The Use and Perceptions of the Defense and Veterans Pain Rating Scale by Nursing Personnel.

BACKGROUND: In 2010, the Office of the US Army Surgeon General recommended the Veterans Administration (VA) assess pain using the Defense and Veterans Pain Rating Scale (DVPRS). One item in the DVPRS is for measuring pain intensity. This item contains a combination of five response metrics: categories, faces, colors, numbers, and functional descriptors. A few studies have supported patients' and health care providers' preferences for the DVPRS and its psychometric properties. However, they also left uncertainties about its usability and validity. AIMS: To advance our understanding of the DVPRS, this study examined the use and perceptions of the DVPRS' pain intensity item by nursing personnel during multi-modal care. DESIGN: A cross-sectional survey design was used. SETTING: VA Community Living Center. PARTICIPANTS: Nursing personnel. METHODS: Nursing personnel answered closed- and open-ended survey questions during a single session. RESULTS: Nursing personnel reported sufficient training before implementing the measure and that patients primarily used the numeric metric. When patients used a non-numeric metric, the nursing personnel responded in variable ways. In addition, the nursing personnel interpreted the functional descriptors differently. The nursing personnel also noted the need to supplement the pain intensity item with patients' pain duration and pain location. CONCLUSIONS: Results from this study inform the nursing community about the DVPRS' pain intensity item, which combines multiple response metrics. The results support the need for nursing units to generate and standardize procedures for using the item to measure multi-site pain and for interpreting and documenting patients' non-numeric responses. The effects of such procedures on the measure's usability and psychometric properties warrants additional investigation.

Cerner Millennium's Care Pathways for Specialty Care Referrals: Provider and Nurse Experiences, Perceptions, and Recommendations for Improvements.

BACKGROUND: Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. OBJECTIVE: To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. DESIGN: Qualitative interviews, conducted 12-20 months after Cerner Millennium deployment. PARTICIPANTS: We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. APPROACH: We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. RESULTS: Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. CONCLUSIONS: Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.

A Veterans' Bachelor of Science in Nursing Initiative: Ten Valuable Tips.

ABSTRACT: This article describes a funded grant project whereby 10 tips are shared for those considering starting a veterans' bachelor of science in nursing initiative: secure the support of the institution; establish a point person for the initiative; maximize student success resources; acknowledge past academic work and military experience; hire prior-service Armed Forces Nurse Corps officers as faculty; deliver training opportunities for nonmilitary faculty to learn about veterans; offer students the opportunity to learn and socialize with their noncivilian peers; capitalize on the assets veterans bring to the classroom; provide a structured learning environment; and generate data-based publications.

Ask the question: 'Have You Ever Served?' Caring for military members and veterans in civilian healthcare.

ABSTRACT: This article discusses health issues affecting US military members and veterans, and provides occupation-specific questions to guide civilian healthcare professionals in providing high-quality care to veterans and their families.

Providing Veterans With Innovative Nursing Educational Opportunities.

This funded project assisted veteran students to obtain a baccalaureate in nursing by aligning the skills learned through military training with concepts and skills valued by professional nursing and taught to nursing students. Nine concepts or skills were identified by nursing faculty that validated for course credit. The identified concepts and skills were incorporated into four simulation scenarios. Veteran students' skills were validated through simulation experiences in place of taking a three-credit nursing course. Anecdotal data from the debriefing process were rich with students' experiences and gratitude for being recognized for their military knowledge and service.

Disabled Veteran Leave and Other Miscellaneous Changes. Final rule.

The Office of Personnel Management is issuing final regulations to implement the Wounded Warriors Federal Leave Act of 2015, which establishes a separate new leave category, to be known as "disabled veteran leave," available during a 12-month period beginning on the first day of employment to be used by an employee who is a veteran with a service-connected disability rated at 30 percent or more for purposes of undergoing medical treatment for such disability. We are also rescinding two obsolete leave-related regulations.

Development of Veteran-Centric Competency Domains for Psychiatric-Mental Health Nurse Practitioner Residents.

The mental health needs of military service members, Veterans, and their families are a designated national priority; however, there has been little emphasis on the inclusion of Veteran-centric domains in competency-based nursing education for psychiatric-mental health nurse practitioners (PMHNPs). The current article describes the identification and application of Veteran-centric domains in an innovative pilot residency program for PMHNPs, funded by the Veterans Health Administration Office of Academic Affiliations. Fourteen Veteran-centric competency domains were developed from literature review, including knowledge, attitudes, and skill behaviors. Adoption and application of these domains in curricular components included the resident competency evaluation, baseline assessment of military experience, and evidence-based practice seminars and training. Methods of competency domain evaluation are presented, along with gaps related to the evaluation of competency skills. The delivery of mental health services reflecting these domains is consistent with the VA core values and goal of developing a positive service culture. [Journal of Psychosocial Nursing and Mental Health Services, 54(11), 31-36.].

