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Nursing schools in the United States have not been teaching evidence-based practices for safe patient handling, putting their graduates at risk for musculoskeletal disorders (MSDs). The specific aim of this study was to translate research related to safe patient handling into the curricula of nursing schools and evaluate the impact on nurse educators and students' intentions to use safe patient handling techniques. Nurse educators at 26 nursing schools received curricular materials and training; nursing students received the evidence-based curriculum module. There were three control sites. Questionnaires were used to collect data on knowledge, attitudes, and beliefs about safe patient handling for both nurse educators and students, pre- and post-training. In this study, we found that nurse educator and student knowledge improved significantly at intervention schools, as did intention to use mechanical lifting devices in the near future. We concluded that the curriculum module is ready for wide dissemination across nursing schools to reduce the risk of MSDs among nurses. [ABSTRACT FROM AUTHOR]

While much of the research on falls has focused on the ambulatory elderly, little is known about wheelchair-related falls that occur in persons with disabilities. A thorough understanding of wheelchair-related falls would include the demographics, the mechanism and nature of the fall event, and the nature of any resultant injury, including the cost of treatment and long-term sequelae. The purpose of this article is to provide an overview of the current data on wheelchair-related falls and to make recommendations for avenues for improved quality of care and future research to promote patient safety. [ABSTRACT FROM AUTHOR]

In response to heightened awareness of patient safety, restraint reduction, and the potential for life-threatening entrapment caused by bed rails, a quality improvement program entitled BedSAFE was conducted to systematically and safely decrease the use of bed rails in three nursing home care units. This article describes an interdisciplinary process of individualized patient assessment, selection of appropriate alternatives for residents, compliance monitoring, training, and monitoring of patient outcomes including falls and injuries related to falls from bed. [ABSTRACT FROM AUTHOR]

Despite the well-documented evidence for preventing musculoskeletal injuries among nurses providing patient handling tasks using ergonomic principles, faculty in nursing schools continue to rely on the teaching of body mechanics which fails to reduce the risk of musculoskeletal injuries. In this article the authors report the qualitative data from a parent study designed to develop and test an evidence-based curriculum module in nursing schools. Focus groups were conducted with participating faculty to elicit their perceptions of facilitators and barriers for implementing a new, evidence-based, safe patient handling curriculum module at their nursing schools. Content analysis was used to analyze the data. Faculty, who were overwhelmingly positive about the curriculum module, related numerous implementation facilitators and recommendations for overcoming barriers. Findings from this study can be used to facilitate implementation of the curriculum module at other nursing schools and thus promote the use of safe patient handling throughout healthcare. [ABSTRACT FROM AUTHOR]

Recognizing that risk factors for falls are multifactorial and interacting, providers require guidance on the components, intensity, dose, and duration for an effective fall and fall injury prevention program. Administrators of health care facilities require guidance on resources needed for these programs. Clear guidance does not exist for specifying the right combination of interventions to adequately protect specific at-risk populations, such as nursing home residents with dementia or osteoporosis. Staff education about fall prevention and resident fall risk assessment and reassessments has become part of standards of practice; however, the selection, specificity, and combination of fall prevention and injury protection interventions are not standardized. To address these gaps, this team of researchers conducted a critical examination of selected intervention studies relevant to nursing home populations. The objectives of this literature review were to (1) examine the selection and specificity of fall prevention and injury protection interventions described in the literature since 1990; (2) evaluate the strength of evidence for interventions that both prevent falls and protect residents from fall-related injury; and, (3) provide clinical and policy guidance to integrate specific interventions into practice. [ABSTRACT FROM AUTHOR]

Background: New graduate registered nurse (RN) competencies are complex and difficult to measure. Psychometrically sound tools are needed to evaluate competencies for nurses participating in nurse residencies., Purpose: Project aims were to develop an item pool for a tool to measure new graduate RN competencies for the Veterans Health Administration RN Transition-to-Practice Residency Program; validate item pool content; and use consensus methods to improve item pool content validity., Methods: A sequential, mixed-methods design was used. Item pool creation, content validation, and revisions included a collaborative process with the evaluation team, operational stakeholders, and subject matter experts (SMEs)., Results: Inclusion of SMEs in item development enhanced item pool content validity to measure nurse competency. Stakeholder feedback ensured programmatic logistical and evaluation concerns were met., Conclusions: Engaging SMEs in conceptualization, item development, and aligning existing standards enhanced item pool content validity to measure nurse competencies for new graduate RNs., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc.)

