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

Daily media coverage tells the story of challenges facing returning members of the United States Military. High rates of suicide, more than twenty per day, horrific traumatic injuries necessitating challenging physical and emotional healing, and lingering posttraumatic stress disorders warranting the most advanced methods of treatment are reported daily. As America recoils from two prolonged oversea wars, the need for prepared healthcare providers is essential not only for the Veterans Administration (VA), but also for civilian based healthcare systems. The bulk of nursing education literature seems to evidence a void regarding this segment of the population. What seems like a prime education focus remains yet to be enacted in most nursing programs. The authors have responded to this challenge, by creating curricula developed to increase nursing student awareness of veterans’ unique needs, and to prepare undergraduate nursing students to provide quality care to veterans. Through the creation of a laboratory simulation scenario, students learned how to holistically view and respond to the needs of a veteran client. Debriefing allowed for reviewing the experience and discussing concerns. Outcomes measured via preand posttesting survey reflected the complexity of patient care needs. Students were asked to rate their ability to identify and prioritize appropriate nursing interventions. Anecdotal feedback was positive in that students consistently expressed a need to have additional simulation experiences.


INTRODUCTION
Nurse Educators are being challenged to evolve with the changing times; the needs of new graduates are rigorous and compelling.Curriculum must extend beyond the didactic to facilitate psychomotor skills and application to clinical care of patients.C. Rauen [1] suggests a paradigm shift from an instructor-centered model to a learning centered model.Simulation can be the means to this end.In a previous study conducted by the authors, simulation was found to improve student outcomes.Attrition rates dropped 14.6% with an added low fidelity simulation component as compared to cohorts that were not exposed to simulation in the curriculum.The study was local and limited in sample size.The purpose of the current study was to expand upon the use of simulation by utilizing high fidelity simulation to prepare undergraduate nursing students to respond to the unique and urgent healthcare needs of military veterans.
Current statistics delineate the alarming crisis facing US veterans returning from Afghanistan and Iraq.For every veteran killed by enemy combatants, 25 veterans take their own lives ( [2].A recently established crisis hotline created by the Department of Veteran's Affairs (VA), has documented more than 26,000 calls from actively suicidal military vets.These data are frightening given the tendency toward underreporting of suicidal ideation [3].Veterans with mental illness and substance use disorders accounted for 32.9 percent of all Veterans Health Administration (VHA) costs $12 billion [4].According to the National Alliance for Mental Health (NAMI), rates of PTSD in veterans of the Iraq and Afghanistan wars range from 5 to 37 percent, while rates of depression were found to be as high as 27 percent.The Veterans' Administrationhas treated more than 400,000 post 9/11 veterans for mental health problems [5].
To help meet the mental health and recovery needs of US vets, services and programs geared especially to their unique needs are going to be required [6].Senators have told officials of the VA that they must speed up services for vets with Post-Traumatic Stress Disorder and other OPEN ACCESS mental health conditions [7].A report released in January 2013 by the VA identifies report also identified female veterans and Vietnam-era veterans as two demographic groups that require extra consideration when it comes to suicidal behaviors [8].Keavney [9] notes that there are 22 million vets in the US, a mix of older vets exposed to Agent Orange during the Vietnam war, vets exposed to Malaria and Tuberculosis during conflicts in the Middle East, veterans suffering from traumatic brain injury after encountering improvised explosive devices, and todays vets who are living with very serious injuries.
75% of military vets are cared for through the Department of Veteran's Affairs, which employs about 45,000 registered nurses.The VA is projecting the need for even more RNs to address the best care for veterans' special needs, including post-traumatic stress disorder, mental-health issues and traumatic brain injuries [10].
Many military personnel will ultimately be treated by primary care providers in the community and/or in local hospitals [11].The VA, the National League of Nursing, the American Association of Colleges of Nursing and other industry groups are calling on nursing schools to take a pledge to do more to educate students on how to care for veterans and their families [12].Schools of nursing are being challenged to provide relevant, evidence-based content in their curricula.The American Association of Colleges of Nursing (AACN) has sponsored Joining Forces, which is a collaboration of more than 500 nursing schools that are striving to educate nursing students on best practice methods in caring for military veterans.As part of this initiative, educators are encouraged to prepare students to care for those suffering post-traumatic stress disorder, traumatic brain injury, depression, and other clinical issues [13].
The lay literature has clearly established the plight of the military vet.However, there remains a gap in scholarly nursing journals with regard to how educators are responding.Therefore the authors have developed and implemented a curriculum designed to address the needs of this vulnerable population.Ultimately the curriculum is intended to prepare undergraduate nursing students as they enter into practice and to promote safe practices.The curriculum incorporates concepts of holistic care, meaning that care addresses physical, mental, emotional, sexual, cultural, social and spiritual needs [14].Holistic care as it applies to the military veteran, recognizes the need to shift from traditional problem-based disease care, to person-centered health care [15].In accordance with the philosophy of Holistic Enrichment of Adult Living (HEAL), the aim of this program has been to improve the preparation of nursing students by including the use of relevant clinical assessment tools, addressing the status of client support systems, and improving communication [16].
This scenario was part of a larger set of simulation scenarios designed to decentralize mental health concepts.Decentralization is proposed, not for the purpose of diluting the importance of mental health, but on the contrary, to emphasize the need for all nurses to utilize appropriate psychosocial interventions.In terms of holistic care, psychological well-being is relevant to all realms of nursing practice.Mental health assessment and intervention need to be threaded across all areas of the nursing curriculum.The purpose of this project was to create a BSN curriculum that reflected the mental health needs of patients not only in acute care psychiatric facilities but also in medical-surgical disciplines, maternity units, and community settings.The larger curriculum was designed to also cover mental health throughout the lifespan.The learning objectives were for undergraduate nursing students to initiate and implement an appropriate mental status assessment using therapeutic communication, and also to provide safe care by identifying risk factors and using critical thinking to establish requisite nursing interventions.Therapeutic communication is a concept introduced during the initial theory and clinical courses, therefore the simulation also served to reinforce those skills.Simulation of this type discouraged students from hiding behind clinical tasks in the provision of holistic care.Most importantly, this simulation was designed to help students identify and respond to the individual needs of military veterans.Students were provided appropriate assessment tools including VA/DoD Essentials for Depression Screening and Assessment in Primary Care [17].

