APNA 30th Annual Conference Session 3037: October 21, 2016 Erica - - PDF document

APNA 30th Annual Conference Session 3037: October 21, 2016 Mumm 1

Erica Mumm, DNP, MSN, RN

American Psychiatric Nurses Association 30th Annual Conference October 19th‐22nd, 2016

Disclosure

 This presenter has no conflict of interest to disclose.

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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).

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War Ratio Wounded to Dead OEF: Afghanistan 8 to 2 OIF: Iraq 7 to 2 Vietnam 3 to 2 WorldWar II 2 to 3 WorldWar I 3 to 8

APNA 30th Annual Conference Session 3037: October 21, 2016 Mumm 2 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).

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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).

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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

• f OEF and OIF are at three times the risk of committing suicide over

non‐veteran females.

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APNA 30th Annual Conference Session 3037: October 21, 2016 Mumm 3 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.

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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

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Clinical Studies:

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.

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APNA 30th Annual Conference Session 3037: October 21, 2016 Mumm 4 Clinical Studies:

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.

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Clinical Studies:

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.

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Clinical Studies:

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.

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APNA 30th Annual Conference Session 3037: October 21, 2016 Mumm 5

 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.

Clinical Studies:

Loving Kindness Meditation Intervention.

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Clinical Studies:

Yoga and Mantram Repetition

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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 re‐ experiencing 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. 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 pre‐

licensure nursing students’ and nurse practitioner students knowledge of combat veteran PTSD.

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APNA 30th Annual Conference Session 3037: October 21, 2016 Mumm 6 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.

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Demographic Analysis Results

 Demographic Summary

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Completed Pre‐ tests Completed Post‐ test Matching Pre‐ tests & post‐tests Percent Response Rate 126 89 73 58% Marital Status N = 73 Married 31 Single 31 Divorced 11 Median Age (N =71) 31 years old Gender N (%) Male 5 (7%) Female 68 (93%)

Demographic Analysis Results

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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 Status N = 73 Married 31 Single 31 Divorced 11 English as 2nd Language N (%) Yes 16 (22%) No 57 (78%)

APNA 30th Annual Conference Session 3037: October 21, 2016 Mumm 7

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).

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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.”

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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.

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APNA 30th Annual Conference Session 3037: October 21, 2016 Mumm 8

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.

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