Building academic-military research collaborations to improve the health of service members.

BACKGROUND: Academic-military research collaborations are desirable for many reasons; however, little guidance in the literature exists to help researchers understand collaboration requirements. PURPOSE: To describe the process for establishing academic-military research collaborations. METHOD: Specific collaboration requirements researchers must be aware of are outlined, two case studies are provided, and opportunities for and challenges with collaborations are discussed. DISCUSSION: Academic-military collaborations made it possible to conduct studies of stigma and barriers with mental health care among military nursing personnel and the utilization of secure messaging for health concerns with service members and healthcare providers. Planning these efforts began in the earliest stages of developing research proposals, and additional time was required to complete regulatory requirements prior to study implementation. Understanding military-specific considerations and establishing clear expectations and responsibilities were essential. CONCLUSIONS: Despite the challenges involved, academic-military collaborations improve the quality of the research by enhancing access to funding, expertise, and resources.

Resilience, Stress, Stigma, and Barriers to Mental Healthcare in U.S. Air Force Nursing Personnel.

BACKGROUND: Stigma may deter military service members from seeking mental health (MH) services. Previously, substantial proportions of U.S. Air Force (USAF) registered nurses and medical technicians reported concerns about stigma with accessing MH services; in particular, that unit members might lose confidence in them or perceive them as weak, unit leadership might treat them differently, or accessing care might affect career advancement. OBJECTIVE: This study assessed the extent to which stigma and barriers to accessing MH services as perceived by USAF nursing personnel are associated with resilience, stress, previous deployment, or demographic characteristics. METHODS: An anonymous, online survey was administered to active-duty USAF registered nurses and medical technicians at three locations (N = 250). The survey included demographic items, the Stigma and Barriers to Care scales, Conner-Davidson Resilience Scale, and Perceived Stress Questionnaire. RESULTS: Mean resilience was high, and perceived stress was moderate. About half of participants agreed that unit members might have less confidence in me (54%) or unit leadership might treat me differently (58%). Many also had concerns that it would harm my career (47%), I would be seen as weak (47%), or there would be difficulty getting time off work for treatment (45%). Stigma was positively correlated with perceived stress (r = .40, p < .01) and negatively correlated with resilience (r = -.24, p < .01). Officers had significantly higher stigma and resilience scores and lower stress scores compared with enlisted personnel, but those differences were small. DISCUSSION: This study validated previous findings that substantial percentages of USAF nursing personnel have concerns that accessing MH services may adversely affect their careers and how they are viewed by unit leaders and peers. In addition, higher levels of concern about stigma were associated with higher levels of stress and lower levels of resilience. Limitations included a low response rate (18%) and self-selection biases.

Multidimensional Dyspnea Profile: an instrument for clinical and laboratory research.

There is growing awareness that dyspnoea, like pain, is a multidimensional experience, but measurement instruments have not kept pace. The Multidimensional Dyspnea Profile (MDP) assesses overall breathing discomfort, sensory qualities, and emotional responses in laboratory and clinical settings. Here we provide the MDP, review published evidence regarding its measurement properties and discuss its use and interpretation. The MDP assesses dyspnoea during a specific time or a particular activity (focus period) and is designed to examine individual items that are theoretically aligned with separate mechanisms. In contrast, other multidimensional dyspnoea scales assess recalled recent dyspnoea over a period of days using aggregate scores. Previous psychophysical and psychometric studies using the MDP show that: 1) subjects exposed to different laboratory stimuli could discriminate between air hunger and work/effort sensation, and found air hunger more unpleasant; 2) the MDP immediate unpleasantness scale (A1) was convergent with common dyspnoea scales; 3) in emergency department patients, two domains were distinguished (immediate perception, emotional response); 4) test-retest reliability over hours was high; 5) the instrument responded to opioid treatment of experimental dyspnoea and to clinical improvement; 6) convergent validity with common instruments was good; and 7) items responded differently from one another as predicted for multiple dimensions.

Improving Resiliency in U.S. Air Force Healthcare Personnel: A Randomized Preventive Trial.

