New Insights About Military Interprofessional Healthcare Teams: Lessons Learned and New Directions From a Program of Research

The success of the military is significantly supported by highly effective collaborative teams. While much is known about successful military teams outside the context of healthcare delivery, considerably less attention has been paid to teams working in patient care. Thus, this supplement has explored the features of successful military interprofessional healthcare teams (MIHTs). In this summary paper, the authors discuss what this supplement's investigations have taught us about MIHTs and offer a series of proposed future investigations of MIHTs and their role in military healthcare.

Situational Awareness: Forecasting Successful Military Medical Teams

INTRODUCTION

Military healthcare providers working in military interprofessional healthcare teams (MIHTs) require situational awareness (SA) to ensure safe and efficacious patient care. This study aimed to explore SA in MIHTs to understand how SA can be reinforced and maintained in MIHTs. The research team set out to answer two questions: "What aspects of individual and team SA are particularly important for MIHTs?" and "How can we enable military healthcare providers to be effective MIHTs members with robust SA?".

METHODS

This study used Grounded Theory methodology collecting perspectives from 30 study participants from various backgrounds, including 11 different healthcare professions from the U.S. Army, Air Force, and Navy. Each study participant had experiences participating in, leading one, or leading many MIHTs. Data were collected in three cycles and analyzed within each cycle until saturation was reached.

RESULTS

Five themes were robustly represented in the data set regarding SA: (1) contextually informed adaptability, (2) readiness, (3) trust, (4) communication, and (5) mission focus.

CONCLUSIONS

The urgency often faced by MIHTs brings SA and the principles that underpin SA into sharper focus. The SA themes identified in this research may provide insight into training effectiveness, team strengths and weaknesses, and team performance.

The Ties That Bind: Camaraderie in Military Interprofessional Healthcare Teams

INTRODUCTION

Multiple aspects of interpersonal dynamics can help or hinder the success of teams, particularly those in a Military Interprofessional Healthcare Team (MIHT). One specific mechanism for MIHTs' success is camaraderie and how these military teams are able to achieve, maintain, and enable the development of this important characteristic. Despite our understanding of military service members as being bonded like a family, we have a limited understanding of how this bond is translated into their MIHT experiences.

MATERIALS AND METHODS

This study conducted interviews among 30 individuals who had participated in, led individual, and/or led many MIHTs, using a grounded theory methodology. Participants represented 11 different health professions, including officers and enlisted military members, and three branches of the U.S. military (e.g., army, navy, and air force). Data were collected and analyzed in iterative cycles until saturation was achieved.

RESULTS

We identified six themes that shaped the overarching concept of camaraderie in MIHTs. These themes were (1) confidence in competent peers, (2) shared goals, (3) mutual respect, (4) desire to help one another improve, (5) personal is professional, and (6) bonds of military service. This paper describes each of these themes, provides illustrative examples from the data, and describes how these components contribute to MIHTs' team dynamics. We present a model for how to understand these themes.

CONCLUSIONS

Through the identification and exploration of these aspects of camaraderie, we are able to better understand how MIHTs are able to be successful. MIHTs that demonstrated confidence in their brother/sister in arms possessed shared goals and missions, while maintaining mutual respect, a desire to help one another do better, and creating a personal and professional overlap tended to form stronger bonds of military service. Critically, these six aspects support a more nuanced understanding of the spirit of camaraderie and how it underpins MIHT success.

Military Interprofessional Healthcare Teams: Identifying the Characteristics That Support Success

Military interprofessional healthcare teams (MIHTs) are foundational to the care provided to military members and their families. However, to date, very little research has investigated MIHTs. Notably, we have few insights into what distinguishes successful MIHTs. This manuscript presents findings from a program of research that was carried out to address this gap. We review what is known about MIHTs to date and the Uniformed Services University's (USU) focused efforts to ensure that greater understanding of MIHTs was developed. We provide an overview of the USU-supported research and of the findings that were generated by that inquiry. After summarizing the manuscripts included in this special edition of Military Medicine, we close by acknowledging and thanking key members of the U.S. military healthcare system who supported this research.

Dietary Isoflavone-Dependent and Estradiol Replacement Effects on Body Weight in the Ovariectomized (OVX) Rat

17β-Estradiol is known to regulate energy metabolism and body weight. Ovariectomy results in body weight gain while estradiol administration results in a reversal of weight gain. Isoflavones, found in rodent chow, can mimic estrogenic effects making it crucial to understand the role of these compounds on metabolic regulation. The goal of this study is to examine the effect of dietary isoflavones on body weight regulation in the ovariectomized rat. This study will examine how dietary isoflavones can interact with estradiol treatment to affect body weight. Consistent with previous findings, animals fed an isoflavone-rich diet had decreased body weight (p<0.05), abdominal fat (p<0.05), and serum leptin levels (p<0.05) compared to animals fed an isoflavone-free diet. Estradiol replacement resulted in decreased body weight (p<0.05), abdominal fat (p<0.05), and serum leptin (p<0.05). Current literature suggests the involvement of cytokines in the inflammatory response of body weight gain. We screened a host of cytokines and chemokines that may be altered by dietary isoflavones or estradiol replacement. Serum cytokine analysis revealed significant (p<0.05) diet-dependent increases in inflammatory cytokines (keratinocyte-derived chemokine). The isoflavone-free diet in OVX rats resulted in the regulation of the following cytokines and chemokines: interleukin-10, interleukin-18, serum regulated on activation, normal T cell expressed and secreted, and monocyte chemoattractant protein-1 (p<0.05). Overall, these results reveal that estradiol treatment can have differential effects on energy metabolism and body weight regulation depending on the presence of isoflavones in rodent chow.

