This themed issue honors the men and women in the military and veterans who have served our country. These service members fulfilled duty to the United States in war and peace with commitment, dignity, and courage. In appreciation of active military and veterans of the United States Armed Forces, this issue highlights health care topics relevant to these men, women, and their families. Increased awareness and knowledge of issues specific to service members advances the provision of quality health care services provided by nurse practitioners.
A complex and interrelated approach to health care for members of the military is provided by the Military Health System (MHS). MHS is a federated system of multifaceted professionals and partners, civilian and uniformed, at all levels of the Department of Defense and beyond with representation across the country. The aim of MHS is to ensure that all active and reserve medical personnel in uniform are trained and ready to provide medical care in support of operational forces worldwide. In addition, MHS aims to provide health care benefits for active duty personnel, military retirees, and families. This JAANP issue demonstrates the extent of the diverse elements of MHS as it highlights specific health care topics.
We are also excited to highlight the critical contributions of the Department of Veterans Affairs (VA) health system to the health care of our country. The Veterans Health Administration (VHA) is the country's largest integrated health care system, including 1,255 health care facilities. There are 170 medical centers and 1,074 outpatient sites. Together, they serve 9 million enrolled Veterans each year.
The VA has the largest nurse practitioner workforce in the nation, and nurse practitioners are vital members of the health care team. In 2016, the VA granted full practice authority to its APRNs throughout the nation. Nurse practitioners have employment opportunities in a full range of specialty areas for both men and women Veterans. The VA system also offers residency programs for NPs and encourages ongoing scholarship by clinicians related to veterans' health needs.
Following are synopses of the military and Veterans health topics featured in this issue.
Prevention of veteran suicide in community settings
Psychological and physical effects of exposure to trauma, death, violence, threats to personal safety, and ethical dilemmas place service members at risk for diverse health consequences. The incidence of suicide is one of these risks. This themed issue begins by encouraging nurse practitioners to participate in patient safety efforts aimed at reducing Veteran suicide. The Fellows column presents the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act. A goal of the MISSION Act is to ensure that Veterans have access to health care by streamlining eligibility criteria for community care. Nurse practitioners who work with at-risk Veterans in community settings have the prospect to participate in patient safety efforts aimed at reducing suicide using resources developed by the VA and VHA. Key issues for NPs to be aware of are described in the FAANP Column.
Warfighter brain health
The United States Department of Defense (DoD) acknowledges the importance of brain health in service members with the establishment of the Warfighter Brain Health Initiative and Strategy. The initiative deals with brain health, brain exposures, traumatic brain injury (TBI) and long-term effects of TBI. TBI has been identified as one of the invisible wounds of war. This article describes the DoD strategical framework for a prioritized and rapid development approach for warfighters' brain health. Key practices and policies currently underway in the brain health initiative are described. The initiative framework provides NPs guidelines for clinical practice, patient education, policy development, and emerging research.
Female warfighters perceptions of urogenital health in operational settings
Female war fighters face sex-specific health challenges and report practicing unhealthy hygiene behaviors. An analysis of comments by women in the US army demonstrated the need for the availability of a self-test and self-treatment deployment kit to resolve symptoms quickly. This article addresses that need and provides study findings that explored female warfighters' 1) confidence in seeking sex-specific health care in field and deployment environments and 2) acceptance and willingness to self-test, self-identify, and self-treat urogenital symptoms and infections. Nurse practitioners with heightened awareness of this concern will be well positioned to provide pre-deployment sex-specific educational interventions and anticipatory guidance.
Military transgender care
The integration of transgender individuals into the US military is politically and socially divisive, while at the same time these service members seek sensitive and quality health care. This article describes the shifting political landscape of policies that affect the health and health care experiences of transgender individuals serving on active duty. Nurse practitioners are well positioned to support and assist these service members to find the resources and care that they need, including working to eliminate unnecessary system barriers.
Headache management in a veteran population
Chronic daily headaches and chronic migraines are prevalent in the Veteran population. Many of these Veterans seek care from their nurse practitioner primary care provider. In this article, Williams examines the scope of headache as a diagnostic entity and discusses traditional and alternative treatments available to the population of Veterans. An understanding of the special needs of Veterans is important to all of us because of the specific burdens that the post 9/11 combat Veteran faces with headache and the comorbid issues that complicate the ability to effectively treat this population.
A nurse practitioner-led effort to reduce 30-day heart failure readmissions
Charteris and Pounds report on a quality improvement study in a regional VA system with a greater than 20% 30-day readmission rate for patients diagnosed with heart failure. Although not all heart failure readmissions can be prevented, this study illustrates an action plan that can be replicated at other facilities to improve Veteran-centered care and timeliness of follow-up. The investigators saw limited gains, reflecting the reality of most clinical quality improvement initiatives. Ongoing cycles of improvement are necessary to identify, adjust, and maintain changes to work process to achieve long-lasting improvements.
Quality of life among women veterans
About 2 million women are Veterans, but few of these use the VA health care system. Devine and her team of investigators studied female Veterans to explore their quality of life and depression levels as associated with socioeconomic status, parity, years of service, and history of military sexual trauma (MST). Few studies of this type have been conducted, and this study contributes to the body of knowledge about the impact of MST on overall quality of life as well as depression scores. The study also identifies the need for gender-specific instruments to assess health characteristics and highlights the clear need to build in prevention of the experience of MST and its grave impact on ongoing quality of life.
Nurse practitioner productivity measurement: an organizational focus and lessons learned
How does productivity of nurse practitioners in the VA system compare with that of other providers? That is the question asked by Lucatorto and Walsh-Irwin in their study of NP productivity measures. The question is based on the 2015 decision by the VHA to set standards for productivity measurements for NPs, physician assistants, and clinical nurse specialists. The VA chose to adapt an existing physician productivity model for the NP workforce. The paper describes the process of adapting the model, the operational definitions, and productivity calculations. The authors point out that understanding NP productivity as well as quality of care and patient satisfaction provides a balanced scorecard to reflect the contributions of NP providers.
The year of the nurse and midwife
Our penultimate feature honoring nurses in 2020 is a reminder of the important work of Mary Seacole, born on November 23, 1805, a Jamaican nurse who served in the Crimean War along with her better-known counterpart, Florence Nightingale. Seacole loved to travel and had worked in cholera and yellow fever epidemics in her home country. She funded her own trip to the Crimea and established the British Hotel to care for convalescing soldiers. In 1857, she published an autobiography, The Wonderful Adventures of Mrs. Seacole in Many Lands. She died in 1881 (Mary Seacole Trust, 2020).
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