, so the types of educational programs and availability may differ, although both agencies have scholarships available for nurses. If a nurse in the military has started an academic program, but leaves active duty and comes to the VA before completing it, they would have to ask the VA for funding to continue.” Whether coming to the VA straight out of nursing school, from civilian practice, or the military, VA nurses are offered a wide range of educational programs and support, including: • Education Debt Reduction Program (EDRP): EDRP provides student loan reduction payments to employees with qualifying loans who are in health care positions providing direct patient care services and in positions that are considered hard to recruit or retain. The loan must be for the health professional’s education that qualified the applicant for a specific position. • Employee Incentive Scholarship Program (EISP): This program provides funding for Veterans Health Administration

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AVANA / ASSOCIATION OF VETERANS AFFAIRS NURSE ANESTHETISTS

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(VHA) employees to further their education and/or obtain degrees that qualify them for specific health care occupations. EISP assists VHA in meeting its needs for qualified health care staff in certain occupations for which retention and recruitment is difficult. • VA Learning Opportunities Residency (VALOR) program: This program provides opportunities for outstanding students to develop competencies in clinical areas while at an approved VA health care facility. Opportunities for learning include didactic or classroom experiences, competencybased clinical practice with a qualified preceptor, and participation in clinical conferences. • VA National Education for Employees Program (VANEEP): This program provides salary replacement dollars, along with funds to cover tuition, books, and certain fees, for

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The certified registered nurse anesthetists (CRNAs) staff at the Southern Arizona VA Health Care System. CRNAs are a group of nurses who most often join the Department of Veterans Affairs (VA) after leaving the military. VA employs the greatest number of CRNAs in the federal sector on a full-time basis.

employees enrolled in nursing education programs. The employees enrolled in licensed practical, registered nurse, or other eligible health care occupation programs on a full-time basis are eligible to apply. The hospital receives replacement salary for that nurse. • National Nursing Education Initiative (NNEI): This program provides funding for VHA’s registered nurses to complete or expand their formal education. It is primarily aimed at

supporting associate degree and diploma registered nurses to obtain a bachelor’s degree in nursing. It also can be used to obtain advanced degrees in nursing or related fields. Scholarships are awarded to registered nurses to cover tuition costs and related educational expenses. • Student Loan Repayment Program (SLRP): This program allows VHA to recruit or retain highly qualified candidates the organization would have difficulty recruiting or retaining in the absence of offering student loan repayment. • Public Service Loan Forgiveness (PSLF) program: This program was established to encourage individuals to work in public service by forgiving the remaining balance of certain qualifying loans after an individual has made 120 (10 years) qualifying monthly payments under a qualifying repayment plan while working

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Educational Programs and Support for Military Nurses

U.S. AIR FORCE PHOTO BY AIRMAN 1ST CLASS NATHAN BYRNES

WWW.BLOGS.VA.GOV

Above: VA nurses are offered a wide range of educational programs and support, including the Employee Incentive Scholarship Program, which provides VHA employees the opportunity to further their education. Below: Capt. Min Choi, 99th Inpatient Operations Squadron clinical nurse in the critical care unit at the Mike O’Callaghan Federal Medical Center at Nellis Air Force Base, Nevada, March 2016. Critical care nursing is a complex and challenging nurse specialty to which many registered nurses aspire. full time for a qualifying employer. VA employees and trainees may be eligible for the PSLF program. “VA RNs [registered nurses] serve in four career paths: clinical, advanced practice, supervisory/administrative, and consultative. Examples of advanced practice roles include clinical nurse specialists, nurse practitioners, and certified registered nurse anesthetists. Nurses in these roles are generally referred to as advanced practice nurses,” Bernstein said. “Consultative roles have evolved in areas such as infection control, informatics, community health research, and education [e.g., nurse executives, nurse investigators, and nursing program faculty]. VA nurses function as administrators to provide advanced leadership in resource allocation and evaluation. VA nurse researchers receive both VA and non-VA funding to conduct research to address nursing care issues for veterans.”

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n RECEIVING A NURSING DEGREE AND JOINING the military is only the first part of a continuing education process required of military nurses for future promotions and assignments, from U.S.- or overseas-based military hospitals to combat zones. “RNs [registered nurses] who are officers, have to have a B.S. in nursing, passed their RN boards, and met all the military requirements to be in the military,” according to Col. Michael Ludwig, chief nursing officer at Brooke Army Medical Center, in San Antonio, Texas. “Then there are the licensed practical nurses, who are enlisted; the Army has the most of those in the military. They have to have at least a two-year certificate and pass the LVN [licensed vocational nurse, a job title specific to some states] board. The majority of LPNs are homegrown, where all RNs get their degrees from a civilian school before entering the military – more than half through Navy ROTC programs.” Once in the Army, a number of educational opportunities are available to RNs, who must take them in order to be promoted beyond the rank of major. There is no expectation for LPNs to get a master’s. As a result, tuition assistance is available, but long-term health education is not. As with everyone in the military for more than a year, continuing education is a requirement. As a result, according to Ludwig, between local training at the hospitals, civilian courses, and schools and continuing education credits at the hospitals, 100 percent of Army nurses participate in the educational opportunities offered, “because we are a knowledge-driven field. “On the RN side, they are offered a lot of opportunities, including getting their master’s, leading to a doctorate in nursing practice. The most common option is through long-term health education and training, where they receive pay and funding for the school. You get that in a specific skill set at your school of choice, although some fields do mandate going to a government-run program at the Uniformed Health Services University [Uniformed Services University of the Health Sciences] in Bethesda, Maryland,” he explained. “A very popular program is the certified registered nurse anesthetist, which is also put on by the military through the Uniformed Health Services University. They also can get an advanced degree on their own, with available tuition assistance, especially if they want a master’s that is not in nursing.”

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PHOTO BY JASON W. EDWARDS

There are a number of educational opportunities for RNs to specialize, taking courses run out of Army hospitals, including Brooke’s Critical Care Nurse program. The specialty programs also are open to nurses in the Army National Guard and Army Reserve. “Once they pass that course, they get a skill identifier. We have similar programs for OB [obstetrics], psychiatry, public health, and emergency. Those are very popular. There also are various short courses for self-enrichment, medical-related training, and continuing education, which is available to both RNs and LPNs,” Ludwig said. “We also have courses in trauma nursing care, combat casualty care, medical management of burns, biological care, basic health care administration, etc. Army nurses have to go to current courses before being deployed,” added Lt. Col. Mitzi Fields,

Members of Brooke Army Medical Center’s medical staff simulate emergency care during the 2018 San Antonio Mass Casualty Exercise and Evaluation at Brooke Army Medical Center, Fort Sam Houston, Texas, Oct. 11, 2018. chief of the Department of Hospital Education at Brooke. “We’re always evolving, with new courses since the last Gulf War, such as taking care of patients in medevac helicopters. We have to be more nimble and able to operate in austere environments. The big push these days is to afford these nurses opportunities while they are in garrison,” Ludwig continued. “We have to be ready to go at a moment’s notice, so we try to give them as much exposure in garrison, because we won’t have time to train once combat begins. There also is a big push to get our medics to work up their levels; we may not own the battlefield

in the future, and they will need to be able to manage patients under fire.” Overall, there are some 3,000 RNs on active duty in the Army, not including medics, who are considered part of the nursing team. All are expected to meet standards for the military as well as nursing and have to go through military leadership programs to be promoted. Those promotions, as well as training and deployments with units most civilians might not expect, can advance a nurse to the rank of general – including two three-star nurses who have served as surgeon general of the U.S. Army. “The promotion pickup rates the Army Nurse Corps has [are] equivalent to other segments of the military,” Ludwig noted. “We also encourage them to get badges in field medical, air assault, and airborne. Nurses also are assigned to special ops in five- to eight-man teams, depending on their assignment. That’s a two-year position. They go through airborne training, SERE [survival, evasion, resistance, and escape], tropical medicine, and air assault, having to pass special physicals for each.” “They start off as generalists, but tend to specialize,” Fields added. “The most common specialty is critical care, which is what you need the most of when it comes to combat deployments.” Ludwig said the “laser focus” of all nursing training in the military is “about making sure our individuals are ready to care for our sons and daughters as they go down range,” adding that the training and educational opportunities offered to Army nurses are common across all branches of the military. “Maybe not the exact same programs, but there is an expectation across the services for nurses to get advanced degrees and training,” Ludwig said. “We have Navy nurses who sit in on our critical care course, because they don’t have one that is organic. The Air Force does have that course.”

always evolving, with new courses since the last Gulf War, “We’re such as taking care of patients in medevac helicopters. ” www.defensemedianetwork.com

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SPONSORED BY ELEKTA

CANCER PATIENTS AT SOUTH TEXAS VETERANS HEALTH CARE SYSTEM RECEIVE ENHANCED TREATMENTS WITH CENTER’S ADVANCED LINEAR ACCELERATOR Integrated Imaging Technology Helps Clinicians See What They Treat.

n DECEMBER 2016 MARKED THE BEGINNING of a new era of radiation therapy at South Texas Veterans Health Care System (STVHCS), which began treating patients with its new Elekta radiation therapy system (Versa HD). The linear accelerator – which replaced two aging radiotherapy systems and recently completed its second full year of service – has markedly improved treatment speed and accuracy, according to William E. Jones, III, MD, Chief of Radiation Oncology at STVHCS. “One of the most significant advantages of the new system over the two previous systems is the integrated cone beam CT [CBCT] imaging technology,” he noted. “With the patient on the table, we can do a ‘mini-CT’ right then and there,

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which enables us to see if the organs have moved since planning. For example, the bowel contents of a prostate cancer patient may have caused the prostate to shift forward. Being able to see the target every day and correct for this motion is a huge change for us. “We’re delivering with more confidence and greater precision using CBCT,” he added. “So, we have gradually progressed to using smaller treatment margins around the tumor. That means a minimal amount of healthy tissue surrounding the tumor is exposed to the treatment radiation.” STVHCS’ lung cancer patients have also benefited from the new system’s imaging capabilities, specifically, the new

