APNA 30th Annual Conference Session 3037: October 21, 2016 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 WorldWar II 2 to 3 WorldWar I 3 to 8 3 Mumm 1
APNA 30th Annual Conference Session 3037: October 21, 2016 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
APNA 30th Annual Conference Session 3037: October 21, 2016 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 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. 9 Mumm 3
APNA 30th Annual Conference Session 3037: October 21, 2016 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. 10 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. 11 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. 12 Mumm 4
APNA 30th Annual Conference Session 3037: October 21, 2016 Clinical Studies: 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 Clinical Studies: Yoga and Mantram Repetition Author Sample Study Results Mitchell et Yoga Group – 20 RCT methodology: Yoga Group : decreased re ‐ experiencing al. (2014) women veterans with Groups met weekly & hyperarousal PTSD. 75 min yoga class for a group session Control Group : decreased re ‐ + group session to complete experiencing and anxiety. Control Group – 18 questionnaires. Further investigation into the value of women veterans with group process is needed. PTSD. Group session Bormann Mantram Repetition Treatment group Intervention group : Clinically significant et al. Group – 66 veterans engaged in CAPS score: 24% improvement in PTSD (2013) with PTSD Mantram symptoms Control Group – 70 Repetition + TAU Control group: 12% improvement in veterans with PTSD practices over 6 symptoms. weeks. 6 week follow-up : Intervention group: reduced depression, increasing mental Control group was and spiritual health and quality of life. TAU only. 97% satisfaction rate. 14 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. 15 Mumm 5
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