H presented to the primary care NP complain- ing of nightmares interrupting his sleep, irritabil- ity, a very short temper, and a sense of detachment

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r. H presented to the primary care NP complain- ing of nightmares interrupting his sleep, irritabil- ity, a very short temper, and a sense of detachment

from others. He deployed to Iraq in 2003 and then again from 2005 to 2006. He was exposed to numerous combat experiences, including witnessing a friend killed in action, surviving an injury from an improvised explosive device (IED), and experiencing mortar fi re while under an attack in a remote base.

Mr. H sought help for his symptoms at the army base and was advised to follow up with a mental healthcare pro- vider on his return to the United States. He deferred visiting the mental healthcare provider and managed well enough over the ensuing months. However, Mr. H continued to feel

Assessment, intervention, and referral of veterans

By Nancy P. Hanrahan, PhD, RN, FAAN; Kate Judge, BA; Grace Olamijulo, MS, BSN, RN; Lisa Seng, BSN, RN; Matthew Lee, MS, BSN, CDR; Pamela Herbig Wall, PhD, NC, USN, PMHNP; Sandy C. Leake, MSN, RN; Elizabeth Czekanski, DNP, MS, RN-BC, NE BC, VHA-CM; Suzanne Thorne-Odem, DNP, RN; Erika E. DeMartinis, MSN, RN; Ursula A. Kelly, PhD, ANP-BC, PMHNP-BC;

Lucas Blair, PhD; and Warren Longmire, BS

Abstract: Approximately 20% of veterans

suffer from posttraumatic stress disorder

(PTSD). NPs are well positioned to provide

early detection and assist veterans with

access to life-saving treatment. The PTSD

Toolkit for Nurses helps nurses improve

their skills in assessing PTSD and provides

a specialized intervention and referral

procedure that promotes help-seeking

behavior among veterans. Keywords: e-learning, PTSD, PTSD Toolkit for Nurses, public health intervention, simulation, veterans

The PTSD Toolkit for Nurses:

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46 The Nurse Practitioner • Vol. 42, No. 3 www.tnpj.com

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irritable and moody, which became a source of conflict between him and his wife.

In 2007, Mr. H deployed for a third time. When he began training exercises to prepare for deployment, his nightmares returned, and he was unable to shake off memories of his combat experience. He was also unable to sit through the training and lashed out at the commanding offi cer. Mr. H was having trouble getting to sleep and soon found he could not perform his job.

■ Military personnel Mr. H’s story is typical of a military person who develops posttraumatic stress disorder (PTSD) from traumatic experiences during military service. Nearly two-thirds (62%) of the 2.2 million troops that served in Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom in Iraq were exposed to serious training acci- dents, such as vehicle or helicopter crashes, coming under fi re, or suffering from wounds caused by an IED, physical violence, or sexual assault.1

In 2011 alone, nearly 1 million service members or veterans received a diagnosis of at least one psychological condition while they were active service members, and half of them had two or more psychological conditions diagnosed.2 PTSD is just one of many psychological con- sequences of war; other conditions include adjustment disorders, depression, anxiety disorders, and substance use disorders.

Signs and symptoms of PTSD or other psychological conditions are diffi cult to recognize, and veterans with these symptoms experience major barriers to reintegrating into society or the work force.2 Veterans may be stoical and not easily share their symptoms. Unfortunately, delays in receiv- ing help are common and raise the risk of negative conse- quences. With much stigma attached to mental illness, individuals with psychological problems tend to hide their conditions because they feel shame or guilt.3 Therefore, nurses need to be alert to patients who have served in the military so as to properly assess their stress responses and need for help.

Consequences of untreated psychological condi- tions affect service members and their families alike, with the degree of hardship and negative consequences increasing with the number of the service member’s expo- sure to traumatic or life-altering experiences.3,4 One dire statistic—a veteran commits suicide every 65 minutes— suggests that veterans need assistance.4,5 Psychological conditions resulting from experiences during military service or adjusting from military life to civilian life are treatable. Veterans and their families need to fi nd help early.

