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.

A VA Health Care Innovation: Healthier Kidneys Through Your Kitchen-Earlier Nutrition Intervention for Chronic Kidney Disease.

To provide earlier nutrition intervention for chronic kidney disease (CKD), Veterans Administration (VA) Registered Dietitians (RDs) developed Healthier Kidneys Through Your Kitchen. In this program, Veterans with stage 3 CKD are identified and offered participation in a one-time class that explains CKD stages, nutrition, and physical activity to slow progression of CKD. Veterans learn about monitoring dietary protein and sodium and the importance of blood pressure and glucose control. Weight and waist circumference are measured. Participants enjoy a Healthy Teaching Kitchen demonstration where RDs prepare tasting recipes. Veterans are encouraged to meet with the RD for medical nutrition therapy, behavior change counseling, motivational interviewing, review of individual kidney laboratory values, and exercise recommendations. A postclass evaluation revealed important knowledge gaps: one-third were unaware that uncontrolled blood pressure and uncontrolled diabetes lead to kidney failure. This program is currently implemented in 14 VA clinics and has reached over 400 Veterans.

Virtual Standardized Patients vs Academic Training for Learning Motivational Interviewing Skills in the US Department of Veterans Affairs and the US Military: A Randomized Trial.

Importance: Despite the need for effective and scalable training in motivational interviewing (MI) that includes posttraining coaching and feedback, limited evidence exists regarding the effectiveness of using virtual (computerized) standardized patients (VSPs) in such training. Objective: To evaluate the efficacy of training with a VSP on the acquisition and maintenance of MI skills compared with traditional academic study. Design, Setting, and Participants: This study was a 2-group, parallel-training randomized trial of 120 volunteer health care professionals recruited from a Department of Veterans Affairs and Department of Defense medical facility. Motivational interviewing skill was coded by external experts blinded to training group and skill assessment time points. Data were collected from October 17, 2016, to August 12, 2019. Interventions: After a computer course on MI, participants trained during two 45-minute sessions separated by 3 months. The 2 randomized training conditions included a branching storyline VSP, which provided MI skill rehearsal with immediate and summative feedback, and a control condition, which included academic study of content from the computerized MI course. Main Outcomes and Measures: Measurement of MI skill was based on recorded conversations with human standardized patients, assessed using the Motivational Interviewing Treatment Integrity 4.2.1 coding system, measured at baseline, after training, and after additional training in the randomized condition 3 months later. Results: A total of 120 volunteers (83 [69%] women), with a mean (SD) of 13.6 (10.3) years of health care experience, participated in the study; 61 were randomized to receive the intervention, and 59 were randomized to the control group. Those assigned to VSP training had significantly greater posttraining improvement in technical global scores (0.23; 95% CI, 0.03-0.44; P = .02), relational global scores (0.57; 95% CI, 0.33-0.81; P = .001), and the reflection-to-question ratio (0.23; 95% CI, 0.15-0.31; P = .001). Differences were maintained after the 3-month additional training session, with more improvements achieved after the 3-month training for the VSP trainees on the reflection-to- question ratio (0.15; 95% CI, 0.07-0.24; P = .001). Conclusions and Relevance: This randomized trial demonstrated a successful transfer of training from a VSP to human standardized patients. The VSP MI skill outcomes were better than those achieved with academic study and were maintained over time. Virtual standardized patients have the potential to facilitate dissemination of MI and may be useful for training in other evidence-based skills and treatments. Trial Registration: ClinicalTrials.gov Identifier: NCT04558060.

Innovative Model to Recognize Previous Military Training of BSN Students.

BACKGROUND: Many of our military transitioning to civilian life are expertly trained medics, corpsmen, and health care specialists. PROBLEM: The medical training of these veterans does not follow traditional degree granting academic protocols. These individuals seeking formal academic credentials to work in the nonmilitary sector are often forced to start their health education over from the beginning. APPROACH: An innovative model was developed for waiving the requirements for specific nursing courses for veteran-students. Using a skills self-assessment tool and a validation process, veteran-students are able to demonstrate their knowledge, training, and experience. OUTCOMES: As part of the program, 32 veteran-students have validated out of 65 courses for 115 credit hours. All students have successfully progressed through the BSN program. CONCLUSION: This skills validation model represents a model that can be implemented for students entering a nursing program with a variety of health care backgrounds.

A Patient Portal Intervention for Menopause Knowledge and Shared Decision-Making.

