Erica Mumm, DNP, MSN, RN American Psychiatric Nurses Association 30 th Annual Conference October 19 th 22 nd, 2016 Disclosure This presenter has no conflict of interest to disclose. 2 OEF & OIF: A Different Kind of War Length of time in theater, repeated deployments to multiple theaters, unclear enemy and battlefield resulting in hypervigilence, & significant family separation (IOM, 2014;Tanielian & Jaycox, 2008). A different population of warriors (Geiling et al., 2012, p. 1236). War Ratio Wounded to Dead OEF: Afghanistan 8 to 2 OIF: Iraq 7 to 2 Vietnam 3 to 2 World War II 2 to 3 World War I 3 to 8 3 Mumm 1
The Background: OEF and OIF Veterans Out of 2.2 million veterans who returned from OEF/OIF between 2001 and 2013, 11 30% have PTSD. (Kearney, 2012; Rand Corporation: Invisible Wounds of War Project website, 2008). Variables Impacting PTSD Statistics: Time duration following the traumatic exposure and elapsed time of reporting. Varying criteria that are being assessed. Type of symptoms being reported. Collaborative presentation of depression, suicidal ideation, anxiety, TBI, and substance abuse. Lack of reporting of PTSD symptoms all together. (Kearney, 2012; Rand Corporation: Invisible Wounds of War Project website, 2008). More veterans are seeking care outside of the VA in their own communities (Luesse, 2012; IOM, 2013; Geiling et al., 2012). 40% of veterans seek care through Complementary and Alternative therapies (Strauss & Lang, 2012). 4 Significance: Combat Veteran PTSD is a National Health Crisis. The cost to treat one OIF/OEF veteran with depression and PTSD over the next 50 years would be $1,250,000 (Geiling et al., 2012). June 2014 IOM Report Brief: Demands for PTSD services among current and former service members are at unprecedented levels and continue to grow (p. 3). Long term sequelae include: obesity, diabetes, musculoskeletal changes, addiction, suicide, cardiovascular decline, financial instability, divorce, anxiety, depression, GI ailments, and obesity (Schnurr & Green, 2004). 5 Significance: Suicide More than 100,000 suicides occurred between the initiation of OEF and 2010 (CDC; Veterans Affairs). In comparison to hostile deaths of veterans in OEF and OIF combat, which accounted for 5,358 soldiers as of October 2014, suicides were significantly higher (Defense Casualty Analysis System, 2014). Wisco et al. (2014) studied 1,649 Army and Marine veterans and concluded, depression and PTSD remained significantly associated with suicidal ideation (p. 247). In 2012, 325 OEF and OIF veterans committed suicide, nearly 33% more than non veterans (IOM, 2013). Additionally, female veterans of OEF and OIF are at three times the risk of committing suicide over non veteran females. 6 Mumm 2
Significance: Stigma 50% of 181 vets with PTSD reported problems with traditional treatment, mainly related to stigma and not wanting talk therapy and medications (Elbogen et al., 2013). I don t want to be prescribed medications. I would be seen as weak. I don t want to talk about my war experience. Mittal et al. (2013) interviewed 16 OEF/OIF veterans on their perceived concerns for PTSD related stigma. Public stigma labels veterans as violent or crazy. Public blames veteran for returning with PTSD Outcome: stigma prevented veterans from initially seeking care. 7 Four Mindfulness Practices: What they are and why they were examined. Mindfulness Meditation: Typically the MBSR program by Kabat Zinn (1979) Loving Kindness Meditation (LKM) Yoga Mantram Repetition (MR) http://jillbormann.com/4.html 8 MBSR with Veterans with PTSD Kearney s et al. (2012) study examined mental health states and quality of life states in a heterogeneous sample of veterans with PTSD using Mindfulness Based Stress Reduction (MBSR) through group intervention. Longitudinal study of 92 veterans over 17 months. Tools: PTSD (PCL) checklist, 5 Facet Mindfulness Questionnaire. Results: 40% of the participants had significant decrease in PTSD symptoms at the 2 month follow-up and a 48% decrease in PTSD symptoms at the 6-month follow-up. The use of mindfulness skills increased. 9 Mumm 3
MBSR with Veterans with PTSD Kluepfel et al s., (2013) single-group, pre-test post-test design consisted of 30 veterans enrolled in the model MBSR 8 week program. Baseline and post-intervention assessments were measured via high validity scales for perceived stress, sleep, mindfulness, and depression. Results: Values for perceived stress and depression showed significant improvement as well as an overall improvement in sleep. All participants indicated that their ability to cope with stress and their perceived overall well-being improved. 10 MBSR with Veterans with PTSD Omidi et al s. (2013) quasi-experimental study investigated the effect of MBSR on mood and the emotional and behavioral functions of 62 male veterans with PTSD. The veterans, aged 39-59 years, were divided into an intervention group (MBSR) of 31 and a control group (TAU = antianxiety and antidepressant medications) of 31. Results: Veterans who received the MBSR intervention had a significant reduction in their reported rates of depression, dizziness, fatigue, and tension. 11 Loving Kindness Meditation Intervention Frederickson et al. (2008): 102 participants in LKM group; 100 waitlist control group. Hypothesis: Becoming skilled in LKM will, over time, increase people s daily experiences of positive emotions, which in turn, build a variety of personal resources that hold positive consequences for the person s mental health and overall life satisfaction (p. 1047). Findings: 9 week intervention yielded an increase in mindful attention, self acceptance, positive relations with others, improved physical health. Increased life satisfaction; decreased depression. 12 Mumm 4