Study Design: A 5-year longitudinal, retrospective, cohort study., Objectives: Develop a prediction model based on electronic health record (EHR) data to identify veterans with spinal cord injury/diseases (SCI/D) at highest risk for new pressure injuries (PIs)., Setting: Structured (coded) and text EHR data, for veterans with SCI/D treated in a VHA SCI/D Center between October 1, 2008, and September 30, 2013., Methods: A total of 4709 veterans were available for analysis after randomly selecting 175 to act as a validation (gold standard) sample. Machine learning models were created using ten-fold cross validation and three techniques: (1) two-step logistic regression; (2) regression model employing adaptive LASSO; (3) and gradient boosting. Models based on each method were compared using area under the receiver-operating curve (AUC) analysis., Results: The AUC value for the gradient boosting model was 0.62 (95% CI = 0.54-0.70), for the logistic regression model it was 0.67 (95% CI = 0.59-0.75), and for the adaptive LASSO model it was 0.72 (95% CI = 0.65-80). Based on these results, the adaptive LASSO model was chosen for interpretation. The strongest predictors of new PI cases were having fewer total days in the hospital in the year before the annual exam, higher vs. lower weight and most severe vs. less severe grade of injury based on the American Spinal Cord Injury Association (ASIA) Impairment Scale., Conclusions: While the analyses resulted in a potentially useful predictive model, clinical implications were limited because modifiable risk factors were absent in the models., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. The articles in this new installment of the series explain principles for promoting safe mobility that nurses should reinforce with family caregivers. Each article also includes an informational tear sheet-Information for Family Caregivers-that contains links to instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage the caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. The articles in this new installment of the series explain principles for promoting safe mobility that nurses should reinforce with family caregivers. Each article also includes an informational tear sheet-Information for Family Caregivers-that contains links to instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage the caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patient falls are the most common adverse events reported in hospitals. Although it is well understood that the physical hospital environment contributes to nearly 40% of severe or fatal hospital falls, there are significant gaps in the knowledge about the relationship between inpatient unit design and fall rates. The few studies that have examined unit design have been conducted in a single hospital (non-Veterans Health Administration [VHA]) or a small number of inpatient units, limiting generalizability. The goal of this study is to identify unit design factors contributing to inpatient falls in the VHA., Objective: The first aim of the study is to investigate frontline and management perceptions of and experiences with veteran falls as they pertain to inpatient environmental factors. An iterative rapid assessment process will be used to analyze the data. Interview findings will directly inform the development of an environmental assessment survey to be conducted as part of aim 2 and to contribute to interpretation of aim 2. The second aim of this study is to quantify unit design factors and compare spatial and environmental factors of units with higher- versus lower-than-expected fall rates., Methods: We will first conduct walk-through interviews with facility personnel in 10 medical/surgical units at 3 VHA medical centers to identify environmental fall risk factors. Data will be used to finalize an environmental assessment survey for nurse managers and facilities managers. We will then use fall data from the VA Inpatient Evaluation Center and patient data from additional sources to identify 50 medical/surgical nursing units with higher- and lower-than-expected fall rates. We will measure spatial factors by analyzing computer-aided design files of unit floorplans and environmental factors from the environmental assessment survey. Statistical tests will be performed to identify design factors that distinguish high and low outliers., Results: The VA Health Services Research and Development Service approved funding for the study. The research protocol was approved by institutional review boards and VA research committees at both sites. Data collection started in February 2018. Results of the data analysis are expected by February 2022. Data collection and analysis was completed for aim 1 with a manuscript of results in progress. For aim 2, the medical/surgical units were categorized into higher- and lower-than-expected fall categories, the environmental assessment surveys were distributed to facility managers and nurse managers. Data to measure spatial characteristics are being compiled., Conclusions: To our knowledge, this study is the first to objectively identify spatial risks for falls in hospitals within in a large multihospital system. Findings can contribute to evidence-based design guidelines for hospitals such as those of the Facility Guidelines Institute and the Department of Veterans Affairs. The metrics for characterizing spatial features are quantitative indices that could be incorporated in larger scale contextual studies examining contributors to falls, which to date often exclude physical environmental factors at the unit level. Space syntax measures could be used as physical environmental factors in future research examining a range of contextual factors-social, personal, organizational, and environmental-that contribute to patient falls., International Registered Report Identifier (irrid): DERR1-10.2196/24974., (©Ronald I Shorr, Sherry Ahrentzen, Stephen L Luther, Chad Radwan, Bridget Hahm, Mahshad Kazemzadeh, Slande Alliance, Gail Powell-Cope, Gary M Fischer. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 13.07.2021.)

Background: Responding to National Academy of Medicine and National Council of State Boards of Nursing recommendations, the Department of Veterans Health Affairs (VHA) implemented full practice authority (FPA) for Advanced Practice Registered Nurses in VHA medical centers (VAMCs) in 2017., Purpose: To evaluate FPA policy implementation's impact on quality indicators including access to care as measured by new patient appointments in primary, specialty and mental health services., Methods: Linear growth models compared early (n = 85) vs. late (n = 55) FPA implementing VAMCs on the trajectories of each of the three quality indicators., Findings: Early FPA implementing VAMCs showed greater rates of improvement over time in new patient appointments completed within 30 days of preferred date for primary care (p = .003), specialty care (p = 0.05), and mental health (p = 0.001)., Discussion: VAMCs that started implementation of FPA policy early showed greater improvement in access to care for Veterans over time than VAMCs that did not., (Published by Elsevier Inc.)