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PHOTO COURTESY OF ELEKTA

By Jerry Duncan


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system’s 4D image guidance technology, which enables clear visualization of moving targets. “Some patients have lung tumors that can move substantially during breathing,” Dr. Jones noted. “CBCT works well for stationary targets, but moving objects become blurred. By taking a 4D planning scan – which shows the ‘envelope’ of space within which the tumor is moving during the patient’s breathing cycle – we can more easily localize moving tumors.” STVHC’s Versa HD also features a highly advanced beam shaping device that conforms the radiation beams precisely to the tumor’s shape and ensures that radiation transmission is kept to the absolute minimum. “Having low transmission means patients are exposed to much lower radiation,” he said. During the last two years, the radiation Oncology Department has been able to treat significantly more patients

Opposite page: The Versa HD Radiation Therapy System. Above: Dr. William E. Jones, III, chief of radiation oncology at South Texas Veterans Health Care System.

per day, by virtue of the new system’s speed, according to Dr. Jones. “I don’t think we had ever managed to treat 30 patients in a day with our previous linacs,” he noted. “Even with daily CBCT with the new linac, we’re routinely treating over 30 patients a day. And, we now give prostate cancer patients hypofractionated therapy – 20 fractions versus the typical 39 fractions – which is another operational efficiency we’ve realized. But more importantly, it’s a major benefit for patients who will need to visit the hospital fewer times, some from long distances.” Additional improvements are on the horizon at STVHCS, as the center gears up to perform Stereotactic Body Radiation Therapy (SBRT) this year. SBRT – a form of radiotherapy that localizes body tumors using their precise 3D coordinates – involves the delivery of a single high-dose radiation treatment or a few radiation treatments over time.


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COMBAT NUTRITION Feeding the Troops – Yesterday, Today, and Tomorrow

n THERE IS NO EVIDENCE THAT Napoleon Bonaparte, whose Grand Army conquered much of Europe in the early 19th century, ever said or wrote the words now widely attributed to him: “An army marches on its stomach.” But in the winter of 1812, during his disastrous invasion of their country, the Russians destroyed much of the food, provisions, and shelter the Grand Army might have used to survive, administering to Napoleon a brutal lesson about the importance of feeding an army. About 1 of every 6 French soldiers survived the campaign. American military history has likewise been fraught with the problem of how to keep warfighters fed and healthy for combat. World War II was the first major conflict in which more military personnel were killed in combat than died of diseases – diseases often worsened, if not caused, by poor nutrition. Nutrition, unfortunately, wasn’t the main criterion for the earliest field rations; foods were chosen because they traveled well. The first standard ration issued to soldiers in the Continental Army included a pound a beef, 18 ounces of flour, 3 pints of peas or beans, a pint of milk, a half-pint of rice and, to prevent scurvy, a quart of cider or spruce beer. This first ration immediately ran into problems: It proved impossible, for example, to supply and transport milk in such quantities, and meats had to be heavily salted to avoid spoilage. While the Army and the Navy worked to mature the bureaucracy and infrastructure necessary to administer field feeding, the ration itself had changed very little

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by the Civil War, when the Union Army’s marching ration consisted of a pound of hard bread, salt pork or fresh meat, sugar, coffee, and salt – hardly sufficient to supply nutrients to a mature human body. An Army camp manual written by Florence Nightingale emphasized meat and milk as protein sources and whole grains, fruits, and vegetables for carbohydrates. Fruits and vegetables proved difficult to procure, however; scurvy was common in the winter, and soldiers often fought over berry patches in the spring. Some soldiers developed night blindness – poor vision in low light – due to a lack of vitamin A. The “travel ration” distributed to soldiers in the 1898 Spanish-American War was the first military ration to contain canned meat, though it was of such poor quality that troops ate very little of it, and the hot and humid climates of the Caribbean and Pacific often caused other foods to rot. With the turn of the 20th century came the realization that field rations had to be tailored to particular combat situations and environments. New processing technologies were developed, and by World War I, the Army had

The first standard ration issued to soldiers in the Continental Army included a pound a beef, 18 ounces of flour, 3 pints of peas or beans, a pint of milk, a halfpint of rice and, to prevent scurvy, a quart of cider or spruce beer.

devised a reliable system of bringing perishable foods to troops. Garrison rations contained more carefully calibrated measures of protein, fat, and carbohydrate – but the “reserve ration” issued to World War I soldiers still differed little from that issued in the Civil War. As nutrition scientists began identifying the importance of particular vitamins and minerals during the 1920s and 1930s, a series of new rations were developed by the Army, beginning with the “D-ration” – basically a vitamin-fortified chocolate bar meant to stand in for a missed meal. These new rations would be the key to feeding an armed force that was deployed to every corner of the globe, and served in a variety of operational situations, during World War II. The A-ration, the classic garrison ration, typically consisted of fresh or frozen meat, fresh dairy products, and fresh fruits and vegetables. For obvious reasons, the A-ration was normally supplied to an established military base or camp, and was sometimes brought closer to the front lines with the use of portable kitchens or insulated containers. A second garrison ration, the B-ration, was composed of canned, dried, and dehydrated items that could be unitized and scaled to feed people in increments of five, 10, and 100. The most notorious of the World War II rations was the C-ration, the boxed operational ration issued to soldiers each day and initially consisting of three different canned meat entrees and two different combinations of bread, coffee, and sweets (the M- and B-unit cans). Unfortunately, troops were forced to rely on the C-ration – designed for temporary

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U.S. AIR FORCE PHOTO BY AIRMAN 1ST CLASS ERICK REQUADT

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feeding during combat or when A- or B-rations were unavailable – more than anticipated, often eating C-rations for up to 90 days. For this and other reasons, it became widely reviled. The C-ration had other problems: Even among the 11 different varieties, there was little variation in taste and texture. The C-ration was bulky and heavy, and deployed soldiers often lightened their loads by simply discarding items. According to Sanders Marble, Ph.D., senior historian at the Army’s Office of Medical History, this was one reason designers of field rations tried to spread key nutrients among different food items; another was that most of the ration’s vitamin C was supplied by a difficult-to-stomach powdered lemon juice concentrate: “Troops considered it ‘bug juice,’” he wrote, “and used it to bleach floors rather than drink.” Several customized rations emerged to feed troops in specific situations or environments during World War II. The K-ration, nutritionally dense and lightweight, was issued to airborne troops and

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Meals, Ready-to-Eat (MREs) rest on a table during an MRE open-package inspection, April 6, 2018, at Moody Air Force Base, Georgia. Airmen from the 23rd Aerospace Medicine Squadron Public Health examine MREs defects and overall quality and determine whether they’ll be utilized here, at other bases, or to condemn the batch. Public Health monitors more than 8,400 MREs yearly to ensure they are safe and fit for consumption, so as to maintain a healthy fighting force. other short-duration mobile forces. The Mountain (M)-ration was designed for preparation at high altitudes; the Jungle (J)-ration, which included water purification tablets, was developed for troops in warm, wet tropical locations. Neither the M- nor J-rations ever caught on with the Army’s Quartermaster Command; both were discontinued in 1943 in favor of the K-ration. By 1944, Army nutritionists, now organized into a Medical Nutrition Laboratory, were able to improve the palatability of C-rations somewhat and expand the entrée choices to 10, but ration development stalled after the war; the C-ration remained the standard in Korea, and was

even used in Vietnam, where a freezedried field ration, the Long Range Patrol (LRP) ration, was developed for use by special operations troops on long-range reconnaissance teams. In the late 1950s, Army researchers developed what was essentially a more varied C-ration. Initially known as the Meal, Combat, Individual ration, it consisted, like the C-ration, of individually canned items to be eaten at the same time. It was this concept of increased variety and portability, along with advances in food processing and packaging technology, that eventually led to the development of the Meals, Ready-to-Eat (MREs). The MRE’s up-front design specifications were unprecedented in military feeding: It was required to be acceptable as a service member’s sole diet for seven consecutive days. New processing and packaging technologies, such as freeze-drying and flexible retort pouches, allowed for a greater variety in the MRE menu. Later improvements, such as the addition of a flameless heater

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PHOTO BY U.S. ARMY, JEFF SISTO

Tom Yang, Ph.D., a senior food technologist at the Combat Feeding Directorate, portions out fruit to be vacuum microwave dried (VMD), a technology that applies vacuum and microwave to rapidly and economically dry ration components with low temperature to reduce the weight of rations while retaining their shelf stability, quality, nutrition, and safety. VMD allows partially dried food components to be compressed to further reduce weight and volume of individual and squad-sized military ration components.

and condiments such as hot sauce in the 1990s, made the meals more palatable. The MRE, lighter in weight and more acceptable to troops, was rolled out in the early 1980s along with a program of periodic feedback and improvement that continues to this day. Stephen Moody, who directs the Combat Feeding Directorate at the Army’s Combat Capabilities Development Command (CCDC) Soldier Center in Natick, Massachusetts, was around for the MREs’ early days, when he was an active-duty Army warrant officer during Operation Desert Storm. “We sent a lot of people over there quickly,” he said, “and they were eating MREs for a long time.” While there were 12 different menus at the time, Moody said, there wasn’t a reliable rotation system in place. “You could be eating the same thing three, four times a week,” he said. “That was a big problem, because eventually people just stopped eating.” Under-consumption during training and field operations was a significant enough problem that the Combat Feeding Directorate (CFD) and nutrition scientists at the U.S. Army Research Institute of Environmental Medicine (USARIEM) began a review to examine it – to determine whether, and to what extent, the energy deficits caused by under-consumption affected the performance of military personnel – and to formulate strategies for reducing it. One of the most obvious strategies, Moody said, was simply to increase the variety of MRE offerings: “So, we expanded the menus to 24, and added two vegetarian menus, just to try to improve consumption. We’ve got Asian flavors, Latin flavors, and Caribbean flavors. It just reflects the diversity of the

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Army these days, and the tastes of the young soldiers.” 21st CENTURY COMBAT FEEDING Since 1993, more than 280 new MRE items have been added to the mix, and meals are continuously evaluated and revised. While several military agencies and advisory entities work today on studying and supplying military nutrition, the key collaborators remain the CFD and USARIEM’s Military Nutrition Division (MND), also located in Natick. The MND’s job, according to James McClung, Ph.D., the nutrition biologist who leads it, is “to understand the biomedical basis for nutrition requirements. We go where warfighters are, whether it is basic combat training, whether it is in a submarine or at the top of a mountain, to characterize nutrition requirements.” The MND’s research directly informs the CFD’s development and evaluation of food products.

