Marissa Cence, age 26, presents to the ED with chest pain and pressure. (This patient is a composite of several cases we've encountered in our practice.) She was driven to the ED by a neighbor who's now in the waiting room with the patient's two young children. Ms. Cence is tachycardic and diaphoretic. She expresses concern that, if she's admitted, she knows of no one who can care for her children. She begins to cry.
The intake nurse schedules Ms. Cence for a thorough cardiac workup, starting with an electrocardiogram within 10 minutes, two 81-mg aspirin tablets by mouth, supine patient positioning, sublingual nitroglycerin 0.4 mg (1/150 grain) for vasodilation and pain relief, oxygen at 4 to 6 L per minute by nasal cannula, pulse oximetry, immediate portable chest X-ray, IV access with a saline lock, and cardiac panel laboratory studies.
The intake interview reveals that Ms. Cence's husband Greg, a 10-year member of the National Guard, was recently deployed to Afghanistan, having returned from a tour in Iraq only two years ago. The family has dealt with deployment previously, and the military has provided them with information on family separation issues, but Ms. Cence still finds herself struggling with everyday activities and has become increasingly obsessed with TV coverage of the Afghanistan conflict. Her current chest pain started shortly after she heard a TV report that fighting had intensified near the area in which her husband is stationed.
Ms. Cence's situation isn't unusual. In a study of 798 spouses of active duty military personnel, deployment was found to have a markedly negative effect on health and well-being, with spouses reporting loneliness, anxiety, and depression in 78.2%, 51.6%, and 42.6% of all cases, respectively.1 Families of National Guard and reserve members face additional challenges. Unlike active duty military families, who live on or near a military base, families of guardsmen and reservists tend to live within the civilian community and are often unaware of supportive and preventive services available to them through the military.2 When problems arise, they may delay seeking care, presenting initially to an ED.
Would you be able to provide a military spouse like Ms. Cence with the information she needs to access available resources that could help her address the issues creating stress in her life and, possibly, contributing to her current health concerns? How would you proceed if her evaluation showed her to be facing a true medical emergency?
Given the number of guardsmen and reservists currently deployed in Afghanistan and Iraq, it's vital for civilian nurses to know how to address the needs of military families residing within the community. This article underscores the most important aspects of nursing assessment and care of the families stressed by military deployment.
SOLDIERING ON
According to the White House and the Department of Defense, as of August 2010, there were 87,000 U.S. troops deployed in and around Afghanistan as part of Operation Enduring Freedom and 56,000 U.S. troops conducting stability operations in Iraq (down from a high of 180,000).3,4
Of the 143,000 soldiers currently deployed to support these two operations, an estimated 40% are activated guardsmen and reservists5 whose families lack the support of a military base. In addition to the stress of separation, guardsmen and reservists have been subject to multiple deployments since 2007, when changes in mobilization policies made them available for service on an indefinitely recurrent basis.6
With deployment, these military families must quickly make decisions and finalize arrangements regarding finances, health care, child or elder care, and advance directives. Conversations about such topics can exacerbate the stress of deployment and create resentment among those affected.7 These stressors remain after deployment and may grow as the family faces everyday challenges without the presence and support of the military member. Nurses need to know how to identify and assess patients in military families, as well as how to provide appropriate intervention for any social or psychological health problems they face.
IDENTIFYING AND ASSESSING AFFECTED PATIENTS
A quick review of insurance coverage can provide the first clue that your patient has a deployed family member. TRICARE is the health care program for military members and their families. Approximately 9.5 million people are eligible for this health care plan, including active duty members and National Guard and reserve members, and their families.8 If you suspect that a patient without TRICARE coverage may have a deployed service member in the family, you might include in your admission assessment a question about family military involvement, particularly if the patient presents with a mental health issue, such as depression, anxiety, or substance abuse. Keep questions conversational, and avoid asking specifics about the family member's deployment or mission because, as family members are frequently reminded by the military, sharing such details with those outside the family may jeopardize troop or mission security.