Background: Since 1999, the Veterans Health Administration's (VHA) National Nursing Education Initiative (NNEI) has provided 16,294 scholarships for registered nurses to attain baccalaureate and advanced nursing degrees., Purpose: The goal of this evaluation was to determine factors that enhanced or hindered a scholarship recipient in the completion of their degree and service obligation., Methods: A regression analysis was performed to identify predictors of degree completion for 10,043 participants in 162 VHA facilities., Findings: Significant predictor variables for degree completion were intended occupation, entry degree, gender, age, and year entering the program. Eighty-six percent (86.7%) of participants completed the degree requirement. Of those who completed their degree, 97% completed the service obligation., Discussion: As recruitment and retention initiative, NNEI scholarships are poised to address the VHA nursing staffing shortages as well as build a highly qualified nursing workforce capable of providing the best care to our Nation's Veterans., (Published by Elsevier Inc.)

Purpose: Nursing home residents sit in wheelchairs (WCs) for extended periods, often with slumped posture. They often experience pneumonia, pressure ulcers, and pain. This study described WC seated posture with its selected predictors and outcomes in the nursing home environment, throughout the daytime hours of 1 day., Design and Methods: This observational study (n = 45) in two Veterans Administration Community Living Centers introduced a new measure of WC fit and described WC seated posture of older Veterans, with selected predictors and outcomes., Findings: Wheelchair seated posture was predicted by cognitive status, WC fit, WC skills, and duration of sitting, but not by level of sitting ability. Poor posture measured by the Seated Posture Scale was associated with pain. Highest interface pressures measurable were seen in peak pressure index (PPI = 200 mm Hg), indicating risk of pressure injury. Veterans often denied discomfort, possibly lowering overall pain scores, while reporting severe pain in specific body parts., Conclusions: Wheelchair seated posture was predicted by cognitive status, WC fit, WC skills, and duration of sitting. Poor posture was associated with pain, and poor posture was an outcome of poor WC fit. Poor WC fit in this study supported earlier findings in non-Veterans Administration nursing homes., (Copyright © 2020 Association of Rehabilitation Nurses.)

Background: Of 23 million US veterans, 2 million are women. Female veterans often have physical and mental health disorders, but only 6.5% use the Veterans Health Administration (VA) system. Health care for women veterans is challenging in a health care system unfamiliar with this population., Purpose: The purpose of this study was to investigate how receipt of treatment by female veterans at a VA women's health specialty clinic affected levels of distress, quality of life (QOL), and depression., Methods: A retrospective record review was completed on 51 female veterans between the ages of 40 and 60 years attending a VA clinic. The clinic provides comprehensive women's health services to female veterans. Multiple linear regression models were fit to explore QOL and depression levels with socioeconomic status, parity, years of service, and military sexual trauma (MST)., Results: Female veterans had significantly lower baseline scores for QOL than did a comparison group. The only significant predictor associated with higher health-related symptom scores at baseline was a history of MST (β = 0.363; t = 2.44; p = .02). Means and standard deviations for total scores were significantly higher than those of the comparison group. Higher symptom scores indicated lower QOL among female veterans., Implications for Practice: Study findings suggested that timely, comprehensive, gender-specific health care can significantly improve overall QOL and depression levels. Nurse practitioners play a leading role in providing primary care to this population with significant potential to impact QOL, depression levels, and overall health of female veterans.

Purpose: As part of a larger study to test the efficacy of the Concussion Coach cell phone application for patients with post-concussion symptoms, qualitative data were gathered to assess barriers and facilitators for app use and differences in use of the app among those who declined or improved in symptom severity, or were low-use users., Materials and Methods: Using a prospective descriptive study design, 35 semi-structured qualitative interviews were conducted between 2016-2018. Participants had a history of mild traumatic brain injury and were symptomatic. Interview data were analyzed using qualitative content analysis., Results: Primary facilitators were the app's ease of use, privacy, availability/portability, and increased self-efficacy of the user. Primary barriers were a lack of sufficient app training, stigma, overly "basic" content, and symptom severity. While there were not prominent differences among user groups, users whose symptom severity improved described using more modules of the app than users who declined. Low-users attributed not using the app to content that was too basic or to their forgetting., Conclusion: Interview data suggest that Concussion Coach can benefit Veterans with post-concussive symptoms through increased agency, perceived benefits to emotional well-being, and the availability of non-stigmatized strategies for symptom management.

