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Veteran means a person who served in the active military, naval, or air service and who was discharged or released under conditions other than dishonorable.

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Why Nurses Need to be Aware of Military Culture when Caring Veterans? (Part. 1)

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Why Nurses Need to be Aware of Military Culture when Caring Veterans? (Part. 1)

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Although all discharged, injured, or ill military personnel could be eligible to receive care from a Veterans Affairs (VA) hospital, it may not be practical due to the financial burden of copayment, distance from the VA location, and limited specialty services, so many seek care in civilian hospitals across the United States. Civilian hospitals are well-equipped to provide the technical and medical care needed, but few are prepared to provide holistic care of military personnel based on their unique values, principles, beliefs, and customs. Some veterans may feel uncomfortable seeking care in these hospitals, because they do not understand the military culture.
However, nurses are expected to communicate and interact effectively with a broad range of clients with varied cultural origins and to work within their cultural context. Therefore, nurses need to understand the health concerns and challenges associated with military veterans and their families to enhance efficient care because they are frontline health care providers who can make a difference in veterans' lives. Nurses also need to understand that military cultural influence includes people beyond those who have worn a uniform. People who are directly influenced by military culture include: uniformed service members, civilian defense employees, veterans, and their families. By understanding the military culture, nurses can provide health care services to many people who are affected by the culture besides the veterans.

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Understanding Military Culture for Mental Health and Nursing Care (Part. 2)

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Understanding Military Culture for Mental Health and Nursing Care (Part. 2)

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Military culture affects all veterans after the discharge. Understanding the influence of military culture upon health-related behaviors will help the nurse appropriately plan treatment to help the veteran.

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Richard J. Westphal, PhD, PMHCNS-BC, APRN
Sean P. Convoy, DNP, PMHNP-BC

With over 13 years of war and military combat operations, the number of veterans, military families, and service members with mental health needs continues to increase across civilian and federal healthcare services. Knowledge about severe battle wounds, traumatic brain injury, and traumatic stress has influenced the delivery of healthcare. The invisible wounds of war associated with brain injury and traumatic stress will increase clinical care challenges into the foreseeable future. The purpose of this article is to describe two interrelated concepts, military cultural competence and stress injuries. The authors also differentiate stress reactions versus stress injury. Nurses with military cultural competence and knowledge about stress injuries will be better able to deliver patient-centered care to patients with military culture experiences.

Citation: Westphal, R., Convoy, S., (January 31, 2015) "Military Culture Implications for Mental Health and Nursing Care" OJIN: The Online Journal of Issues in Nursing Vol. 20, No. 1, Manuscript 4.

DOI: 10.3912/OJIN.Vol20No01Man04
https://doi.org/10.3912/OJIN.Vol20No01Man04

Key words: Military, mental health, cultural competence, military ethos, warrior, veteran, stress injury, trauma, loss, fatigue, moral injury, occupational stress, posttraumatic stress

The Global War on Terrorism (GWOT) officially began on September 11, 2001 ( U.S. Department of State, 2009) and continues more than 13 years later with a shift in focus from direct combat mission to support and training in often dangerous areas of the world. There is yet another American generation whose adolescence and young adulthood has been influenced, and arguably, defined by military culture and war. As of 2012, over 2.5 million women and men have served in GWOT combat with 1.56 million (78%) having left active duty and qualify for government care ( Bilmes, 2013).

Understanding how military culture, policies, and research may influence mental health behaviors, help-seeking, and therapeutic relationships is important to nursing practice in a wide range of settings. Only 41% of veterans who qualify for benefits from Veterans Health Administration (VHA) are enrolled in VHA care ( Kang, 2008). The remainder of veteran's healthcare occurs in civilian healthcare facilities. Understanding how military culture, policies, and research may influence mental health behaviors, help-seeking, and therapeutic relationships is important to nursing practice in a wide range of settings. Healthcare practices are one area where military culture and military healthcare policies have a direct impact on care and treatment across the continuum of care for both veterans and non-veterans.

As in past wars, medical discoveries and knowledge have progressed tremendously over the past decade. This knowledge comes with a significant cost in lives, quality of life, and resources. The mental health impact on post 9/11 veterans alone includes post-traumatic stress (49% for combat veterans); family life strain (48%); anger management problems (47%); and readjustment problems (44%) ( Pew Research Center, 2011).

In 2007, the U.S. Congress appropriated over $600 million to focus on traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD) for military personnel ( U.S. Troop Readiness, Veterans' Care, Katrina Recovery, and Iraq Accountability Appropriations Act, 2007). Annual Congressional funding for research, treatment, mental health promotion programs, and hiring clinical professionals remained near that level for over four years ( Institute of Medicine [IOM], 2014). Long-term goals for this funding were to improve access to care and quality of clinical services, and to promote innovations to improve the quality of life for injured and wounded service members and veterans. These efforts have produced volumes of new data, concepts, and clinical interventions to further understanding and improve the mental health and neurological care of service members and their families.

The purpose of this article is to describe two interrelated concepts that are important for understanding the mental health needs of service members, veterans, and their families. The first concept is military cultural competence. As with other forms of cultural competence, nurses need to identify and understand the needs, help-seeking behaviors of our clients and tailor services that are culturally relevant.