The interaction of dietary isoflavones and estradiol replacement on behavior and brain-derived neurotrophic factor in the ovariectomized rat

Phytoestrogens are plant derived, non-steroidal compounds naturally found in rodent chows that potentially have endocrine-disrupting effects. Isoflavones, the most common phytoestrogens, have a similar structure and molecular weight to 17β-estradiol (E2) and have the ability to bind and activate both isoforms of the estrogen receptor (ER). Most isoflavones have a higher affinity for ERβ, which is involved in sexually dimorphic behavioral regulation. The goal of this study was to examine the interaction of isoflavones and E2 presence in the OVX rat on anxiety- and depressive- like behavior and the related BDNF pathophysiology. E2 administration resulted in anxiogenic behaviors when isoflavones were present in the diet (p<0.05), but anxiolytic behaviors when isoflavones were not present (p<0.05). E2 resulted in antidepressive-like behaviors in animals fed an isoflavone-rich diet (p<0.05), with no effect when isoflavones were removed. Increased hippocampal BDNF expression was observed in animals fed an isoflavone-rich diet after E2 administration (p<0.05). BDNF expression in the amygdala and hypothalamus was increased after E2 treatment in animals fed an isoflavone-rich diet. Overall, these results demonstrate that the presence of dietary isoflavones can differentially regulate the effect of E2 replacement on behavior and BDNF expression.

The effect of chronic immobilization stress on leptin signaling in the ovariectomized (OVX) rat

Previous studies have shown that both 17β-estradiol (E2) treatment and chronic stress may attenuate post-OVX weight gain in the female rat. However, the interaction between E2 and stress is unclear. This study examined the effect of E2 treatment and chronic immobilization stress on body weight. Adult OVX Sprague-Dawley rats were randomly assigned to one of four treatment groups in a 2X2 factorial design examining hormone treatment [vehicle (VEH) or E2, sc] and stress (no stress vs stress 60 min/day for 22 days). After 22 days, E2 significantly inhibited weight gain and food intake in OVX rats. In contrast, chronic stress reduced body weight only in control OVX animals but did not affect food intake. E2 reduced circulating leptin levels in non-stressed animals, but not in animals subjected to chronic immobilization. Western blot analysis indicated that E2 treatment increased leptin receptor (Ob-Rb) expression in the medial basal hypothalamus (MBH); however, this treatment also increased suppressor of cytokine signaling 3 (SOCS3), which is an inhibitor of leptin signaling. Chronic immobilization stress blunted the E2-induced increase in Ob-Rb and SOCS3 levels. These results suggest that chronic stress counteracts E2 effects on leptin signaling in the MBH without altering body weight.

Effects of immobilization stress and hormonal treatment on nociception

The purpose of this study was to evaluate the effects of stress and estradiol (E2) on pain tolerance. Ovariectomized rats were assigned to treatment groups based on a 2 x 4 factorial design comprising stress (nonstress x stress) and hormone treatment vehicle x E2 [0.25 mg/kg/d]) x estrogen receptor alpha (ERalpha)-selective agonist propyl pyrazole triol (1 mg/kg/d) x estrogen receptor beta (ERbeta)-selective agonist diarylpropionitrile (1 mg/kg/d). Stressed animals underwent daily 60-minute immobilization for 22 days. Pain tolerance was assessed with the hot plate test, an acute thermal pain test. In this study, stressed rats showed increased (P < .05) pain tolerance compared with nonstressed rats (25.0 +/- 1.92 s vs 20.4 +/- 1.02 s, respectively). Increased (P < .05) pain threshold was observed in nonstressed and stressed rats treated with E2 and the ERalpha agonist compared with vehicle-treated rats. Interestingly, the ERbeta agonist only increased (P < .10) pain thresholds in stressed rats. Stressed rats exhibited higher (P < .05) beta-endorphin levels compared with nonstressed rats in all hormone-treatment groups. With the exception of stressed rats treated with the ERbeta agonist, there was no hormone effect on beta-endorphin levels. These studies suggest that E2's effect on pain thresholds may be mediated via the ERalpha, while the interaction between chronic stress and ERbeta may also enhance pain threshold.

Postovariectomy weight gain in female rats is reversed by estrogen receptor alpha agonist, propylpyrazoletriol

OBJECTIVE

The objective of this study was to distinguish the role of specific estrogen receptors (ERs), ERalpha and ERbeta, on body weight regulation using a rat model of weight gain subsequent to menopause.

STUDY DESIGN

Ovariectomized rats were utilized as the animal model to simulate the postmenopause weight gain. The rats were ovariectomized and subcutaneously injected daily with vehicle, estradiol-17beta (E2), propylpyrazoletriol (PPT; ERalpha agonist) and diarylpropionitrile (DPN; ERbeta agonist). To further control for the possible effect of estrogen secreted from adrenals, a second experiment was conducted during which the rats were adrenalectomized and ovariectomized.

RESULTS

Ovariectomy significantly increased (P < .05) body weight, whereas treatment of ovariectomized rats with E2 and PPT, but DPN decreased (P < .05) body weight. The results from the second study with ovariectomized/adrenalectomized rats were consistent with the first experiment.

CONCLUSION

These results suggest that the activation of ERalpha is important in regulating body weight.