INTRODUCTION: The effectiveness of the Stress Management and Resilience Training (SMART) with U.S. military personnel has not been reported in the literature. The purpose of this study was to examine the effectiveness of SMART in increasing resilience in Air Force healthcare personnel. MATERIALS AND METHODS: We conducted a pilot, randomized preventive trial with active component Air Force healthcare personnel. SMART was offered via an in-person, 2-h training session delivered through face-to-face or synchronous video teleconference training, or via a self-paced, computer-based training. A baseline survey included demographics questions and the Connor-Davidson-10 Resilience Scale (CD-10), Perceived Stress Scale (PSS), Generalized Anxiety Disorder Scale (GAD-7), and overall quality of life (QOL) measure. Follow-up surveys with the CD-10, PSS, GAD-7, and quality of life were sent to participants at 12, 18, and 24 weeks after completing SMART. RESULTS: Fifty-six service members completed the baseline assessment and were randomized to either the in-person modality (comprised of video teleconference or face-to-face training) or the computer-based training modality, and 49 participants completed SMART. Significant increases in median CD-10 scores were observed among all participants, showing a 4-point (14%), 6-point (21%), and 5-point (17%) increase at week-12, -18, and -24, respectively, from the baseline. A significant overall decrease in median PSS scores from baseline were observed, with 5.5-points (22%), 7.81-points (32%), and 8.5-points (35%) decrease at 12, 18, and 24 weeks post-SMART, respectively. CONCLUSIONS: In this pilot study, SMART demonstrated significant and meaningful improvements in self-reported CD-10 and PSS-14 scores at 12, 18, and 24 weeks post-training completion. A future replication of the study is necessary to evaluate the effectiveness of SMART on a larger scale.

An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea.

BACKGROUND: Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE: The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS: An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS: Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS: Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.

Test-retest reliability of multidimensional dyspnea profile recall ratings in the emergency department: a prospective, longitudinal study.

BACKGROUND: Dyspnea is among the most common reasons for emergency department (ED) visits by patients with cardiopulmonary disease who are commonly asked to recall the symptoms that prompted them to come to the ED. The reliability of recalled dyspnea has not been systematically investigated in ED patients. METHODS: Patients with chronic or acute cardiopulmonary conditions who came to the ED with dyspnea (N = 154) completed the Multidimensional Dyspnea Profile (MDP) several times during the visit and in a follow-up visit 4 to 6 weeks later (n = 68). The MDP has 12 items with numerical ratings of intensity, unpleasantness, sensory qualities, and emotions associated with how breathing felt when participants decided to come to the ED (recall MDP) or at the time of administration ("now" MDP). The recall MDP was administered twice in the ED and once during the follow-up visit. Principal components analysis (PCA) with varimax rotation was used to assess domain structure of the recall MDP. Internal consistency reliability was assessed with Cronbach's alpha. Test-retest reliability was assessed with intraclass correlation coefficients (ICCs) for absolute agreement for individual items and domains. RESULTS: PCA of the recall MDP was consistent with two domains (Immediate Perception, 7 items, Cronbach's alpha = .89 to .94; Emotional Response, 5 items; Cronbach's alpha = .81 to .85). Test-retest ICCs for the recall MDP during the ED visit ranged from .70 to .87 for individual items and were .93 and .94 for the Immediate Perception and Emotional Response domains. ICCs were much lower for the interval between the ED visit and follow-up, both for individual items (.28 to .66) and for the Immediate Perception and Emotional Response domains (.72 and .78, respectively). CONCLUSIONS: During an ED visit, recall MDP ratings of dyspnea at the time participants decided to seek care in the ED are reliable and sufficiently stable, both for individual items and the two domains, that a time lag between arrival and questionnaire administration does not critically affect recall of perceptual and emotional characteristics immediately prior to the visit. However, test-retest reliability of recall over a 4- to 6-week interval is poor for individual items and significantly attenuated for the two domains.

Personal growth, symptoms, and uncertainty in community-residing adults with heart failure.

BACKGROUND: Personal growth has not been studied extensively in heart failure (HF). OBJECTIVES: To characterize personal growth in HF and its relationships with symptom burden, uncertainty, and demographic and clinical factors. METHODS: Associations among personal growth, uncertainty, symptom burden, and clinical and demographic variables were examined in adult outpatients with HF using bivariate correlations and multiple regressions. RESULTS: Participants (N = 103; 76% male, mean age = 74 years, 97% New York Heart Association classes II and III) reported moderate levels of personal growth, uncertainty, and symptom burden. Personal growth was weakly correlated with age and symptom burden but not with other study variables. In a regression model, age, sex, ethnicity, disease severity, time since diagnosis, symptom burden, and uncertainty were not significant independent correlates of personal growth. CONCLUSIONS: Community-residing patients with HF report moderate personal growth that is not explained by uncertainty, symptom burden, or demographic and clinical variables.