Unfortunately, when healthcare professionals, health policy leaders, and the public look for disorder and illness there are missed opportunities to prevent mental illness and support mental health promotion. Understanding military culture was critical to the development of the second concept; stress injury. Most people recognize that trauma exposure is an occupational hazard for military members. This focus on trauma created a discourse about post-traumatic stress disorder and traumatic brain injury as the signature wounds of the Iraq and Afghanistan veterans ( Tanielian & Jaycox, 2008). Unfortunately, when healthcare professionals, health policy leaders, and the public look for disorder and illness there are missed opportunities to prevent mental illness and support mental health promotion. Nurses working with veterans and their families in a wide range of clinical environments need to be able to assess early signs of stress injury, create opportunities to address stress related functional changes, and account for the impact of stress injuries in treatment planning.

Nurses are expected to communicate and interact effectively with a broad range of clients with varied cultural origins and to work within a patient's cultural context ( Camphinha-Bacote, 2011). Cultural competence training tends to focus on people with ethnic and language influences that impact healthcare literacy and health practices. Military culture includes patterns of beliefs, language, and cultural practices that impact use of healthcare services and health practices.

Military culture includes patterns of beliefs, language, and cultural practices that impact use of healthcare services and health practices. The need to develop healthcare professional training and awareness specific to military culture was identified from an unintended consequence of expanding mental health services. From 2007 through 2010, the Veterans Health Services (VHS) and Department of Defense (DoD) hired over 10,000 mental health and neurocognitive professionals. Most of these new hires had little to no military experience. Many of the new hires adapted quickly and integrated military culture skills into their practice based on trial and error; but many did not. Skilled clinicians who did not incorporate military cultural competencies into practice created an additional barrier to care and help-seeking.

The need for providers with military cultural competence has been identified by service members who received quality, evidenced-based care (e.g., manualized cognitive behavioral therapy), but felt the delivered therapy was not relevant or that their provider did not actually understand the context of military trauma ( Acosta et al., 2014). A young military spouse described, "Sometimes, depending on the situation, it was too difficult to try to take the time to teach them [provider] when we are going to them for help, there were a couple of times where we changed providers because it was frustrating and they did not have an understanding." ( Center for Deployment Psychology, 2014; available: www.deploymentpsych.org/faces-of-military-culture, select "On Cultural Competent Care", Play Video 96). A recent survey of behavioral health and primary care providers in Maryland identified substantial knowledge and confidence gaps related to assessing and treating those with military experience ( Koblinsky, Leslie, & Cook, 2014).

Military culture shapes a shared set of behaviors, beliefs, and values that are learned and reinforced through the lived experience of military service. Nurses need to understand that military cultural influence includes people beyond those who have worn a uniform. People who are directly influenced by military culture include: uniformed service members, civilian defense employees, veterans, and their families ( Convoy & Westphal, 2013). "Military culture can be defined as the sum total of all knowledge, beliefs, customs, habits, and capabilities acquired by service members and their families through membership in military organizations" ( Center for Deployment Psychology, 2014; Select "Take the Course" then select Module 1, p. 21). Military culture shapes a shared set of behaviors, beliefs, and values that are learned and reinforced through the lived experience of military service. People who have not directly experienced the military culture often see the explicit representations of military culture; uniforms and other clothing, customs, training, weapons, media images; and infer how military culture influences service members, veterans, and their families. It is important for nurses and other healthcare professionals to recognize explicit representations of military culture and learn about implicit representations, values, and beliefs, on the health behaviors of those who are members of the military culture.

One area in particular that can be problematic is the tension between the public discourse of military service as heroic and the experience military members and their families have in their daily lives and across their careers. Military service members are often referred to as "heroes" in our public discourse. For those outside of the military culture, many of the characteristics of the military ethos are consistent with the Greek concept of heroes. The rhetoric of heroism often simplifies and misses the complexity of military culture and military ethos.

The rhetoric of heroism often simplifies and misses the complexity of military culture and military ethos. Military ethos is sometimes called the warrior ethos. The term "warrior ethos" is used most often when referring to those trained in the combat arms specialties; military roles that engage an enemy in combat. The term "military ethos" applies to all those who serve in the military and includes diverse roles ranging across many specialties such as, logistical support, medicine, and intelligence. The military ethos reinforces and rewards selflessness, courage, loyalty, stoicism, and commitments to excellence, living by a moral code, and defending the social order ( Coker, 2007; French, 2003; Pressfield, 2011). For some service members, the military and warrior ethos becomes a permanent part of their self-identity and worldview. Figure 1 depicts a U.S. Army soldier's tattoo of the Army Warrior ethos.
Figure 1. U.S. Army Soldier with Warrior Ethos Tattoo

Figure 1. Inscription:
Warrior Ethos
I will always place the mission first
I will never accept defeat
I will never quit
I will never leave a fallen comrade

Photo Credit: Staff Sgt. Stephanie van Geete. Source: www.army.mil/article/27582/ (Public domain)

In many ways, the military ethos is an unattainable ideal that influences daily lives of those who work, live, and have experienced military culture. Someone outside of the military culture may see striving to live by military ethos ideals as heroic, while the person living within the military culture may be acutely aware of their failings to meet those ideals.