Background: Menopause is a time often fraught with changes and symptoms, which may require difficult choices and decision-making. During this period, women would benefit from a better understanding and in-depth discussions with providers regarding menopause, associated conditions, and appropriate therapy. Patient portals offer a potential means to improve knowledge and shared decision-making (SDM) about menopause. Materials and Methods: This protocol article explores the feasibility of using the secure messaging (SM) function of the Veterans Affairs (VA) Patient Portal, "My HealtheVet" to implement an educational intervention and measure its impact on knowledge and SDM in the management of menopause. Results: This is a quality improvement pilot study in which women veterans of menopausal age in the Miami VA are offered an educational intervention via a patient portal, while women veterans in two neighboring VA facilities are not. Intervention participants receive weekly SMs with information on menopause symptoms, and treatment. After 6-months, all participants are surveyed on menopause knowledge, SDM, and satisfaction with the program. Conclusion: This study is among the first to assess the impact of an innovative patient portal intervention to improve knowledge and SDM between patients and providers regarding menopause. If successful, our program will add to the "meaningful use" of patient portals and offer a scalable and timely resource for SDM about menopause.

Serving Those Who Serve Their Country: Preparing Military Veterans for Nursing Degrees.

BACKGROUND: Challenges remain for integrating Veterans into civilian occupations postservice. This article describes an innovative project affording military service personnel serving in health occupational specialties the opportunity for completion of a Bachelor of Science in Nursing (BSN) degree. METHOD: The Vets2BSN project, launched in July 2014, has achieved several years of enrollment and graduation success using standardized measures and assessment of student modifiers to establish project success. RESULTS: Nearly 80 eligible students holding current or former rank as corpsmen or medics have enrolled in the program with 59 conferrals and an NCLEX pass rate of 98% (48 of 49). Prospective assessment of progress allows real-time intervention and remediation to achieve successful graduation rates. CONCLUSION: Collaboration of university administration and faculty has provided a foundation for reintegration of military health professionals possessing skills allowing for educational credit and acceleration of studies toward earning the BSN and joining the workforce as nursing professionals. [J Nurs Educ. 2019;58(8):444-453.].

Cooking Education Improves Cooking Confidence and Dietary Habits in Veterans.

PURPOSE: The purpose of the study was to evaluate a 12-week cooking education class on cooking confidence, dietary habits, weight status, and laboratory data among veterans with prediabetes and diabetes. METHODS: The sample for this study included 75 veterans within the Overton Brooks Veteran Affairs Medical Center who completed the 12-week class in an in-person group setting in Shreveport, Louisiana, or via Clinical Video Telehealth (CVT) in Longview, Texas. Veterans were referred to the Healthy Teaching Kitchen by their primary care provider or primary care dietitian. Enrollment in the class was on a volunteer basis. The cooking and nutrition education classes included topics such as carbohydrate counting, safety and sanitation, meal planning, and creating budget-friendly recipes. Participants completed 2 questionnaires for assessment of healthy dietary habits and confidence related to cooking. Changes in body weight, lipid panel, and hemoglobin A1C were assessed. Differences in class settings were tested via independent samples t tests. Paired samples t tests were completed to compare changes in mean laboratory results, weight, and questionnaire responses. RESULTS: Subjects lost a mean 2.91 ± 5.8 lbs (P < .001). There was no significant difference in percent change in laboratory data and weight between subjects participating via CVT and subjects in the live class. Overall, there was significant improvement in the confidence questionnaire ratings and Healthy Habits Questionnaire responses. CONCLUSIONS: Cooking and nutrition education can increase cooking confidence and dietary quality. These results provide support for the need for further research on the long-term effects of nutrition cooking education and for the benefits of using CVT software to provide education to remote facilities.

Focused on the Objective: Experience of Male Combat Veterans in BSN Programs.

Background Veterans may provide a recruitment source to increase the diversity of the nursing workforce and increase the percentage of baccalaureate-prepared nurses. This study sought to understand the lived experience of male combat veterans in pre-licensure baccalaureate degree nursing programs. Method Using Van Manen's interpretive phenomenology methodology, a purposive sample of seven male combat veterans in pre-licensure baccalaureate degree nursing programs participated through written lived-experience descriptions (n = 2), photo-elicitation (n = 2), and unstructured interviews (N = 7). Findings The essential nature of the phenomenon is focused on the objective and four themes describing the participant's experiences were identified: tools of the trade, identity, turbulent waters, and fuel. Conclusion Despite the presence of barriers and frustrations, participants applied their identity and used the strengths gained through military service along with supports to focus on their objective of becoming a nurse. Thus, this research has implications for nurse educators.

Impacts of a web-based educational program for veterans who read their mental health notes online.

