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Health Services Research & Development

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Spotlight: VA Nursing Research

May 2015

The VA healthcare system has one of the largest nursing staffs of any healthcare organization in the world, employing more than 89,000 nursing care providers, including PhDs, Licensed Practical Nurses, Licensed Vocational Nurses, and nursing assistants. VA nurses work with Veterans to help prevent illness, maintain, or regain health; they also assist Veterans in coping with service-related trauma, and offer hospice and palliative care for Veterans at the end of life.

In addition to the wide range of complex clinical and practical care services they provide, VA nurses play a significant role in advancing research through the Nursing Research Initiative (NRI). The NRI is a VA Health Services Research & Development (HSR&D) administered program that encourages new and experienced nurse investigators to participate in research aimed at high-priority health issues for Veterans, with a particular emphasis on patient-centered care. NRI-funded research may be developed with a clinical, rehabilitation, health services, or biomedical laboratory focus. NRI projects have contributed to the evidence-base for a wide range of conditions impacting the health of Veterans. The following describe just a few of the ongoing and recently completed HSR&D studies funded through the NRI.

  • Nurse-delivered Alcohol Brief Intervention for Hospitalized Veterans. Improving the identification and management of alcohol misuse is a VA priority, and VA recommends a set of clinical strategies (SBIRT, or Screening, Brief Intervention, and Referral to Treatment) to identify and address alcohol misuse in primary care settings. Brief intervention (BI), a core component of SBIRT, significantly reduces alcohol consumption, morbidity, and healthcare utilization in hazardous drinkers, but more evidence is needed to establish its effectiveness outside of outpatient settings, such as the hospital setting, where nurses are well-positioned to deliver BI. In this ongoing study, investigators are looking at the effectiveness of nurse-delivered alcohol BI with hospitalized patients who are hazardous drinkers, and hope to identify barriers and facilitators to implementation of BI in inpatient settings.

    Participants in the study will come from Veterans admitted to one of the three medical-surgical units at the VA Pittsburgh Healthcare System. Study participants will be randomly assigned to one of three groups. Veterans in Group 1 will receive a three-part, nurse-delivered BI. Veterans in Group 2 will receive an attention control/usual care intervention, while those in Group 3 will receive usual care plus healthy lifestyle brochures that address healthy lifestyle behaviors, such as limited alcohol consumption, tobacco cessation, and weight management.

    Investigators expect that study results may provide additional evidence for the efficacy of BI in hospitalized patients, and could, in turn, improve the quality of VA inpatient care by providing additional justification and guidance for the mandatory implementation of BI-related hospital accreditation measures from the Joint Commission. VA clinicians and hospital administrators charged with BI implementation will be interested in efficacious, efficient, and practical BI delivery models.

    Broyles LM, Wieland ME, Confer AL, Youk AO, Gordon AJ. Holes in the pipeline: addressing recruitment challenges for an alcohol brief intervention trial in the acute care setting. [Abstract]. Substance Abuse. 2014 Jan 1; 35(2):208.

  • Mindfulness Based Stress Reduction for Women at Risk for Cardiovascular Disease
    Chronic stress has been shown to significantly increase the risk for heart attack and has also been linked to the inflammatory process that can lead to coronary artery disease and stroke. While previous research into stress and cardiovascular disease (CVD) has focused primarily on male Veterans, recent statistics indicate that between 80 and 92 percent of women Veterans report at least one traumatic event sometime in their lives. Given that strong links exist between prior life adversity and stress-related inflammatory disease, such as CVD, assisting women Veterans to reduce stress and develop coping strategies may improve psychological well-being and reduce CVD risk.

    In this ongoing study, investigators seek to determine the extent to which a Mindfulness-Based Stress Reduction (MBSR) program improves psychological well-being, decreases inflammatory burden, and reduces cardiovascular risk in women Veterans. Investigators also will evaluate protective and risk factors that might moderate the effect of MBSR. MBSR involves intensive training in mindfulness, which promotes positive adaptation to life stress. MBSR also has been found to reduce symptoms of depression and improve quality of life in Veterans experiencing Post-Traumatic Stress Disorder.

    Investigators are enrolling women Veterans between the ages of 18 and 70 years who have at least one CVD risk factor. Participants are then randomly assigned to either an 8-week MBSR program intervention or to a health education program as the control. Preliminary findings suggest that women Veterans (as opposed to non-Veterans) experience high levels of early life adversity, which is associated with depressive symptoms. Investigators expect that further findings will support MBSR as an effective method of improving psychological well-being and reducing CVD risk. Given that CVD is a major cause of mortality, this research may have broader implications for reducing CVD in the general population.

  • Telehealth Care Management and Tobacco Cessation for Veterans with PTSD . Veterans with post traumatic stress disorder (PTSD) have high rates of smoking and lower quit rates than non-Veterans. Since smokers experience reductions in all-cause mortality when they quit, even a small increase in quit rates can improve health and life expectancy. Motivational Interviewing (MI) has been shown to increase readiness to change, and care management using telehealth has been shown to improve access to care while reducing costs for Veterans with chronic diseases. In this study, investigators examined whether nurse-based integrated care management using telehealth and MI counseling plus usual care would increase the proportion of patients who make self-reported quit attempts, progress in the stages of change, and quit smoking; increase Veterans' perception of care coordination and patient satisfaction regarding MI counseling and smoking cessation content; and improve PTSD, depression, pain symptoms and quality of life.

    Investigators enrolled 178 Veterans in the study, and participants were randomized to either an intervention group (PTSD home telehealth care management program and nurse care management, plus MI-based written smoking cessation curricula on home telehealth and weekly telephone-based smoking cessation MI counseling by a nurse); or to a control group (PTSD home telehealth care management program and nurse care management alone).

    Findings from the intervention period showed:
    • Approximately 1/3 of participants in both groups made at least one self-reported 24-hour quit attempt;
    • Approximately 1/4 of participants in both groups reported seven-day smoking abstinence; and
    • Slightly less than half of both groups progressed along the stages of change.

    Findings from the six-month follow-up period showed:
    • A slight increase in making at least one self-reported, 24-hour quit attempt among the control group (from 33% to 36%);
    • A slight decrease in making at least one, self-reported 24-hour quit attempt among the intervention group (from 38% to 27%)
    • No significant change in either group in reported seven-day smoking abstinence, and,
    • Steady, but less significant progression along the stages of change for both groups.
    • The intervention group showed improved depression and PTSD symptoms.

    Interviews found that all participants were highly satisfied with home telehealth services. The intervention group found the MI counseling to be supportive, non-judgmental, and informative. Participants in both groups wanted more information about PTSD and smoking, relied on smoking as a coping mechanism for PTSD, and believed that quitting was an individual choice.

    This study directly addressed gaps in smoking cessation care delivery by using home telehealth and telephone counseling. Investigators effectively and safely integrated tobacco cessation curricula into an in-use VA home telehealth system.

    Battaglia C, Benson SL, Cook PF, Prochazka A. Building a tobacco cessation telehealth care management program for veterans with posttraumatic stress disorder. Journal of The American Psychiatric Nurses Association. 2013 Mar 1; 19(2):78-91.

    Peterson J, Prochazka A, Battaglia, C. Smoking cessation and care management for veterans with posttraumatic stress disorder: a study protocol for a randomized controlled trial. BMC Health Services Research. 2015 (15)46.

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