Treatment-Seeking Beliefs and Behaviors in Air Force Nursing Personnel.

INTRODUCTION: Perceptions of stigma and barriers associated with seeking mental health services have been described in past research with military service members who reported or screened positively for mental health concerns or who reported an intention to seek care. The reported influence of stronger perceptions of stigma on treatment seeking has varied. MATERIALS AND METHODS: An anonymous, online survey was administered to Air Force nursing personnel (N = 250) at three locations to describe beliefs associated with seeking mental health treatment and to investigate the extent to which stigma and barriers, stress, and resilience were related to mental health treatment seeking. RESULTS: Over 40% reported having accessed mental health services in their lifetime. A majority who accessed mental health services did so during their service, but there was no significant relationship with a deployment. Approximately 44% reported experiencing a current stress or emotional problem, and 28% accessed mental health services within the past 6 months. Levels of stress were significantly higher among individuals who accessed mental health care in the previous 6 months. There were no significant differences in stigma, barriers to care, or resilience on the basis of having accessed mental health care. Military resources were preferred to address a mental health concern, and respondents preferred to seek care from a mental health professional rather than other providers. CONCLUSION: Additional resources may be needed to address military personnel's nondeployment-related mental health concerns. Improved screening for increased levels of stress may aid in identifying service members who could benefit from referral to a mental health professional.

A Concept Analysis of Stigma Perceived by Military Service Members Who Seek Mental Health Services.

PROBLEM: The aim of this concept analysis is to clarify military service members' stigma associated with seeking mental health services (MHS). Since 2001, over 2 million military service members have been deployed for or assigned to support military operations. Many service members develop a mental health concern during or after a deployment. Although researchers have assessed perceptions of stigma associated with accessing MHS, defining stigma is difficult, and conceptual clarity regarding stigma is lagging behind studies focused on its effects. METHODS: Stigma was explored using Walker and Avant's method of concept analysis. Thirty articles were found in the PsycARTICLES, PsycINFO, and PubMed databases and selected for inclusion and synthesis. FINDINGS: Military service member stigma is a set of beliefs, based on the member's military and prior civilian enculturation, that seeking MHS would be discrediting or embarrassing, cause harm to career progression, or cause peers or superiors to have decreased confidence in the member's ability to perform assigned duties. CONCLUSIONS: Nurses are ideally suited and situated to play an important role in decreasing stigma inhibiting service members from seeking MHS. Healthcare providers and civilian and uniformed leaders must communicate the value of seeking MHS to ensure service members' health, unit readiness, and overall force preparedness.

Symptoms among patients receiving in-center hemodialysis: A qualitative study.

INTRODUCTION: Assessment of dialysis-related symptoms is not currently a requirement for hemodialysis (HD) providers in the United States. The purpose of this study was to describe patients' perspectives on symptoms associated with end-stage chronic kidney disease treated with thrice-weekly, in-center HD. METHODS: We performed a qualitative study using interpretive description. Interview questions were based on a KDIGO (Kidney Disease Improving Global Outcomes) controversies conference and a literature review. Semi-structured interviews were analyzed for characterizations of symptoms. FINDINGS: Fifty participants (48% female; 42% Hispanic; 30% American Indian; 14% Black; 12% non-Hispanic White) were recruited from six outpatient dialysis centers (four urban, two rural) in the southwestern United States. Median HD duration was 4 years. Of 13 symptoms assessed, nearly all participants reported difficulties with muscle cramping, fatigue, or both. Negotiating fluid removal with dialysis personnel helped to manage cramping. Some participants tried to adjust dialysis days and shift to mitigate fatigue. Most participants reported having experienced depression early in the course of dialysis; for some, it was a persistent or recurrent problem. Relatively few participants reported using antidepressants or counseling to cope with depression. Itching was highly distressing for those who experienced it frequently. Topical treatments, antihistamines, dietary modifications, and phosphate binders were identified as potentially helpful by some participants. DISCUSSION: The major symptoms attributed to HD treatment by participants were cramping, fatigue, depression, and itching. Greater attention by health care providers to the most common and bothersome symptoms could positively impact daily life for HD patients.

