Strategies to support nurse work reintegration after deployment constructed from an analysis of army nurses' redeployment experiences.
Subject: Nurses (Military aspects)
Nurses (Analysis)
Nursing (Research)
Nursing (Military aspects)
Nursing (Analysis)
Author: Hopkins-Chadwick, Denise L.
Pub Date: 10/01/2012
Publication: Name: U.S. Army Medical Department Journal Publisher: U.S. Army Medical Department Center & School Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 U.S. Army Medical Department Center & School ISSN: 1524-0436
Issue: Date: Oct-Dec, 2012
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Accession Number: 309980597
Full Text: Since January 2003, the United States and its allies have been engaged in extended military operations with most military nurses deploying into and out of combat environments. During these deployments, nurses have operated under extreme conditions exposing them to both primary and secondary trauma. As early as 2004, emerging evidence from these deployments supported the correlation between trauma exposure, increased behavioral health symptoms, and premature military attrition for the military population in general. (1,2) This evidence suggests that deployments have an impact on military personnel. Nurse work during deployment is different from nurse work after deployment, and most military personnel report an adjustment period after returning home from deployment. (3) With record numbers of military nurses returning from their first, second, and third deployments, the author used data collected during a Nurse Deployment and Retention Study to construct evidence-based strategies to support nurses returning from deployment to nondeployed nurse work. The goal is to facilitate the transition of nurses to nondeployed nurse work using the proposed supportive strategies.

DEPLOYMENT NURSE WORK IS DIFFERENT

In a study of the most comparable deployed hospital, a full complement combat support hospital operating out of a fixed facility, Filliung et al (4) reported that nurses were taking care of a broader spectrum of injuries and illnesses as well as contending with greater complexity than when not deployed. The most common type of battle injuries were blast (79.3%) and gunshots (20.7%). The most common type of nonbattle injuries were crush (21.2%), with vehicle accidents at 13.6%. No nondeployed military treatment facility would have a patient profile that is comparable. If the patients are different, is the environment of providing care also different?

Mark et al (5) designed a study which closely examined the research question, "What is the nature of deployment experiences as perceived by Army Medical Department personnel?" Using a qualitative design, she and the other investigators conducted 12 focus groups and one individual interview. Twenty-four hours of transcription yielded 3,429 passages that were analyzed. Three areas of differences emerged: leadership, readiness, and safety. The authors noted that in their literature review of 9 other studies, the themes were consistent even when other studies included different services, branches, environments, and missions.

When it came to describing the actual environment, participants told investigators Scannell-Desch and Doherty (6) that living conditions were varied depending upon where the nurse was assigned, as well as how early or late in the military operations that they deployed. In the beginning, nurses would not shower for days, even weeks, living in dirty tents and containerized housing. However, nurses deploying later reported more mature housing and hygiene facilities. But most often, they report continuous nursing work with high levels of trauma and high levels of personal risk. (6) What are the effects of this different patient population and work environment on nurses once they return?

EFFECTS OF DEPLOYMENTS ON NURSES

Unfortunately, most studies concerning the effects of deployment do not report findings by occupation. In fact, it has been noted that healthcare workers often do not participate in the routine screenings for pre- and post-deployment health, especially when they are individual augmentees and do not return as part of a large group. A study by Akbayrak et al (7) provides insight with its examination of the effects that witnessing trauma and being exposed to personal threat had on Turkish military healthcare workers. Turkish military healthcare workers are often exposed to higher levels of trauma than their US counterparts due to natural disasters, terrorism, and the high rate of traffic accidents. Terrorism events have been common in parts of Turkey for the past 20 years. Military healthcare workers have witnessed the deaths of many people, including the loss of their loved ones, while under the threat of dying themselves. In the study, Turkish military healthcare workers were found to be at least as affected as their civilian counterparts by trauma exposure.

While studying military who had served in the Vietnam combat theatre of operations, Carson et al (8) reported that nurses were more vulnerable to the negative effects of trauma exposure, possibly due to the feelings of inadequacy that overwhelming mass casualty situations cause. Kolkow et al (9) found that in a population of healthcare workers responding to anonymous surveys after deployment, 9% met the criteria for posttraumatic stress disorder (PTSD) and 5% met the criteria for depression. They also found that threat of personal harm was the most predictive factor in PTSD. Scannell-Desch and Doherty (6) interviewed 37 Army, Navy, and Air Force nurses who had deployed to Iraq and/or Afghanistan on 4 to 16 month tours from 2003 to 2009. They concluded that nurse work during a war is unique for those doing it, regardless of education, preparation, or training. They postulated that there are many variables that impact the response that nurses have, and that the variables are both personal and professional. Specifically, the nurses they interviewed recalled images, sounds, and smells years after returning. These nurses would all describe at least one lasting memory of a patient, a memory that they said would stay with them for the rest of their lives. They shared their feelings toward the children caught in the combat and the outrage they had still today for the circumstances. Under the theme of "my wartime stress--I'm a different person now," they talked about how the war changed them. Some talked about having anxiety and panic attacks at work once back home, while also noting that their capacity for empathy and compassion had diminished. Short-fused anger, guilt, depression, sleep problems, and flashbacks were also reported. So, if nurse work deployed is different and deployment has lasting effects, what is the best way to support nurses as they transition from combat nurse work to the nurse work they will do once they return home?