■ Nurses have impact RNs are the single largest group of healthcare professionals and work in all areas of healthcare.6 All RNs, including NPs, meet active military service members and veterans in health- care or community settings, such as churches, grocery stores, or social groups. RNs are in a unique position to make a difference in the lives of these men and women. First, the nurse must ask if the patient has served. In civilian dress, it is often not obvious that an individual served in the armed forces.

Once identifi ed, the RN assesses for psychological symp- toms of stress and trauma, determines the severity of the symptoms, intervenes, and refers the individual for help. RNs have the opportunity and position to help change the lives of service members and their families who experienced psychological trauma and continue to experience symptoms that disrupt their work or social lives. The PTDS Toolkit for Nurses is a self-directed online resource designed to teach or reinforce the nurse’s knowledge about the treatment of veterans with PTSD.

The PTSD Toolkit for Nurses (www.nurseptsdtoolkit. org), sponsored by the American Nurses Foundation, was developed to teach nurses about the psychological conse- quences of stress and trauma (including PTSD) among vet- erans, to build competence in helping veterans take action to get help, and make referrals specifi cally for veterans. The PTSD Toolkit for Nurses is web-based and provides videos alongside brief case summaries that highlight essential points for nurses to assess, intervene, and refer veterans with PTSD.

Additionally, the website has interactive simulation for nurses to practice the assessment, intervention, and referral skills. This article reviews key points of the PTSD Toolkit for Nurses that promotes assessment of PTSD and interven- tions for veterans and family members to seek the help they need. NPs assess, diagnose, and treat complex health chal- lenges, making them preferred providers for the often com- plex physical and emotional needs of veterans. NPs can use the PTSD Toolkit for Nurses to enhance their capacity for directed PTSD care.

■ Assessment Symptoms of PTSD vary. Fear-based reexperiencing, emo- tional, and behavioral symptoms may be dominant for some individuals.7 For others, a lack of pleasure in people or things that used to give them pleasure (anhedonia) or a persistent state of dissatisfaction, anxiety, restlessness, or fi dgety mood may be most distressing.8 For other individuals, reactivity and hypervigilance, including sensitivity to sounds, touch, and light, are prominent. In contrast, others have dissociative symptoms where they avoid or withdraw from people and places.8

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Some individuals exhibit combinations of these symptom patterns. In the case study of Mr. H, his anger and irritability are dominant psychological symptoms (see Mr. H). He is also emotionally distant and detached, avoiding his wife and others. He uses alcohol to help him sleep. His arousal system is on hyper-alert, exhibited as being easily startled. Flashback symptoms are triggered by loud noises, and Mr. H often relives an experience in which he witnessed his friend being killed in an IED explosion. Even though Mr. H’s psychological condition is painful, isolating, and threatening his marriage and job, he is embarrassed and reluctant to seek help.

Examples of traumatic events include shooting, mug- ging, burglary, physical or sexual assault, bullying, car crash- es, serious injuries, and life-threatening illnesses.9 Trauma can also be experienced by witnessing traumatic events. A close relative or friend can be indirectly traumatized when learning about a violent or accidental traumatic event. Such events include suicide, serious accidents, and serious per- sonal injuries.

However, “death due to natural causes” does not quali- fy as a traumatic event for the purpose of diagnosing PTSD. The disorder may be especially severe or long-lasting when the stressor is interpersonal and intentional (for example, torture, sexual violence, and intimate partner violence).10 Individuals may experience extreme horror, fear, or a sense of helplessness when they witness or experience something so traumatic. They might exhibit a fi ght, fl ight, or freeze response.