This collaboration has yielded noteworthy innovations. In 2001, in order to standardize supply and packaging and reduce costs, the old LRP ration was merged with the Meal, Cold-Weather (MCW) ration – both of them compact, calorie-dense meals intended for use by active warfighters in the field. Each of the 12 MCW/LRP meals weighs about a pound and they differ only in the accessory packs that accompany the entrees: MCW accessories are freeze proof and intended for use in cold weather or high altitudes; LRP accessories are for light infantry or special operations forces in temperate or hot climates. Under-consumption and the accompanying risk of weight loss continued to be a problem for expeditionary warfighters during the Global War on Terrorism, particularly in Afghanistan. Lack of variety wasn’t the problem this time. It was the weight of MREs. On extended expeditions outside a forward operating base, lugging three MREs for

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each day of travel became far too burdensome; weight and space limitations led most service members to “fieldstrip,” sometimes discarding more than half their food, along with a considerable percentage of the nutrients necessary for replenishing their bodies’ fuel supply. With the help of the National Academy of Sciences’ Institute of Medicine and nutrition experts from all over the world, MND and CFD developed the First Strike Ration (FSR) for troops serving for extended periods outside a forward operating base. The FSR, rolled out in 2009, is designed for the extreme portability demanded by a 72-hour dismounted mission, packing the nutrients of three MREs into a single container that weighs less than half as much. According to Moody, the ration is also designed for flexibility. “We have entrée-type items,” he said, “and then we’ve also added those kinds of ‘pogey bait’ items, the trail mix, the beef jerky, those type of eat-on-the-move items. There are times when you’re out there, if you’ve got the luxury of time,

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Soldiers from the 82nd Airborne Division eat the First Strike Ration as part of a user evaluation by the Department of Defense Combat Feeding Directorate during a training exercise held on Fort Bragg, North Carolina, in June 2018. you’ll sit down and eat almost the whole thing if you’ve been burning a lot of calories. But there are other times when you just don’t have that time to do that.” At around the same time as the FSR rollout, MND and CFD began collaborating on a line of calorie supplements designed to refuel service members

There are times when “ you’re out there, if you’ve got the luxury of time, you’ll sit down and eat almost the whole thing if you’ve been burning a lot of calories. But there are other times when you just don’t have that time to do that.

operating under demanding conditions or environments. Three MREs a day provide service members with a minimum of 3,600 calories – but during exceptionally heavy activity, a warfighter’s daily calories needs can climb as high as 4,500 to 6,000. After a study of not only how service members burn calories while operating in different terrain, but also of their food preferences in different circumstances, Army food scientists and engineers developed the Modular Operational Ration Enhancement (MORE), designed to boost cognitive and physical performance and to counter weight loss and fatigue. The MORE, intended as a supplement to the entrees in standard MREs, FSRs, or MCW/LRPs, is tailored to the environment in which a warfighter is operating: All contain carbohydrates, caffeine, electrolytes, and vitamins, but some contain more carbohydrates, to counter both the increased energy requirements of high-altitude operations and the symptoms of altitude sickness, while others, designed for

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PHOTO BY DAVID KAMM, U.S. ARMY

Senior food technologist Michelle Richardson (left) and chemical engineer Ann Barrett, Ph.D., from the Combat Feeding Directorate, are working on both conventional compression and sonic agglomeration technologies to develop compressed foods in order to reduce the weight and volume of operational rations carried by U.S. soldiers in the field and by NASA astronauts for future manned missions to Mars.

hot weather operations, contain beverages for replacing electrolytes lost to perspiration. Each MORE weighs less than three-quarters of a pound and is easily compressible, taking up very little space. As all these new products were being studied by the MND and rolled out by CFD, it remained the case that military customers who wanted to obtain precise nutritional information about them – calorie counts or amounts of fat, protein, carbohydrate, sugar, sodium, vitamins, and more – needed to either read the labels on products already ordered, or to contact the appropriate experts at CFD. To make this detailed information readily available to service members, military dieticians, food services officers, and other customers, the CFD partnered with the Human Performance Resource Center (HPRC) at the Uniformed Services University of the Health Sciences to create an online web portal. It was a difficult and time-consuming process, involving chemical analysis by MND scientists of every single food component packaged into military meals, but the interactive website, the Combat Rations Database (ComRaD), launched in 2015, now offers accurate, up-to-date nutritional information about individual combat-ration menus and the individual components packed inside them. Another recent innovation, the Performance Readiness Bar, was released just last year in response to research suggesting basic trainees are

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twice as vulnerable to bone injury as their civilian counterparts. According to McClung, the incidence of stress fractures during basic training – the eight- to 10-week course introducing enlisted personnel to the rigors of military service – is historically high: Up to 5 percent of male trainees suffer stress fractures during basic training, and up to 18 to 20 percent of women. “Through our biomedical research,” said McClung, “we’ve discovered that the requirement for calcium and vitamin D may be higher at that time, that there may be an association between vitamin D status, calcium status, and the incidence of stress fracture, and that providing a product such as the Performance Readiness Bar as a snack during that period of time may optimize bone health.” The bar was developed by the CFD under the guidance of the MND. The significantly higher rate of stress fractures among women trainees, along with other data about active-duty women in the military, has caught the attention of military nutritionists. For the most part, McClung said, the nutritional requirements of men and women are the same – with a few noteworthy exceptions. “Iron requirements for women are significantly higher than they are for men,” he said. “In fact, they’re more than double. So, this does result in some difficulty, beginning in the basic combat training environment, where we need to think about ways to provide more iron, or prevent decrements in iron state if they occur due to training.” As they begin basic training, female Army

recruits are given a briefing by medical personnel on the importance of iron nutrition, and then throughout training are offered voluntary dietary supplements – multivitamins – containing additional iron. The role of calcium and vitamin D in bone health is well known, which is why the Performance Readiness Bar offers these nutrients in abundance – but the degree to which iron depletion plays a role in the higher rates of stress fractures among women trainees isn’t yet known. “It’s likely that there is some association between poor iron status in the incidence of injury,” McClung said, “and that’s also an active area of nutritional science research.” FEEDING FOR LETHALITY McClung and Moody both realize the military has encountered problems in field feeding during every conflict in its history, and that these problems were identified and remediated ad hoc – often too late to be effective, and ensuring that the armed forces began each new war with operational rations designed to avoid the problems of the previous war. One of the most recent developments in field feeding, still underway, is an attempt to create a solution as the need arises for it within the armed forces. When Gen. Mark A. Milley became the Army’s chief of staff in 2015, he developed strategic guidance that built on the Army modernization concept espoused by his predecessor, Gen. Raymond Odierno. The battlefield of the future is likely to look quite different – relying less on massive force mobilizations and more on “light footprint” operations carried out by smaller groups of specialized

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PHOTO BY DAVID KAMM, U.S. ARMY

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forces. “The current chief came in and we started talking about near-peer adversaries, what the battlefield of the future might look like,” said Moody. Those discussions evolved to envision small units that could operate semi-independently for seven days without resupply. “That really caught our attention, because our rations right now aren’t really suitable for that.” Such an expedition would require a service member to carry about 32 pounds of MREs, or 18 pounds of First Strike Rations. In March 2018, then-Secretary of Defense James Mattis acted on his concern that a growing number of training and duty requirements for close-combat infantry warfighters – many of which had little to do with making them deadly – were sapping the ability of U.S. infantry to engage in their core mission of intense, violent, close-in fighting. To remove these obstacles and provide infantry units with new training, tools, and technology to provide overmatch, Mattis established the joint-service Close Combat Lethality Task Force (CCLTF). The CCLTF is working along several lines of effort – including human performance, which McClung said necessarily involves nutrition. “A number of efforts in the modernization of the Army and the DOD [Department of Defense] are focused on lethality, particularly close-combat lethality,” he said. “Human performance is, of course, one dimension of that, so efforts we share with the Combat Feeding Directorate are really aimed at tailoring the feeding platform to the environment – in this case, tailoring it to close combat.” While the CCLTF goes about its work, the MND and CFD are working to develop the next generation of operational rations, known as the Close Combat Assault Ration (CCAR), which is envisioned to achieve about a 40 percent reduction in both the weight and volume of the First Strike Ration while further boosting physical and cognitive performance. “We’ve looked to see what we could do to make the ration even smaller and lighter,” said Moody. A pair of new technologies is helping with this effort: first, vacuum microwave drying (VMD), which helps create compact, lightweight and nutrient-dense food. Among other foods, Moody said, the CFD is testing VMD on cheesecake. “It sounds a little exorbitant for a ration,” he said, “but it’s a good test for us. It’s very dense in terms of calories and energy. We’re able to vacuum microwave dry this cheesecake to a point where we’ve pulled off enough moisture to make it shelf stable, but it still has a soft enough mouthfeel that you can just eat it as is.” Mouthfeel is an important factor in the CFD’s evaluations; reducing a ration’s footprint to an absolute minimum will be of little value if it renders food dry and unpalatable. A new compression technology, sonic compression, can help improve the texture of dried ration foods. Instead of just drying and squishing food, Moody said, the new technology applies sonic waves during compression that fuse food molecules together. “So, instead of a crumbly product,” Moody said, “you have more of a solid food bar.” Some tricks of the industrial trade used to smooth out compact energy bars – adding syrups and binders, for example – tend to add non-nutritional bulk, as well