Predictors of emergency department visit disposition for patients with chronic obstructive pulmonary disease.

STUDY OBJECTIVES: The study objective was to validate among patients with chronic obstructive pulmonary disease (COPD) clinical predictors of emergency department (ED) disposition (admission vs discharge) found in a previous study. We hypothesized that the initial heart rate (HR) at presentation and the number of nebulizer treatments would predict visit disposition adequately and that existing triage criteria would not. METHODS: In this correlational study, all ED visits to a university medical center related to a diagnosis of COPD over a 2-year period were identified and reviewed retrospectively (N = 114 patients and 226 visits). Associations of clinical predictors with visit disposition was by contingency table or receiver operating characteristic curve analysis. RESULTS: The overall admission rate was 60.2%. An initial HR slightly greater than normal limits (HR >/= 106 vs HR

Impermanence and Sense of Coherence: Lessons Learned From the Adaptive Behaviors of Sri Lankan Buddhist Nuns With a Chronic Illness.

PURPOSE: The purpose of this study was to explore the influence of traditional Buddhist spiritual beliefs and practices on coping with chronic illness. DESIGN: The study was a descriptive ethnography. Participant observation and semistructured interviews were used with 45 Sri Lankan Buddhist nuns with a chronic illness and 20 secondary informants. Cultural domains and taxonomies were explored to uncover themes pertaining to traditional Buddhist spirituality and experiences of chronic illness. FINDINGS: A repeating cultural theme, responsibility, was identified. Responsibility took four forms: to the Buddha, to the social circle, to self-liberation through meditation, and to finding security in old age. Nuns shaped spiritual practices (some with folk origins) to fulfill these responsibilities. Coping ranged from health-seeking to resigned acceptance. CONCLUSIONS: Responsibilities and coping were situated in a context of Buddhist spiritual beliefs about impermanence. Findings were congruent with Antonovsky's model of salutogenesis, in particular, the construct of sense of coherence.

Stigma and barriers to accessing mental health services perceived by Air Force nursing personnel.

We investigated perceptions of stigma and barriers associated with accessing mental health services among active component U.S. Air Force officer and enlisted nursing personnel (N = 211). The Britt and Hoge et al Stigma scale and Hoge et al Barriers to Care scale were administered via an anonymous, online survey. Stigma items pertained to concerns that might affect decisions to seek mental health treatment. Most of the sample agreed with the items "Members of my unit might have less confidence in me" and "My unit leadership might treat me differently." Approximately 20% to 46% agreed with the other four stigma items. Officer nursing personnel were significantly more likely than enlisted to agree that accessing mental health services would be embarrassing, harm their career, or cause leaders to blame them for the problem (p ≤ 0.03 for each comparison). Getting time off from work for treatment and scheduling appointments were perceived as barriers by 41% and 21% of respondents, respectively. We conclude that proportions of Air Force nursing personnel reporting concerns about potential stigmatizing consequences of seeking mental health care are substantial and similar to ranges previously reported by military service members screening positive for mental health problems after deployment.

Unpacking the 2 × 2 table.

Statistics estimated from a 2 × 2 contingency table, such as sensitivity, specificity, and likelihood ratios, are usually presented in contexts of diagnostic decision making or evaluation of screening tests. However, their use is not restricted to those contexts. The purpose of this article is to summarize for clinicians and researchers in nursing and other health care disciplines the conceptual basis, calculation, application, and limitations of statistics derivable from a 2 × 2 table and to provide a worked example based on previous research. It will be shown that these statistics can potentially be used for analyzing any binary outcome (e.g., occurrence vs. nonoccurrence of some event) with a binary predictor (e.g., present vs. absent or above vs. below some cut point). Most can be estimated with a hand-held or online calculator, and, apart from chi-square statistics, without first converting observed data to a test-statistic. Clearer understanding of the derivation and clinical meaning of these statistics will encourage their wider use in health research and clinical practice.

Validation of a three-factor measurement model of dyspnea in hospitalized adults with heart failure.