Approximately 20% of military personnel and veterans develop PTSD, and those with physical injuries are 30% to 79% more likely to develop PTSD.2 The risk of PTSD is higher among women; younger individuals; individuals with a lower enlisted rank; single individuals; individuals with a lower educational level; individuals with a history of childhood trauma or abuse; individuals who lack social support (such as friends or family); individuals who have been deployed more than once; individuals who have have more time exposed to combat; and/or individuals who are a member of the Army, Navy, Air Force, National Guard, or reserve.11

■ Symptom clusters of PTSD PTSD has four main clusters of symptoms: reexperiencing, negative alterations in cognition and mood, avoidance, and hyperarousal.10

Reexperiencing. Certain contexts trigger intrusive mem- ories of the traumatic event, nightmares, and fl ashbacks. Veterans may have a heightened psychological and physi-

ologic response (such as fear or rapid heart rate) when ex- posed to these triggers.10

Negative alterations in cognition and mood. Alterations in cognition and mood can occur with exposure to trauma. Poor recall of the trauma and low self-esteem are charac- teristic of altered cognition and mood. For example, the individual may blame him- or herself or others for the traumatic event(s). Negative emotional states, such as fear, shame, guilt, and anger, may be disproportionate to the

situation. Feelings of detachment or distance from others, including spouses, friends, and children, are characteristic of negative alterations in mood and cognition.10

Avoidance. Symptoms are characterized by thoughts or feelings of detachment from people, activities, and/or plac- es. An individual with PTSD may avoid thinking or talking about troubling memories of the traumatic event. The vet- eran may exhibit anhedonia, which is a lack of interest in people, activities, or places that used to be pleasurable. A most troubling response is that the veteran may become emotionally detached from loved ones.10

Hyperarousal. Symptoms include distinct alterations in the arousal system of the brain.8 The veteran may have problems falling or staying asleep and problems with con- centration. He or she may be irritable or get angry with little or no provocation, which is typically expressed as

Mr. H

Mr. H is a 25-year-old active duty marine infantryman who has been deployed twice to Afghanistan. While there, he experienced multiple traumatic incidents, including fi refi ghts and IEDs that detonated and killed a friend. Although Mr. H’s friend was killed instantly, he feels responsible and guilty for not being able to save his life.

When Mr. H came back from his second deployment, he began to experience anger and irritability—especially with his wife and while driving in heavy traffi c. He was emotionally distant and avoiding his wife; he spent extra time staying late at work. Mr. H was not sleeping well, so he drank a six-pack of beer every night hoping that it would help him fall asleep. He is easily startled and sometimes has very bad nightmares of his friend being killed. One day, when a friend slammed a freezer door shut, Mr. H had a fl ashback and relived the IED explo- sion. His marriage and job are in jeopardy.

PTSD has four main clusters of symptoms:

reexperiencing, negative alterations in cognition

and mood, avoidance, and hyperarousal.

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The PTSD Toolkit for Nurses: Assessment, intervention, and referral of veterans

verbal or physical aggression toward people or objects (see Mr. M). One may feel the need to constantly scan the envi- ronment and may have a heightened or exaggerated startle refl ex (for example, responding to loud noises such as a car backfi ring or during fi reworks).

Mr. M’s case exemplifi es a hyperaroused response; how- ever, his injuries are rooted in trauma incurred while serving as a soldier in Iraq. PTSD can easily be missed when a health- care provider does not know that the patient is veteran. Providers should ask, “Have you served in the military?” Mr. M needs further evaluation for PTSD.

The symptoms of PTSD must be present for at least 4 weeks and the symptoms must cause a signifi cant disruption in the individual’s ability to work or function in social en- vironments.10 For example, sleep disturbances may cause an individual to oversleep and be late for work, resulting in poor work performance, irritability, or angry outbursts. Often, PTSD coexists with other mental health or medical disorders, such as depression, anxiety, traumatic brain injury, or substance abuse. In addition, individuals are at increased risk for suicide.12

Anxiety or fear is a normal physical and psychological response to stress. Individuals vary in coping with and

adapting to experiences that cause anxiety or fear. However, an emotional reaction to stress or trauma is not a criterion for a PTSD diagnosis.12 Prominent symptoms of anhedonia, dysphoria, angry and aggressive symptoms, or dissociative symptoms following exposure to stressful and traumatic psychological conditions are distinctly associated with the PTSD diagnosis.12

Such experiences of psychological distress following exposure to catastrophic or aversive events is grouped as a trauma and stress-related disorder by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).13 An individual may have some combination of PTSD with or without anxiety, depression, substance use, or other physical problems (see Ms. S).14

Psychological distress following exposure to a trau- matic or stressful event can vary widely depending on the individual’s psychological coping reserve and the context of the experience. Ms. L’s history shows she was in the mil- itary for many years without developing PTSD (see Ms. L). During her most recent deployment, she witnessed an IED explosion that left a friend with multiple limb amputa- tions. Irritability, emotional detachment from her husband and sons, sleeplessness, and fl ashbacks prevent her from working.

