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Issues up close


VA, DoD nurse leaders work together to meet healthcare needs of service members, veterans

U.S. Air Force Col. Margaret McNeill, PhD, RN, CCRN, recently spent 6 months in Iraq at a military field hospital providing critical care to servicemen and women with traumatic injuries. Now back in the States, she continues to provide care to wounded soldiers and Marines hospitalized in the ICU at Andrews Air Force Base and helps prepare critical care nurses to deliver the best possible care when they are deployed overseas.

Brenda Stidham, MSPH, RN, coordinates the care of wounded active-duty soldiers as they and their families move from Walter Reed Army Medical Center in Washington, D.C., to one of the four polytrauma rehabilitation centers run by the Department of Veterans Affairs (VA).

They are just two of the RNs who represent nursing’s efforts to provide top-notch care as part of an increasingly strong collaboration among nurses in the Department of Defense (DoD), VA, Federal Nurses Association (FedNA), and other government and professional nurses groups. All want to make sure active-duty military personnel and veterans’ healthcare needs are met.

“Active duty and veterans benefits are managed differently, and patients and their families can have a hard time figuring out who and what is covered as they move between the systems,” says Cathy Rick, RN, NEA-BC, FACHE, chief nursing officer of the Veterans Health Administration and an American Nurses Association (ANA) member. “We know how complicated the system is, so we (VA and DoD nurse leaders) have developed several strategies to ensure smoother transitions in care. And we’ve strengthened our partnership to provide specialized services to military personnel returning from Iraq and Afghanistan whose needs can be highly complex.”

ANA has long recognized nurses’ historic role in meeting the acute and chronic healthcare needs of service members. And with the backdrop of ongoing deployments to Iraq and Afghanistan, the roughly 600 nurse leaders attending ANA’s 2008 House of Delegates (HOD) wanted to build greater awareness among nurses and the public about current healthcare services available to active-duty military personnel and veterans and to spotlight nurse-led innovations aimed at improving care and outcomes.

The resolution, introduced by the New York State Nurses Association and overwhelmingly passed by delegates, also calls for ANA to work with the VA, DoD, FedNA, and U.S. Department of Health and Human Services to advance health care services and research on the healthcare needs of veterans and their families, including posttraumatic stress disorder and other chronic illnesses.

Zeroing in on the numbers and the systems

As of November 20, 2009, a total of 31,571 service members have been wounded in action in Iraq and Afghanistan, according to a DoD report. The total number of enrollees in the VA Health Care system in fiscal year 2008 was 7.84 million, according to the National Center for Veterans Analysis and Statistics.

The DoD provides a wide range of acute care and primary care services to active-duty military and their families—from combat-related critical care to mental health counseling to prenatal care.

The VA provides veterans with free or low-cost comprehensive services at more than 1,400 sites, but recipients must meet certain eligibility criteria. Enrollees include retired and honorably discharged or released veterans who once were in active military service, as well as members of the Reserves and National Guard called to active duty by a federal executive order who have completed their full assignment. Family members also may be eligible to receive limited benefits. (For more details, go to

Then there are the ongoing healthcare needs of wounded service members returning from Iraq and Afghanistan, who may alternate between the DoD and VA systems as their care needs or active-duty status changes, according to Rick.

“Increasingly the VA and DoD are establishing partnerships and creating phenomenal programs so that service members returning from Afghanistan and Iraq receive quality and seamless care,” says U.S. Air Force Col. John Murray, PhD, RN, CPNP, CS, FAAN, president of FedNA. And many FedNA members also have been closely involved in educational efforts and research on ways to improve care to all veterans and assist individuals with war-related injuries and their families adapt to a ‘new normal.’”

VA/DoD initiatives include the following:

  • Ongoing work to develop a shared electronic health record system.
  • The creation of a nurse liaison role to help servicemen and women better navigate the VA system.
  • The establishment of a clinical nurse liaison role that coordinates care between the DoD hospitals and the VA polytrauma rehabilitation centers.
  • The development of a standardized nursing hand-off tool.
  • Ongoing, scheduled meetings between VA and DoD chief nursing officers to evaluate current programs and determine new projects to support each other’s missions.

Preparing nurses for the combat zone

Critical Care Master Clinician McNeill says that although she’s had a great deal of experience in peace-time trauma care, the injuries she treated then did not compare to those she encountered in wounded servicemen and women at the Joint Base Balad Field Hospital in Iraq.

“Many of the soldiers and Marines have catastrophic, multisystem injuries caused by blasts,” McNeill says. These include what McNeill refers to as the “signature” war injury—traumatic brain injuries—as well as lost limbs and ruptured tympanic membranes. In addition to providing life-saving care, nurses help family members connect to wounded patients by arranging a videoconference or having them meet at a military base in Germany.

Once back in the U.S., McNeill tries to ensure that ICU patients and their families receive two of the things they most need from healthcare providers: consistent, honest information and an agreed-upon plan of care. “Many of these patients will need rehab and prostheses, but also ongoing psychological and emotional support,” she said. “Even concussions can lead to long-term problems.”

McNeill also helps hone the advanced trauma care skills of her colleagues scheduled to be deployed. “To better prepare them for the types of trauma they will see, we assign them patients arriving within 48 to 72 hours after being injured in Iraq or Afghanistan,” McNeill says. “I also tell nurses that, while the concepts are the same, the environment they’ll be providing care in is different. They won’t have all the equipment and medications they normally have. So they’ll always have to think of a contingency plan.”

Coordinating care a priority

Stidham, a VA/DoD polytrauma rehabilitation liaison, helped develop a standardized, electronic nursing hand-off tool that’s used when wounded servicemen and women are transferred from Walter Reed or Be­thesda Naval Medical Center to a VA polytrauma rehabilitation center. The note is sent from the military treatment facility to the VA inpatient electronic record within 10 minutes of patient discharge. The note then resides in the VA electronic record, where it serves as a resource for nurses.

“The tool is like a written head-to-toe assessment, and includes information such as the nature of the injury, number of systems involved, symptoms, I.V. or other tubes inserted, the last time pain medication was given, and the name and contact information of the nurse who filled out the form,” Stidham says. Verbal reports between the military treatment facility and the VA are completed to supplement the electronic note. The combination of phoned and electronic hand-off provides necessary clinical data during transfer of care.

And as part of her clinical liaison role, Stidham rounds with physicians and staff nurses on polytrauma patients, and prepares patients and their families for the transfer to the rehabilitation facility. “I tell them what they can expect, and also answer all their questions,” Stidham says. “Some are concerned about where their wife will stay or whether their pain will be adequately controlled. Others want to know how many hours of therapy they’ll receive a day.” These sessions not only ease patients’ and families’ concerns, but improve communication between the military treatment facilities and VA polytrauma teams.

Understanding the VA system

Martha Turner, PhD, RN, assistant director in ANA’s Center for Ethics and Human Rights and retired Colonel, USAF, NC, who helped facilitate discussions on the final HOD resolution, adds that it’s important for all nurses to understand more about the VA system, because they may be seeing patients in their own practice settings who might benefit from VA programs, such as counseling and primary care services. (For a link on ANA’s website to VA resources and the HOD resolution, go to

Susan Trossman is the senior reporter in ANA’s communications department.

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