Because depression, generalized anxiety, stress reactions, and sleep disorders are all associated with the deployment of a spouse,1,9,10 look for signs and symptoms of such disorders, including feelings of hopelessness, a loss of interest in daily activities, changes in eating habits (significant weight gain or loss), a change in sleeping habits (too much or too little), and irritability. Ask patients how they cope with the stress of deployment and, if they use any particular stress-relieving techniques, whether they find them helpful. While assessing the patient, keep in mind the stressors most commonly associated with military deployment: parenting issues, limited information, inadequate social support, and financial pressures.
Suddenly a single parent. In addition to assuming sole responsibility for maintaining the couple's household, the spouse of the deployed must also act as a single parent when children are involved, a change that often disrupts schedules, multiplies responsibilities, and radically alters family dynamics.
A lack of information. Depending on a unit's deployment location, there may be no ready access to phones or computers, making it difficult for a service member to maintain regular contact with family at home. Before deployment, service members designate who should receive their deployment updates (when updates are available), but to prevent unnecessary worry, some service members opt to exclude extended family from this list, and even when family members are designated to receive updates, communication between the unit and the home front may be limited. Unfortunately, a lack of information about a deployed family member may cause significant stress and worry.
Insufficient social support. Ask whether the military member is a guardsman or reservist because this may influence opportunities to socialize with other military families and family awareness of available services. Military support systems are available, but experts say many reservist and guard families never access them.11
Financial issues. For families of activated reservists and guardsmen, deployment may represent a significant financial loss, because it means they no longer receive payment for any civilian job the deployed service member held.5 The pay scale for military members varies widely, but the starting monthly pay for enlisted military members may be as low as $1,347 per month.12
In the ED with Ms. Cence. In performing the intake assessment, the nurse discovers that Ms. Cence has no family nearby, besides her two young children. Trying to hold down a full-time job while caring for her children has left Ms. Cence feeling overwhelmed. There's no military base near her home, and she doesn't know where to turn for guidance or support.
The nursing assessment further reveals that, since her husband's deployment, Ms. Cence has been feeling anxious, cries frequently, and has had difficulty focusing. She's having trouble sleeping. She's often too upset to eat, has stomach pains when she does eat, and has lost 15 pounds.
NURSING INTERVENTIONS
As families' caregiving, financial, and personal burdens mount, nurses can help them locate and avail themselves of the military systems that can assist them with these matters and any associated mental health problems. Advise patients to contact the "Family Program" or "Family Readiness Group" associated with the military branch in which their family member is enlisted (see Military Support Programs and Resources). The appropriate officer for a family to contact is determined by the unit or battalion of the deployed military member.
Military support programs can often assist harried parents in locating appropriate respite and child care services. For family members stressed by a lack of information, the Family Program or Family Readiness Group officer can brief families on unit deployment and other activities. Some military branches post contact information for family programs on their Web sites. Others establish secure virtual Family Readiness Groups, customized to and controlled by the particular units. Through these virtual groups, family members can download photos and videos from their loved one's unit and submit questions to the unit commander through the group leader.
Refer military families with financial hardships to the Armed Forces Relief Trust (http://www.afrtrust.org), which provides emergency assistance in the way of interest-free loans and grants to military families in need.13 Consider referring patients with loneliness, anxiety, or depression to mental health services as needed. Some may require antidepressant or antianxiety medication. (If military base support is available, such services may be found there.)
Finding support for Ms. Cence. Recognizing Ms. Cence's lack of social and financial support, the nurse helps her contact the Family Program office for her husband's National Guard unit and to the Armed Forces Relief Trust. The nurse also refers Ms. Cence to mental health services for anxiety.
