UAB School of Nursing raising bar on service for veterans

Partnering with Birmingham's VA Medical Center and with colleagues across a wide range of health care professions, the University of Alabama at Birmingham School of Nursing is raising the bar on service for veterans and their families. By sharing costs and pooling intellectual capital, the school and its partners are building an incredible infrastructure to advance science and best practices, enrich students' learning experiences, and prepare a new generation of leaders to transform health care for America's active military and veteran communities.

There are almost 23 million veterans in this country. The state of Alabama alone has close to half a million, most of whom are wartime veterans. And each one of those veterans represents a family and a community.

In 2011, UAB Dean of Nursing Doreen C. Harper, PhD, RN, FAAN, was one of 20 nursing deans nationwide invited to the launch of Joining Forces, a federal program committed to supporting and encouraging America's military families. UAB joins more than 500 nursing schools and organizations in committing to enhance research, education, and practice in veterans' care and to work col¬laboratively to improve care for military families across the country.

UAB already had in place what would become the cor¬nerstones of its efforts on behalf of Joining Forces: the VA Nursing Academy (VANA) and the VA National Quality Scholars Program (VAQS). Both programs give the school an opportunity to work hand-in-hand with Birmingham's VA Medical Center (VAMC).

"We're enhancing the education of our students in a real-world clinical environment, one that places them in direct contact with veterans, their families, and providers who are incredibly skilled and knowledgeable about the unique needs of this population," explained Harper. "Our veterans are everywhere in this country. Vir¬tually every county in Alabama has mobilized Reserves and National Guard units to go to the Middle East. We also have many veterans from other wars, as well as those who have served during peacetime. Think about the impact of active and combat duty on those families and communities."

Many of the challenges in veterans' care are related to changes in the military itself. "Because we no longer have a draft, we now have many more citizen soldiers, more deployed Reservists, than ever before," said Associate Dean for Clinical Affairs and Partner¬ships Cindy Selleck, DSN, FNP. "The wars in Afghanistan and Iraq have created a huge cadre of patients who are not getting their health care at VA facilities. They're returning from active duty, resuming their civilian lives, and seeking care from local community providers. And often during the assessment process, no one even asks, 'Are you, or is anyone in your family, a current or former service member?'"

For convenience or other reasons, even career military families often seek care outside the VA system, away from the physicians and nurses who understand them best. A veteran who is admitted to a hospital for a physical reason—a heart attack or stroke, for example—might have an underlying health issue, such as Post Traumatic Stress Disorder (PTSD), that goes undiagnosed by providers who've never seen it before and simply aren't trained to recognize it. Through VANA, UAB not only is training highly skilled future VA nurses, but also is creating an innovative curricu¬lum to ensure that all of its nursing students become more attuned to the unique needs of veterans and their families.

"At the beginning, nursing students do not understand what an impressive responsibility they have, in terms of caring for people and hold¬ing patients' lives in their hands," said Myra Smith, PhD, RN, who is the former VANA program co-director for the School of Nursing. "Teach¬ing them that crucial lesson is part of their acculturation at UAB. We want to graduate nurse leaders who are change agents and advocates for patients. When it comes to veterans, we want our nurses to understand that what these patients have experi¬enced, whether in combat or civilian life, is different from the experience of someone who has never served in the military. "

Pat Patrician, PhD, RN, FAAN, is a retired Army colonel and the Donna Brown Banton Endowed Professor at the UAB School of Nurs¬ing. "There are many behavioral issues that we as care providers might not pick up on, but the spouses do," Patri¬cian explained. "So it's very important to listen to these patients and to their spouses and to understand that some of the things they experience with mild traumatic brain injury or PTSD are normal responses to an abnormal situation. That means we need to do a really good assessment and ask the right questions to determine whether an underlying mental health issue needs to be addressed. A lot of them are grieving the loss of comrades, and we tend not to think about that, but it's important."

The Department of Veterans Affairs created VANA as a five-year, $60 million pilot program in 2007. Two years later, the UAB School of Nursing and Birmingham VAMC were chosen for the third VANA co¬hort, becoming one of only 15 VANA sites in the country. Primary goals of VANA include expanding educational opportunities for students; increasing the number of BSN nurses; increas¬ing VA recruitment and retention; and encouraging new nurses to join the VA.

From a financial standpoint, the program supports the added faculty needed to increase nursing school enrollment, with those additional students focusing their studies on veterans' care. Over a three-year period, UAB has graduated 36 VANA stu¬dents. So far, the VA central office has extended VANA funding for an ad¬ditional year beyond the pilot program, enabling UAB to enroll a new cohort this fall.

"The benefits have been so great that Dean Harper and I made a commitment to each other to continue to sustain elements of the VANA program, with or without continued funding from VA's central office," said Birmingham VAMC Chief Nursing Officer Greg Eagerton, DNP, RN, NEA-BC.