METHODOLOGY
Students were provided with related didactic lecture material prior to their scheduled simulation experience.They were also assigned readings relevant to nursing research that supported evidenced based practice.Simulation was a mandatory assigned experience.Students were placed in pairs to provide care for the simulated patient.Two faculty members supervised the simulation, one as a facilitator and one serving behind the scenes as the voice of the patient.Students were required to complete a pre-test prior to simulation.The pretest consisted of a 10 question inventory submitted anonymously through the survey monkey website.Questions included 6 true/false questions designed to measure students understanding of concepts related to depression, spinal cord injury and care of the military veteran.One question was dedicated toward dosage calculation as suggested by QSEN competencies.The final 3 questions were anecdotal questions in which students were asked to rate their comfort in prioritizing care and identifying appropriate nursing interventions.The exact same questions were formatted into a post-test and administered following the debriefing session of the simulation.
Through the creation of a laboratory simulation scenario, students learned how to holistically view and respond to the needs of a veteran client.In the scenario, a young female veteran experienced depression and suffered a spinal cord injury as a result of an attempted suicide.It is an intermediate care setting, where the patient is awaiting transfer to a rehabilitative facility.Students were expected to utilize the nursing process, perform psychosocial assessments, and recognize signs and symptoms of depression.Students were also expected to prioritize their nursing interventions to provide a safe and supportive environment.Therapeutic communication was integral to their approach as they prioritize numerous patient needs.Furthermore, students were expected to provide physical care including positioning, turning, , and neurological checks.This scenario was different from typical nursing simulations in that it progressed based upon the patient's verbal and psychosocial presentation rather than according to significant changes in physiological patterns.The patient was intentionally created as a female for the purpose of eschewing the stereotype of males only in the military and also for the purpose of increasing the awareness that females in the military are also at high risk for suicide.Debriefing was conducted with all assigned students and with the involved faculty members.Students were encouraged to voice their concerns regarding their progress as the scenario unfolded.Faculty reiterated that the simulation lab allows for a safe place to make mistakes.It is important to note that this particular population of students was at the junior level in a B.S.N. program and as such had not had a course in mental health nursing yet.Retention will be measured at a six-month interval subsequent to this simulation by administering the same post-test.

