Mixed methods study examining work reintegration experiences from perspectives of Veterans with mental health disorders

Transition Needs Among Veterans Living With Chronic Pain: A Systematic Review

INTRODUCTION

A third of Canadian Armed Forces veterans report difficulty adjusting to post-military life. Moreover, an estimated 40% of Canadian veterans live with chronic pain, which is likely associated with greater needs during the transition from military to civilian life. This review explores challenges and transition needs among military personnel living with chronic pain as they return to civilian life.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science from inception to July 2022, for qualitative, observational, and mixed-method studies exploring transition needs among military veterans released with chronic pain. Reviewers, working independently and in duplicate, conducted screening and used a standardized and pilot-tested data collection form to extract data from all included studies. Content analysis was used to create a coding template to identify patterns in challenges and unmet needs of veterans transitioning to civilian life, and we summarized our findings in a descriptive manner.

RESULTS

Of 10,532 unique citations, we identified 43 studies that reported transition challenges and needs of military personnel; however, none were specific to individuals released with chronic pain. Most studies (41 of 43; 95%) focused on military personnel in general, with one study enrolling individuals with traumatic brain injury and another including homeless veterans. We identified military-to-civilian challenges in seven areas: (1) identity, (2) interpersonal interactions/relationships, (3) employment, (4) education, (5) finances, (6) self-care and mental health, and (7) accessing services and care.

CONCLUSIONS

Military personnel who transition to civilian life report several important challenges; however, the generalizability to individuals released with chronic pain is uncertain. Further research is needed to better understand the transition experiences of veterans with chronic pain to best address their needs and enhance their well-being.

Social determinants of health among noncitizen deported US veterans: A participatory action study

This qualitative study examines the social determinants of health among noncitizen deported United States veterans. We utilized Photovoice, a participatory action research method used to inform structural level change, with 12 veterans. Audio-recorded semi-structured interviews explored photos and discussed deportation's effects on veteran health. We performed rapid template and matrix analysis of interview transcripts. Interviews were conducted in Tijuana, Mexico from December 2018 to January 2019. Study findings show that veterans prioritize returning to the United States to improve their quality of life. Analysis of photos and narrative text indicated that deportation caused social, economic, and political insecurities. Veterans struggled to maintain access to necessities post-deportation. Disrupted social networks compounded their situation, resulting in chronic stress and poor health outcomes. The findings from this study offer insight into the ways deportation acts as a social determinant of health. The findings suggest modifying veteran reintegration programs, as well as reforming criminal justice and immigration laws, such as creating more Veteran Treatment Courts and allowing immigration judges to consider military history during deportation proceedings involving noncitizen veterans.

Modeling Contingency in Veteran Community Reintegration: A Mixed Methods Approach

Researchers need approaches for analyzing complex phenomena when assessing contingency relationships where specific conditions explain an outcome only when combined with other conditions. Using a mixed methods design, we paired configurational methods and qualitative thematic analysis to model contingency in veteran community reintegration outcomes, identifying combinations of conditions that led to success or lack of success in community reintegration among US military veterans. This pairing allowed for modeling contingency at a detailed level beyond the capabilities of either approach alone. Our analysis revealed multiple contingent relationships at work in explaining reintegration, including social support, purpose, cultural adjustment, and military separation experiences. This study contributes to the field of mixed methods by pairing a mathematical cross-case method with a qualitative method to model contingency.

Adapting a family-involved intervention to increase initiation and completion of evidenced-based psychotherapy for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is disabling condition among United States Veterans. Training programs for evidenced-based therapies have been rolled out nationally in the Veterans Health Administration (VHA), but provider adoption of these treatments is limited and rates of Veteran dropout are high. Increasing support for mental health therapy within the Veteran's social network would improve treatment engagement. We discuss the adaptation of Recovery-Oriented Decisions for Relatives' Support (REORDER)-a family-based intervention for individuals with serious mental illness- to create Family Support in Mental Health Recovery (FAMILIAR), an intervention that seeks to strengthen support partners' abilities to help Veterans engage in therapy. Our goal was to apply modifications to meet the needs of Veterans with PTSD and their support partners. We used input from Veterans, support partners, clinicians and VA system leaders to inform the modifications. Then, a multi-disciplinary intervention development team met to determine which modifications would be applied and how. We used the domains from the Framework for Adaptations and Modification (FRAME) to systematically track and describe modifications. Adaptations made to REORDER included changes in content, structure, and delivery format. The resulting intervention, FAMILIAR, was a 3-4 session intervention beginning prior to EBP initiation and continuing through sessions 3, 4 or 5 of the EBP. Sessions were designed for maximum flexibility and could be offered either in-person or virtually, and sessions involve interactions between the interventionist with the Veteran and support partner alone and together. We learned the importance of including diverse stakeholder perspectives to develop a comprehensive understanding of the needs of the target population and the health system. While feasibility and effectiveness testing is needed, we applied a proactive adaptation approach that we anticipate will make FAMILIAR successful in addressing patient, clinical, and system considerations of a family approach to increase Veteran engagement in PTSD treatment.

Toward a System Theory of Stress, Resilience, and Reintegration

Military to civilian reintegration is a complex, multidimensional phenomenon warranting holistic perspectives. Complex phenomena require theory to understand and interpret relationships among concepts. Despite the need for theory-driven research, recent nursing reports often lack a theoretical structure. We extracted relevant concepts from the Neuman's Systems Model (stressors, environment, and person) and the Transactional Model of Stress and Coping (primary and secondary appraisal, coping, and adaptation) to form a Conceptual-Theoretical-Empirical model. Exemplar empirical instruments are presented, along with their conceptual and theoretical dimensions. An integrated System Theory of Stress, Resilience, and Reintegration is presented with its utility demonstrated through a research application.