A Psychiatric Mental Health Nurse Practitioner Program: Meeting the Needs of the Community and Veterans as Students as Well as Care Recipients.

The goal of excellence in nursing education has led to efforts to recruit students into baccalaureate and graduate programs. Additionally, a need exists to prepare practitioners to meet the mental health needs of health care recipients, including veterans. As a strategy for meeting these objectives, educators from an urban private college proposed a Psychiatric Mental Health Nurse Practitioner (PMHNP) program. This program was developed in response to an identified need in the community for improved mental health services. Although several groups in need would be served, attention was focused on veterans in need of care as well as those veteran students interested in Psychiatric Mental Health (PMH) nursing. Some factors that supported this thinking included the proximity of the campus to the Veterans Administration Medical Center and other veteran community services, the college's significant number of student veterans, and its distinction as among the most veteran friendly campuses in the nation. This article reviews the literature that supports the need for graduate education in this specialty and the value of providing educational opportunities for interested veterans.

After the parade: military nurses' reintegration experiences from the Iraq and Afghanistan wars.

The purpose of the current study was to describe reintegration experiences of U.S. military nurses returning from deployments in the Iraq and Afghanistan wars. A qualitative study using a phenomenological method was conducted. The population comprised nurses who served in the U.S. Army, Navy, or Air Force in Iraq or Afghanistan during 2003-2013, including Active Duty, National Guard, and Reserve nurses. Purposive sampling with Veteran and professional nursing organizations yielded a sample of 35 nurses. Nine themes emerged from analysis: (a) homecoming; (b) renegotiating roles; (c) painful memories of trauma; (d) getting help; (e) needing a clinical change of scenery; (f) petty complaints and trivial whining; (g) military unit or civilian job: support versus lack of support; (h) family and social networks: support versus lack of support; and (i) reintegration: a new normal.

The VA Caregiver Support Line: A Gateway of Support for Caregivers of Veterans.

In passing the Caregivers and Veterans Omnibus Health Services Act of 2010, Congress created a legislative mandate for the Veterans Administration (VA) to strengthen its program of support services for caregivers of veterans. As part of this expansion, the VA implemented a nationwide toll-free telephone Caregiver Support Line (CSL). The CSL is a single point of entry system to link caregivers to national and local services to support care of a veteran. This article describes the CSL and its role in supporting aging veterans and their caregivers, discusses social workers' contributions to its development and implementation, and reports utilization data.

The Interservice Physician Assistant Program: Education quantity and quality.

The Interservice Physician Assistant Program (IPAP) was formed in 1996 by the assimilation of three service programs (Army, Air Force, and Navy). Applicants are selected from each service and upon successful completion of the program become commissioned officers within their respective medical corps. Clinical training takes place within military treatment facilities across the United States. Located in San Antonio, Texas, the program graduates about 169 PAs a year. Graduates are deployed to attend to service personnel, refugees, civilians, and victims of epidemics. The IPAP is unique in that it is the largest PA program in the world and its applicant pool is restricted to military personnel.

Military Veteran Matriculation in US Physician Associate/Assistant Programs.

INTRODUCTION: This study aims to determine whether veterans have differential access to physician associate/assistant (PA) education by examining likelihood of matriculation relative to nonveteran peers. We explore associations between veteran status and likelihood of matriculation for change over time and whether effects differ among active duty versus non-active-duty applicants. METHODS: Multivariate logistic regression was used to investigate associations between self-identified military status and likelihood of PA program matriculation in five Centralized Applicant Services for Physician Assistants admissions cycles (2012-2013, 2014-2015, 2016-2017, 2018-2019, 2020-2021). Models controlled for age, sex, race/ethnicity, patient care experience hours, total undergraduate grade point average, and number of applications submitted and applied a Bonferroni correction for alpha inflation. RESULTS: Veteran applicant numbers were small across the study time frame but increased from 2012 (n = 708) to 2020 (n = 978), representing a 38% increase over the lookback period. Despite growth, the proportion of veterans in the matriculant pool has decreased from 4.2% in 2012 to 3.0% in 2020. In unadjusted models, military status was not strongly associated with odds of matriculation. In adjusted models, both veteran and active-duty status were associated with higher odds of matriculation, although this increase was not statistically significant at the 0.005 level for applicants on active-duty. DISCUSSION: Military veterans and active-duty military personnel have higher likelihood of matriculation into US PA programs relative to nonveteran peers. The proportion of veterans in the matriculant pool has decreased over time. This suggests that while PA programs seems to value previous military experience, further efforts to evaluate and address barriers to military veterans in applying for admissions is needed.