Introduction: The Veterans Health Administration (VHA) registered nurse (RN) Transition to Practice (TTP) program is a 1-year comprehensive, standardized curriculum taught for entry-level nurses to assist them in transitioning to VA-trained, competent, professional RNs. The TTP program includes revised modules on Evidence-Based Practice (EBP) clinical decision making. The revised curriculum emphasizes EBP as a problem-solving approach to clinical decision making rather than a project-based approach to implement practice changes. The goal of this quality improvement project was to evaluate the content, delivery, and outcomes of a revised Evidence-Based Practice Curriculum (EBPC) for use in the VHA RN TTP program., Methods: Focus groups were conducted with TTP coordinators, who teach the program and facility EBP content experts from 32 VHA Medical Centers. All attended a three-day face-to-face training at a central location. Qualitative data were managed and analyzed with a rapid assessment process., Discussion: Leaders within and outside of organizations are commonly believed to affect the success of implementing and sustaining any program or initiative through their influence on organizational climate, leadership processes, and leadership alignment across multiple levels of leadership. Our findings were in line with other research showing that leaders should prioritize EBP and fuel it with resources to create sustainable change., Conclusions: In conclusion, the EBPC was reviewed very favorably by all who planned to use it in their facilities in teaching the content to practicing registered nurses. Future evaluation will focus on the degree to which faculty use the program, how they use the modules, and what feedback nurses provide after exposure to EBPC., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest.

Background: Using personal experience stories as teaching tools, clinical narratives are an effective means for sharing the art of nursing practice and provide insight into nurses' critical thinking and clinical proficiency. Using clinical narratives to assess curriculum effectiveness provides important insights into changed practice and learning beyond the classroom., Aim: This article provides an example of using clinical narratives in the evaluation of the Department of Veterans Health Affairs Office of Nursing Services (ONS) Evidence Based Practice Curriculum (EBPC)., Methods: As part of a larger mixed-method evaluation of the EBPC, clinical narrative methods were employed to describe one incident where participants (n=3) applied at least two of three evidence based practice components (best available evidence; clinical expertise; patient preference)., Results: Examination of clinical narratives demonstrated successful application of key components of evidence based practice and an integration into individual nursing practice beyond data obtained from other evaluation methods., Conclusions: Incorporating rich clinical narratives into a rigorous mixed-method program evaluation protocol provides insights beyond information uptake, satisfaction, efficacy, or competency assessment scores., Competing Interests: Conflict of Interest The authors declare that they have no conflict of interest.

Background: Increasingly, occupational and physical therapists are using safe patient handling and mobility (SPHM) equipment, such as mechanical lifts, in rehabilitation. However, there is little guidance in the literature on how SPHM equipment can be used to assist patients to reach rehabilitation goals. The purpose of this projectwas to document and categorize common and innovative ways rehabilitation therapists use SPHM equipment in their clinical practice., Objective: This article investigates common and innovative uses of SPHM equipment in rehabilitation practice., Methods: Occupational, physical and kinesio therapist employed at the Veterans Health Administration wrote narratives and took photos describing rehabilitation therapy activities where they used SPHM equipment in their clinical practice. The authors used a systematic process to review and categorize the narratives and subsequent photos by using the World Health Organization's International Classification of Functioning, Disability and Health (ICF)., Results: Thirty narratives (13 innovative and 17 common) were coded into four categories on the ICF section of mobility. The most common category was "changing and maintaining basic body position"(21) followed by "walking and moving" (5). The category "carrying, moving and handling objects" garnered two narratives and there were no narratives for "using transportation.", Conclusions: Project findings may serve as a guide for therapists who would like to enhance their use of SPHM equipment in rehabilitation. Additional research is needed to expand the use of SPHM in rehabilitation practice and evaluate the impact on patient rehabilitation outcomes and therapist safety outcomes.

Background: Doctoral-prepared nurses with diverse skillsets are required to meet nursing care needs in a complex and changing healthcare environment. A better understanding of the roles of doctoral-prepared nurses in Veterans Health Administration (VHA) workforce will help leverage their expertise to meet the needs of Veterans., Purpose: Assess the current roles of doctoral-prepared nurses within the VHA., Method: A cross-sectional survey was used to collect information on doctoral-prepared nurses within the VHA in 2016. Multiple strategies were used to identify doctoral-prepared nurses to recruit for an online survey. Survey invitations were sent electronically to unique individuals identified (N = 2403)., Results: Responses were received from 1015 nurses (42.2% response rate), with 929 nurses with a doctoral degree identified. DNP/DNAP degrees were most common (55%), followed by a PhD or DNS (33%). Significant differences were noted between nurses in different doctoral education categories across four main roles: research, clinical, educational, and administration., Conclusions: This survey generated the first comprehensive list of VHA doctoral-prepared nurses. Findings are being used by the VHA Office of Nursing Services to align degree types, duties of different positions, functional statements, and position expectations. Results support the continued need for collaboration between nurses with PhDs and DNPs to achieve research and clinical goals., (Published by Elsevier Inc.)

