A Grounded Theory Approach to Navigating Infertility Care During U.S. Military Service.

INTRODUCTION: In this study, we aimed to understand how active duty service members and their partners navigate the infertility care process within the Military Health System (MHS) while managing a military career. MATERIALS AND METHODS: We obtained Institutional Review Board approval to employ a qualitative design using grounded theory methods. We recruited participants using purposive sampling, followed by theoretical sampling. We derived data from demographic questionnaires and semi-structured interviews. Consistent with grounded theory methods, we began analysis with line-by-line coding and moved to focused coding. We employed constant comparative analysis throughout the process to name, categorize, and conceptualize data and relationships. RESULTS: The participants included 28 patients, five partners, nine health care providers, and two military leaders. The infertility care process began with active duty service members and their partners recognizing the desire to have a child and discovering infertility, followed by deciding to seek infertility care. The experience was temporally bound within the context of the military environment. We identified the following themes, which described facilitators and barriers to accessing care: Duty station location, career stage, military versus the civilian cost of services, command climate, and policy. These facilitators and barriers varied widely across the Department of Defense (DoD), which resulted in fragmented and inconsistent care cycles, contributed to emotional and physical stress, and created tension between career progression and family formation. CONCLUSIONS: Understanding how military couples perceive and manage demands of infertility care may enhance access to care, decrease patient costs, improve outcomes, result in better support for military couples who experience infertility, and ultimately improve the health and military readiness of our armed forces. The results support the need for action by providers, policy makers, and military leaders to develop effective infertility treatment programs and policies in the DoD.

We're Stronger Together: A Collaboration to Support Military Families During the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic has created challenges for every segment of the U.S. population, including military personnel and their families. The TriService Nursing Research Program's Military Family Research Interest Group (FIG) formed a collaboration with Blue Star Families, a civilian non-profit organization, to identify potential issues faced by military families during the pandemic. DATA COLLECTION METHODS: The Pain Points Poll was introduced online by Blue Star Families, and findings were aggregated weekly between March 18 and May 26, 2020. Volunteer poll respondents were mainly recruited through social media outreach. FIG-informed questions were incorporated in week 4 of polling and focused on workplace environment, financial health, social support, physical and mental health, child behavior, utilization of family care plans, and general well-being. Data were collected to gain real-time insights into the major challenges posed by the pandemic. Findings from FIG-informed questions were collaboratively reviewed and analyzed by FIG and BSF teams. Data-driven recommendations were made to stakeholders to improve processes and reprioritize investments for services that aim to alleviate the impact of COVID-19 on military families. FINDINGS: A total of 2,895 military family units (i.e., service members and spouses) responded to the poll, a majority of which (88%) represented active duty family units. Although the majority of families (range: 59%-69%) noted no impact to their finances, approximately one in five families endorsed dipping into their savings during the pandemic. A majority of respondents (69.5%) reported taking active measures to support their mental health, endorsing various strategies. Among parents of special needs children, 45% of active duty families and 60% of single-parent service members reported the inability to maintain continued services for their children. A majority of parents with school-aged children (65%) reported child behavioral changes due to their child's inability to socialize with peers. Among military service members, 41% were concerned about obtaining fair performance evaluations during the crisis. CONCLUSIONS: The COVID-19 pandemic produced significant challenges for military families. Collaboration between military and civilian partners can inform policies and appropriate strategies to mitigate the impact of COVID-19 for military families. The findings presented here provide insight into areas where military families can be supported for optimal outcomes during unprecedented times.

Finding the evidence: Screening of Military Family Research, 2014-2017.

Of 1.3 million active duty service members, the majority have family responsibilities; 54.3% are married, and 41.2% have at least one child. The authors sought to determine existing areas of focus in military family research and to identify areas that are currently understudied. The authors queried four literature databases from January 2014 to May 2017, and 2,502 articles were identified in the initial catchment. All 595 article abstracts that met inclusion criteria were sorted into one or more of 12 topics. Topics with the highest number of articles included Mental Health and Care (n = 276), Adult/Couple Partner Relationships (n = 247), and Deployment Issues (n = 244). Topics with sparse articles included Maternal/Child & Newborn Health (n = 27), Health Promotion (n = 10), and Special Heath Care Needs (n = 4). The three topics with the highest number of articles reflect interdependent and overlapping themes and showcase the importance of family relationships to the operational readiness of active duty members. The topics with fewer numbers of articles highlight areas where more evidence is needed. Understanding the current evidence allows nurse practitioners to support military families appropriately in real time.