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Several individual meals are compressed into the size of the one in this photo, showing an omelet, mixed vegetables with dressing, diced ham, and cheddar and Swiss cheeses. as unhealthy sugars. “We definitely don’t want to go that route,” Moody said. “So, by adding sonic energy, we can avoid adding some of those ingredients while still allowing warfighters to eat food out of their hands without it crumbling all over the place.” With these new technologies, CFD engineers are evaluating several new candidates for inclusion in the CCAR, including a compressed chili con carne bar that can either be eaten dry or rehydrated into a stew if time permits – but Moody knows stewbuilding is a luxury most warfighters on dismounted missions won’t be able to afford. The CCAR’s reduced footprint will necessarily involve less flexibility. “Our intention, really, for the CCAR is that it’s not a sit-down-and-eat-type ration,” he said. “It’s a snack on the move. You’re not going to have time to eat. It’s just to give you energy until you can get back to a base.” Even as operational rations are shrunk to their absolute minimum, the Army’s nutrition scientists are still looking to the future, when the focus of research and development efforts may turn from the foods service members eat to the way in which their own bodies absorb and process nutrients. The body’s inflammatory response, for example – which is particularly relevant to close-combat situations – is known to affect the absorption of nutrients. “We’re trying to study ways to overcome that inflammation,” said McClung, “whether it’s through providing the right nutrients at the right time or combating the effects of inflammation in a different way, perhaps in a medical way.” Another area of potential innovation is research in the human microbiome – the ecosystem of microorganisms in the human body, particularly the gut. “We’re working to understand the effects of consuming the ration on the microbiome, and the effects of the environment on the microbiome,” McClung said. “Perhaps we can harness the microbiome itself to overcome nutritional demands.” It may seem like science fiction – a wild idea, manipulating the human ecosystem to reduce the amount of food a soldier has to carry – but at the pace the Military Nutrition Division and the Combat Feeding Directorate have been working over the past decade, it’s a future that seems far more likely than not.

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THE VA’S BRAIN REHABILITATION RESEARCH CENTER

Harnessing the Brain’s Ability to Recover from TBI and Stroke

n IN 1999, WHEN THE DEPARTMENT of Veterans Affairs (VA) established its Brain Rehabilitation Research Center (BRRC) at the Malcom Randall VA Medical Center in Gainesville, Florida, it was in part a response to exciting new discoveries in neuroplasticity (the brain’s ability to form new connections and pathways after injury); neurogenesis (the ability of the brain to grow new neural cells and the dendrites that connect them); and angiogenesis (the generation of new blood vessels that oxygenate tissue and restore function). These advances helped to establish a core mission for the new BRRC: to identify the mechanisms involved in each of these areas – how, exactly, the brain might be induced to generate new pathways and neural tissues – and use that knowledge to develop interventions for people who suffer central nervous system damage. Veterans who’ve suffered injuries to the central nervous system also suffer impairments in cognitive, motor, or emotional functioning – often in combination. Even a single functional impairment can significantly affect a person’s health and quality of life and can impose significant emotional and financial burdens. In the BRRC’s two decades of existence, its investigators have focused their efforts primarily on recovery and neuro-rehabilitation from two of the most prevalent causes of these impairments: traumatic brain injury (TBI) and stroke.

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CREATIVE AND INNOVATIVE COLLABORATIONS Supported by the VA’s Office of Rehabilitation Research and Development (RR&D), the BRRC is adjacent to the University of Florida (UF) campus, and each of the center’s investigators is dually appointed to the university’s College of Medicine. The two facilities share resources, including the BRRC’s 11,000 square feet of laboratories and workstations and sophisticated tools for measuring and analyzing both brain function and motor control performance. The BRRC is also part of a research consortium that includes colleagues in the UF College of Medicine and the Brooks Rehabilitation Hospital in Jacksonville, Florida, whose Clinical Research Center shares the BRRC’s mission of advancing neural rehabilitation. Nationwide, BRRC investigators collaborate with other VHA institutions, including the health care centers in Portland, Oregon, and Tampa, Florida, as well as two other RR&D centers in Cleveland, Ohio: the Functional Electrical Stimulation (FES) Center, which evaluates neurostimulation methods, and the Advanced Platform Technology (APT) Center, where investigators explore engineering solutions to create new rehabilitation interventions. By design, BRRC’s investigative leadership is composed of 12 scientists, each with his or her own research program

in basic or clinical science. The fields studied by each, while varied, are also interrelated, including neuroscience, biomedical engineering, electrical engineering, neuropsychology, experimental psychology, neurology, physical therapy, biomechanics, and muscle physiology. According to Janis Daly, Ph.D., the BRRC’s director, the interdisciplinary nature of the center’s work “gives us the capability to consider a problem from multiple vantage points.” These different perspectives often generate creative and innovative explorations that hold promise for new treatments. For example, BRRC investigators are working to discover neuropathologies underlying the cognitive problems often associated with TBI. Neuroscientists Prodip Bose, M.D., Ph.D., and Floyd Thompson, Ph.D., have identified structural and functional damage to a structure called the locus coeruleus (LC) during brain injury. Located in the pons of the brainstem, the LC is a hub of neural activity that, under normal circumstances, relays critical brain signals to parts of the brain that serve other functions – the spinal cord, cerebellum, cerebrum, hypothalamus, amygdala, and others. Damage to the LC causes a complex of dysfunctions, and now that Bose and Thompson have identified it as a consequence of brain injury, several new clinical studies have been launched to address these dysfunctions. William Perlstein, Ph.D., a BRRC

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investigator who also directs the ClinicalCognitive Neuroscience Laboratory at UF, has identified two different types of cognitive dysfunction that often occur among chronic severe TBI patients: deficits in “regulative” function, which supports cognitive control of thoughts and behaviors, and “evaluative” function, which monitors the need for regulative control. Working forward from this distinction, Perlstein is in the process of assessing different treatments he’s designed to restore metacognition – the awareness and understanding of one’s own thought processes – in patients with regulative and evaluative dysfunction. Perlstein’s treatments will target executive function (the set of mental skills that enable people to coordinate thoughts and behaviors and get things done) and attention. BRRC investigators also have made important advances in rehabilitating the brain after stroke. David Clark, Sc.D., has developed ground-breaking

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Multi-color image of the whole brain. The Brain Rehabilitation Research Center investigators are working to discover how the brain might be made to generate new neural pathways and tissues after injury. methods for measuring brain function during walking, and discovered that as people develop problems with gait due to aging, disease, or a stroke event, they are increasingly likely to experience a corresponding loss of cognitive resources in the brain’s frontal lobe. “In other words,” Daly said, “he found that stroke survivors attempting challenging walking tasks require a great deal more brain resources in the pre-frontal cortex than those who have not had a stroke.” Clark and other investigators are building on this finding to target specific interventions for gait training after stroke. The experimental treatments are of two types: first, interventions involving “activity-dependent plasticity,” or treatments that draw on a

patient’s own intrinsic brain activity and ability to learn and form new processes. Using Clark’s methods of measuring brain activity, these treatments may be adjusted and refined over time, so that therapy is more individualized and, ultimately, the patient’s gait becomes more coordinated. A second type of gait treatment under investigation involves brain stimulation – either transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tDCS) – to facilitate brain signal activity in the prefrontal cortex while a patient is undergoing gait training. The BRRC’s sophisticated technologies and processes for measuring brain activity have also helped a research team led by Daly to develop treatments for stroke patients with upper limb dysfunction. One of the team’s most important findings was that while undergoing treatment and regaining motor function, patients demonstrate changes in brain activity – but these changes

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are highly variable and individualized. Daly’s findings suggest neurorehabilitation interventions need to be customized to match the brain activity patterns of individual patients. So far, Daly’s precision-treatment protocol is producing greater improvement in upper limb function, compared to other interventions in use, and can be integrated into treatment plans for stroke survivors with chronic limb dysfunction. The technologies used by BRRC investigators to measure brain and motor performance aren’t simply diagnostic tools; they can also be useful in treatment. For the past two years, Daly and her colleagues have been developing a neural feedback system for improving upper limb coordination in stroke survivors:

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An MRI machine in use. VA researchers are using functional MRI imaging to help stroke survivors practice difficult wrist and hand movements. While viewing functional magnetic resonance imaging or functional near infrared spectroscopy images of their own brains, stroke survivors practice difficult wrist and hand movements. Receiving feedback in real time, while practicing challenging motor tasks, has encouraged these patients to modify their own brain signals during movement. “We’re providing them a signal that’s showing them how their brain is working and how strong the signal is,” said Daly, “and we’re asking them to enhance that signal. These are folks who, for example, can’t extend

their wrist in preparation for grasping something. While they’re practicing extending their wrist, we’re showing them their brain signal, and we’re asking them to enhance the signal in that spot in the brain while they’re attempting to move. It’s biofeedback, based on brain signaling.” TRANSLATION INTO PRACTICE Because the mechanisms of neuroplasticity are incompletely understood, most studies of its processes haven’t yielded clinically significant improvements yet – there are no “cures” for the complex of cognitive, motor, and emotional dysfunctions caused by TBI and stroke. BRRC investigators