SUPPORT STRATEGIES

As each service and each branch within each service begins to examine the evidence and develop the best strategies to support reintegration after deployment, it is possible that some strategies will be the same for all and some may have service, branch, and gender specific implications. Doyle and Peterson (10) reviewed case studies that reported successful reentry and found that successful reintegration was related to inclusion of families and communities early in the process. Nonmedicalization of distress along with easy access to mental health professionals was also found to be key. In a study of military reservists done by Mcnulty, (11) organizational support was a good predictor of work adjustment. Specifically, organizational support in the form of job reassurance, differential pay, and reorientation training were meaningful.

DEPLOYMENT-RELATED NURSE RETENTION STUDY

A few years after the current military conflicts started, senior Army Nurse Corps (ANC) leadership approached the nurse scientists at Madigan Army Medical Center (noted in the acknowledgements) expressing their concerns over the redeploying nurses who were telling them that they wanted to leave the Army Nurse Corps, and in some cases leave nursing altogether. The scientists designed a descriptive qualitative study using Hursselian Phenomenology studying the research question, "what is it about deployment that makes a nurse want to stay or leave the Army Nurse Corps upon return?"

Study participants talked about their experiences in 3 phases: preparing to deploy, being deployed, and coming home. The author uses the "coming home" data to construct evidence-based support strategies that redeployers and those who lead and work with them in medical treatment facilities can follow to facilitate the transition back to nondeployed nurse work.

"COMING HOME" RESULTS

Three focus groups were conducted, each with 4 participants for a total of 12 participants. The response rate was 57%. Of the 43% who did not participate: 9% declined to participate and 88% were unavailable due to work schedule conflicts. Four specialties (medical/surgical, emergency department, intensive care unit, and operating room) and 6 combat support hospitals were represented. Most of the participants were 1st lieutenants (44%), followed by majors (33%), captains (15%), and 2nd lieutenants (8%). Focus group discussions were guided by the following questions:

* What is it about deployment that affects a nurse's decision to stay or leave the ANC?

* If you were the Chief of the ANC, what 2 or 3 things would you fix first in order to have a huge impact on ANC retention?

The following probes were used:

* What made these positive/negative experiences?

* How would you make it better?

* Is there anyone in the room who has different views?

* Pre, during, post?

* Being deployed with a unit with which you did not train or were not stationed?

* Deployment work issues?

* Comfort/environment issues?

Five themes emerged when study participants discussed the "coming home" phase of their deployment:

1. Recognize us and our families with a "welcome home."

2. Make an honest effort to give us assignments that move us forward in our career.

3. Treat us like we are staying in the military.

4. You make nursing work harder than it has to be

at home.

5. Evaluate postdeployment health, suggest Army OneSource, collocate if possible.

Since 2005, these themes have been presented to countless nurses returning from deployment, and their input have resulted in only 2 modifications. The first theme "Recognize us and our families with a 'Welcome Home'" was changed to "Welcome Home for Everybody," and one of the recommendations in that theme (see below) was changed to read negotiable leave instead of 30 days leave. The following information is presented first with the theme followed by some representative quotes concluding with an explanation of the participants' discussions. Lastly, these themes, representative quotes, and explanations are reworked to create a list of evidence based support strategies that can be used by leaders and peers who are welcoming deployed nurses back to the workplace.

Recognize Us and Our Families With a "Welcome Home"

* When we came back, the leadership did nothing. It was just, "when do you want to come back to work?"

* It should be an immediate "welcome back," not followed with "by the way, do you want to kill yourself?"

* We were met by the commanding general. It was individualized. Recognition is important.

* Follow the recognition with 30 days of leave (individualized).

Nurses who had been individual augmentees or PROFIS* personnel expressed how awkward and lonely it was to walk off the plane for the first time back on American soil at a place where they did not live or were not assigned, because no one they knew was there to greet them. They were irritated by the "check the box" feeling they got from redeployment screeners. They appreciated any recognition, although they acknowledged that they were hesitant to notify their supervisors back home about when they were returning. They feared being put back to work too soon, or they did not feel a relationship with them anymore since they did not hear from them while they were deployed. They wanted some automatic leave to "decompress," but after that, they wanted to be able to negotiate their leave over the following year.