The Family and Medical Leave Act. Final rule.

This Final Rule amends certain regulations of the Family and Medical Leave Act of 1993 (the FMLA or the Act) to implement amendments to the military leave provisions of the Act made by the National Defense Authorization Act for Fiscal Year 2010, which extends the availability of FMLA leave to family members of members of the Regular Armed Forces for qualifying exigencies arising out of the servicemember's deployment; defines those deployments covered under these provisions; extends FMLA military caregiver leave for family members of current servicemembers to include an injury or illness that existed prior to service and was aggravated in the line of duty on active duty; and extends FMLA military caregiver leave to family members of certain veterans with serious injuries or illnesses. This Final Rule also amends the regulations to implement the Airline Flight Crew Technical Corrections Act, which establishes eligibility requirements specifically for airline flight crewmembers and flight attendants for FMLA leave and authorizes the Department to issue regulations regarding the calculation of leave for such employees as well as special recordkeeping requirements for their employers. In addition, the Final Rule includes clarifying changes concerning the calculation of intermittent or reduced schedule FMLA leave; reorganization of certain sections to enhance clarity; the removal of the forms from the regulations; and technical corrections to the current regulations.

The changing physician assistant profession: a gender shift.

The physician assistant (PA) movement originally served as an avenue for male veterans to transition into the civilian workforce. After a half-century of development, the profession in the United States is now predominantly female and nonveteran. Using archival data and other resources, this article documents the influences on gender and age shifts in the PA profession with related policy perspectives. Now entering its sixth decade, the profession continues to evolve as demand for PA services outpaces supply.

Evaluating serious stress in military veterans, their carers and families: a protocol.

In 2018, the Armed Forces Covenant Fund Trust (ACFT) allocated approximately £4M to seven UK projects to address serious stress in military veterans, their carers and families. These programmes commenced between May and October 2019 and will conclude in August 2021.This paper outlines the protocol for the evaluation of the Tackling Serious Stress programme and the novel support provided to grant holders. Entry into the programmes was through multiple routes, including self-referrals with an anticipated sample of approximately 2000 participants. A common outcomes framework was designed to measure outcomes. Grant holders accepted ownership for data collection and quality and were supported through accompanying guidance material.Veterans were often reluctant to seek support, and the anonymous and confidential nature of the evaluation plus the study team's military background helped address this. Participants' voices were a key part in developing the protocol, leading to results to inform policy and highlight success, efficiency and cost effectiveness, and providing markers for future development.The study provided a reservoir of information. Interim reports indicated compliance with performance indicators and provided timely evidence. Shared learning provided grant holders with an indication of what was helping the beneficiaries and what needed to be improved. The combination of all data sets provided the ACFT with a resource to demonstrate success and insight into projects where improvement was required, and indicators of how to redress these problems. The study protocol provided a platform for building lasting partnerships.

Evaluation of Patient Experience with Veterans Affairs Clinical Pharmacist Practitioners Providing Comprehensive Medication Management.

Patient experience is considered an important dimension of health care quality and thus is included as part of the quadruple aim of health care. The VHA Clinical Pharmacist Practitioner (CPP) operates as an advanced practice provider (APP) providing comprehensive medication management (CMM) with authority to initiate, discontinue or modify medication under a scope of practice (SOP). The VHA CPP practices in many different outpatient clinical areas to include but not limited to primary care, mental health, pain management, cardiology, substance use disorder and anticoagulation. While literature regarding the ability of the VHA CPP to increase access and quality of care is well published, very little information exist regarding patient experience with the VHA CPP. We sought to report the patient experience with VHA CPP as measured electronically over 1 year by Veterans. Patient experience surveys were electronically sent to randomly selected Veterans via email to evaluate a recent outpatient healthcare encounter at a VA medical center or outpatient clinic with a CPP with scoring on a Likert scale of 1-5 with 5 being optimal. A total of 743 Veteran surveys were completed for a response rate of 20%. For individual domains of patient experience based on respondent scores of 4 or 5, ease and simplicity were rated at 94.4%, quality 91.9%, employee helpfulness 94.9%, satisfaction 95.0% and confidence/trust 91.9%. Results demonstrate that Veterans' experience with the CPP in every patient care experience domain was positive with scores ranging from the low to high 90th percentile.