As Eagerton explained, nurses at the Birmingham VAMC must be educated to serve two very different patient populations: "We have a large population of veterans 60 and older, from the Vietnam era and earlier, but now we're starting to see a lot of veterans from Operation Enduring Freedom and Operation Iraqi Freedom, many of whom are in their early twenties. In that older population, we're dealing with a lot of chronic health care issues. In our younger population, we're dealing with some traumatic physical injuries—missing limbs, traumatic brain injury, spinal cord injuries—but, sadly, we're seeing more mental health issues, such as PTSD, schizo-effective disorders, and substance abuse."

A caring and empathetic nature is important for any nurse serving any patient population, and that's definitely true for nurses who work with the military community, said Kim Froelich, PhD, RN, NE-BC, who is outpatient chief nurse and VANA program co-director at the Birmingham VAMC. "Veterans and their families deserve nurses who care about the people they are serving," Froelich said, "and that empathy and concern should be evident the moment a nurse enters the patient's room."

To prepare nurses who possess both the compassion and skill to serve these patients, VANA in Birmingham brings together three key groups: (1) VA Nurse Scholars, who are all BSN or RN Mobility students; (2) master's-prepared VA nurses chosen to join the School of Nursing faculty and teach students in the program; and (3) School of Nursing faculty who provide mentorship to VA nurses.

Unlike students in some VANA programs, UAB's VA Nurse Scholars are competitively selected. Newly enrolled BSN and RN mobility students must submit an application and go through an interview process. Besides seeking students with a high probability of success and a high degree of professionalism, the School of Nursing also wants VANA candidates with a per-sonal connection to veterans and a real passion for veterans' care.

VA Nurse Scholars take the same courses as other nursing students in the BSN or RN-Mobility program, plus a required online module called Caring for America's Heroes, focusing on veterans' care. (This course is an open elective for non-VANA nursing students.) These scholars are taught primarily by VA nurses, some of whom have seen active duty themselves. (Meet VANA Instructor Randy Moore, MSN, RN, at left.) These students have all of their clinical training, with the exception of pediatrics and obstetrics, at the Birmingham VAMC, and they experience veteran-based community health through outpatient rotations.

Conversely, VA nurses have received specialized training in the school's simulation lab. Here, the Birmingham VAMC emergency room staff went through a burn and trauma simulation created by Nanci Swan, MSN, RN, who was recently chosen for the Jonas Nursing Scholars Program for Veterans Health. (The Jonas scholarship will provide funding for her PhD program.) Swan moulaged a simulation mannequin to mimic burn injuries. This high-tech "patient" was also programmed to develop complications from his injuries. Birmingham VAMC Education Coordinator Ellen Smith, MSN, RN-BC, provided standards of care and other VA-specific information to assist with the simulation, which required teams of three ER nurses to initiate care and determine whether to transport to UAB Hospital or complete treatment at the VAMC.

Another innovative learning opportunity came through a collaboration between the School of Nursing, the Birmingham VAMC, and the UAB Department of Theatre. Norman Keltner, EdD, MSN, CRNP, PMHNP-BC, scripted several scenarios depicting both negative and positive nurse-patient interactions with veterans suffering from mental and psychiatric disorders. Actors chosen and prepared by UAB Theatre performed the scenarios, which were videotaped, along with an expert panel discussion analyzing each interaction at the conclusion of each vignette. Keltner worked with Cindy Selleck, Myra Smith, and Kim Froelich. The four collaborated to produce the dramatized scenarios, which not only will be used to train VANA students but will also be sent to VA facilities around the country. "I believe the video scenarios will provide nurses and students with insight into how best to care for mental health patients admitted to an inpatient medical unit," Froelich said.

VAMC nurses who are chosen by the UAB School of Nursing as VANA faculty receive intensive development on all aspects of teaching—in the classroom, the clinical setting, and the simulation lab. They also are mentored in scholarship and research.

"The VA nurses, particularly their nurse managers and nurse educators, have shown great ability to develop and implement evidence-based studies designed to enhance veterans' care," said Myra Smith. "They are learning how to disseminate that information through professional conferences and publications. Our faculty have been instrumental in helping them get the word out about the wonderful care they're providing. That allows other nurses to learn from their experience and, in turn, share that knowledge with the families and care givers of veterans."

All that support from colleagues in academia, Eagerton said, has been a huge motivator for nurses at the Birmingham VAMC. "We have a high percentage of bachelor's- and master's-prepared nurses, and we've gone from two or three doctorally prepared nurses—mostly DNPs—to about 18. Our collaboration with the School of Nursing has truly sparked an environment for life-long learning and quality improve¬ment practices, which is wonderful—not just for our nurses but for our patients."