HELPING CHILDREN AND ADOLESCENTS
According to the Department of Defense, more than 40% of active duty troops and selected reservists (those most likely to be deployed in times of conflict) are parents. More than 1.19 million children have parents on active military duty, and half of these children are under the age of seven.12 An additional 715,613 children have parents who are selected reservists.12
In military families, children ages 11 through 17 have more emotional difficulties than their nonmilitary counterparts, with the older children and girls of all ages having trouble with school, their families, and peers.14 In addition, adolescents with family members deployed to Iraq have significantly higher heart rates and blood pressure measurements than those who don't have deployed family members, although the clinical significance of this difference is unclear.15
According to some military health experts, children need at least four weeks to adjust to a parent's deployment.16 Maintaining a family routine may help children through this adjustment phase,16 although they may still be at risk for increased stress and anxiety, as well as physiologic and behavioral problems (such as changes in school performance).7
When working with children of deployed military members, assess them for potential psychological or behavioral problems. In younger children, this might include excessive crying, temper tantrums, regression with toilet training or bed-wetting, or thumb sucking; in older children, assess for feelings of isolation, difficulty making decisions, use of alcohol or drugs, or sexual promiscuity. Address the fears and concerns of younger children through play therapy, puppets, or storytelling. When dealing with older children, ask open-ended questions and keep all responses nonjudgmental. Ask parents about any changes they've observed in their children's sleeping, eating, or activity patterns. Military psychiatrists have suggested that "the media (particularly television) [serve] as the military children's most significant source of stress related to potential parental death."17 Because Ms. Cence had mentioned at intake an obsession with TV coverage of the Afghanistan conflict, the nurse suggests that she limit the amount of news coverage she allows herself and her children to watch.
Researchers speculate that the structure inherent in the school day may help reduce stress in children with deployed parents.18 Teachers and guidance officers may help identify problems, and school nurses can play a vital role in providing support, working with other school personnel to help the student develop or strengthen peer relationships within the school, and offering the nursing office as a safe haven. To promote involvement of school personnel, you might suggest that parents refer the nursing or guidance office to the online toolkits available at the Web site of the American Association of School Administrators (http://www.aasa.org/MilitaryChild.aspx).19
PATIENT EDUCATION
After completing an initial assessment and identifying needs, patient teaching focuses on coping strategies.
Seeking support. In addition to military readiness and support programs, churches, synagogues, mosques, and community meeting places often provide support groups for military families. If a support group isn't readily available in your area, consider starting a list for patients of local military families who are interested in talking with other military families. Many patients find it helpful to connect with others who share the same problems and concerns. Take care to ensure patient privacy through adherence to Health Insurance Portability and Accountability Act guidelines.
Stress management. Often patients need to be reintroduced to coping mechanisms and stress management strategies incorporated in military pamphlets designed to prepare families for deployments. Encourage patients to make time for themselves. Distraction has been found to be an effective strategy for adolescents,11 and patients of all ages may benefit from attending movies or sporting events (as finances allow), reading, taking walks, or engaging in other activities they find enjoyable. It can be healthy for parents to arrange to spend time away from their children, and it may be possible for them to swap babysitting days with other military families or members of church or local community organizations.
Reinforce the importance of attending to psychological or spiritual needs through such activities as meditation, silent thought, or prayer. Finding time to do all that is necessary to keep healthy while keeping up with daily chores can be difficult. Remind patients to take one day at a time. With the right attitude and support, dealing with the deployment of a loved one will be less overwhelming.
Social engagement. Caution patients about spending too much time alone. Encourage them to spend time with family and friends whose company they enjoy. Suggest social networking on the Internet as a means of allowing family members to provide support over long distances.