Admissions Interviews: How History Can Pave the Way Toward a Holistic Future in Military PA Program Admissions and Hiring.

Admissions processes for graduate health professions, including physician assistant (PA) and medical school, were built over time through trial and error. Admissions process research was not common until the early 1990s, and it seemingly began because the system of admitting applicants solely on the basis of the highest academic metrics resulted in unacceptable attrition rates. Recognizing interpersonal attributes were unique from academic metrics and critical to success in medical education, admissions interviews were added as a component of the admissions process and have since become nearly ubiquitous for medical and PA applicants. Understanding the history of admissions interviews informs ways to optimize admissions processes for the future. The PA profession was originally comprised entirely of military veterans with extensive medical training during their service; the number of service members and veterans matriculating has significantly decreased and is not reflective of the percentage of veterans in the US. Most PA programs receive applications in excess of available seats; yet, based on the 2019 PAEA Curriculum Report, the all-cause attrition rate is 7.4%. Given the large pool of applicants available to select from, it is valuable to identify students who will succeed and graduate. This is especially critical for the Interservice Physician Assistant Program, the US Military's PA program, to optimize force readiness by ensuring sufficient PAs are available. Utilizing a holistic admissions process, considered best practice in admissions, is an evidence-based way to decrease attrition and support increased diversity, including increasing the number of veterans becoming PAs, by considering the breadth of an applicant's life experiences, personal attributes, and academic metrics. The outcomes of admissions interviews are high-stakes for the program and applicants, as they are often the final step prior to admissions decisions. Additionally, there is considerable overlap between the principles of admissions interviews and job interviews, the latter of which may occur as a military PA's career unfolds and they are considered for special assignments. Though numerous different interview modalities exist, multiple mini-interviews (MMI) are highly-structured, effective, and are supportive of a holistic admissions approach. Through examining historical admissions trends, identifying a modern way to select applicants through holistic admissions can support decreased student deceleration and attrition and increased diversity, optimizing force readiness and supporting the success of the PA profession into the future.

Elder veteran program: A description of a nurse practitioner-led inpatient geriatric consult model.

ABSTRACT: This article describes the Elder Veteran Program (EVP), a nurse practitioner (NP)-led inpatient consult service at one Midwestern Veterans Administration (VA) hospital. The EVP was designed to address the needs of older hospitalized veterans and serves as a model that uses geriatric expert clinicians as mentors to grow geriatric expertise. Unique to EVP, nurses are coached to identify high-risk older veterans, initiate the consult process to drive geriatric medical and nursing review, and implement best geriatric nursing practice. As a result of EVP implementation, there was a 13-fold increase in the number of older hospitalized veterans receiving geriatric evaluation. The EVP highlights how NPs lead implementation of an evidence-based program that creates a path for engaging, educating, and growing geriatric nursing knowledge and skill while improving veteran access to geriatric sensitive care.

Veterans Affairs Graduate Medical Education Expansion Addresses U.S. Physician Workforce Needs.

The United States has a well-trained, highly specialized physician workforce yet continues to have care gaps across the nation. Deficiencies in primary care and mental health specialties are most frequently cited, though critical shortages in multiple disciplines exist, particularly in rural areas. Sponsoring institutions of physician graduate medical education (GME) have created rural residency tracks with modest federal funding and minimal incentives, though efforts targeting shortages in these specialties and geographic locations have been limited. In response to access problems in the Veterans Health Administration, Department of Veterans Affairs (VA), the second largest federal funder of GME with the most expansive clinical education platform, Congress passed the Veterans Access, Choice, and Accountability Act of 2014. This act directed the VA and provided funding to establish 1,500 new positions, a 15% expansion of VA-funded positions at the time. Priority for position selection was given to primary care, mental health, and any other specialties the secretary of VA determined appropriate. Importantly, priority was also given to VA facilities with documented physician shortages, those that did not have GME training programs, those in communities with high concentrations of veterans, and those in health profession shortage areas. Many rural facilities match this profile and were targeted for this initiative. At the conclusion of fiscal year 2021, 1,490 positions had been authorized, and 21 of the 22 VA medical centers previously without GME activity had added residents or were planning to soon. Of the authorized positions, 42% are in primary care, 24% in mental health, and 34% in critically needed additional specialties. Targeted GME expansion in the VA, the largest integrated health care system in the nation, has been successful in addressing physician GME training that aligns with physician shortages and may serve as a model to address national physician specialty and geographic workforce needs.