Ms. L is most concerned that her marriage is dissolving and she is not able to care for her children. Ms. L came to the attention of the nurse who was caring for her while she was in the hospital for a minor surgical procedure. Ms. L complained about not sleeping and asked for a sleeping medication. The nurse asked her if she had served in the military. Inquiring about a military history opened the door for Ms. L to share her ongoing psychological symptoms and her worry about losing her family.

Ms. L, Mr. M, Mr. H, and Ms. S represent veterans who had problems transitioning back to civilian life. Ms. L was an outpatient, Mr. M was seen in the ED, and Ms. S was a patient in the hospital. The fact that they are veterans is not readily apparent, making it essential that nurses ask the question “Did you serve in the military?” If the response is yes, the nurse must evaluate the patients’ conditions care- fully and refer them for treatment with a mental healthcare professional who understands the military context of PTSD. The American Nurses Association initiated a national cam- paign titled “Have You Ever Served in the Military?”(www. haveyoueverserved.com) to raise awareness of all nurses to identify veterans.15

Assessment of symptoms is the first step in an inte- grated treatment approach between the healthcare providers, the patient, the family, and behavioral healthcare. There are several recommended questionnaires that can assist in screening for a PTSD condition. For example, the PTSD

Mr. M

Mr. M is a 39-year-old Black male who served in the army from 2004 to 2006. During this period, he was deployed to Iraq. Since returning, Mr. M has had trouble reinte- grating. His family life with his wife and four children is rocky, and he has been unable to get a job. Mr. M feels distant from his children and believes the children avoid him. He thinks the world is against him. Mr. M is cur- rently being treated in the ED for minor injuries related to a bar brawl. He is drinking almost every night and is often in arguments or fi ghts at the bar. Mr. M describes feeling at the end of his rope.

Ms. S

Ms. S is a single, 20-year-old Mexican American U.S. Navy veteran. She served for 2 years, during which she was deployed to Equatorial Guinea to work as a transla- tor. Ms. S was released with an honorable discharge 6 months ago related to PTSD symptoms following a traumatic experience while serving. She was admitted to an inpatient psychiatric unit after a suicide attempt. Ms. S is currently on suicide precautions. She describes feeling detached and distant from her family. Ms. S’s family has always been her greatest sense of connection and sup- port. She has not found work since leaving the military and she feels guilty that she is not trying hard enough. Ms. S expresses inordinate shame about her current situ- ation, which grew exponentially when she was admitted for a psychiatric hospitalization.

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checklist has a military, civilian, and specifi c trauma ver- sion.16 The PTSD Checklist-Military (PCL-M) has 17 ques- tions with responses on a Likert scale.16

Examples of the questions include: Over the last month, how much you have been bothered by repeated, disturbing memories, thoughts, or images of a stressful military expe- rience? In addition, over the last month, how much have you been bothered by suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)?16 The PCL-M is available online at http:// sph.umd.edu/sites/default/fi les/fi les/PTSDchecklist.pdf. NPs can incorporate this questionnaire to screen for a PTSD condition. A 20-item self-report measure, the PTSD Check- list for DSM-5 (PCL-5) is used to screen individuals for PTSD and monitor symptoms during and after treatment.17 The PCL-5 can be used to provide a provisional PTSD di- agnosis. A complete diagnostic assessment and treatment by a mental healthcare professional with experience with military PTSD is recommended.

■ Intervention Ideally, mental healthcare professionals who have specialty education and experience with the veteran population should do the diagnosis and treatment of veterans with PTSD. However, access to mental healthcare professionals may take time, and much work can be done to prepare a patient for treatment. NPs can evaluate patients’ readiness for seeking help and help patients take steps to understanding their condition and prepare them to accept professional help.