Background: Numerous studies of community reintegration (CR) in traumatic brain injury (TBI) have been conducted in civilian populations, but research is limited in veteran and military service member populations. Little is known about how knowledge from civilian studies translates into veterans' experiences and needs. The US Department of Veterans Health Administration (VHA) recognizes the distinctive health care needs of post-9/11 veteran and military service members, particularly with TBI, including the need to bridge health and rehabilitation-related services from acute care and inpatient settings to veteran and military service members' homes and communities to facilitate CR., Objective: The goal of this study is to better understand the experiences of veterans with complicated mild, moderate, or severe TBI; their families; and CR workers as veterans and servicemembers transition to and sustain living in communities. This paper describes the rationale, design, and methods used to reach this goal., Methods: This five-year longitudinal mixed methods study uses both a community-engaged research (CEnR) approach and an ethnographic approach. The sample includes 30 veterans and service members with TBI, 13 family caregivers, 11 CR specialists, 16 key stakeholders, and 82 community events. Interviews and observations are coded and analyzed using hierarchical coding schemes and thematic analysis. Analyses include data from surveys, interviews, and participant observations. Content analysis is used to highlight the complex social context of reintegration and to triangulate quantitative data. Egocentric (personal) social network analysis is used to examine the support system a veteran or service member has in place to facilitate reintegration., Results: Study enrollment and data collection are completed. Data analyses are underway., Conclusions: The results of this study may provide a heightened understanding of environmental factors affecting CR in complicated mild, moderate, or severe TBI. Veteran, servicemember and family voices and insights provide VHA clinicians and policy makers with an ecological view of CR that is grounded in the life experiences of veterans, military service members, and families. The results of this study provide a roadmap for designing and testing interventions to maximize CR in a variety of domains. The longitudinal ethnographic approach allows for capturing detailed experiences within the naturalistic context. CEnR allows collaborative assessment of the social context of reintegration with community members., International Registered Report Identifier (irrid): DERR1-10.2196/14170., (©Christine Melillo, Kiersten Downs, Christina Dillahunt-Aspillaga, Jason Lind, Karen Besterman-Dahan, Bridget Hahm, Nicole Antinori, Christine Elnitsky, Angelle M Sander, Heather G Belanger, Peter Toyinbo, Gail Powell-Cope. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 22.11.2019.)

Purpose: Earlier, we reported development and initial testing of a rapid, low burden measure of wheelchair seated posture (the Seated Posture Scale [SPS]) for research and clinical use. The purpose of this study was to test the intrarater reliability, interrater reliability, and criterion related validity of the SPS., Design: We used a descriptive design to test and develop the instrument., Methods: We used the method described by Walter, Donner, and Eliasziw to determine 46 participants were needed, from two Veterans Administration nursing homes or CLCs (community living centers). Using a digital goniometer to score rapidly and with two trained raters, we scored individual participants simultaneously and again in succession. For criterion related concurrent validity, we also scored each participant with Section 2 of the Seated Postural Control Measure for Adults. Intrarater reliability, interrater reliability, and criterion related, concurrent validity were assessed using kappa statistics for individual instrument items (and corresponding 95% confidence intervals where appropriate) and intraclass correlation coefficients (ICC) for total scores., Findings: The intrarater intraclass correlation coefficient (ICC) was .995; interrater ICC was .80; interrater reliability kappas ranged from -.03 to .80. Criterion-related, concurrent validity kappas ranged from .13 to .91. ICC for total scores was .85., Conclusion: The SPS has sufficient preliminary validity and reliability to support measurement of wheelchair-seated posture in outcomes research and clinical use., Clinical Relevance: In the future, rehabilitation nurses may use the SPS to improve management of wheelchair seated posture, to improve clinical outcomes, particularly for those who do not reposition themselves.

Evidence suggests that inaccurate and incomplete pressure injury (PI) documentation threatens the validity of treatment and undermines policy and quality improvement. This quality improvement project sought to identify barriers and facilitators when conducting and documenting the daily comprehensive skin assessment in 31 Department of Veterans Affairs (VA) facilities. Evaluators in this 1-year, cross-sectional quality improvement project, using a qualitative approach, interviewed nurses of medical-surgical and critical care units. Participants (N = 62) from 12 high reassessment units (HRUs) and 13 low reassessment units (LRUs) were interviewed using telephone focus groups. Staff from HRUs reported 9 activities that ensured consistency in clinical practices, in validating data, and in correcting inaccuracies. The LRU staff tended to report performing only 2 of the 9 activities. The main barriers to accurate documentation were lack of knowledge, poor templates, and staffing issues such as understaffing and turnover, and main facilitators were an internal data validation process and a documentation template to local practices. Findings from this project led to increased VA leadership engagement, development of 3 innovative, award-winning VA mobile PI prevention and management applications, updated policies and directives on PI prevention, and upgrading of the national VA HAPI workgroup to an advisory committee and improved collaboration between the PI advisory committee and nursing informatics.

Population-based post-deployment screening programs within the Departments of Defense and Veterans Affairs have been implemented to assess for mental health conditions and traumatic brain injury. The purpose of this paper is to systematically review the literature on post-deployment screening within this context and evaluate evidence compared to commonly accepted screening implementation criteria. Findings reflected highly variable psychometric properties of the various screens, variable treatment referral rates following screening, low to moderate treatment initiation rates following screening, and no information on treatment completion or long-term outcomes following screening. In sum, the evidence supporting population based post-deployment screening is inconclusive. Implications are discussed.