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are focused on the difficult task of discovering the neural mechanisms that prevent recovery and rehabilitation, a challenging endeavor that will be built on valid diagnostic and measurement tools. Several such tools have been translated into practice while the center’s investigators continue to research neuroplasticity and complete studies aimed at providing treatments that can be easily deployed into practice. Examples of the diagnostic and clinical tools developed by BRRC researchers and in use today include: • The Gait Assessment and Intervention Tool (GAIT), developed by Daly and initially designed for stroke survivors, was recently translated into Spanish and is undergoing reliability testing for patients with multiple sclerosis. A comprehensive scoring system for assessing incremental improvements in the components of gait, the tool is currently being used for stroke survivors in Thailand, Colombia, and Spain. • The first FDA-approved blood test to evaluate for mild TBI (mTBI), which was developed with significant contributions from Kevin Wang, Ph.D., and colleagues at the BRRC. The test, which measures levels of two proteins associated with brain injury, allows for TBI diagnosis in the field, which will make it a critical tool, for example, in evaluating whether injured service members should be returned to combat. • A diagnostic tool for the early detection of brain disease risks, developed by Keith White, Ph.D., and colleagues. White’s patented method, which uses commercially available MRI systems, detects elevated iron oxide nanoparticles in the brain. White’s tool builds on research indicating that abnormal iron oxides may be formed early in the disease process, possibly due to a malfunction in the brain’s iron-storage protein. To improve the accuracy of MRI data, White has also developed a patented method to correct for a patient’s head motion in the scanner, which can result in inaccurate measurement. White’s method is available for use in research and clinical applications. • A new intervention for restoring non-verbal communication skills to patients who have suffered TBI. The treatment, developed by Susan Leon, Ph.D., targets a condition known as aprosodia – a deficit in understanding or expressing the variations in vocal tone, pitch, or rhythm used to convey emotional cues – that is often caused by damage to the areas of the brain involved in language production. The intervention is currently being evaluated by Leon and another BRRC investigator, Kay Waid-Ebbs, Ph.D. • A smartphone application, developed by Waid-Ebbs, to help veterans with TBI apply the principles involved in Goal Management Training™ (GMT, a validated metacognitive intervention for treating TBI) to everyday tasks. The application, VA Task Manager, is available for download from the Google Play store. • An objective, quantitative tool for diagnosing post-traumatic stress disorder (PTSD), developed by Mo Modarres, Ph.D., the bioengineer who coordinates the BRRC’s brain function measurement. Building on his encephalographic (EEG)

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measurements of brain activity among veterans with and without PTSD, Modarres has identified EEG signal markers and produced a diagnostic index for both the presence of PTSD and its severity. Modarres has also developed and patented a portable EEG system that can be used in veterans’ homes to diagnose PTSD and sleep disorders associated with TBI and PTSD. “EEG is a non-invasive method to collect brain signals from surface electrodes on the scalp,” Daly said, “and the EEG signal for those with PTSD exhibits significantly different characteristics compared to those who don’t have PTSD. In both clinical practice and in research, it’s important that we apply an accurate, objective measure in identifying those with PTSD, in order to provide proper care.” A FUTURE PARADIGM FOR BRAIN REHABILITATION RESEARCH Because brain injuries are often sustained in traumatic experiences, there is a strong correlation or “dual diagnosis” of PTSD and TBI. As of June 2018, the Defense and Veterans Brain Injury Center (DVBIC) reports more than 380,000 diagnoses of TBI in the military since 2000, and studies suggest up to half of all service members with combat-related TBI meet the diagnostic criteria for PTSD. As more has become known about the relationship between TBI and PTSD, some BRRC investigators have turned their attention toward the problem of how to diagnose and treat the neural dysfunctions associated with PTSD – a chronic condition that affects the brain’s limbic structures and can lead to hyperarousal, a persistent perception of threat, flashbacks, and nightmares. In recent years, BRRC investigators, led by John Williamson, Ph.D., and Damon Lamb, Ph.D., have begun to examine new methods for mitigating the emotional dysregulation that often accompanies PTSD. With novel treatments such as these being explored by BRRC researchers, Daly is optimistic that the center will, over the next five years, lay the foundation for a paradigm shift in precision neurorehabilitation for veterans with TBI and stroke who suffer persistent cognitive, motor, and emotional dysfunction. This foundational work, Daly said, will include the discovery of new neuroplastic targets for treatment; new sensitive measures and biomarkers; and new treatments based on neuroplastic mechanisms, developed and tested for feasibility. In the near future, said Daly, “We’ll be testing 17 new interventions for restoring these signature problems of TBI and stroke: cognitive and motor dysfunction, and the devastating emotion dysregulation that accompanies PTSD and TBI. As a center, we respond to the needs of veterans and we, under the auspices of the VA RR&D, are mandated to be within their mission – so as their mission changes, and as veterans’ needs evolve and change, we’ll respond.”

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VA Research

DEPRESSION By Craig Collins

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The U.S. Army STARRS Study found major depression to be five times higher among active-duty service members compared to civilians.

DEVELOPING A “PICTURE OF DEPRESSION” Identifying risk factors for depression is more difficult than with most illnesses; depression weaves a tangled etiological web with other mental and physical health problems. It can occur along with literally all other psychiatric and physical diagnoses. Physical illness is known to increase the risk of developing depressive illness, though many of the cause-effect relationships – or whether cause-effect relationships are involved at all – remain unknown.

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COURTESY PHOTO

n ACCORDING TO THE NATIONAL INSTITUTES OF MENTAL HEALTH, more than 15 million American adults suffer at least one major depressive episode in a given year – about 6.7 percent of the population. It’s a percentage that makes depression one of the nation’s most common and burdensome mental health disorders. Among active-duty service members and veterans, this rate is higher: The landmark Army STARRS Study, completed in 2014, found the incidence of major depression to be five times as high among active-duty soldiers as civilians. In 2008, the Department of Veterans Affairs (VA) estimated that about 1 out of every 3 veterans visiting a primary care facility displayed at least one symptom of depression, while 1 in 5 had serious symptoms suggesting the need for further evaluation. According to the National Alliance on Mental Illness, the diagnosis rate for major depression among veterans, requiring treatment with psychotherapy or antidepressants, is 14 percent. More than the occasional bout of melancholy or grief, depressive disorder is marked by sustained feelings of sadness or hopelessness that last for two weeks or longer, often accompanied by a loss of interest in activities once enjoyed. It can lead to other emotional and physical problems, and can be disabling, reducing a person’s ability to function at home and at work. Untreated depression is known to increase the risk for suicide, a cause of death that has been on the increase among veterans – particularly younger veterans – in recent years. Despite its often devastating effects, major depression is a treatable illness: About 8 out of 10 veterans receiving VA care are effectively treated. VA researchers aim to increase this percentage by developing models of intervention and social support to help veterans recover from depression and other mood disorders. Some investigators are exploring which risk factors – including brain chemistry, genetics, personality, and environmental factors such as stress or trauma – increase the likelihood of depression; others are evaluating the effectiveness of medications and other treatments.


U.S. AIR FORCE ILLUSTRATION BY AIRMAN 1ST CLASS KATHRYN R.C. REAVES

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Many VA investigators explore relationships between depression and factors often associated with the disorder – whether they can be determined to be risk factors or not – and whether these relationships may have implications for further treatment. Alan Teo, M.D., M.S., an investigator at the Center to Improve Veteran Involvement in Care at the VA Portland Health Care System and an associate professor of psychiatry

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While there are several associative aspects of mental health, VA researchers found loneliness to be associated with higher levels of depression and suicidal thoughts.

at Oregon Health & Science University, has spent much of his career exploring the role of social contact in depression. In April 2018, Teo and colleagues published a study in the Journal of Affective

Disorders, measuring the degree to which several facets of social connectedness – number of confidants, social support, interpersonal conflict, social norms, and loneliness – are correlated with depression. Teo and his investigators didn’t mean for loneliness to be the dominant theme of the study, he explained, but it became one of the primary takeaways: Among veterans in VA primary

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care, loneliness – a level of social engagement below what one hopes for – was associated with higher levels of depression and suicidal ideation, as well as lower patient help-seeking intentions and behaviors. “Loneliness is not a defining symptom for depression,” said Teo, also a practicing psychiatrist – but at the same time, he and his colleagues know it’s a common experience among their veteran patients. “It’s there between the lines,” he said, “without patients explicitly bringing it up, this idea of being disconnected from people or lacking social relationships. We don’t use it to diagnose depression, so we often don’t think of it as something to treat. But it impacts their mental well-being, so I think it’s something we need to think about as a health issue. It’s definitely distinct from depression, but it’s a significant part of the picture of depression in veterans.” Teo isn’t consumed with determining whether loneliness is a cause or consequence of depression; he views it as both, and also as a treatable circumstance. To build on this study, Teo intends to explore the obvious question: Can making people less lonely make them less depressed? “That’s an unanswered question,” he said. “But I think it’s an important one.” Teo has a head start in answering it: In several studies, he’s already explored whether using certain 21st century modes of social connection – email, video-chatting, and social media platforms such as Facebook – are linked to reduced risk of developing depression. So far, he’s discovering there is no substitute for faceto-face contact between human beings – including video-chatting, which may be a tool to help fend off depression. “We should think about measuring and asking our primary care patients about loneliness,” Teo said. “And that can open up the opportunity for thinking through strategies to address it. The jury is still out on definitely what is going to work.” Another condition known to strongly correlate with depression – to the point that it is, actually, one of the diagnostic criteria for the disorder – is insomnia.

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Variations in the human genome account for differences in the way some antidepressants are metabolized in the liver or processed by the brain – but without knowledge of an individual patient’s genes, it’s impossible for clinicians to tailor medications and dosages appropriately. Fully two-thirds of people with depression also meet the diagnostic criteria for insomnia. The reason for this association isn’t known, but insomnia worsens the course of depression and makes patients more resistant to treatment – and unfortunately, some commonly prescribed antidepressants are known to promote or worsen sleep disturbance. Elaine Boland, Ph.D., a research psychologist at the Corporal Michael J. Crescenz VA Medical Center (VAMC) and clinical associate at the Perelman School of Medicine of the University of Pennsylvania, is conducting a study aimed at identifying the biopsychosocial processes common to both insomnia and depression – and ultimately, perhaps, developing a treatment targeting patients suffering from both. Boland’s study is designed to build on the knowledge that people with depression tend to devalue rewards that require significant effort to obtain – a phenomenon known as “effort discounting.” Some preliminary evidence suggests sleep disturbance may lead to effort discounting, but it’s never been evaluated among adults with clinically significant insomnia. Boland’s volunteer subjects will take a computerized battery of behavioral tests – “Designed,” Boland said, “to assess how much effort individuals will put forth for monetary rewards.” The subject sample includes individuals who have sleep disturbance, and also individuals who don’t, with subjects who

may have some degree of depression in the mix. “The question I was really interested in answering,” Boland said, “is when sleep disturbance is severe enough, does it actually exert kind of an additional effect on the reward system that makes it even harder for these depressed patients to recover?” If improving sleep can reduce effort discounting, such a finding would encourage further studies into how insomnia and depression are treated together. “I think it might help us get closer to developing more targeted treatment for veterans that have both depression and insomnia,” said Boland. “They clearly aren’t responding as well to traditional depression treatments. I think we need to do a better job, through either the development of psychotherapies that target sleep and depression together, or maybe rehabilitating the desired reward response.”