Stigma regarding mental illness related behaviors, labels, and behavioral health treatments is strongly influenced by the military ethos. Culturally competent care for service members and veterans may hinge on understanding the extent to which individuals identify with the military ethos. The military ethos values and beliefs have a powerful influence on recognizing and interpreting symptoms, help-seeking behavior, and engagement with healthcare services ( Tanielian & Jaycox, 2008). Stigma regarding mental illness related behaviors, labels, and behavioral health treatments is strongly influenced by the military ethos ( Ben-Zeev, Corrigan, Britt, & Langford, 2012; Hoerster et al., 2005; Vogt, 2011).

The military ethos can be a strength and vulnerability for service members, veterans, and military family members when facing life stress and mental illness symptoms ( Center for Deployment Psychology, 2014; Module 1 Slide 47). Military ethos is a source of strength and resilience when it helps individuals, families, and groups engage resources and leverage emotional and instrumental supports, and promotes hope. Military ethos can be a vulnerability when beliefs act as a barrier to resources, supports, and hope. Table 1 presents some of the strengths and vulnerabilities associated with military ethos traits.
Table 1. Military Ethos Strengths and Vulnerabilities
It is important to recognize that learning about and understanding military culture does not mean that nurses must agree with or support the how the U.S. Government engages the military role. Developing military cultural awareness begins with self-reflection and self-assessment regarding one's own experiences and beliefs about the military, military culture, and those who choose to serve in uniform or as civilian employees of military and veteran organizations. It is important to recognize that learning about and understanding military culture does not mean that nurses must agree with or support the how the U.S. Government engages the military role. Nurses and other healthcare professionals do need to be able to recognize, assess, and understand the degree to which military culture influences a patient or family and how strongly the patient relates to or rejects the military ethos.

Fortunately, many resources related to developing military cultural awareness have been developed over the past few years. One resource in particular is designed to assist nurses and healthcare professionals to move beyond awareness toward cultural competence in clinical practice. Table 2 provides information about a no fee, eight contact hour online course designed to provide core military cultural competencies ( DVA, 2014).

Table 2. Military Culture Training Course
_____________________________________________________________________
Sponsor: Department of Veterans Affairs and the Center for Deployment Psychology
Continuing Education: 8 ANCC Contact Hours. 2 contact hours for each module.
Fee: None
Expires: November 8, 2015
Module 1: Self-Assessment and Introduction to Military Ethos
Module 2: Military Organization and Roles
Module 3: Stressors and Resources
Module 4: Treatment, Resources, and Tools
Weblink: www.deploymentpsych.org/military-culture
_____________________________________________________________________
DVA ( 2014)

TBI and PTSD have been called the invisible wounds of war mainly because there are minimal physical deformities or obvious scars. These wounds are far from invisible, if one knows where to look. The evidence of the wounds is found in diminished quality of life, impaired occupational functioning, loss of family integrity, and myriad physical and cognitive impairments. These invisible wounds can impact the context of care. Combat deployments are associated with increased risk of posttraumatic stress disorder, depression, suicide, substance abuse, and eating disorders that impact between 12% and 23% of those deployed ( Wells et al., 2011). Prevalence rates of mental disorder diagnoses do not capture the broader range of mental health impact that is associated with the military occupation that includes combat deployments; non-combat and humanitarian operations; family separation for training; and international peace keeping roles and reintegration challenges for service members, their families, and military communities. The broader context of behavioral health impact associated with military service can include stress reactions such as impaired sleep, cognitive functions, and relationships; and drug use ( SAMSHA, 2012).

Part of the goal to shift the discourse toward injury was to decrease diagnostic stigma, while increasing recognition that stress injuries were similar to physical injuries in needing immediate care to reduce risk of further harm. To address broader issues of behavioral health impact versus focusing on impairment, the military services developed various programs that focused on stress injury and resilience. These programs were consistent with individual military branch culture. Initially, stress injuries were referred to as combat and operational stress reactions (COSR) or injuries (COSI). Part of the goal to shift the discourse toward injury was to decrease diagnostic stigma, while increasing recognition that stress injuries were similar to physical injuries in needing immediate care to reduce risk of further harm. Nurses working with service members, veterans, and families need to listen for and be ready to use the concept of stress injury. Stress injuries are defined as:

More severe and persistent distress or loss of functioning caused by disruptions to the integrity of the brain, mind, or spirit after exposure to overwhelming stressors. Stress injuries are invisible, but literal, wounds caused by stress, but, like more visible physical wounds, they usually heal, especially if given proper care ( Figley & Nash, 2007; USMC & USN, 2010, p. 1-3).

Hans Seyle's ( 1956) work on the Global Adaptation Syndrome (GAS) provided knowledge and insights that everyone responds to stress as a human physiological event. Stress reactions have both physiological and psychological components. In stress reactions, the stress response will deminish and the person returns to baseline behaviors when the stressor is removed or when the person uses additional coping resources. Stress reactions are normal, expected, and transient.

Typically, people with stress reactions do not need helping interventions or have long-term health issues. A tree branch bending in the wind is one of the metaphors used for teaching patients about the differences between stress reactions and stress injury ( Nash, 2011). Like the prevailing wind, a stress reaction causes a branch to bend but not break. The bending of the branch helps to make it stronger and more resilient. If the force of wind is too strong or the tree already has a vulnerability, there is risk of the branch breaking.