Diet, exercise, and sleep. Talk to patients about the importance of eating the right foods, exercising daily, and getting a good night's sleep to preserve overall wellness. Instruct patients to limit or completely avoid caffeine, alcohol, and cigarettes because each can create or exacerbate physical and mental health problems. Consider referring patients who are having dietary problems to a nutritionist and smokers to a tobacco cessation program. Research suggests that community-based wellness programs that target unhealthy behaviors among active duty soldiers and their spouses can reduce family and personal stress while improving important health behaviors.20
EMERGENCY SITUATIONS
When home-based family members of deployed military personnel experience a critical or life-threatening health condition, the deployed service member may need to be notified. Depending on the rank, location, and classification of the service member, families may find it difficult to contact deployed love ones. The American Red Cross can assist in delivering emergency messages and can even reach military units in remote locations around the world in the event of a family member's death or serious illness, the birth of a child, or another type of family emergency.21 Family of active duty service members residing in the United States can contact the Red Cross by calling their toll-free number: (877) 272-7337. Family of active duty military members, guardsmen, or reservists deployed outside of the United States can contact their local Red Cross chapter.
Family members need to provide specific information about the deployed loved one, including her or his full name, branch of service, rank or rating, date of birth, military address, and unit information. The Red Cross verifies the information about the emergency and provides timely, confidential, and factual information when notifying the appropriate military personnel. This information keeps deployed military members informed and helps commanding officers make appropriate emergency-leave decisions.21
ESTABLISHING A SUPPORT SYSTEM
Although the deployment of a loved one is always stressful, nurses can do a great deal to identify and assess family needs, help family members access available resources, and intervene with patient education and appropriate referrals.
Ms. Cence goes home. In Ms. Cence's case, a thorough workup reveals no cardiac involvement. Her chest pain is attributed to deployment stress, and she's discharged to her home within 23 hours. Through the National Guard Family Program and the Armed Forces Relief Trust, she obtains assistance in meeting her household, family, and financial obligations and begins to meet regularly with other military spouses, which greatly reduces her feelings of isolation and stress. She has no further episodes of chest pain.
Military Support Programs and Resources
The following military organizations and Web sites can answer questions, provide articles and other resources, offer assistance, and help military families establish support networks.
General support for military families:
* American Red Cross (http://www.redcross.org)
* Armed Forces Relief Trust (http://www.afrtrust.org)
* Force Health Protection and Readiness (http://fhp.osd.mil/deploymentTips.jsp)
* 4 http://Militaryfamilies.com (http://www.4militaryfamilies.com)
* Military Homefront (http://www.militaryhomefront.dod.mil)
* Military http://OneSource.com (http://www.militaryonesource.com)
* Military http://SOS.com (http://www.militarysos.com/forum)
* National Military Family Association (http://www.nmfa.org)
* TRICARE military health care program (http://www.tricare.mil)
* U.S. Department of Defense (http://www.defenselink.mil)
For Air Force families:
* Airman and Family Readiness Center and Key Spouse Program (contact the local base for information)
* Official Web site of the U.S. Air Force (http://www.af.mil)
For Army families:
* Army Family Readiness Group (http://www.armyfrg.org/skins/frg/home.aspx)
* Official Homepage of the United States Army (http://www.army.mil)
For Coast Guard families:
* United States Coast Guard (http://www.uscg.mil/mwr)
For Marine Corps families:
* Marine Corps Family Team Building (http://www.usmc-mccs.org/mcftb/index.cfm)
* Official U.S. Marine Corps Web site (http://www.usmc.mil)
For National Guard families:
* National Guard Family Program (http://www.jointservicessupport.org/fp)
For Navy families:
* Naval Services FamilyLine (http://www.cnic.navy.mil/FamilyLine)
* Commander, Navy Installations Command Fleet and Family Readiness Programs (http://www.cnic.navy.mil/CNIC_HQ_Site/WhatWeDo/FleetandFamilyReadiness/index.htm)
* Official Web site of the United States Navy (http://www.navy.mil)
For Reservist families:
* Army Reserve Family Programs (http://www.arfp.org)
* Marine Forces Reserve Family Readiness Home (http://www.marforres.usmc.mil/Family/default.asp)
* Official Web site of Air Force Reserve Command (http://www.afrc.af.mil/index.asp)
REFERENCES