One of the most important parts of the initial assess- ment includes evaluating the extent to which the military member or veteran is ready to seek help. In today’s military, many factors, such as stigma or embarrassment, keep service members from seeking out help— especially when it involves a behavioral or mental health problem. It is also an important cause of dropping out of care prematurely.

Although there has been an ag- gressive anti-stigma campaign waged both in the military and in civilian populations, stigma remains a strong barrier to help-seek- ing. Being mindful of stigma and its impact on care-seek- ing behaviors is a critical component for assessing patients with PTSD.8,18,19 Perhaps the greatest contribution by NPs and all healthcare providers is to evaluate patients’ percep- tions of barriers to accepting mental healthcare and then guiding them to seek help.

Prochaska’s concept of readiness for change is a helpful conceptual framework (see Stages of Change: Intervention

Matching Guide).20,21 The change model establishes whether or not the patient believes that he or she has a problem; if the patient has intent or willingness to seek assistance for the problem; if he or she is currently engaging in activities that help to solve the problem; if he or she is maintaining behaviors that have been successful in helping the problem; or if the patient has relapsed into old negative behaviors and is willing to restart treatment again.20

■ Strengthen motivation to get help After the NP identifi es where the patient is in the change continuum, the NP elicits and strengthens a patient’s motivation for seeking help (see Changes: Perceived need for help).20 To be effective, the NP must understand the patient’s perception and motivation for seeking help that is congruent with his or her own values, beliefs, and wishes.

The nurse’s response is grounded in a respectful stance with a focus on building rapport in the initial stages of a relationship. Too often healthcare providers talk at the pa- tient about what he or she should and should not do, or healthcare providers focus on how to “fix it.” These ap- proaches may aggravate a patient’s guilt and shame about his or her symptoms and alienate the patient.

There are three essential elements to the PTSD nurse- patient intervention:22

Ms. L

Ms. L began her military service at age 21. She has been a service member for the past 14 years. Ms. L was de- ployed three times to the Middle East. Her most recent deployment was to Afghanistan, where she witnessed frequent combat-related injuries and violence such as amputations, disfi gurements, and bombings. Ms. L returned home where she is currently raising two sons with her husband of 16 years. For more than a month, she describes feeling irritable and distant from her sons and husband; she knows that they notice her distance and she is concerned that her husband is unhappy with her remoteness. When Ms. L sleeps, she wakes fre- quently from nightmares about a friend who died in an explosion. She feels jumpy around loud noises. Ms. L’s greatest concern is keeping her family together, as she feels she is losing them.

The symptoms of PTSD must be present

for at least 4 weeks and cause a signifi cant

disruption in the individual’s life.

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The PTSD Toolkit for Nurses: Assessment, intervention, and referral of veterans

• Build a partnership with the individual that is grounded in the point of view and experiences of the patient. The patient is the expert on his or her traumatic past and current symptoms. An effective partnership is one that builds mutual understanding, not the NP being right or having the right answer to problems.

• Draw out the patient’s story by seeking his or her thoughts and ideas without making an attempt to fi x the problem or imposing personal opinions. Motivation and commit- ment to change are most powerful and sustainable when they come from the patient.

• Ultimately, it is up to the patient to follow through with making a change. This is empowering to the individual but also gives the patient responsibility for his or her actions.

The NP reinforces that there is no single “right way” but, in fact, there are multiple ways that change can occur.

Motivational interviewing principles and techniques are excellent guides for the NP.23 There are four distinct prin- ciples, and it is helpful to hold true to these principles throughout the patient’s treatment. • First, express empathy. Empathy involves seeing the world

through the military members’ eyes, thinking about things as they think about them, feeling things as they feel them, and sharing in their experiences. This approach provides the basis for military members to be heard and understood; in turn, they are more likely to honestly share their experiences in depth. It is critical to listen without judging during this process.