Stress injuries are different from stress reactions in that the stress response stays active after the stressor is removed or does not diminish when additional coping resources are used. Stress injuries are different from stress reactions in that the stress response stays active after the stressor is removed or does not diminish when additional coping resources are used. Stress injuries are often associated with sustained GAS response that is further activated by routine life stressors and often associated with cardiovascular, respiratory and GI system reactivity. Changes in role functions such as difficulty in intimate relationships, decreased work or school performance, and diminished competency in coping skills begin to create additional sources of stress that can exceed in immediacy the original stress injury stressor.

Key behaviors that signal potential stress injury include persistent functional impairment in any of several areas including: sleep, emotions, cognitions, self-calming, anger, memory, enjoyment, moral/ethical decision making, personal safety ( Nash, 2011). Common metaphors used to understand stress injury include a scar from a wound or a tattoo. Scars represent the remnants of a wound that will fade over time but will never disappear. The tattoo as metaphor for stress injury has been useful for helping patients and family members understand stress injury behaviors. The ability to see stress injuries is like seeing tattoos. Some tattoos are hidden and only can be seen by trusted others. Some tattoos peek out from under the edge of clothing to indicate something is there, but not clearly what. Other tattoos vividly declare an image for all to see.

While there are hundreds of different types of stressors that can cause stress reactions, there are four classes of stress exposures identified as sources of stress injury. The four sources of potential stress injury are life threat; loss; wear and tear; and inner conflict ( USMC & USN, 2010; Nash, 2011). A demand-resource imbalance is proposed as the primary pathway from stress reaction to stress injury ( Bates et al. 2010). Demands are stressors that require biological, psychological, social, and spiritual resources to be engaged to meet coping challenges.

The four sources of potential stress injury are life threat; loss; wear and tear; and inner conflict. Acute demand stressors that have the potential to rapidly exhaust or overwhelm coping resources include life threat, loss, and inner conflict. Chronic stressors require that resources be replenished regularly; exhausting resources over time leads to wear and tear. Nursing burnout is an example of a wear and tear stress injury. Most people have adequate coping resources to meet significant stress demands. However, when the sources of stress injury begin to overlap, there are additional demands that may lead to stress injury or stress related illnesses. It is important for nurses to understand that trauma is not the only pathway to stress injury.
Figure 2. Four Sources of Stress Injury

Nash, Westphal, Watson & Litz, 2010, p. 3 (Public domain)
Life Threat - Trauma
It is important for nurses not to assume that a traumatic exposure may be the patient's most problematic experience. Perceiving that your life or the life of someone you care about deeply is at risk, witnessing trauma in person, or repeated exposure to traumatic event details are stressors that place immediate demands on coping resources. This can result in a traumatic stress injury if resources are overwhelmed. The exposure is a potentially injurious event. Functional impairment related to the exposure is the injury. Functional impairment plus intrusion symptoms, avoidance, impaired mood or cognitions, or marked reactivity would be the stress illness of PTSD. Not everyone who experiences any given exposure will develop trauma stress injury or go on to develop PTSD. The concept of exposure, injury, illness can help explain why not everyone who experiences a traumatic event will experience functional impairment or disorder. It is important for nurses not to assume that a traumatic exposure may be the patient's most problematic experience.
Loss - Grief Injury
Loss is the experience of separating from a person, a cherished object, or an ideal before being ready to let go. In many ways, it is the substantial emotional penalty for an early withdrawal. One of the most profound loss experiences is the traumatic death of a loved one. Death as a loss often produces an intense grief response. Grief is the physical, psychological, and spiritual reaction to the perception of loss ( Rando, 1984). Intense grief often results in somatic distress, preoccupation with the deceased, guilt, diffuse anger, and loss of functions in daily living ( Lindemann, 1944). Loss is the potentially injurious event and grief is the stress injury.

...that the traumatic loss of a military buddy, a brother or sister in arms, can be as powerful as the loss of a spouse, parent, or a sibling. In many ways, traumatic loss is one of the clearest examples of a stress injury that is not immediately considered an illness. There is an identifiable stressor that creates an overwhelming demand on coping resources that often results in immediate functional impairment. The common peer response is to immediately provide additional physical, psychological, and spiritual resources. The activation of instrumental social supports is an often used response, depending on the social context of the loss. The expectation is that by augmenting resources the person will be able to "work through" the grief and regain functional skills. Yet, the loss experience has left a scar, an experience that is sensitive to sights, sounds, smells, or a memory that may produce future episodes of functional impairment.

People with grief injuries are often afforded time, resources, and socially sanctioned expectations to facilitate healing. It is important for nurses to understand that the traumatic loss of a military buddy, a brother or sister in arms, can be as powerful as the loss of a spouse, parent, or a sibling. Service members whose role is to deploy in combat will often talk about the bond of love that is forged through training and facing an enemy.

Moral and ethical challenges can create inner conflict. Inner conflict as a potentially injurious experience occurs by, "perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations" ( Litz et al., 2009, p.700). The process of aspiring to live in accordance with military ethos and the harsh reality of combat and disaster experiences are fraught with inner conflict. Inner conflict increases the demand on moral, ethical, and existential resources needed for renewal and reconciliation.