Congenital Chylothorax: A Unique Presentation of Nonimmune Hydrops Fetalis in a Preterm Infant.

BACKGROUND: Nonimmune hydrops fetalis secondary to congenital chylothorax (CC) is a rare disease process associated with high morbidity and mortality related to abnormal formation of the lymphatic system and disrupted management of fetal fluid. Hydrops fetalis is typically diagnosed prenatally by the presence of pleural effusions or other fluid collection on ultrasonography. Congenital chylothorax is diagnosed when the analysis of pleural fluid is deemed chylous. Neonatal presentation is often respiratory distress secondary to lung compression or pulmonary hypoplasia. Management ranges from supportive medical management such as high-frequency ventilation, chest drainage, and nutrition support, to controversial therapies such as octreotide administration and chemical pleurodesis, to surgical interventions such as thoracic duct ligation and mechanical pleurodesis. PURPOSE: To discuss a range of management techniques and supportive therapies for hydrops fetalis and CC. METHODS/SEARCH STRATEGY: PubMed and CINAHL were searched using the terms "hydrops fetalis," "congenital," "chylothorax," "neonate," and "preterm." Twenty-two English language articles published within the last five years were identified and included to determine the current body of evidence surrounding treatment options for hydrops fetalis and CC. CASE FINDINGS: In this case, a preterm male infant presented at birth with prenatally known bilateral pleural effusions and ascites, later diagnosed as nonimmune hydrops fetalis secondary to CC. A combination of supportive medical management, octreotide therapy, and surgical intervention effectively resolved this infant's chylothorax and hydrops. IMPLICATIONS FOR PRACTICE: Antenatal intervention may be appropriate for some infants, otherwise supportive medical management including respiratory and nutrition therapies should be prioritized for infants born with hydrops fetalis and CC. IMPLICATIONS FOR RESEARCH: Nonimmune hydrops fetalis secondary to CC presents a complex challenge for neonatal providers, as no definitive treatment strategy currently exists. Further research is needed to determine the safety and efficacy of controversial therapies including octreotide.

Improving the Process of Enteral Nutrition Preparation With Milk Technicians: Perceptions of Cost, Time, and Quality.

BACKGROUND: Neonatal intensive care nurses have historically been responsible for preparing enteral feedings--a costly and time-consuming process that may require leaving the bedside. To address these concerns, the Milk Technician Program was implemented at a major military treatment facility. Milk technicians were specially trained and responsible for handling, storing, and preparing enteral feeds. PURPOSE: To determine effectiveness of the Milk Technician Program, changes in length of time required to first attain full feeds, cost of feeding preparation, adherence to feeding preparation procedures, and nurse and milk technician role variables were evaluated. METHODS: A pre-/postdesign was used to compare length of time to full enteral feedings and cost. A plan-do-study-act design was used to evaluate protocol adherence and to identify and evaluate nurse and milk technician role variables. Data were collected via surveys, direct observations, and retrospective chart reviews to determine the overall effectiveness of this intervention. RESULTS: The average time for extremely and very preterm infants (<28 to 31 weeks) to first reach full feeds decreased from 32 to 19 days, t (33.1) = 2.33, P = .026, d = 0.704. Estimated feeding preparation cost savings for all infants admitted to the unit was $767 per day. Observed milk technician adherence to preparation procedures was 95.5%. Most nurses reported that the program saved time (97%) and all milk technicians reported improved job satisfaction. Nurses expressed concerns about accuracy and safety of preparation. Milk technicians reported concerns with communication, supplies, and lack of perceived support. IMPLICATIONS FOR PRACTICE: Milk technicians offer significant benefit to infants and nurses in the neonatal intensive care unit, including reducing time for infants to reach full feeds, saving nurses' time, and reducing costs. IMPLICATIONS FOR RESEARCH: Further research is needed to identify ideal educational backgrounds for milk technicians and to directly measure the effect of milk technicians on hospital length of stay and infant growth parameters.