Objective: This study evaluates whether a web-based educational program for patients who read their mental health notes online improves patient-clinician communication and increases patient activation. Methods: The web-based educational program, developed with end-user input, was designed to educate patients on the content of mental health notes, provide guidance on communicating with clinicians about notes, and facilitate patients' safe and purposeful use of their health information. Eligible patients were engaged in mental health treatment (≥1 visit in the prior 6 months) and had logged into the Veterans Health Administration (VHA) patient portal at least twice. Participants completed measures of patient activation, perceived efficacy in healthcare interactions, patient trust in their clinicians, and patient assessment of the therapeutic relationship before and after participating in the program. A total of 247 participants had complete data and engaged with the program for 5 minutes or more, comprising the analytic sample. Multivariate analysis using mixed effects models were used to examine pre-post changes in outcomes. Results: In bivariate analyses, patient activation, perceived efficacy in healthcare interactions, and trust in clinicians increased significantly between pre- and post-training assessments. In fully adjusted models, changes in patient activation [b = 2.71 (1.41, 4.00), P < 0.01] and perceived efficacy in healthcare interactions [b = 1.27 (0.54, 2.01), P < 0.01)] remained significant. Conclusions: Findings suggest that this educational program may help empower mental health patients who read their notes online to be active participants in their care, while also providing information and tools that may facilitate better relationships with their clinicians.

Veteran-to-Veteran Program.

More Veterans are receiving health care outside of the Veterans Health Administration. Over concern for the Veteran's safety and the provider's competency, three progressive steps have been taken within the state of West Virginia. J Contin Educ Nurs. 2018;49(11):493-495.

Actualizing veterans education in nursing.

A grant driven partnership among a west Texas university, Texas Workforce Commission's College Credits for Heroes, and the Health Resources and Services Administration provided the funding needed to create a competency based education (CBE) model for recognizing military veteran service training and experience. Through this model, we call Competency Assessment Placement (CAP), prior learning credits can be awarded for upper division nursing courses leading to a Bachelor of Science in Nursing. The process used by faculty to create this direct assessment method for awarding credit, performance data of Cohort I using the CAP, and our initial "lessons learned" are provided. Incorporating an on-going reflection of military veteran student learning needs, a persistent concern for improvement of the nursing program, as well as a frequent review of veteran educational benefit policies will continue as this CAP model provides beneficial outcomes for the students.

A Coaching by Telephone Intervention on Engaging Patients to Address Modifiable Cardiovascular Risk Factors: a Randomized Controlled Trial.

BACKGROUND: A large proportion of deaths and chronic illnesses can be attributed to three modifiable risk factors: tobacco use, overweight/obesity, and physical inactivity. OBJECTIVE: To test whether telephone-based health coaching after completion of a comprehensive health risk assessment (HRA) increases patient activation and enrollment in a prevention program compared to HRA completion alone. DESIGN: Two-arm randomized trial at three sites. SETTING: Primary care clinics at Veterans Affairs facilities. PARTICIPANTS: Four hundred seventeen veterans with at least one modifiable risk factor (BMI ≥ 30, < 150 min of at least moderate physically activity per week, or current smoker). INTERVENTION: Participants completed an online HRA. Intervention participants received two telephone-delivered health coaching calls at 1 and 4 weeks to collaboratively set goals to enroll in, and attend structured prevention programs designed to reduce modifiable risk factors. MEASUREMENTS: Primary outcome was enrollment in a structured prevention program by 6 months. Secondary outcomes were Patient Activation Measure (PAM) and Framingham Risk Score (FRS). RESULTS: Most participants were male (85%), white (50%), with a mean age of 56. Participants were eligible, because their BMI was ≥ 30 (80%), they were physically inactive (50%), and/or they were current smokers (39%). When compared to HLA only at 6 months, health coaching intervention participants reported higher rates of enrollment in a prevention program, 51 vs 29% (OR = 2.5; 95% CI: 1.7, 3.9; p < 0.0001), higher rates of program participation, 40 vs 23% (OR = 2.3; 95% CI: 1.5, 3.6; p = 0.0004), and greater improvement in PAM scores, mean difference 2.5 (95% CI: 0.2, 4.7; p = 0.03), but no change in FRS scores, mean difference 0.7 (95% CI - 0.7, 2.2; p = 0.33). CONCLUSIONS: Brief telephone health coaching after completing an online HRA increased patient activation and increased enrollment in structured prevention programs to improve health behaviors. CLINICALTRIALS. GOV IDENTIFIER: NCT01828567.

Building Capacity for Complementary and Integrative Medicine Through a Large, Cross-Agency, Acupuncture Training Program: Lessons Learned from a Military Health System and Veterans Health Administration Joint Initiative Project.