Moral injury occurs when individuals are unable to separate the implications of an event from their own identity. Poor integration leads to guilt, shame, and anxiety and persistent psychological distress, intrusive thoughts, and avoidance of potential triggers ( Litz, et al. 2009). Mental health implications from moral injury include increased risk of self-harm behaviors, ranging from poor self-care though active self-injury; self-handicapping behaviors; undermining successes or feelings of joy and happiness; and demoralization, ranging from persistent sense of hopelessness through active self-loathing ( Litz et al. 2009).

Key words that may indicate the presence of moral injury are: could've, should've, ought'of, and only if. Assessing the presence of moral injury is challenging. Key words that may indicate the presence of moral injury are: could've, should've, ought'of, and only if. Nursing practice implications for recognizing moral injury include understanding that patients may not believe that they deserve care and compassion and may behave in a manner that ensures rejection. For example, a service member who was randomly pulled off of an assignment where his or her replacement was killed may believe that he or she should be dead instead. Additionally, the shame and guilt that can accompany moral injury often requires the development of a trusting therapeutic relationship over time, time that may not be available in many clinical encounters ( Staal, 2004).

Long-term exposure to ongoing stressors from multiple sources without adequate renewal of coping resources is a potentially injurious experience. A single event may not rise to the level of creating functional impairment or injury. Yet, over time, the accumulation of daily hassles, sleep deprivation, poor nutrition, strained social relationships, occupational stress, and loss of self in monotonous daily routines takes a steady toll on physical and psychological health ( Staal, 2004). The demands of repeated deployments; navigating multiple deployment cycles of pre-deployment training and anticipation; deployment strain and worry; and post-deployment reintegration until the next pre-deployment cycle create a baseline of sustained stress for many service members and military families.

In high stress organizations and jobs, the presence of stress injury may be endemic, reducing further the ability to see one's behavior as out of sync. A fatigue stress injury is identified when there are sustained functional changes in important roles, activities of daily living, or reactivity to new stressors. A fatigue stress injury is similar to other forms of chronic occupational stress including burn-out and work-related stress illness. One of the challenges for people who have a fatigue stress injury is to recognize that their behavior is injured. The onset is slow and insidious with subtle changes over time, making it difficult to identify a point where their stress reactions and tolerance changed. In high stress organizations and jobs, the presence of stress injury may be endemic, reducing further the ability to see one's behavior as out of sync.

Principles of nursing care have long recognized the impact of chronic stress on health, illness, and recovery. The nursing implication for working with service members, veterans, and families is to understand that they may not recognize multiple simultaneous stressors as being unusual or problematic. Additionally, it is important to remember that the presence of a fatigue stress injury can reduce the availability of coping resources when trauma, loss, or inner conflict events occur.

The fatigue stress injury can play an important role in delayed responses. For example, the first deployment may have traumatic exposure and loss events. A second deployment experience may have moral injurious events. However, it was the third deployment with seemingly minor or few stressful events that brought all four sources of stress injury into a focus that severely impacted function and quality of life.

Proper diagnosis and the delivery of quality care does not change because a patient or family has military culture related experiences, injuries, or health problems. What does change is the context that those who have lived and worked within the military culture may bring to the healthcare experience and the therapeutic relationship. It is important that nurses be able to recognize the influence of military culture, given the potential strengths and vulnerabilities that the military ethos can interject in expression of symptoms, help-seeking behaviors, or the willingness to stay engaged in treatment.

The language of psychological health and mental disorders has been shifting within the military services since 2007 ( USMC & USN, 2010; Meredith, et al., 2011).To assess and understand potential mental health issues for patients influenced by military culture, it is important to be knowledgeable about the concept of stress injury. Identifying the presence of one or more sources of stress injury, and knowledge about which source of stress injury is dominant in the patient current life experience, has potential to improve diagnostic accuracy and facilitate true patient-centered care versus diagnosis-centered services.

Richard J. Westphal, PhD, PMHCNS-BC, APRN
Email: rjw5a@virginia.edu

Richard J. Westphal, PhD, PMHCNS-BC, APRN is a Professor of Nursing at the University of Virginia, School of Nursing in Charlottesville, VA. He is a retired Navy nurse with over 32 years of military service as a Hospital Corpsmen; a mental health clinician serving Sailors and Marines; educator of psychiatric technicians and healthcare professionals; co-author of the Department of the Navy Maritime Combat and Operational Stress Control (COSC) Doctrine; co-author of the Combat and Operational Stress First Aid (COSFA) program; and a psychological health programs and policy advisor to the Navy Surgeon General and the Marine Corps COSC program.

Sean P. Convoy, DNP, PMHNP-BC
Email: sconvoy@vcu.edu

Sean P. Convoy, DNP, PMHNP-BC is an Associate Professor of Nursing at Virgina Commonwealth University's Graduate School of Nursing in Richmond, VA. He is a retired Navy nurse with over 22 years of military service as an advanced practice clinician and military leader. In a wide variety of innovative roles and assignments, he has been a pioneer advancing Psychiatric - Mental Health Advanced Practice Nursing role function within the Department of Defense.