Make an Honest Effort to Give Us Assignments that Move Us Forward in Our Career

* We were ready for new challenges. It was insulting to resume a preceptorship or return to a low speed area.

* Even though I went back to the same floor, the paperwork had really changed.

* I was glad that I did not get a leadership position. I needed to decompress for a while.

* I wanted to go to the ICU but could not, at least let me freshen up my EKG skills or something.

Nurses expressed the frustration they felt when their coworkers and supervisors appeared to not understand the level of work they did while deployed. Some of them wanted to "decompress" and even take jobs outside of the emergency room or ICU for a while. Only on one occasion did a nurse indicate a desire to leave nursing altogether, but even then it was seen as a temporary emotion. Some of the nurses in these focus groups had deployed shortly after graduating from the Basic Officer Leader Course and were gone for a prolonged period of time. A few nurses discussed missing certain positions or opportunities while deployed that could have accelerated their career. Almost all of them expressed concern about their lack of connection and/or communication with their coworkers and supervisors back home. To them, they had been forgotten and even somewhat abandoned, which seemed to erect a wall with their leadership once they returned, making it all the more difficult to discuss career advancement. They did not want to go back into an "orientation/preceptorship," but many administrative procedures had changed and they felt frustrated with the status as behind on training.

Treat Us as if We Are Staying in the Military

* When I came back, the supervisors said I would be assigned to this floor until I left the Army. I don't know where they got the idea that I was getting out.

* Everyone kept saying "you are getting out of the Army aren't you?"

* I asked to be stationed near my family but was informed that since I had indicated that I was getting out, I could not move. I was still thinking about staying in, but when that happened, I was discouraged.

Often nurses have not firmly decided whether to stay or leave the military or nursing. The best course of action for coworkers and supervisors is to treat all returnees as though they are staying--continue to coach, teach, and mentor, no matter what the returning nurse may say.

* In the states, nursing work seems to be made more difficult than it has to be.

* It was almost a black hole for me. Reintegration was as though I was immersed in a fog.

* I took care of Soldiers with body parts blown off; here I took care of chronic alcoholics and smokers who did this to themselves. I became more callous.

* The staff make everything bigger than it really was. "You need to be quicker," and I would think that he's not really dying.

* Supervisors said I did not understand how things worked on the inpatient unit. I had some apathy.

* I got busted out for being laissez faire.

* I learned to separate from the job; here, nurses are overly involved in their work.

* This job seems less important; there you have a sense of doing the ultimate job. You're not worried about standard operating procedures. You're doing what is important.

* You can't ask the nurses here to be more sensitive to us, because they just don't get it. They won't understand.

* I don't worry about the paperwork and stuff. That stuff will take care of itself.

Perhaps the worst job for a returning nurse is to be in charge of a Joint Commission task force. Returning nurses need time to disengage from the pace of deployment. One example given was a nurse who returned to a recovery room position. His supervisor noted that he was not using oxygen on all of his recovering patients and assumed that he was not providing quality nursing care because he had lost his "edge" postdeployment. But when questioned, the nurse explained that he felt like some of the patients were doing so well that they did not need the oxygen, after all, he had seen patients in combat who really needed oxygen. A good leader would facilitate the transition of the returning nurse through patient, gentle coaching and nonjudgmental reinforcement to readopt the nondeployed standards.

Evaluate postdeployment health, suggest Army Onesource, collocate if possible

* Immediately upon returning, we get tired of being asked if we are suicidal or homicidal.

* A few months after return, we need someone to check on us because that is when the issues surface.

* Recommend OneSource, let people know it is there at the 3 to 6 month mark.

* Chief Nurse interviews should be done 3 to 6 months after deployment, and Head Nurses should always be checking their people.

* I would really have liked a meeting to talk about how to make it better for the next group.

* We need our postdeployment health evaluated, ie, hearing, mental health, asthma.

Three things were heavily discussed under this theme. First: as medical personnel or individual augmentees, the returnees often were overlooked in postdeployment screening. Some of them even admitted to avoiding the postdeployment screening and using getting back to work as an excuse to not attend the usual "cattle calls." Second: they discussed the "honeymoon phase" of postdeployment, a time when they really had no negative reactions to deployment and were not really interested in thinking too deeply about the impact of deployment. But those feelings faded, most often in the 3 to 6 month postdeployment period. They did want to be "checked on," and rejected the suggestions of mandatory support groups, especially if they are led by people who do not have deployment experience. Third: they related best to those who had also deployed and often looked to see if people were wearing the right shoulder patch, indicating deployment veterans with whom they would have more in common.