Loving Kindness Meditation Intervention. Kearney et al. (2013): 42 vets with PTSD received LKM in small group format (12-15) over 12 weeks. High validity tools were used to measure: qualities of lifetime traumatic events, PTSD symptoms, depression, self-compassion, altruistic love, and mindfulness skills. Data was collected post-intervention, 3 months, 6 months. Findings: PTSD symptoms, depression, self-criticism, rumination, and thought suppression decreased. Mindfulness and self-compassion increased; No participants withdrew from worsening symptoms. 13 Yoga and Mantram Repetition Author Sample Study Results Mitchell et al. (2014) Yoga Group 20 women veterans with PTSD. 75 min yoga class + group session Control Group 18 women veterans with PTSD. Group session RCT methodology: Groups met weekly for a group session to complete questionnaires. Yoga Group: decreased re experiencing & hyperarousal Control Group: decreased reexperiencing and anxiety. Further investigation into the value of group process is needed. Bormann et al. (2013) Mantram Repetition Group 66 veterans with PTSD Control Group 70 veterans with PTSD Treatment group engaged in Mantram Repetition + TAU practices over 6 weeks. Control group was TAU only. 14 Intervention group: Clinically significant CAPS score: 24% improvement in PTSD symptoms Control group: 12% improvement in symptoms. 6 week follow-up: Intervention group: reduced depression, increasing mental and spiritual health and quality of life. 97% satisfaction rate. The Inquiry Research Question: What is the effect of the implementation of the ibook nursing curriculum, OEF and OIF Veterans, PTSD, and Mindfulness Practices on pre licensure May 2015 nursing graduates, pre licensure nursing students, and nurse practitioner students knowledge for the content areas of: OIF and OEF combat veterans, PTSD, related neuroscience, mindfulness meditation, yoga, mantram repetition, and Loving Kindness Meditation? Design: Pilot Study Single group quasi experimental pre test, post test design. To evaluate the effects of a pilot educational program on prelicensure nursing students and nurse practitioner students knowledge of combat veteran PTSD. 15 Mumm 5
The Study The Study (Part 1 of 3): Pre test / Post test comparison of 22 knowledge based questions containing 7 content constructs: Knowledge of OEF/OIF veterans Knowledge of combat veteran PTSD Knowledge of trauma related neuroscience Knowledge of yoga Knowledge of Loving Kindness Meditation Knowledge of Mantram repetition Knowledge of Mindfulness meditation. Content structures were created via interactive ibook technology. 16 Demographic Analysis Results Demographic Summary Completed Pretests Completed Posttest Matching Pretests & post tests Percent Response Rate 126 89 73 58% Marital Status N = 73 Married 31 Single 31 Divorced 11 17 Gender N (%) Male 5 (7%) Female 68 (93%) Median Age (N =71) 31 years old Demographic Analysis Results Type of Nursing Program N (%) Family NP 27 (37 %) Psych NP 25 (34 %) Adult/Geri NP 11 (15 %) Women s Health NP 7 (10 %) BSN 2 (3%) May 2015 ADN Graduate 1 (1 %) Marital N = 73 Status Married 31 Single 31 Divorced 11 18 English as 2 nd N (%) Language Yes 16 (22%) No 57 (78%) Mumm 6
Data Analysis Results: Paired t test of the 22 Knowledge Questions A comparison of the total number of pre and post test scores were analyzed using a paired t test to assess the mean and standard deviation. While all questions showed an increase in post test scores, the pre and post score analysis of ten of the questions were statistically significant (p value <0.0001.) Questions: 1, 2, 3, 5, 6, 7, 8, 12, 14, and 16 (See Appendix F in dissertation). 19 Data Analysis Results: Paired t test of the 7 Content Constructs Paired t test of the 7 Content Constructs 5 / 7 constructs showed statistically significant values. Knowledge of OEF/OIF veterans Knowledge of combat veteran PTSD Knowledge of trauma related neuroscience Knowledge of yoga Knowledge of Loving Kindness Meditation The two constructs that were not statistically significant were Knowledge of Mantram Repetition and Knowledge of Mindfulness Meditation. 20 Data Analyses: Conclusion Demographic Analysis: Conclusion: Post test scores were a true representation of knowledge gained through the ibook curriculum and without affiliation with a demographic category. Knowledge Question and Construct Analysis: Conclusion: In comparing the pre and post test scores, a significant statistical improvement was seen in the aggregate post test score (p value<0.0001) as well as in 5 out of 7 constructs. This data supports the hypothesis of improved knowledge growth from having participated in the ibook learning module. 21 Mumm 7
Data Analyses: Additional Conclusions The significance of the knowledge growth identified within the statistically significant constructs is valuable to nursing education. There was a clear knowledge deficit amongst the sample population that improved after the ibook learning module was implemented. These statistically significant constructs serve as an indicator for potential areas of knowledge growth for nursing and nurse practitioner students and are content areas that nursing curricula should pay closer attention to moving forward when developing curricula. The conclusion can be made that participants in this study are exiting this ibook course with more knowledge about these constructs than when they arrived. 22 Mumm 8