OUTCOMES
Students entered into each scenario with a high degree of confidence as evidenced by their pretest ratings.It is likely that students had not realized the complexity of the scenario and/or the psychosocial aspects of care.Students favorably rated their own ability of identify symptoms relevant to appropriate assessments for each scenario as evidenced by pretest questionnaires.In some scenarios students were more in need of coaching and facilitation when patients initiated emotionally charged discussions or self disclosed serious issues such as deliberate attempt to hurt oneself.Students by and large were able to accurately provide safety measures related to suicidality, and were also competent in recognizing presenting symptoms of depression.Students were noticeably paralyzed in responding to the hopeless attitude of the patient.Not all students recognized that the patient was in fact a military vet.The authors suspect that the students misunderstood the patient's demand for self-reliance, wanting to be left alone, and overall stoic demeanor as uncooperativeness rather than the common mind set of a military vet.Students voiced surprise that the scenario included a female as a military veteran.
De-briefers emphasized to students that these were new experiences in which they were not necessarily expected to know exactly how to respond, thereby a true opportunity for learning in a safe environment.Students still rated themselves as not comfortable in providing holistic care to a patient with a spinal cord injury nor able to prioritize interventions for safe care with the same population as evidenced by post-testing.Lower scores on self assessments in the post-test may reflect the complexity of learning needs and further substantiates the need for teaching this content.
Students are rarely engaged in sensitive topics of discussion during actual clinical rotations.Therefore simulation affords the opportunity to standardize such experiences and allows for feedback prior to exposure in actual clinical settings.Students do not have their psychiatric nursing rotation until the fall semester of their senior year and therefore were not expected to diagnosis as part of the scenario, but were expected to be able to communicate effectively, to provide safety measures, and to recognize the need for collaboration and/or need for referrals.In debriefing sessions, students voiced appropriate concerns about being caught off guard by patient concerns and not knowing how to respond.It is worth noting however that students in the junior class had back to back scenarios over two consecutive weeks and those students voiced improvement in their communication skills and were noticeably more responsive in problem solving with patient.Additionally, the authors suggest that this simulation will serve as the perfect segway as students transition into the fall of their senior year in which they enroll in mental health nursing.
Anecdotally students identified an ability to transfer knowledge between simulations in lab to patient care in clinical setting.Students consistently have requested the opportunity to participate in more simulated scenarios.

DISCUSSION
The authors have addressed a gap in the literature with regard to simulation in psychiatric nursing while simultaneously creating a timely curriculum.Simulation in nursing is not new, however the scenario created in this simulation is unique.It encompasses a psychosocial focus along with traditional physical care.The focus is on therapeutic communication and emotional well-being.This type of simulation enables students to address the patient in a more comprehensive manner.Simulation offers standardized clinical experiences for the purpose of teaching critical concepts that students are unlikely to encounter.It allows for additional patient care scenarios of varying acuity in an era when short-term care facilities have shorter length of stay.Simulation has the added benefit of debriefing, which allows for reflection and inquiry.Simulation allows for the introduction of specific population needs such as the care of military veterans.Curriculum needs to evolve to meet the changing needs of society.The VA has a backlog of over 897,000 claims for disability benefits related to mental health [2].Nurses need to be well equipped to provide comprehensive care in all settings, understanding the unique needs that each patient may present.There is an imperative to provide safe care for those who protected the safety of our country.Future endeavors will be to measure knowledge retention at a six-month interval following the simulation.