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Wells, T. S., Miller, S. C., Adler, A. B., Engel, C. C., Smith, T. C. & Fairbank, J. A. (2011). Mental health impact of the Iraq and Afghanistan conflicts: A review of US research, service provision, and programmatic responses. International Review of Psychiatry, 23(2), 144-152. doi:10.3109/09540261

© 2015 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2015

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Military Culture Implications for Mental Health and Nursing Care

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Richard J. Westphal, PhD, PMHCNS-BC, APRN Sean P. Convoy, DNP, PMHNP-BC With over 13 years of war and military combat operations, the number of veterans, military families, and service members with mental health needs continues to increase across civilian and federal healthcare services.

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Veteran Homelessness Statistics from 2010 to 2020

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Veteran Homelessness Statistics from 2010 to 2020

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Click the bullet point "Total Veterans Experiencing Homelessness" to see the number of veteran homelessness

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As of January 2020, Virginia had an estimated 5957 experiencing homelessness on any given day, as reported by Continuums of Care to the U.S. Department of Housing and Urban Development (HUD). Of that Total, 621 were family households, 395 were Veterans, 234 were unaccompanied young adults (aged 18-24), and 813 were individuals experiencing chronic homelessness.

Public school data reported to the U.S. Department of Education during the 2018-2019 school year shows that an estimated 20443 public school students experienced homelessness over the course of the year. Of that total, 185 students were unsheltered, 1937 were in shelters, 3262 were inhotels/motels, and 15059 were doubled up.

Use our map to compare Virginia homeless statistics with other states and filter statistics by the data source. You can also find contact information for each state under the map.

If you are experiencing homelessness, please contact the Continuum of Care in your local area for assistance.
Need to update your state's contact information?

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As of January 2020, Virginia had an estimated 5957 experiencing homelessness on any given day, as reported by Continuums of Care to the U.S. Department of Housing and Urban Development (HUD). Of that Total, 621 were family households, 395 were Veterans, 234 were unaccompanied young adults (aged 18-24), and 813 were individuals experiencing chronic homelessness.

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Importance of Family when Caring for an Individual Veteran

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Importance of Family when Caring for an Individual Veteran

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Family care is very important when caring for an individual veteran. Family can affect individual s’ health and development of well-being. Healthy family can communicate well with one another when they listen, use nonverbal messages to express feelings and care, and cooperate to solve problems. A family that collaborates to create this positive environment can achieve a healthy family through comforting and healing processed.
Moreover, family health routines are strongly related to behaviors with disease risks for patients. For instance, food consumption influences greatly on wellness or disease management. If a family does not change its dietary plan that increases risks of worsening health conditions, it will affect all members of family’s health. It will be difficult to change the individual and family health routines in a short time, but they must work together to stop the bad habits. Therefore, nurses should recognize family as the unit of care because it will help them to “understand that shared lives, resources, and identities play active roles in one another’s health or illness. Family contributes the most in patients’ recovery by playing active roles in one another’s health.

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Homelessness and a Nursing intervention 

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Homelessness and a Nursing intervention 

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Veterans are at greater risk for homelessness than non-veterans. One of the reasons was a dishonorable discharge. According to researchers with VA’s Salt Lake City Health Care System and National Center on Homelessness Among Veterans (NCHAV) (2021), 5.6 percent of Iraq and Afghanistan Veterans between 2001 and 2012 were discharged for misconduct, usually related to drugs and alcohols. The VA (2021) also found out that they accounted “for 28.1 percent of those who became homeless within a year of their discharge”. Dishonorable veterans lose all veterans’ benefits and are forbidden from working for the government and taking out bank loans. Without all these benefits, most of them are at high risk of being homeless. As a matter of fact, another study by the Department of Veteran Affairs, veterans without benefits are much more likely to become homeless (Ismay, 2016). Also, because they were given a dishonorable discharge, they are not eligible for either disability compensation or health care benefits. This can deteriorate their health issues because they will have hard time finding jobs and do not have any financial resource to cover their disabilities. Moreover, veterans with military sexual trauma (MST) are at high risk of homelessness. Researchers at VA’s Salt Lake City Health Care System and VA’s National Center for PTSD (2021) reported that “1.6 percent of veterans were homeless within 30days of leaving the military”, and this number more than doubled within a year and hit 9.6 percent after 5 years, which is double rate for veterans without MST. They can have physical health problems, use alcohol or drugs to escape from negative feelings, and feel unsafe, which all can hinder them from starting a new life. Fortunately, VA (2022) provides MST-related outpatient services to every VA medical center and treat them so that they can recover and find their lives.

One of nursing interventions for homelessness is that nurses provide health services and work as a team to address different needs of veterans while social workers and others help find housing. For example, VA (2021) has a homeless program called Homeless Patient Aligned Care Teams (HPACTs) that creates a collaborative homeless medical home modeling. HPACTs include a social worker, medical staff, mental health and substance use counselors, nurses, and homeless program staff. It assists homeless veterans by providing housing and social services and medical care. Social workers outreach these homeless veterans and increase their access to needed care. Medical and homeless program staff engage “veterans in intensive case management that is coordinated with community agencies for continuing care,” including food and clothing assistance, showers, laundry facilities and other services on-site (O ’Toole, 2021). Nurses provide direct nursing care with nursing assessment, implementing intervention and monitoring outcomes. They also plan and schedule community homeless outreach nursing visits in HPACT clinics. Mental health and substance use counselors treat their mental and emotional disorders and promote overall mental health. With each professional’s help in their positions, HPACT can eliminate barriers to “accessing quality health care by incorporating social detriments of health into care delivery, and to fast-track permanent housing placement” (AHRG, 2017).