CONCLUSIONS

Taking the themes, representative quotes, and explanation given by one investigator, the author has constructed a list of tasks, presented in the Table, for coworkers and supervisors to use in supporting returning nurses. Since this study was completed, other nurse investigators have advanced postdeployment questions concerning returning nurses, classes have been added to hospital orientations, and content has been integrated into the Army Nursing Leader Academy which is made available to deploying and redeploying units and supplying units upon request.

ACKNOWLEDGEMENTS

The author acknowledges and thanks the investigators who conducted the Deployment Related Retention Study: COL (Ret) Laurie McNabb, Dr Lori Loan, Dr Mary McCarthy; and the support staff: Dr Bill Reeder, Ms Kathi Hamilton, and MAJ Jess Calohan.

REFERENCES

(1.) Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. N Engl J Med. 2004;351;13-22.

(2.) Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;296(5):1012-1032.

(3.) Blais A, Thompson MM, McCreary DR. The development and validation of the Army post-deployment reintegration scale. Mil Psychol. 2009;21(3):365-386.

(4.) Filling DR, Bower LM, Hopkins-Chadwick DL, Leggett MK, Basca C, Harris K, Steele N. Characteristics of medical-surgical patients at the 86th Combat Support Hospital during Operation Iraqi Freedom. Mil Med. 2010;175(12):971-977.

(5.) Mark DD, Connelly LM, Hardy MD, Robison J, Jones CC, Street TA. Exploring deployment experiences of Army Medical Department personnel. Mil Med. 2009;174(6):631-636.

(6.) Scannell-Desch E, Doherty ME. Experiences of US military nurses in the Iraq and Afghanistan wars, 2003-2009. JNurs Scholarsh. 2010;42(1):3-12.

(7.) Akbayrak N, Oflaz F, Aslan O, Ozcan CT, Tastan S, Cicek HS. Post-traumatic stress disorder symptoms among military health professionals in Turkey. Mil Med. 2005;170(2):125-129.

(8.) Carson MA, Paulus LA, Lasko NB, et al. Psychophysiologic assessment of posttraumatic stress disorder in Vietnam nurse veterans who witnessed injury or death. J Consult Clin Psychol. 2000;68:890-897.

(9.) Doyle ME, Peterson KA. Re-entry and reintegration: returning home after combat. Psychiatr Q. 2005;76(4);361-370.

(10.) Kolkow TT, Spira JL, Morse JS, Grieger TA. Post traumatic stress disorder and depression in healthcare providers returning from deployment to Iraq and Afghanistan. Mil Med. 2007;172(50):451-455.

(11.) McNulty PA. Reported stressors and healthcare needs of active duty Navy personnel during three phases of deployment in support of the war in Iraq. Mil Med. 2005;170:530-535.

* PROFIS predesignates qualified Active Duty health professionals serving in other units to fill Active Duty and early deploying and forward deployed units of Forces Command, Western Command, and the medical commands outside of the continental United States upon mobilization or upon the execution of a contingency operation.

COL Denise L. Hopkins-Chadwick, AN, USA

AUTHOR

COL Hopkins-Chadwick is Chief, Department of Nursing Science, Army Medical Department Center and School, Fort Sam Houston, Texas.
How coworkers and supervisors can support and smooth
the transition of redeploying nurses.

              Task

1. Provide recognition and
   welcome back (for everyone).

2. Approve negotiated leave unless
   the nurse requests something different.

3. Evaluate postdeployment health (ongoing).

4. Negotiate job assignment. If unable
   to provide first choice, create a plan
   to move toward first choice.

5. Recognize that most people report the
   need for additional support at the 3
   to 9 month postdeployment point, and
   that most people prefer an outside
   source or peers with the same experience.

6. Understand that most people report
   a period of apathy and callousness that
   may be perceived as loss of motivation
   and the intent to leave the ANC;
   this usually resolves over time.

7. Understand that personnel returning
   to the same work unit will find that
   things have changed while they were away.
   They may need a miniorientation.

8. Provide time to re-inprocess, perhaps
   one or 2 days during the week.

                  Notes

1. Always say "welcome back." If you
   are meeting them in a common area,
   greet everyone, even if you do not
   personally know them.

2. Better yet, contact them before
   they return and negotiate leave.

3. Remind them and give them time to
   do all of the reverse deployment screening.

4. Best to begin conversation before
   they return. Be flexible, their
   aspirations will likely change.

5. After the "honeymoon phase," asking
   someone how reintegrated he or she is
   today on a scale of 1 to 100 (%) helps
   to identify if and when they need
   additional support.

6. The antidote for apathy and callousness
   at work is usually time, but if it is
   not gone at 9 months, support nurse
   in getting help and/or counseling.

7. Minimize labeling returning nurses
   as delinquent on training. Make
   reorientation fun and easy.

8. Avoid immediate scheduling
   to rotating shifts.
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