Stages of Change: Intervention Matching Guide

• Offer factual information • Explore the meaning of events that

brought the person to treatment

• Explore results of previous efforts • Explore pros and cons of targeted

behaviors

• Explore the person’s sense of self-effi cacy

• Explore expectations regarding what the change will entail

• Summarize self-motivational statements

• Continue exploration of pros and cons

• Offer a menu of options for change

• Help identify pros and cons of various change options

• Identify and lower barriers to change

• Help person enlist social support • Encourage person to publicly

announce plans to change

• Support a realistic view of change through small steps

• Help identify high-risk situations and develope coping strategies

• Assist in fi nding new reinforcers of positive change

• Help access family and social support

• Help identify and try alternative behaviors (drug-free sources of pleasure)

• Maintain supportive contact • Help develop an escape plan • Work to set new short- and

long-term goals

• Frame recurrence as a learning opportunity

• Explore possible behavioral, psychological, and social antecedents

• Help to develop alternative coping strategies

• Explain the Stages of Change and encourage person to stay in the process

• Maintain supportive contact

Adapted from Prochaska JO. Transtheoretical model of behavior change. Encyclopedia of Behavioral Medicine. Springer; 2013:1997-2000. Used with permission.

1. Precontemplation 2. Contemplation 3. Determination

4. Action 5. Maintenance 6. Recurrence

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• Support self-effi cacy. The PTSD intervention is a strength- based approach that assumes the individuals have within them the capabilities to change successfully. An individ- ual’s belief that change is possible is needed to instill hope about making those diffi cult changes. Focus on the pa- tient’s previous successes and highlight skills and strengths that the patient already has.

• Roll with resistance. Resistance may occur when a patient experiences a confl ict during treatment. Rather than be- ing confrontational, the best approach is to deescalate the situation, examine the concerns of the patient, and guide the patient in identifying his or her own solutions to the problem. This will help reduce resistance and reinforce motivation for treatment.

• Help the patient identify where he or she is now and where he or she wants to be. This will help defi ne patient- identifi ed treatment goals and encourage motivation for change.

On the PTSD Toolkit for Nurses website (www.nurseptsd toolkit.org), there are additional PTSD intervention strate- gies adopted from motivational interviewing techniques.24,25 These strategies will help NPs develop a therapeutic relation- ship with the patient throughout the assessment, interven- tion, and referral phases.

■ Referral After determining a positive screen and discussion of the re- sults with the patient, NPs should identify community referral resources, including both pri- vate clinicians and Department of Vet- erans Affairs (DVA) resources, which specialize in evidence-based care for veterans with PTSD. NPs should also maintain a list of current available re- sources so the veteran can participate in selecting the preferred referral. Ac- cording to the Institute of Medicine, the DVA offers a full range of PTSD treatment, including services to prevent, screen, and diagnose PTSD.26

Referral for treatment may include veterans receiving care through DVA primary care clinics (which include primary care mental health integration teams) or patient-aligned care

teams (which provide an effective approach for managing those with low-to-moderate symptoms of PTSD). Many other DVA-specialized outpatient and inpatient treatment programs exist to help those veterans with more severe symptoms.

Active military members are provided with free mental healthcare through their local military medical care system or through a referral via the military medical system called TRICARE (www.tricare.mil). DVA provides mental health- care for eligible nonactive military members and veterans. A veterans affairs eligibility checker and PTSD program loca- tor (www.va.gov/directory/guide/ptsd_fl sh.asp) can further assist healthcare providers in the referral process.

DVA also has a variety of electronic resources for both professionals and veterans, including a Community Provider Toolkit (www.mentalhealth.va.gov/communityproviders/ index.asp#sthash.SE96f1ID.dpbs) to provide information regarding military culture as well as screening tools. A pub- lic DVA website (www.mentalhealth.va.gov) describes a variety of mental health services and resources for healthcare staff and veterans. Resources specifi c to PTSD include con- tinuing education for staff (www.ptsd.va.gov/professional/ continuing_ed/index.asp) as well as a PTSD online coach and mobile application for veterans (www.ptsd.va.gov/ public/treatment/cope/index.asp).

Military service members and veterans are also afforded eight free sessions of mental healthcare through the Military One Source referral program (www.militaryonesource.mil).

By calling the number on the website, the program will connect the military member or veteran with a local mental healthcare provider. For those with comorbid substance abuse problems, pain, and sleep disturbances, it is important to get them involved with multidisciplinary collaborative care early to ensure maximal success.