NEW AND IMPROVED TREATMENTS VA investigators are working to develop and refine treatments for the 20 percent of patients with depression who don’t respond well to established treatments – who have what’s known as “treatmentresistant” depression. Antidepressant medications, for example, work well for the majority of patients with major depression, but a 2015 study by investigators at the Institute of Psychopathology in Rome, Italy, suggested these drugs don’t improve symptoms for 10 to 15 percent of patients with depression. Thirty to 40 percent of patients who take them notice only a partial improvement in their symptoms. In 2017, the VA began recruiting for an ambitious clinical trial aimed at evaluating the link between patient genomics and the effectiveness of these antidepressants: the PRIME Care (PRecision Medicine in MEntal Health Care) initiative, led by Dr. David Oslin, director of the regional (VISN4) Mental Illness Research, Education and Clinical Center (MIRECC) at the Crescenz VAMC in Philadelphia.

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As Oslin pointed out, variations in the human genome account for differences in the way some antidepressants are metabolized in the liver or processed by the brain – but without knowledge of an individual patient’s genes, it’s impossible for clinicians to tailor medications and dosages appropriately. The standard dosage of sertraline (Zoloft®), for example, is 100 milligrams, but some patients do fine on a dose of 50 milligrams, while others may need a dose of 200. It’s still unknown whether genes explain these different dosage requirements, but investigators in the PRIME Care initiative aim to find out – and to discover, as well, whether genes may make patients more receptive to some medications than others. The study, scheduled to be completed in 2022, seeks to enroll 2,000 veterans who have not responded well to previous treatments for depression. From each of these patients, 12 genes associated with the brain’s and body’s ability to metabolize and process 55 commonly prescribed drugs will be gathered by means of a simple cheek swab and analyzed with an algorithm designed by a private company, Myriad Genetics, Inc. In addition to analyzing these outcomes, the study is designed to examine the best ways to provide these test results to veterans and their health care providers – and perhaps to guide similar pharmacogenomic studies of other illnesses. It’s sometimes the case even when patients with major depression are responsive to antidepressants, these drugs sometimes take several weeks or even months to achieve their maximal effect. VA researchers including Dr. Sanjay Mathew, a psychiatrist with the Michael E. DeBakey VAMC in Houston, and a professor of psychiatry at the Baylor College of Medicine, have been exploring the effectiveness of ketamine – traditionally an anesthetic – as a rapid-acting antidepressant. In early 2019, the U.S. Food and Drug Administration (FDA) approved the use of esketamine (a patented derivative of ketamine) as a nasal spray, in conjunction with an oral antidepressant, for adults with treatment-resistant depression. Dr. Paul Holtzheimer, M.S., deputy director of research at the National Center for PTSD (post-traumatic stress disorder) in White River Junction, Vermont, and an associate professor of psychiatry and surgery at Dartmouth Geisel School of Medicine, said that VA researchers are continuing to explore the implications of ketamine’s faster-acting antidepressant effect. The VA has recognized ketamine’s potential for treating patients with severe depression, including those at risk for suicide. “Ketamine,” said Holtzheimer, “has been shown to have very rapid antidepressant effects that unfortunately tend to wear off in a few days or a few weeks. So, we’re looking at different ways of extending the efficacy of that.” Investigators in the National Center for PTSD’s Clinical Neurosciences Division

have also been looking into ketamine’s potential for the treatment of PTSD. “Early findings are suggesting there may actually be some efficacy there as well,” Holtzheimer said.

DEPRESSION, PTSD, AND NEURAL CIRCUITRY It’s unsurprising, Holtzheimer said, that some treatments may be effective in treating both depression and PTSD. “In patients with PTSD,” he said, “there’s an extremely high comorbidity with depression. Fifty percent or more of patients with PTSD have clinically significant depression. There are also a lot of PTSD symptoms that really overlap with symptoms of depression as well, and that indicates possible overlap of neurobiology.” Holtzheimer’s own research into depression and other mood disorders has focused on interventions involving the brain’s neural circuitry – direct stimulation of brain neurons – which show promise for treating both treatment-resistant depression and PTSD. One of the most effective treatments for severe or treatment-resistant depression is electroconvulsive therapy (ECT), a procedure done under general anesthesia in which electrical currents are passed through the brain and trigger a brief seizure. ECT appears to cause changes in brain chemistry that can quickly reverse symptoms of depression, and is much safer today than in its early years, when higher voltages of electricity were administered without anesthesia. But several side effects and drawbacks remain: It’s still an indiscriminate application of electricity that may produce confusion, memory loss, or other side effects. VA investigators are exploring more targeted neuro-stimulation techniques, interventions aimed at areas of the brain known to be involved in mood and emotion. The less invasive of these options, transcranial magnetic stimulation, or TMS, involves the application of magnetic currents from a coil placed on the patient’s head. More than 30 studies of TMS have been done over the past two decades, and most have suggested the procedure is effective for at least some patients suffering from depression. A 2012 study at 42 TMS clinics in the United States evaluated outcomes among more than 300 patients who were non-responsive to antidepressants, and found that 58 percent “responded positively” to TMS, while 37 percent had their symptoms go into remission. A handful of recent studies, including a 2017 investigation by Chinese researchers, has suggested that TMS may also be helpful in treating PTSD. But researchers still have much to learn about TMS: how and why it works, and how many treatments are necessary for the most effective outcome. A VA study of 81 veteran patients with

VA investigators are exploring more targeted neuro-stimulation techniques, interventions aimed at areas of the brain known to be involved in mood and emotion.

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NIH IMAGE

Illustration of transcranial magnetic stimulation, or TMS. Studies suggest that TMS is effective for at least some patients suffering from depression.

treatment-resistant depression, published in June 2018, demonstrated a similar rate of remission, 40 percent, among patients who received active stimulation – but 37 percent of those who received a “sham” treatment, or procedural placebo, also reported remission. “In most of the prior TMS studies, the sham remission rate is down around 5 to maybe 10 percent,” said Holtzheimer. “To have a study with such a high [sham] remission rate suggests something about the study, or something about the patients being enrolled, is very different from all of the probably close to a thousand patients enrolled in studies prior to that.” Holtzheimer has collaborated with Dr. Helen Mayberg, a neurologist at Emory University, in analyzing a brain stimulation technique Mayberg pioneered to target the subcallosal cingulate region of the brain. Often

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known simply as Area 25, this region is rich in serotonin transporters and is known to be metabolically overactive in patients with treatmentresistant depression. Mayberg’s intervention, deep brain stimulation (DBS), involves the surgical insertion of a battery-powered electrode directly into this region of the brain. The amount and frequency of pulses delivered by the device are fine tuned after the surgery. According to Mayberg, many of the patients who received the first DBS implants have lived depression-free since the first operations were performed more than a dozen years ago, while other patients with depression appear not to be helped by DBS. So far nobody, including Mayberg nor Holtzheimer, understands why, and the FDA hasn’t yet approved it for the treatment of depression. Holtzheimer’s most recent study of the procedure,

published in Lancet Psychiatry in 2017, demonstrated that it was a safe and feasible procedure – and that while it was only slightly more effective than sham treatments after a period of six months, patients who were treated over a period of two years did well compared to subjects of earlier studies. “There’s still the possibility that longerterm stimulation could be effective in highly resistant patients,” Holtzheimer said, “and the patients who get better didn’t seem to relapse. They tended to stay better over time.” More studies are needed, he concluded, to investigate factors such as electrode placement and other clinical features. “We’re hoping we can do another study, designed somewhat differently,” he said, “to better show that active stimulation works and evaluate longerterm effects of the treatment. The flipside of this is that in patients where DBS seems to work – and we did this in our first study at Emory – when you turn off the stimulation, almost 100 percent of the patients get depressed again … and then if you turn it back on, they get less depressed.” More data are coming out from patients studied at both Emory and Dartmouth, Holtzheimer said, and more studies of the procedure are being planned. In the last few years, early studies of DBS in the regions of the brain associated with fear and anxiety – including a 2015 study of veterans at the VA Greater Los Angeles Healthcare System – have shown the procedure to be safe and effective in treating PTSD. Activation of the brain’s neural circuits represents a new frontier in treating depression and other psychiatric conditions, and Holtzheimer and other VA investigators are at the vanguard of explorers hoping to unlock their secrets and put them to work for American veterans.