Introduction: Complementary and integrative medicine (CIM) use in the USA continues to expand, including within the Military Health System (MHS) and Veterans Health Administration (VHA). To mitigate the opioid crisis and provide additional non-pharmacological pain management options, a large cross-agency collaborative project sought to develop and implement a systems-wide curriculum, entitled Acupuncture Training Across Clinical Settings (ATACS). Materials and Methods: ATACS curriculum content and structure were created and refined over the course of the project in response to consultations with Subject Matter Experts and provider feedback. Course content was developed to be applicable to the MHS and VHA environments and training was open to many types of providers. Training included a 4-hr didactic and "hands on" clinical training program focused on a single auricular acupuncture protocol, Battlefield Acupuncture. Trainee learning and skills proficiency were evaluated by trainer-observation and written examination. Immediately following training, providers completed an evaluation survey on their ATACS experience. One month later, they were asked to complete another survey regarding their auricular acupuncture use and barriers to use. The present evaluation describes the ATACS curriculum, faculty and trainee characteristics, as well as trainee and program developer perspectives. Results: Over the course of a 19-mo period, 2,712 providers completed the in-person, 4-hr didactic and hands-on clinical training session. Due to the increasing requests for training, additional ATACS faculty were trained. Overall, 113 providers were approved to be training faculty. Responses from the trainee surveys indicated high satisfaction with the ATACS training program and illuminated several challenges to using auricular acupuncture with patients. The most common reported barrier to using auricular acupuncture was the lack of obtaining privileges to administer auricular acupuncture within clinical practice. Conclusion: The ATACS program provided a foundational template to increase CIM across the MHS and VHA. The lessons learned in the program's implementation will aid future CIM training programs and improve program evaluations. Future work is needed to determine the most efficient means of improving CIM credentialing and privileging procedures, standardizing and adopting uniform CIM EHR codes and documentation, and examining the effectiveness of CIM techniques in real-world settings.

Information-Seeking about Anxiety and Perceptions about Technology to Teach Coping Skills in Older Veterans.

OBJECTIVE: We sought to learn where older veterans seek information about anxiety and coping. Due to increasing use of technology in health care, we also explored benefits and barriers of using technology to teach coping skills. METHODS: Twenty veterans (mean age = 69.5 years, SD = 7.3) participated in semi-structured interviews in which we inquired about where they seek information about anxiety. We explored quantitative and qualitative differences for veterans with high versus low anxiety. In follow-up focus groups, we examined opinions about learning coping skills using technology. RESULTS: Though veterans primarily named health care professionals as sources of information about anxiety, online searches and reading books were frequently mentioned. Reported benefits of using technology were convenience and standardized instruction of coping skills. Barriers included lack of interaction and frustration with technology usability. CONCLUSION: Older veterans use multiple sources, heavily rely on interpersonal sources (e.g., professionals, friends), and employ varied search strategies regarding how to cope with anxiety. Using technology to teach coping skills was generally acceptable to older veterans. CLINICAL IMPLICATIONS: Health care professionals could guide patients towards credible online and book sources. Providing instruction about using technology may help older adults use technology to learn coping skills.

Feasibility of a Skills-Based Group Reintegration Workshop for OEF/OIF Veterans: STEP-Home.

OBJECTIVE: To evaluate the feasibility of a newly developed reintegration workshop for Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) Veterans that is based on an evidence-based rehabilitation program shown to be effective in treating mild traumatic brain injury-related symptoms in civilians. Underutilization and resistance to mental health treatment remain a significant problem for OEF/OIF Veterans. Innovative, integrative, transdiagnostic, and acceptable interventions are needed, particularly for this heterogeneous group. PARTICIPANTS: Eighty-four OEF/OIF/Operation New Dawn Veterans (74 male and 10 female)-mean age = 35; standard deviation = 7.4. SETTING: VA Healthcare System. INTERVENTION: A 12-week, 2-hour/wk, group skills-based workshop with individual skill building to assist all OEF/OIF Veterans (with and without psychiatric and/or traumatic brain injury) in reintegration after military service. MAIN MEASURES: Primary outcomes were feasibility measures including treatment fidelity, acceptability, tolerability/adherence, and treatment-related skill acquisition. Secondary outcomes were interest and engagement in future treatment and reintegration status. RESULTS: Veterans' enrollment, adherence, and attrition data indicated that Short-Term Executive Plus adapted for Veteran civilian reintegration (STEP-Home) was acceptable and tolerable. Pre-/postintervention differences in attention, problem-solving, and emotional regulation skills demonstrated treatment-related skills acquisition. Secondary outcome data demonstrated Veterans who were hesitant to participate in mental health treatments before enrollment were more open to treatment engagement after STEP-Home, and reintegration status improved. CONCLUSIONS: This study demonstrated that the STEP-Home workshop is feasible in OEF/OIF Veterans and changes in treatment-related skill acquisition and reintegration status were observed. STEP-Home has potential to facilitate readjustment and serves as a gateway to additional, critically needed Veterans Administration services.