Making the transition: How finding a good job is a risky business for military Veterans in Northern Ireland

Veterans transitioning from the military to civilian life may encounter difficulties in different domains of functioning. Most research in this area comes from the US and Israel, with Veterans in Northern Ireland (NI) in the United Kingdom, remaining an understudied population. This qualitative study aimed to examine the nature of transition experiences of NI Veterans by analyzing responses (N = 252) to an open-ended question related to the transition process, in a self-report survey. Thematic analysis highlighted both positive and negative experiences across high-level themes. These were related to (1a) how good the military life had been, (1b) the transition had been easy for some Veterans, and (1c) the skills gained in the military have been valuable; (2) it was hard to adjust to civilian life/still adjusting; (3) negative employment experiences; (4) lack of trust; (5) transitioning is hard in NI; and (6) inadequate support, post-service. The findings highlight that NI Veterans share some of the same challenges as other Veterans; however, the challenges in NI are compounded by ongoing security concerns and political tensions, which means living under the radar is a reality for many, making finding meaningful work and community integration difficult. The findings indicate that preparation for civilian life and the acculturation process needs to start many months before discharge. Perhaps more crucially, regiments should work closely with and support civilian employers to equip them to recognize and value the skills ex-Services Veterans can offer, and find a good fit for their skills within their organizations.

Leveraging institutional support for family caregivers to meet the health and vocational needs of persons with disabilities

BACKGROUND

Family caregivers might enhance veteran engagement in health and nonhealth services (i.e., vocational/educational assistance).

PURPOSE

To describe how veterans with disabilities perceive their recovery needs, identify types of social support from caregivers that help veterans engage in Veterans Affairs (VA) health and nonhealth services, and explore participant views of VA institutional support for caregivers to help veterans engage in these services.

METHODS

Joint in-depth qualitative interviews with U.S. veterans and family caregivers (n = 26).

FINDINGS

Caregivers performed social support functions that helped veterans engage in health and vocational/educational services and institutional support from VA enhanced caregivers' capacity.

DISCUSSION

Caregivers are well positioned to align health and nonhealth services with patient needs to enhance recovery. Staffing a point person for caregivers within the health system is key to help families develop a coordinated plan of treatment and services to improve patient success across health and nonhealth domains. Nurses are well suited to perform this role.

The long and winding road to postsecondary education for U.S. veterans with invisible injuries

OBJECTIVE

Veterans with "invisible injuries" (a mental health diagnosis or a traumatic brain injury) often pursue higher education to enhance employment and community reintegration, but frequently experience challenges to success. This mixed methods study examined how the educational experiences of Veterans with invisible injuries become intertwined with broader transitions between military and civilian life and the resulting implications for rehabilitation services.

METHOD

Thirty-eight Veterans with mental illness or a traumatic brain injury who served in a post-9/11 conflict and attended a postsecondary institution within the past 60 months completed in-depth interviews and questionnaires. We used a constant comparative approach to analyze barriers and facilitators to educational functioning and community reintegration.

RESULTS

Managing school-specific challenges, coping with mental and physical health problems, forming a new sense of self, and forging new career pathways were major factors influencing education experiences and reintegration. Participants discussed the challenges of balancing these processes while progressing toward an academic degree, which often resulted in a longer, nonlinear educational pathway. While some participants attempted to "compartmentalize" educational goals, separate from health and family concerns, these aims were inevitably interlaced. In addition, multiple and longer military deployments tended to lengthen the time to degree completion.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Many Veterans with invisible injuries face complex challenges stemming from military experiences, the family dynamics to which they return, and reintegration issues that demand novel forms of resilience. Collaboration between university staff and health practitioners may be important in enhancing support for student Veterans coping with invisible disabilities. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Association of the Exposure to Work-Related Traumatic Events and Work Limitations among Firefighters: A Cross-Sectional Study

Many firefighters suffering from traumatic events while on duty participate in the work force. However, the impact of work-related traumatic events on work performance is unclear. To address this issue, we administered a work-related traumatic event experience survey, the health-related work limitations questionnaire, the Korea Depression Scale, and the World Health Organization quality of life assessment to firefighters from four cities in Korea. The health-related work limitations questionnaire measured limitations in their ability to perform three specific work demands-physical, psychosocial, and environmental. Of 685 firefighters enrolled in the study, 618 (90.2%) were included in the final analyses. Their mean age ± standard deviation (SD) was 41.1 ± 8.0 years and mean employment period ± SD was 163.0 ± 101.2 months. A large percentage of participants reported they had experienced work-related traumatic events. Among the firefighters, the total work limitation prevalence was 21.5%, 16.8% of them were limited in their abilities to perform physical work demands, 15.5% were limited in performing psychosocial work demands, and 13.8% were limited in their abilities to function without difficulty within the ambient work environment. Based on multivariable logistic regression, with having work-related traumatic event experience of a threat or injury to self, the odds ratio (OR) of having work limitations in physical (OR = 3.32, 95% CI = 1.17⁻9.41), psychosocial (OR = 3.05, 95% CI = 1.08⁻8.61), environmental (OR = 4.89, 95% CI = 1.66⁻14.40) work demands, and total work limitation (OR = 3.73, 95% CI = 1.44⁻9.68) increased significantly. With experiences of treating fatalities or injured patients, the OR of total work limitation increased significantly (OR = 2.07, 95% CI = 1.09⁻3.91). We demonstrated a relationship between the firefighters' exposure to work-related traumatic events and their work limitations. A professional care management system for firefighters to prevent and manage work-related traumatic events should be developed in order to protect and improve their performance ability.