: Purpose: Despite the evidence supporting safe patient handling and mobility (SPHM) practices, anecdotal evidence suggests that such practices are not universally taught in academic nursing programs. The primary goal of this cross-sectional descriptive study was to understand what nursing programs teach students about lifting, turning, transferring, repositioning, and mobilizing patients., Methods: Faculty from baccalaureate and associate's degree nursing programs in the United States were invited via e-mail to complete a 64-item survey questionnaire, which was accessible through an online link. Participants were also invited to send documents related to SPHM course content to the research team., Results: Faculty from 228 baccalaureate and associate's degree nursing programs completed the questionnaire. Most curricula included outdated manual techniques, taught reliance on body mechanics to reduce the risk of musculoskeletal injuries, and made use of nonergonomic aids such as draw sheets. Elements of SPHM in the curricula were less common, and nearly half of the respondents didn't know whether their affiliated clinical facilities had an SPHM program., Conclusions: The survey results suggest many possibilities for improvement-such as partnering with faculty in physical and occupational therapy departments, clinical partnering, and working with equipment vendors-to better incorporate evidence-based SPHM principles and practices into nursing curricula.

Background: In recognition of the incidence of traumatic brain injuries (TBIs) in the Iraq and Afghanistan conflicts, the Department of Veterans Affairs (VA) has, since 2007, examined returning U.S. service members for symptoms of TBI, a pre-condition for VA treatment of TBI. This study characterizes "Traumatic Brain Injury screen" service delivery, according to the barrier and facilitator viewpoints of those experiencing the delivery., Methods: The purposeful sample comprised both Veteran patient and VA staff participants in the TBI screen program (n = 64), including patients (n = 14), health care providers (n = 38), and key informants (n = 12). Telephone interviews were conducted per standardized, semi-structured interview scripts; respondent narratives recorded and transcribed verbatim; natural emergence of key themes of discourse fostered through conventional content analysis; themes coded by meaning and meaning units organized by nature of influence on service delivery., Results: A wide variety of structural, administrative, and communications barriers impede TBI screen service delivery, and certain case management and other functions promote delivery., Conclusions: The value of VA TBI screen service delivery is appreciated by its participants, but delivery is perceived as vulnerable to failure; the extent of such failure and short- and long-term effects on patient health and well-being outcomes is incompletely understood and merits investigation. Evaluating VA TBI screen service delivery under alternate modes of delivery, e.g., one-stop visits, expanded hours of delivery, shared appointment sessions, telehealth, and intensified case management is suggested., (Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2018.)

Traumatic brain injury (TBI) has been called the signature injury of the post-9/11 wars in Iraq, Afghanistan, and neighboring countries. Although similarities exist between veterans and service members with TBI, levels of severity and different constellations of coexisting comorbid conditions affect them differently. These conditions affect physical, cognitive, and emotional function, which in turn can complicate community reintegration (CR), or the ability to return to family, vocational, and community life. This special supplement of the Archives of Physical Medicine and Rehabilitation consists of articles written by accomplished teams from multiple disciplines, including anthropology, neuropsychology, nursing, occupational therapy, psychology, and rehabilitation sciences. Each article brings a different perspective to bear on what CR means for veterans and service members from examination of predictors and perceptions of veterans and service members and others to measurement studies. Collectively, this group of articles represents current thinking about CR and lays the groundwork for testing interventions to improve CR outcomes for veterans and service members (eg, employment, living situation, family life)., (Published by Elsevier Inc.)

: This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series explain principles for promoting safe mobility that nurses should reinforce with family caregivers. Each article also includes an informational tear sheet-Information for Family Caregivers-that contains links to instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage the caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

: This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series explain principles for promoting safe mobility that nurses should reinforce with family caregivers. Each article also includes an informational tear sheet-Information for Family Caregivers-that contains links to instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage the caregivers to watch the videos and ask questions. For additional information, see Resources for Nurses.

Objectives: To examine the length of time to return to work (RTW) among service members and veterans (SM/V) with traumatic brain injury (TBI) and to identify variables predictive of RTW., Setting: Department of Veterans Affairs Polytrauma Rehabilitation Centers (VA PRC)., Participants: SM/V enrolled in the VA PRC Traumatic Brain Injury Model Systems database who were of 18 to 60 years of age and admitted with the diagnosis of TBI., Design: Prospective observational cohort study., Main Outcome Measures: Employment status at 1-year postinjury follow-up; Time to Employment (ie, number of days it took to RTW) as documented during 1-year postinjury follow-up., Results: The final sample (n = 293) included male (96%) SM/V with severe TBI (69%). Approximately 21% of the sample participants were employed at 1 year postinjury. Younger individuals who self-identified as nonminority returned to work sooner. Significant associations were observed for time to employment for cause of injury and injury severity., Conclusions: Few SM/V with moderate to severe TBI returned to work at 1 year postinjury. Predictors such as younger age at the time of injury, minority status, and severity of TBI affected time to and probability of RTW. Findings from this study have important implications for rehabilitation planning and service delivery across the continuum of recovery.