Cooking Classes: A Diabetes Self-Management Support Intervention Enhancing Clinical Values.

Purpose The purpose of this study is to examine the relationship between Healthy Teaching Kitchen (HTK) attendance among veterans who are diagnosed with type 2 diabetes mellitus (T2DM) and clinical outcomes as measured by A1C and blood pressure. Methods This retrospective chart review collected data from veterans with T2DM who participated in the Diabetes Self-Management Support (DSMS) HTK program at the Louis Stokes Cleveland VA Medical Center (LSCVAMC) between February 2013 and May 2016. Data collected included demographic information, frequency of DSMS HTK attendance, 3 A1C values, and 3 blood pressure values. Each subject was assigned to 1 of 4 quartiles based on frequency of DSMS HTK attendance. Results A1C values of all groups improved over time, regardless of DSMS HTK attendance quartile. However, as total DSMS HTK class attendance increased, there was a significant decrease in the A1C difference score. Conclusions Participation in a DSMS program that focuses on healthy, economical cooking skills may lead to a significant improvement in A1C regardless of frequency of attendance. However, individuals with more frequent attendance may experience additional improvement in glycemic control.

Interservice Physician Assistant Program: Educators for an Expanding Profession.

PURPOSE: The number of physician assistant (PA) programs has increased exponentially across the past decade, and the demand for PAs will likely remain strong through 2025. Because of this rapid growth, both new and established PA programs face significant challenges in recruiting experienced educators. We describe the value of using PAs trained through the Interservice Physician Assistant Program (IPAP) as civilian PA educators. METHODS: The literature on IPAP and its graduates proved too limited to conduct a formal systematic review. We searched the PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases for works speaking to the value that IPAP-trained PAs may bring to civilian PA training. Those findings were supplemented with informal conversations with IPAP-trained PAs currently employed in the military and those working in civilian PA education. Themes were identified supporting the potential value of IPAP-trained PAs in civilian training. RESULTS: Military PAs work within hierarchical organizations and may transition easily to academic settings. They leave military service not only as highly trained and proficient primary care providers but also as experienced educators. Military PAs must demonstrate professionalism across their entire military careers. They serve as leaders and work in teams, but they are also experienced in negotiating up chains of command. They are trained in and apply the latest innovations in health care delivery and have provided care with a degree of autonomy uncommon in civilian PA practice. CONCLUSIONS: The PAs trained through IPAP leave the service with skills and experiences valuable to civilian PA training. Employing these PAs in civilian education honors their service contributions while addressing emerging PA educator workforce demands.

Overdose education and naloxone distribution for veterans with opioid use disorder: Results from a pilot initiative.

Patients with opioid use disorder are at a high risk of overdose. To minimize that risk, a program offering intranasal naloxone rescue kits was piloted at a Veterans Administration Hospital. The purpose of this study was to characterize veterans who accepted these potentially lifesaving kits. Retrospective medical chart review of 158 veterans with opioid use disorder receiving treatment on either the inpatient psychiatry detoxification units or outpatient methadone maintenance setting who were offered overdose education and naloxone rescue kits. One hundred and ten of 158 veterans (70%) accepted overdose education and naloxone rescue. Overall, they had a mean age of 39.1 years and averaged 12.7 years of opioid use. In the prior month, they averaged 14.3 days of heroin use; they used alone 48.5% of the time. They estimated an average of 2.8 accidental overdoses over their lifetimes. There were few significant differences between those who accepted and those who declined with regard to demographic and clinical variables. However, significantly higher percentages of outpatients accepted overdose education and naloxone rescue compared to inpatients (89% versus 63%, p = 0.003, Chi-square); the odds of acceptance were increased four-fold when offered to outpatients. Outpatients were nearly a decade older, with more years of opioid use (19.0 versus 11.0), but with less utilization of inpatient services in the prior year (all p < 0.05). The main finding was that 70% of veterans accepted overdose education and naloxone rescue, but significantly higher proportions of outpatients were more receptive than inpatients (89% versus 63%, p = 0.003). Efforts to increase overdose education and naloxone rescue acceptance in all settings are encouraged.