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VA Research

SUBSTANCE USE DISORDER By Craig Collins

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VA investigators examine the problem of substance use from all angles: investigating how substances interact with the nervous system and other organ systems, conducting clinical trials of treatments, and leading big-picture evaluations of its own health care system, aimed at increasing the value of, and expanding access to, care delivered to veterans with substance use disorder. BIOMEDICAL RESEARCH VA research now includes several studies aimed at understanding – and ultimately, countering – the effects of substances on human tissues and cells, particularly in the central nervous system. Funded projects include investigations into biomarkers associated with alcohol misuse, the neurobiology of alcohol and nicotine co-addiction, and the mechanisms by which alcohol use accelerates other diseases. VA recently funded a study into whether a class of cell membrane proteins called calveolins may protect brain neurons from compulsive methamphetamine use. Several VA studies are underway investigating what role genetics may play in determining people’s vulnerability to alcoholism and addiction. Michael Charness, M.D., chief of staff of the VA Boston Healthcare System and a professor of neurology at both Harvard and Boston University, has spent much of his research career studying the problem of alcohol toxicity in the developing nervous system – a field of research that has implications for the growing number of women veterans of childbearing age. In previous studies, Charness and colleagues

VA research now includes several studies aimed at understanding – and ultimately, countering – the effects of substances on human tissues and cells, particularly in the central nervous system. www.defensemedianetwork.com

PTRUMP16 VIA WIKIMEDIA COMMONS

n SUBSTANCE USE DISORDER (SUD) – a pattern of using alcohol, drugs, or other psychoactive substances that results in health issues or problems at work, school, or home – is generally more prevalent among military veterans than among other Americans, for a number of reasons, including the demands of military service, the trauma of combat, and the difficulty many veterans experience in re-integrating into civilian society. A 2011 Department of Veterans Affairs (VA) study revealed that around 25 percent of Iraq and Afghanistan veterans 18 to 25 years old met the full criteria for substance use disorder. Because of its widespread availability, alcohol remains the substance most commonly used among veterans with SUD, though – as with the American population in general – the use of addictive opioid drugs, including prescription pain medications and illicit drugs such as heroin and fentanyl, rose sharply over the first decade of the 21st century. In 2015, about 68,000 veterans had opioid use disorder, a threefold increase over a period of 12 years, and the VA reported that veterans were twice as likely as nonveterans to die of accidental opioid overdose. Since the VA’s launch of its Opioid Safety Initiative in 2013, the rate of opioid prescriptions has declined, while the percentage of veterans receiving treatment for opioid use disorder has increased. Among the factors that make SUD treatment challenging for veterans to access is that substance use is often concurrent with other psychiatric or medical conditions. A 2017 study by investigators at the Ralph H. Johnson VA Medical Center (VAMC) in Charleston, South Carolina, revealed that 63 Iraq and Afghanistan veterans diagnosed with an SUD also met criteria for post-traumatic stress disorder (PTSD) – and that those with this dual diagnosis were more likely to have additional psychiatric and medical conditions such as liver disease, HIV, anxiety disorders, schizophrenia, and bipolar disorder. Despite the higher risk for veterans, however, the Charleston team pointed out that veterans with SUD receive treatment at about the same rate as other Americans – and that rate is low. Only about 10 percent of SUD-positive veterans receive any type of treatment.


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have established that alcohol disrupts the activity of a cell adhesion molecule, L1, that plays a role in neural cell growth and, more significantly, in moving new neurons to where they’re needed in the developing brain. “The L1 molecules on one cell stick to the L1 molecules on other cells,” explained Charness. “It serves as a guidepost. We’ve learned that alcohol inhibits the function of that molecule – two cells that depend on forming a nucleus together by sticking, through the actions of that molecule, won’t do so. They won’t migrate to the right place and their axons won’t make the right connections.” This failure may be a partial cause of the irreversible brain damage and growth problems known collectively as fetal alcohol spectrum disorder (FASD). In a recently completed study building on this knowledge, Charness’ team discovered that alcohol’s effect on the L1 molecule can be blocked by other substances, known as antagonists, that essentially keep L1 sticky in the presence of alchohol. One of these antagonists, a peptide abbreviated as NAP,

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The March 6, 2018, issue of JAMA included a report of a long-term study that suggested the risks of opioid pain therapy – including side effects and addiction – outweighed the benefits. Roughly 10 percent of substance use disorder-positive veterans receive any kind of treatment.

critical part of the brain that’s necessary for alcohol to produce important effects. That’s a long way off – but it’s not total science fiction.” TREATMENTS FOR SUD – AND NON-OPIOID TREATMENTS FOR PAIN

prevented both alcohol’s effect on the L1 molecule and the development of FASD in mouse embryos. The implications of Charness’ findings, and of other research into the alcoholbinding sites of cellular molecules, go beyond the discovery of substances that can be used to block the harmful effects of alcohol on development: It suggests the possibility of genome editing for adults with alcoholism to alter the interaction of alcohol with critical amino acids in proteins that mediate the addictive properties of alcohol. Gene therapy would probably never become a firstline treatment for alcoholism, Charness said, but could present a solution for some adults with treatment-resistant alcoholism. “Maybe we could, through gene editing, flip just one amino acid in a

VA investigations of SUD treatments include trials of existing drugs that suggest novel treatments for substance dependency. A team at the VA Connecticut Healthcare System, for example, is studying the effectiveness of zonisamide, an anticonvulsant, in reducing heavy drinking and improving outcomes for veterans with alcohol dependency, while another Connecticut team is investigation the effectiveness of ketamine – a controlled substance traditionally used as an anesthetic – in rapidly treating major depression and alcohol use disorder. Researchers at the Michael E. DeBakey VAMC are evaluating the effectiveness of doxazosin, an antihypertensive drug, in blunting the acute effects of cocaine use.

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MICHAEL E. CHARNESS, M.D., CHIEF OF STAFF, VA BOSTON HEALTHCARE SYSTEM

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Next to alcohol, cocaine accounts for the second-most common substance use disorder in the VA system, and there is currently no FDA-approved pharmacological treatment for cocaine use. This is a dangerous circumstance for veterans: According to Christopher Stauffer, M.D., a psychiatrist at the San Francisco VAMC and professor of psychiatry at the University of California-San Francisco, between 30 to 60 percent of patients receiving methadone maintenance treatment (MMT) for opioid use disorder are also actively using cocaine – and dropout rates from MMT and other opioid use treatment programs are as high as 80 percent for cocaine users. The mortality rate of concurrent users of cocaine and heroin is 14 times higher than the general population’s. Two years ago, Stauffer began recruiting for a trial aimed at reducing active cocaine use among veterans receiving MMT therapy. Cocaine use is known to be driven by social stress

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A model showing the location (dotted circle) where alcohol interacts with the L1 molecule to reduce its “stickiness.” and associated with hyperreactivity of the brain’s stress response system – the hypothalamic-pituitary-adrenal (HPA) axis. Stauffer hypothesized that administering the hormone oxytocin to cocaine users might help to weaken this hyperreactivity (oxytocin, which plays a role in parent-child and social bonding, is produced in the hypothalamus and released by the pituitary gland), improve engagement in psychosocial treatments, and perhaps reduce subjects’ desire for cocaine. “There is a lot of animal data showing that oxytocin is helpful for almost every substance of abuse, [including] alcohol, opioids, cocaine, methamphetamine,” Stauffer said. “We don’t really know why yet. Substance abuse highjacks the same neuro-circuitry that is used for social relationships, the same reward. And we know that when people develop

a substance abuse disorder, their relationships with other people kind of fall to the wayside.” It’s also known, Stauffer said, that the brains of cocaine users down-regulate the production of oxytocin. “So, the thought is that if maybe we give them oxytocin from the outside, that might help rebalance things.” This isn’t Stauffer’s only study involving oxytocin and substance use, and he hasn’t yet found that oxytocin, by itself, has reduced subjects’ substance use – though he has noticed, anecdotally, that patients receiving oxytocin seem more engaged in the clinic’s activities: They attend more often and seem more engaged. “I’m starting to believe that you need to give patients something to shift their attention toward,” Stauffer said. “Just giving them the oxytocin without giving them the support I don’t think is going to be as helpful. I think you need the oxytocin plus a positive social relationship to kind of transfer their reward system onto.”

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NIH-DOD-VA COLLABORATORY

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Several recent and ongoing studies are aimed at reducing the prescription and use of opioids within the VA health care system – a principle outlined in the new VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Pain. A VA researcher from the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina, is part of a team working to develop a new non-opioid drug that works on the same pain receptor, and also activates a receptor that blocks addictive effects. While not yet ready for trials with human subjects, the new substance, AT-121, may have the potential to safely and effectively relieve pain, and also to treat prescription opioid abuse. In the March 6, 2018, issue of JAMA, a VA research team from the Minneapolis VA Health Care System’s Center for Chronic Disease Outcomes Research published a study immediately recognized as a landmark in opioid research. The team, led by Erin Krebs, M.D., MPH, studied the use of opioid and non-opioid pain medications over a period of one year among 240 veterans with chronic pain – and discovered that opioids were not only slightly less effective than nonopioid drugs (i.e., acetaminophen or lidocaine) at reducing pain over time, but also

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Since the OSI launched in 2013, the rate of opioid prescriptions has decreased, whereas the percentage of veterans receiving treatment for opioid use disorder has increased.

far more likely to involve negative side effects. It was the first rigorous long-term study to suggest that the risks of opioid pain therapy, including side effects and addiction, outweighed the benefits. IMPROVING QUALITY AND ACCESS Andrea Finlay, Ph.D., of the Palo Alto VA’s Center for Innovation to Implementation (Ci2i), is among the considerable number of VA investigators aiming to improve the quality of VA’s overall SUD care, and to increase the number of veterans who take advantage of it. Finlay recently led a team in exploring the reasons why, among veterans with opioid use disorder (OUD) being treated in VA residential facilities, only about 21 percent are receiving medications to treat their disorder. Medications such as methadone, buprenorphine, and naltrexone target the same receptors as opioids and have

proven effective in reducing opioid use and the related symptoms. They also increase the likelihood that a person will remain in treatment, employed, and out of trouble. Methadone, in particular, reduces the likelihood of overdose death by nearly 60 percent, according to the National Institute on Drug Abuse. So why are so few veterans in VA residential facilities being prescribed these medications? Finlay’s team discovered that though this number was lower than among veterans with OUD overall (35 percent), the barriers to pharmacotherapy weren’t unique. Among the most significant was a strong cultural anti-drug treatment bias at these residential facilities. To address these barriers, VA leaders reached out to educate and enable providers at these residential facilities. “They made sure every residential treatment program had appropriate access to a provider, so that they could prescribe buprenorphine for them,” Finlay said. “They did intensive educational programs in the residential settings … to give them the knowledge they need to improve access and use of these medications.” Patients in residential settings, of course, are easy to reach; the vast

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Did you know this magazine is available online on any device? VETERANS AFFAIRS & MILITARY MEDICINE OUTLOOK SUPPORTS NATIONAL NURSES WEEK 2019

VETERANS AFFAIRS & MILITARY MEDICINE OUTLOOK SUPPORTS NATIONAL NURSES WEEK 2019

Military and VA Nursing History Combat Nutrition Educational Programs

Military and VA Nursing History

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Combat Nutrition Educational Programs