Reference:

American Homefront Project | By John Ismay. “'Bad Paper' Discharge Can Lead to Homelessness, Hopelessness.” The American Homefront Project, 17 May 2021, https://americanhomefront.wunc.org/2016-04-06/bad-paper-discharge-can-lead-to-homelessness-hopelessness.

“VA Homelessness: Homeless Patient Aligned Care Teams.” AHRQ, https://www.ahrq.gov/workingforquality/priorities-in-action/va-homelessness.html.

VA National Center on Homelessness among ... - Va.gov Home. https://www.va.gov/HOMELESS/docs/H-PACT-Program-Brief.pdf.

“Va.gov: Veterans Affairs.” MST-Related Treatment and Support | Resources for Veterans, 7 Jan. 2019, https://www.mentalhealth.va.gov/msthome/treatment.asp.

“We're Here Anytime, Day or Night - 24/7.” Homelessness, https://www.research.va.gov/topics/homelessness.cfm#research1.

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The Civilian Health and Medical Program of the Department of veterans Affairs (CHAMPVA)

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The Civilian Health and Medical Program of the Department of veterans Affairs (CHAMPVA)

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VA provides health care not only veterans but also their family members. But VA health care coverage is only available for certain family members whose veterans are permanently disabled or died serving our nation. Under the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA), VA covers most health care services and supplies that are medically and psychologically necessary. CHAMPVA is often mistaken with the Department of Defense (DOD) Tricare program that manages health care program for active and retired members and their families. Therefore, if you are to be eligible for Tricare, you can not be in CHAMPVA. They can deliver medications by mail right to your door if it is not urgent maintenance.

Beneficiaries of the CHAMPV can also receive pharmacy benefits through a local retail pharmacy in the OptumRx network. How they work is that pharmacies in the OptumRx network will collect your 25% cost share/copay along with the annual deductible and send the claim to CHAMPVA for the remaining amount

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Civilian Health and Medical Program of VA (CHAMPVA)

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Various Veterans Programs for Health and Wellness

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Various Veterans Programs for Health and Wellness

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VA provides different programs for health and wellness to help veterans maintain their healthy body and mind.

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Veterans programs for health and wellness | Veterans Affairs

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Learn about Veterans programs for health and wellness. Get help through VA programs to quit tobacco use, prevent disease, manage your weight, and maintain your mental health.

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Spouse and dependent children can get money for tuition, housing, and books and supplies.

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Transferring the Veteran's Education Benefits to their Dependents

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Transferring the Veteran's Education Benefits to their Dependents

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If a veteran meets the qualifications above, the Department of Defense (DOD) can approve the Transfer of Entitlement, and the veteran's spouse or dependent can apply for up to 36 months of benefits.

Reference:
Transfer your post-9/11 GI bill benefits. Veterans Affairs. (n.d.). Retrieved April 23, 2022, from https://www.va.gov/education/transfer-post-9-11-gi-bill-benefits/

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The Difficult Transition from Military to Civilian Life (Part. 1)

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The Difficult Transition from Military to Civilian Life (Part. 1)

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Various factors during transition to civilian life pose challenges for the men and women who have served in the military.

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Common Challenges During Re-adjustment to Civilian Life

Civilians may not be aware of the unique challenges that separating from military service and returning to civilian life can present. In this handout, we highlight some of these challenges. Veterans may find difficulty:

Relating to people who do not know or understand what military personnel have experienced (and many civilians don't know that they don't know!).

Reconnecting with family and re-establishing a role in the family.
Families may have created new routines during absences and both the family and the Veteran will have to adjust to changes.

Joining or creating a community.
When moving to a new base or post, the military helps military personnel and families adjust. This structure is often not automatically in place when someone separates from the military. The Veteran and his or her family may have to find new ways to join or create a social community.

Preparing to enter the work force.

A Veteran may have never looked for, applied for, or interviewed for a civilian job, especially if he or she had a career in the military. These are new skills he or she will have to learn and master.

In applying for a job, a Veteran will have to determine how to translate his or her military skills and duties into civilian terms and create a resume.

A Veteran may have never created a resume. Instead of a resume the military uses a Field Service Record to detail qualifications, training, and experience.

Returning to a job.

If deployed with the National Guard or Reserve, a Service Member will have to adjust to resuming their previous job or another similar job at the same company. For some recently returning Service Members, they may find themselves behind a desk in as little as 3 days after leaving a combat zone.

Returning to the job may include a period of catching up, learning new skills, or adjusting to a new position. It will also include adjusting to social changes that may have occurred in the workplace.

During the transition back to work, some Veterans also experience worry and fear about possible job loss.

Creating structure.
The military provides structure and has a clear chain of command. This does not naturally exist outside the military. A Veteran will have to create his or her own structure or adjust to living in an environment with more ambiguity.

Adjusting to providing basic necessities (e.g., food, clothing, housing).

In the military, these things are not only provided, but there is often little choice (e.g., you eat at determined times in a certain place, duty station determines your dress).

Given the lack of choices while in the military, the vast array of choices in the civilian world can sometimes be overwhelming.