Changes: Perceived need for help

Behavior change

Not ready Unsure Ready Change

“There is no problem.”

“There may be a problem, but I have mixed feelings.”

“There is a problem and I want to change.”

“My change(s) are working for me now.”

Adapted from Miller WR, Rose GS. Motivational interviewing and decisional balance: contrasting responses to client ambivalence. Behav Cogn Psychother. 2013;11:1-13. Used with permission.

The NP must understand the patient’s perception

and motivation for seeking help that is congruent

with his or her values, beliefs, and wishes.

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When referring care to another healthcare provider, it is best to do a “warm handoff” by verbally contacting the accept- ing provider with the patient and assessment information.

■ Moving forward The assessment, intervention, and referral information in this article provides NPs with the basic tools to get veterans and their families with PTSD the help they need. Even if a veteran does not progress to PTSD, he or she can have ad- justment problems when transitioning to civilian life. Using the assessment, intervention, and referral steps presented in this article, NPs can help these individuals.

NPs help individuals adjust to life stressors. NPs need to identify veterans to determine risk for PTSD or other psychological conditions associated with military life and the transition to civilian life. NPs can make a difference in whether or not military members and their families transi- tion successfully to civilian life.

REFERENCES 1. Hoge CW. Interventions for war-related posttraumatic stress disorder: meet-

ing veterans where they are. JAMA. 2011;306(5):549-551.

2. Brooks E, Novins DK, Thomas D, et al. Personal characteristics affecting veterans’ use of services for posttraumatic stress disorder. Psychiatr Serv. 2012;63(9):862-867.

3. Interian A, Kline A, Callahan L, Losonczy M. Readjustment stressors and early mental health treatment seeking by returning National Guard soldiers with PTSD. Psychiatr Serv. 2012;63(9):855-861.

4. Pukay-Martin ND, Pontoski KE, Maxwell MA, et al. The infl uence of depressive symptoms on suicidal ideation among U.S. Vietnam-era and Afghanistan/Iraq-era veterans with posttraumatic stress disorder. J Trauma Stress. 2012;25(5):578-582.

5. Conner KR, Bossarte RM, He H, et al. Posttraumatic stress disorder and suicide in 5.9 million individuals receiving care in the veterans health administration health system. J Affect Disord. 2014;166:1-5.

6. Padden M, Pitman D, Gillespie K. Nurses: the frontline caregivers for those who have served. N J Nurse. 2013;43(1):12.

7. Goldberg J, Magruder KM, Forsberg CW, et al. The association of PTSD with physical and mental health functioning and disability (VA Cooperative Study #569: the course and consequences of posttraumatic stress disorder in Vietnam-era Veteran twins). Qual Life Res. 2014;23(5):1579-1591.

8. Harpaz-Rotem I, Rosenheck RA, Pietrzak RH, Southwick SM. Determinants of prospective engagement in mental health treatment among symptomatic Iraq/Afghanistan veterans. J Nerv Ment Dis. 2014;202(2):97-104.

9. Hebenstreit C, Madden E, Maguen S. Latent classes of PTSD symptoms in Iraq and Afghanistan female veterans. J Affect Disord. 2014;166:132-138.

10. Black DW, Grant JE. DSM-5® Guidebook: The Essential Companion to the Di- agnostic and Statistical Manual of Mental Disorders. Arlington, VA: American Psychiatric Pub; 2014.

11. Amawi N, Mollica RF, Lavelle J, Osman O, Nasir L. Overview of research on the mental health impact of violence in the Middle East in light of the Arab Spring. J Nerv Ment Dis. 2014;202(9):625-629.

12. Gutierrez PM. Viewing suicide risk through a new lens: the benefi ts of examining symptom trajectories. J Clin Psychiatry. 2014;75(9):e945-e946.

13. American Psychiatric Association. Diagnostic and Statistical Manual of Men- tal Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.

14. Post LM, Rothbaum BO. Trajectories of PTSD symptoms and predictive factors of trajectory membership: a step toward identifying veterans at risk. J Clin Psychiatry. 2014;75(9):e953-e955.