The risk of adverse events (AEs) such as infection and amputation related to diabetic foot ulcers (DFUs) has been studied, but less is known about rate of other AEs such as falls. As part of a quality improvement project, AEs in veterans with diabetes mellitus (DM) with and without a DFU were examined. Demographic data including ICD-9 codes, AEs, and comorbidities for all patients with a diagnosis of DM and/or DFU treated between 2009 and 2014 at the James A. Haley Veterans' Hospital, Tampa, FL, were reviewed retrospectively utilizing the Corporate Data Warehouse (CDW) database. Identifiable protected health information data using patient scrambled social security numbers were collected from the CDW to allow the longitudinal data to be linked at the unique patient level. Descriptive statistics (eg, mean, standard deviation) were determined for demographics, AE, and comorbidities. Adjusted models of AE association with DM and DFU were analyzed using regression modeling via a statistical analysis system. The models were adjusted for age, race, gender, marital status, and comorbidities. Data extracted included individuals diagnosed with diabetes with a DFU (n = 3238, average age 66.0 ± 10.6 years) and diabetes without DFU (n= 41 324, average age 64.4 ± 11.5 years). Participants were mostly Caucasian in both the DFU and non-DFU cohorts (2655 [82.0%] and 32 269 [78.1%], respectively) and male (3129 [96.6%] and 39 580 [95.8%], respectively). The most common comorbidities in this population were peripheral vascular disease (PVD, 39.5%) and peripheral neuropathy (PN, 23.2%). PVD was more common in veterans with (39.5%) than without a DFU (9.2%). Compared to individuals with DM, those with DM and DFU were significantly more likely to experience an infection (OR = 9.43; 95% CI 8.54-10.4), undergo an amputation (OR = 7.40; 95% CI 6.16-8.89), or experience a fracture (OR = 3.65; 95% CI 2.59-5.15) or fall (OR = 2.26; 95% CI 1.96-2.60) (P <.01 for all variables). Although the increased risk of infection and amputation among persons with DFUs has been documented, less is known about the rate of falls and fractures. The current findings will serve as baseline data for future implementation trials to reduce DFU-associated AEs, and clinicians may want to consider expanding DFU patient education efforts to include fall risk.

Background: Pressure ulcers (PrUs) are a frequent, serious, and costly complication for veterans with spinal cord injury (SCI). The health care team should periodically identify PrU risk, although there is no tool in the literature that has been found to be reliable, valid, and sensitive enough to assess risk in this vulnerable population., Objective: The immediate goal is to develop a risk assessment model that validly estimates the probability of developing a PrU. The long-term goal is to assist veterans with SCI and their providers in preventing PrUs through an automated system of risk assessment integrated into the veteran's electronic health record (EHR)., Methods: This 5-year longitudinal, retrospective, cohort study targets 12,344 veterans with SCI who were cared for in the Veterans Health Administration (VHA) in fiscal year (FY) 2009 and had no record of a PrU in the prior 12 months. Potential risk factors identified in the literature were reviewed by an expert panel that prioritized factors and determined if these were found in structured data or unstructured form in narrative clinical notes for FY 2009-2013. These data are from the VHA enterprise Corporate Data Warehouse that is derived from the EHR structured (ie, coded in database/table) or narrative (ie, text in clinical notes) data for FY 2009-2013., Results: This study is ongoing and final results are expected in 2017. Thus far, the expert panel reviewed the initial list of risk factors extracted from the literature; the panel recommended additions and omissions and provided insights about the format in which the documentation of the risk factors might exist in the EHR. This list was then iteratively refined through review and discussed with individual experts in the field. The cohort for the study was then identified, and all structured, unstructured, and semistructured data were extracted. Annotation schemas were developed, samples of documents were extracted, and annotations are ongoing. Operational definitions of structured data elements have been created and steps to create an analytic dataset are underway., Conclusions: To our knowledge, this is the largest cohort employed to identify PrU risk factors in the United States. It also represents the first time natural language processing and statistical text mining will be used to expand the number of variables available for analysis. A major strength of this quantitative study is that all VHA SCI centers were included in the analysis, reducing potential for selection bias and providing increased power for complex statistical analyses. This longitudinal study will eventually result in a risk prediction tool to assess PrU risk that is reliable and valid, and that is sensitive to this vulnerable population., Competing Interests: Conflicts of Interest: None declared., (©Stephen L Luther, Susan S Thomason, Sunil Sabharwal, Dezon K Finch, James McCart, Peter Toyinbo, Lina Bouayad, Michael E Matheny, Glenn T Gobbel, Gail Powell-Cope. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 19.01.2017.)