Adjusting to a different pace of life and work.

In the military, personnel do not leave until the mission is complete. In a private sector business, an employee might be expected to stop and go home at 5pm, whether the "mission" is complete or not. This may not be apparent to all Veterans.

Civilian workplaces may be competitive environments, as opposed to the collaborative camaraderie of the military.

Given the direct nature of communication in military settings, there may be subtle nuances in conversations and workplace lingo that are unfamiliar to Veterans.

Establishing services.

A Veteran may have to learn how to get a doctor, dentist, life insurance, etc. These services were previously provided by the military.

A Veteran may also need to navigate the paperwork and process of obtaining benefits and services from the Department of Veteran Affairs.

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common challenges during re-adjustment to civilian life

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Civilians may not be aware of the unique challenges that separating from military service and returning to civilian life can present. In this handout, we highlight some of these challenges. Veterans may find difficulty: Relating to people who do not know or understand what military personnel have experienced (and many civilians don't know that they don't know!).

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Specific factors that make some veterans have a hard or easy time readjusting to civilian life (part. 2).

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Specific factors that make some veterans have a hard or easy time readjusting to civilian life (part. 2).

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Pew Research Center used a logistic regression to examine the impact on transition of 18 demographic and attitudinal variables. These 4 variables were found to demonstrate that veterans would have an easier time readjusting to civilian life, while the veterans with the other 6 variables would show a difficult re-entry experience.

Reference:
Morin, R. (2020, May 30). The difficult transition from military to civilian life. Pew Research Center's Social & Demographic Trends Project. Retrieved April 23, 2022, from https://www.pewresearch.org/social-trends/2011/12/08/the-difficult-transition-from-military-to-civilian-life/

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Personal Interview with the Veteran (Part. 3). 

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Personal Interview with the Veteran (Part. 3). 

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I interviewed my fellow veteran who served with me when we were stationed in South Korea in 2016. His transition to civilian life was not as easy as he thought. One of the reasons was that he was having difficult time adjusting to the civilian job because it was very different from the military. The civilian job was very profit-orientated while the military was family-oriented. For instance, his wife had two miscarriages after the marriage, one in the military and the other in the civilian life. When she had a miscarriage in the military life, his chain of command understood his family situation and let his battle buddy cover his place so that he can focus on taking care of his family without any penalties. But when she had a miscarriage in the civilian life, his leaders understood his situations but deducted his wages and leave days for time he was absent for taking care of his wife. He says that he still struggles, but many of military benefits like the Veteran Disability Compensation and health care, help him and his family survive and made his transition easier. He was entitled to 80% disability rating, which is worth $1,926.69 per month. VA also covered his wife’s pregnancy care, which encouraged his family to have another baby after the discharge. The GI Bill also helped him because he had been taking some courses since the last year he served in the military, which provided him a basic housing allowance with a full tuition for his college. He also said that his veteran status itself helped him transition to civilian life because he found his first job just because he was a veteran.

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Some of Nursing Interventions for the Rising Suicide Rate

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Some of Nursing Interventions for the Rising Suicide Rate

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First, nurses should be aware of common assessment findings in veterans at high risk of suicidal attempts. Some of them are signs of depression, anxiety, low self-esteem, or helplessness. According to the Veteran Affairs department, they may change their behavior, such as poor performance at work and acting violently and do things to prepare for a suicide (like giving away special personal items, making a will, or seeking access to guns or pills).
Therefore, it is important to have a thorough assessment of the patient and maintain environmental safety. Nurses can assess risk for suicide, monitor patients at risk, and document the assessments and outcomes of intervention. They should also provide a brief and concise report to other clinicians and the treatment team for the appropriate care and intervention because they should continue to develop a plan of care with the interprofessional team. When evaluating the care of outcomes, nurses continue to document suicide risk thoroughly during hospitalization. Documenting risk level during hospitalization and at discharge at key times will demonstrate how effectively nurses care veterans for their suicidal prevention.

Reference:
Veteran suicide prevention. (n.d.). Retrieved March 5, 2022, from https://www.va.gov/health-care/health-needs-conditions/mental-health/suicide-prevention/

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The most interesting reason for this rising suicide rate for veteran was that veterans found an apathy for by the American public. Veterans did not feel supported, which led to mental distress and suicidal thought. Some of the other reasons are trauma and stress, difficulty reintegrating into civilian life, and economic disparity.

According to 2020 National Veteran Suicide Prevention Annual Report by U.S. Department of Veteran Affairs (2020), the rate of suicide among veterans was 32.0 per 100,000 while that of nonveterans was 17.2 per 100,000. This rate shows that the suicide rate for veterans is almost twice higher than that of the nonveterans.

Reference:
2020 National Veteran Suicide Prevention Annual Report. (n.d.). Retrieved March 5, 2022, from https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf

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Report: Suicide Rate Among Post 9/11 U.S. Service Members Climb

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Military Sexual Trauma as a Risk Factor for Suicide Mortality

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Military Sexual Trauma as a Risk Factor for Suicide Mortality

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The study in this article provides important evidence for the impact of MST on the risk of suicide among veterans.

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Military Sexual Trauma and Suicide Mortality

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The Veterans Health Administration health system uses a clinical reminder in the medical record to screen for military sexual trauma. For more than 6 …