V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

Interview Maj. Gen. Barbara R. Holcomb

Commanding General, U.S. Army Medical Research and Materiel Command and Fort Detrick, Maryland; Chief, U.S. Army Nurse Corps

DOD AND VA NURSING Expanding Techniques and Technologies for 21st Century Care

DOD TRAUMA DOCUMENTATION STUDY: FROM PAPER TO ELECTRONIC In one example of an evolving technology, trauma staff at Brooke Army Medical Center (BAMC) in San Antonio, Texas, have been conducting a performance improvement study since August 2018 using T6, an electronic trauma documentation application created by T6 Health Systems. U.S. Air Force (USAF) Lt. Col. (Dr.) Valerie Sams, trauma critical care surgeon at BAMC and the T6 study lead, explained the reason for the study, based on her observations and experience during deployment to Afghanistan a few years ago. Sams said that standard trauma documentation in the United States is still predominantly a paper process. The problem she noted while deployed, “with military health care being a continuum of care, from the point of injury through the Role 4, Role 5 level of care both in Germany and in the States, is that that paper documentation becomes very cumbersome in terms of data capture,” she said. “This is a process that follows people from the battlefield to wherever they’re going for their definitive care. A lot of the documentation was pretty poor, given the fog of war and difficult operational environments.” Sams continued, “In order for us to make decisions about resources, practice guidelines, and casualty care, we really rely on accurate data.” In an effort to improve data capture along the continuum of military trauma care, Sams worked with company representatives to explore an “electronic version of what we’ve been

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U.S. AIR FORCE PHOTO BY CAPT. ANNA-MARIE WYANT

Interview Maj. Gen. Barbara R. Holcomb

Commanding General, U.S. Army Medical Research and Materiel Command and Fort Detrick, Maryland; Chief, U.S. Army Nurse Corps

doing on paper for a very long time.” With improved efficiency and accuracy of data capture, she said, “combat casualty care is only going to get better.” Sams categorized the T6 as a nursing documentation tool, with the application extending “beyond documentation into things like clinical support, clinical practice guideline compliance, supply and logistics chain management, personnel management, coding and billing, and registry data capture,” she said. While those T6 capabilities exist, this yearlong, off-line study focuses solely on the documentation aspect. Because the trauma nursing community is passionate about ensuring accurate and complete documentation, Sams said, “finding an application that they can use and feel confident in was huge.” To evaluate the T6 application as a pilot at BAMC, nursing staff are documenting trauma care both electronically and with the paper method in a head-to-head comparison. Recently, the study has been extended to trauma care in Afghanistan, where Sams was again deployed. In use, Sams said the T6 application is loaded on Apple Inc. iPads® that are mounted to stands in the trauma bays, but are removeable for continuing documentation as patients are transported to other locations for diagnostic studies, such as X-rays. Large monitors also display the documentation in the trauma bay, including checklists, algorithms, warnings, and decisions, so everyone involved “can be on the same page with what is going on with that patient.” “The systematic approach to the T6 design is ideal for the general nursing environment,” said USAF Capt. Seana L. Gerald-Ellsworth, NC, BSN, RN, CEN, emergency/trauma nurse at BAMC. “The wheel set-up allows for head-to-toe guided assessments. It is very user friendly when time allows for the structured flow the T6 provides. The system flags abnormal values in the vital signs flow sheet and also allows for trending of vital signs in a graph format, which adds a visual component to the long-term observation of the patient.” Gerald-Ellsworth also identified challenges in implementing the T6 into their trauma practice. For example, she noted that it does not allow for easy navigation if a patient’s condition requires parts of the assessment to be done out of order, adding, “This also is partially attributed to the comfort or

PTRUMP16 VIA WIKIMEDIA COMMONS

By Gail Gourley n IN ANSWERING THE QUESTION “What is Nursing?” on the American Nurses Association website, it states: “21st Century nursing is the glue that holds a patient’s health care journey together. Across the entire patient experience, and wherever there is someone in need of care, nurses work tirelessly to identify and protect the needs of the individual.” That description is clearly evident throughout the multitude of nursing roles and venues in the Department of Defense (DOD) and the Department of Veterans Affairs (VA). While nurses’ commitment to highly skilled and compassionate care never waivers, the techniques and technologies utilized to deliver that care are continuously evolving.

experience level of the nursing staff with the program. We have only been utilizing this system on a trial basis, which has been staffing dependent on how frequently we are able to use it in live trauma situations.” Gerald-Ellsworth observed that T6 utilization “follows a very structured layout that requires flipping through multiple pages at times to obtain certain categories for documentation. In some sections, there are not adequate options available and minimal ability to free text; for example, lab tests or radiology exams

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Capt. Katie Barnack (left), an emergency room nurse, and Lt. Col. Valerie Sams, a trauma surgeon, both deployed with the 455th Expeditionary Medical Group, demonstrate the T6 Health System, which is in trial phase at the Craig Joint Theater Hospital at Bagram Airfield, Afghanistan, March 30, 2019. The T6 mobile device application is a high-resolution, digital documentation system that may be used to replace some paper records and streamline patient care processes. can only be charted as ‘ordered/not ordered’ and ‘results.’ This is not useful in our trauma environment given that we need to chart the times the blood was

obtained or not obtained. Also, there is not an option for ‘unable to obtain’ or ‘deferred’ in the vital sign categories, which creates difficulties when closing out the charts that require vital signs to be entered.” However, she continued, “These may be [factors] that have potential to be tailored through the developers of the program to whom we have provided feedback when they have returned for follow-up visits. “As with any change to standard practice, there are always difficulties

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V E TE R AN S AFFAI R S & M I LITARY M E D I CI N E O UTLO O K

majority of VA’s SUD treatment programs are in clinics or other outpatient facilities. The power of even the most effective treatments to help veterans recover from SUD will remain limited as long as only about 10 percent of veterans with SUD are receiving them. This shortfall has made VA SUD treatment one of 10 high-priority issues addressed by VA’s Health Services Research and Development (HSR&D) Service, through its CREATE initiative: Collaborative Research to Enhance and Advance Transformation and Excellence. The SUD CREATE is a cluster of studies aimed at increasing the value of, and veteran access to, VA SUD treatment. One of the SUD CREATE investigators is Christine Timko, Ph.D., a senior research career scientist at the Palo Alto VA studying the problem of how to deliver SUD treatment to veterans who’ve been discharged from inpatient detoxification programs. For a variety of reasons – some of them patient centered, such as motivational or environmental; some system related, such as the number of available treatment slots – most veterans don’t engage in SUD treatment after detox. Timko recently completed a study designed to extend the reach of SUD counseling professionals and coaches through enhanced telephone monitoring. “The coach and the patient talk for maybe 15 to 30 minutes, every other week for three months,” Timko said. “The coach is encouraging the patient to think about getting treatment and supporting patients in getting that kind of help. It’s a very low-intensity, lowdemand kind of help.” The results of the study, Timko said, were surprising: “The main outcome was the group that got the telephone calls was less likely to go back into detox again. But they were not more likely to actually get substance abuse treatment.” She speculated that the

phone calls in themselves may have functioned as a kind of informal counseling intervention, keeping patients’ attention on their substance use. “When the telephone calls stopped, the improved outcomes for the telephone patients also stopped.” Two areas of further research have opened up as a result of Timko’s study: She’s leading a team in examining whether telephone monitoring might be beneficial to veterans with SUD who aren’t in detox, but who have both medical/surgical conditions and untreated problems related to alcohol use. Another team has a project designed to guide research priorities for the management of severe alcohol withdrawal syndrome. Timko is leading the translation of this research for communities to improve population outcomes, including reduced morbidity and mortality among alcohol detoxification patients. The SUD CREATE is led by Keith Humphreys, Ph.D., M.A., a senior research career scientist at the Palo Alto VA and the Esther Ting Memorial Professor at the Stanford University School of Medicine. He’s also conducting his own study of the effectiveness of a web-based intervention to reduce alcohol use among veterans with Hepatitis C and other liver diseases. So far his team has designed the intervention, tailoring it to more narrowly focus on a group of about 140 veterans with liver disease who use alcohol, and delivered it in a randomized clinical trial at sites in San Francisco and Palo Alto. “All the data is collected,” Humphreys said. “We’re analyzing it now to see whether or not the intervention lowered their drinking, and also whether it affected any other areas of their health. And then last, what the implications might be for their health care utilization. You know, if it works, maybe they’ll be less likely to end up in the hospital later. That’s the hope.”

A successful web-based intervention, said Humphreys, would constitute a lowcost alternative to treatment for patients with a critical need. “It’s a computer program,” he said. “We can make a million copies by pressing a button. It doesn’t cost anything, and it’s all free and public access.” If it proves even moderately effective, Humphreys said, the VA could email an invitation to participate out to thousands of veterans with current or prior alcohol use disorder and liver disease. “If ... only half the people look at it, and only 25 percent of those complete the whole thing and they cut their drinking a bit, that’s a great investment of VA resources,” he said. Two of the SUD CREATE projects are bigger-picture evaluations of how VA’s SUD treatment system is working overall. Austin Frakt, Ph.D., a health economist at the Boston VA, is studying how funding models and staffing levels influence patient outcomes. At the Ci2i in Palo Alto, Alex Harris, Ph.D., is working to validate more than 40 new measures of addiction treatment quality. Most of these measures are developed by VA mental health experts such as Humphreys – “But sometimes,” Humphreys said, “expert judgment is wrong.” Harris is using data, gathered from interventions with veteran patients, to see if VA programs are, in fact, improving outcomes. “The interesting thing,” said Humphreys, “is that we assume a lot of quality measures we track and encourage clinicians to follow help patients, but sometimes they don’t. So this is really important work.” Like the CREATE’s more patient-focused investigations, these studies of how VA administers and delivers SUD treatment are aimed at the same objectives: lowering the overall cost of care, improving its quality and value, and maximizing the number of veterans who can be helped by it.

Medications such as methadone, buprenorphine, and naltrexone target the same receptors as opioids and have proven effective in reducing opioid use and the related symptoms.

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Veterans Affairs & Military Medicine Spring 2019 Nurses Week Edition