OBJECTIVE: The purpose of this study was to validate a 3-factor measurement model of dyspnea sensory quality (WORK-EFFORT, TIGHTNESS, SMOTHERING-AIR HUNGER) originally derived in patients with exacerbated chronic obstructive pulmonary disease. METHODS: In this validation study, adult patients with heart failure were enrolled after hospital admission (median hospital day 1) and asked to rate the intensity of dyspnea sensory quality descriptors on the day of enrollment (study day 1; N = 119) and in a recall version for the day of admission (study day 0; n = 97). RESULTS: Confirmatory factor analysis demonstrated good model fit for both days. Cronbach's α for each factor was greater than .87 for both study days. CONCLUSION: This is the first study to validate a previously specified measurement model of dyspnea sensory quality in an independent sample. Results indicate that measurement of dyspnea sensory quality in exacerbated cardiopulmonary disease does not necessarily require disease-specific questionnaires.

Predictive validity of short-form health survey [36 items] scales for chronic obstructive pulmonary disease exacerbation.

OBJECTIVE: We evaluated whether any short-form health survey [36 items] (SF-36) domain scale or component scores would predict exacerbations of chronic obstructive pulmonary disease (COPD) during a 1-year period. METHODS: In this prospective longitudinal study, the sample included 127 patients with spirometrically confirmed COPD who completed baseline assessments and > 80% of daily diary card entries during 1 year. Exacerbations were defined as >or= 2 days of worsened respiratory symptoms or as new use of corticosteroids or antibiotics. The predictive validity of baseline SF-36 scores was assessed by receiver operating characteristic analysis. RESULTS: The general health, mental health, and role-physical domain scales and mental component summary score discriminated between those with any versus no exacerbations. The general health domain score was the best predictor overall based on multiple criteria. CONCLUSIONS: The SF-36 general health scale is potentially a reliable and valid predictor of exacerbation for up to 1 year in community-residing patients with COPD.

Psychometric characteristics of dyspnea descriptor ratings in emergency department patients with exacerbated chronic obstructive pulmonary disease.

The purpose of this study was to evaluate the reliability, content validity, and factor structure of dyspnea sensory quality descriptor ratings in emergency department (ED) patients with exacerbated chronic obstructive pulmonary disease (COPD). During an ED visit 104 patients with COPD rated the intensity of 16 dyspnea sensory quality descriptors (numerical ratings of 0-10) in relation to how they felt when they decided to come to the ED (Decision) and 1 week before the visit. Content validity of 15 descriptors was supported. Factor analysis of Decision ratings resulted in seven descriptors and three factors (alpha=.88; 74% common variance): Smothering/Suffocating/Hunger for air (alpha=.87); Effort/Work (alpha=.87); and Tight/Constricted (alpha=.74). Results indicate that the intensity of sensory quality descriptors can be measured reliably in COPD patients during an exacerbation of COPD. The initial descriptor list of descriptors could be cut by more than half while retaining satisfactory psychometric properties.

Assessing recalibration as a response-shift phenomenon.

BACKGROUND: Traditionally, the difference between pretest and posttest scores is used as an estimate of change. This can be problematic when repeated self-report measures are used to assess change resulting from interventions intended to change beliefs, behaviors, attitudes, or values about health or safety. If the intervention is effective, participants may apply more stringent criteria in response to a posttest questionnaire than they did at the pretest. This kind of change has been termed a recalibration response shift. OBJECTIVES: To present scale recalibration as a measurable response shift, and to illustrate a method that can be used to estimate its magnitude and direction: the retrospective pretest. METHODS: In a quasi-experimental study investigating the effectiveness in small construction companies of narrative simulation exercises targeting back and fall injuries, a retrospective pretest was administered concurrently with a delayed posttest 4 months after the simulation exercises. RESULTS: : In the first intervention year, the results from a brief (two-item) retrospective pretest pertaining to safety climate were consistent with a recalibration response shift in the intervention group, but not in the control group. In the second intervention year, when all 10 items of the safety climate questionnaire were used for the retrospective pretest, no evidence of recalibration was found. CONCLUSIONS: Although the evidence of recalibration was equivocal, the findings illustrate circumstances in which recalibration response shifts may occur and characteristic patterns of findings may suggest that recalibration has or has not occurred.