15. Cipriano PF. A powerful question:”Have you ever served in the military?”. Am Nurse Today. 2014;9(3):6.

16. Wilkins KC, Lang AJ, Norman SB. Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specifi c versions. Depress Anxiety. 2011;28(7):596-606.

17. Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. Paper presented at: Annual Convention of the International Society for Traumatic Stress Studies; 1993.

18. Blais RK, Renshaw KD. Stigma and demographic correlates of help-seeking intentions in returning service members. J Trauma Stress. 2013;26(1):77-85.

19. Mittal D, Drummond KL, Blevins D, Curran G, Corrigan P, Sullivan G. Stigma associated with PTSD: perceptions of treatment seeking combat veterans. Psychiatr Rehabil J. 2013;36(2):86-92.

20. Prochaska JO. Transtheoretical model of behavior change. In: Encyclopedia of Behavioral Medicine. Springer; 2013:1997-2000.

21. Clark PG. Toward a transtheoretical model of interprofessional education: stages, processes and forces supporting institutional change. J Interprof Care. 2013;27(1):43-49.

22. Westra HA, Aviram A. Core skills in motivational interviewing. Psychothera- py (Chic). 2013;50(3):273.

23. Noordman J, van der Weijden T, van Dulmen S. Effects of video-feedback on the communication, clinical competence and motivational interviewing skills of practice nurses: a pre-test posttest control group study. J Adv Nurs. 2014;70(10):2272-2283.

24. Miller WR, Rose GS. Motivational interviewing and decisional balance: contrasting responses to client ambivalence. Behav Cogn Psychother. 2013; 11:1-13.

25. Barrowclough C, Haddock G, Tarrier N, et al. Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders. Am J Psychiatry. 2001;158(10):1706-1713.

26. Grossbard JR, Lehavot K, Hoerster KD, Jakupcak M, Seal KH, Simpson TL. Relationships among veteran status, gender, and key health indicators in a national young adult sample. Psychiatr Serv. 2013;64(6):547-553.

Nancy P. Hanrahan is dean and professor at Northeastern University School of Nursing, Philadelphia, Pa.

Kate Judge is an executive director at American Nurses Foundation, Washington, D.C.

Grace Olamijulo is a doctoral student at the University of Pennsylvania School of Nursing, Philadelphia, Pa.

Lisa Seng graduated with a bachelor’s degree in nursing from the University of Pennsylvania School of Nursing, Philadelphia, Pa.

Matthew Lee is a doctoral student at the University of Pennsylvania School of Nursing, Philadelphia, Pa.

Pamela Herbig Wall is a psychiatric/mental health specialty leader department head at Mental Health Naval Health Clinic, Marine Corps Air Station Cherry Point, Havelock, N.C.

Sandy C. Leake is an associate director, nursing and patient care services, and chief nursing offi cer at Atlanta Department of Veterans Affairs Medical Center, Decatur, Ga.

Elizabeth Czekanski is a mental health clinical nurse advisor at The Offi ce of Nursing Services, Veterans Health Administration, Washington, D.C.

Suzanne Thorne-Odem is an acting director of clinical practice at The Offi ce of Nursing Services, Veterans Health Administration, Washington, D.C.

Erika E. DeMartinis is a manager of nursing education at the Philadelphia VA Medical Center, Philadelphia, Pa.

Ursula A. Kelly is an assistant professor at Emory University Nell Hodgson Woodruff School of Nursing and a nurse scientist at the Atlanta VA Medical Center, Decatur, Ga.

Lucas Blair is founder/creative director at Little Bird Games, Pittsburgh, Pa.

Warren Longmire is a web developer at Little Bird Games, Pittsburgh, Pa.

Acknowledgments: The American Nurses Foundation provided funding for the development of the PTSD Toolkit for Nurses.

The authors have disclosed that they have no fi nancial relationships related to this article.

DOI-10.1097/01.NPR.0000488717.90314.62

The post H presented to the primary care NP complain- ing of nightmares interrupting his sleep, irritabil- ity, a very short temper, and a sense of detachment appeared first on Infinite Essays.

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