Objectives: To examine community reintegration problems among Veterans and military service members with mild or moderate/severe traumatic brain injury (TBI) at 1 year postinjury and to identify unique predictors that may contribute to these difficulties., Setting: VA Polytrauma Rehabilitation Centers., Participants: Participants were 154 inpatients enrolled in the VA TBI Model Systems Program with available injury severity data (mild = 28.6%; moderate/severe = 71.4%) and 1-year postinjury outcome data., Design: Prospective, longitudinal cohort., Main Measures: Community reintegration outcomes included independent driving, employability, and general community participation. Additional measures assessed depression, posttraumatic stress, and cognitive and motor functioning., Results: In the mild TBI (mTBI) group, posttraumatic stress disorder and depressive symptoms were associated with lower levels of various community reintegration outcomes. In the moderate/severe TBI group, cognition and motor skills were significantly associated with lower levels of community participation, independent driving, and employability., Conclusion: Community reintegration is problematic for Veterans and active duty service members with a history of TBI. Unique comorbidities across injury severity groups inhibit full reintegration into the community. These findings highlight the ongoing rehabilitation needs of persons with TBI, specifically evidence-based mental healthcare, in comprehensive rehabilitation programs consistent with a chronic disease management model.

Objective: The objective was to implement the evidence-based Spinal Cord Impairment Pressure Ulcer Monitoring Tool (SCI-PUMT) in 23 Spinal Cord Injury/Disorders Centers (SCI/D) in the Veterans Health Administration (VHA)., Setting: A collaborative was held in Minnesota that was attended by key personnel from SCI/D Centers in the VHA., Methods: This initiative was based on a 3-year longitudinal study that established the validity and reliability of a novel pressure ulcer monitoring tool for persons with spinal cord impairment. A multifaceted evidence-based strategy was used to implement the Institute for Healthcare Improvement's framework of Plan-Do-Study-Act. The plan was executed by clinical champions who implemented the tool in their respective SCI/D Centers following a conference that used both didactic and practicum approaches., Outcomes: A 15-item toolkit was developed to educate clinicians and patients regarding use of the SCI-PUMT. Toolkit elements were frequently accessed over the VA intranet (n = 3254). The 1.5-day national conference rolled out the new tool to the SCI/D Centers. Pre/post SCI-PUMT knowledge of the SCI-PUMT improved by 78% during the conference. Following the conference, periodic conference calls cemented the implementation efforts of the SCI-PUMT clinical champions and barriers were mitigated.

The goal of this study was to apply sociotechnical probabilistic risk assessment to prioritize risks and prevention strategies for serious injurious falls of residents in nursing homes. Risk modeling teams consisted of 26 clinical and nonclinical staff from three Department of Veterans Affairs community living centers and one state Veteran's nursing home. Participants met in groups several times to identify and assign probabilities to provider and resident at-risk behaviors and equipment failures. They identified prevention strategies for the failures that accounted for the highest levels of risk. Six scenarios were modeled: (1) transferring from bed to wheelchair, (2) propelling from bedside to bathroom, (3) transferring from wheelchair to toilet, (4) transferring from toilet to wheelchair, (5) propelling from bathroom to bedside, and (6) transferring from wheelchair to bed. The greatest paths of risk were for residents with impaired mobility and high fragility. A 26% reduction in injurious falls could be achieved by (1) reducing the number of unassisted transfers through a modest improvement in response time to alarms, (2) installing automatic brake locks on 90% of wheelchairs, (3) making the wheelchair maintenance process highly reliable, and (4) decreasing improper transfer techniques by 10%.

The goals of this study were to describe clinical practice patterns associated with the Veterans Health Administration's (VHA's) Comprehensive Traumatic Brain Injury Evaluation (CTBIE) and determine whether practice patterns vary by patient, provider, or facility characteristics. Veterans (N = 614) who had initial healthcare visits between 2008, and 2011 and who had previously completed the VHA's traumatic brain injury (TBI) screen and subsequent CTBIE were drawn from a national database. Participants were primarily male (95%) with a mean age of 29.8 yr (standard deviation = 8). Chart reviews were conducted on a random sample of charts with completed CTBIEs from 21 sites. Using a cross-sectional design, patient- and facility-specific variables were investigated as potential predictors of practice variation. During the study period, 79% of patients in this national sample were screened within 1 d of their initial healthcare visit and 65% were evaluated via CTBIE within 30 d of screening. Provider and participant characteristics were generally not associated with timeliness. The CTBIE was completed by individuals versus teams at comparable rates. Much of what occurred during the evaluation, beyond TBI-specific procedures, were medical assessments, such as review of medications and other substances.

Objectives: We determined whether statistical text mining (STM) can identify fall-related injuries in electronic health record (EHR) documents and the impact on STM models of training on documents from a single or multiple facilities., Methods: We obtained fiscal year 2007 records for Veterans Health Administration (VHA) ambulatory care clinics in the southeastern United States and Puerto Rico, resulting in a total of 26 010 documents for 1652 veterans treated for fall-related injury and 1341 matched controls. We used the results of an STM model to predict fall-related injuries at the visit and patient levels and compared them with a reference standard based on chart review., Results: STM models based on training data from a single facility resulted in accuracy of 87.5% and 87.1%, F-measure of 87.0% and 90.9%, sensitivity of 92.1% and 94.1%, and specificity of 83.6% and 77.8% at the visit and patient levels, respectively. Results from training data from multiple facilities were almost identical., Conclusions: STM has the potential to improve identification of fall-related injuries in the VHA, providing a model for wider application in the evolving national EHR system.