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SPECIAL ARTICLE-JOINING FORCES

Mothers going to war: The role of nurse practitioners in the care of military mothers and families during deployment

Agazio, Janice PhD, CRNP, RN, LTC1; Hillier, Shannon L. DO, MPH, LT2; Throop, Meryia PhD, DNP, FNP, LTC3; Goodman, Petra PhD, RN, COL4; Padden, Diane PhD, CRNP, FAANP5; Greiner, Shawna CRNA5; Turner, Annette MSN, RN1

Author Information
Journal of the American Association of Nurse Practitioners: May 2013 - Volume 25 - Issue 5 - p 253-262
doi: 10.1111/j.1745-7599.2012.00811.x
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Abstract

The deployment of military women with children in support of wartime operations is a fairly recent phenomenon. Until 1976, most military women who became pregnant, or had children, were automatically discharged from the military unless they obtained a waiver or were given the option to move to the reserve force (Vuic, 2010). Later, during Operations Desert Storm/Desert Shield in the first Gulf War, women with children were deployed for the first time in a wartime operation, but for a relatively short, intense conflict. The recent prolonged wars in Iraq (Operation Iraqi Freedom[OIF]) and Afghanistan (Operation Enduring Freedom[OEF]), have, for the first time, seen military mothers deployed in large numbers for extended and repeated deployments.

Military women include any woman, either officer, warrant, or enlisted, who may be on active duty, or in the reserves or National Guard, of the U.S. Army, Air Force, Navy, or Marine Corps. Currently, about 203,000 women, or 14% of the total military force, are considered on active duty, meaning serving fulltime in uniform (Department of Defense [DOD], 2010a).

Military mothers are those military women, single or married, who are responsible or caring for children under 18 years of age in their home. Often these children are natural born, but may include adopted children, stepchildren, or extended family members (i.e., younger sibling) for whom they provide primary residence and care. According to a 2009 report of Iraq and Afghanistan Veterans of America, more than 40% of women in the military have children and at least 30,000 single mothers have been deployed over the past 10 years of wartime operations (Mulhall, 2009). Further, it is estimated that over 135,000 military women have deployed at least once during that period and some multiple times to both Iraq and Afghanistan. About half (46.3%) of the active duty women are married and about 42,000 are married to other active duty service members. Approximately 22,511 women in the reserve component are also married to other reservists (DOD, 2010b). The Defense Manpower Center reports that in the four main service branches, as of 2008, there are at least 70,969 women with children on active duty and 54,611 in the selected reserve (Defense Manpower Data Center, February 2009, Personal communication).

Previous research has focused upon the more common father separations, so little has been known about how a military mother's deployment is experienced. Recent studies have indicated that there are unique and at times unexpected concerns and issues that may arise for deployed mothers, children, and caregivers during deployment. Military life places unique stressors on families. These include “separation, risk of injury or death of the service member, long work hours and shift work, frequent relocation, unique organizational culture and norms, and family separations due to military deployments, unaccompanied assignments, field exercises, and training” (DOD, 2010a, p. 8). For those who are active duty, or live close to military facilities, the military often provides services and resources to support the military member and family members in a community familiar with the organizational culture and deployment stressors. Yet, for those who may deploy from the reserve component, resources may not be as available and the community may not be as aware or familiar with the issues inherent during the deployment experience. Nurse practitioners (NPs) may encounter military mothers and their families as the family experiences the deployment from initial notification through preparations to leave, to returning home from war. For some this may include days to months of preparation and months to well over a year of separation of mother and child. This article will describe the experience of military mother deployment along with clinical implications for NPs in military or community settings.

Stages of deployment

In the literature, deployments have been described as being experienced in stages from preparation through reintegration, when the military member returns. Each stage represents different stressors and adjustments for the military member and family members left behind. As the family learns of an impending deployment, the first stage, Pre-deployment, occurs over a 1- to 2-week period marked by tension, protest, and anger. During this stage, preparations are made for deployment; family members feel “on edge”; and the deploying mother may exhibit some emotional and physical withdrawal in anticipation of the separation. The service member and family may experience prolonged absences during the preparation with increased training and administrative requirements, such as firing weapons and preparing wills. As departure becomes imminent, the family may experience more Detachment and Withdrawal, as family members feel increasingly frightened by the impending loss of the military member. Increased emotional detachment in varying degrees by each family member is often reported as a protective mechanism. The second stage, Deployment, is marked by Emotional Disorganization, occurring during the first 6 weeks following departure and characterized by symptoms of sadness, despair, tension, depression, and sometimes even relief that the deployment has finally occurred after such a busy time of preparation. Wives of male service members usually remark upon feeling overwhelmed by having all the responsibility for parenting and household management during this initial adjustment period. However, once the deployment occurs, families learn how to adjust to the separation and establish communication lines with the deployed parent.

During deployment, communication is seen as a lifeline, as all activities may stop to hear the voices of those who are on deployment and those who are home. Rarely can a spouse initiate a call, but rather must wait for a call, often at a predesignated time for an extremely limited period perhaps only lasting minutes. Written communication is coveted, and often shared with others, such as children, parents, and friends of the service member. More recently as the “theater of operation” or footprint of the military presence has stabilized over time, e-mail and Voice-over-Internet programs (VIOP) have emerged as media to increase and normalize contact with the deployed service members' families.

As the deployment nears an end, the service member and family again experience turmoil in the Redeployment stages marked by Anticipation of Homecoming when focus shifts to reuniting the military member with the family. The stage of Reunion/Post-deployment begins upon arrival of the military member home and then up to 6 weeks following as the family becomes a family again, reacquainted with each other, negotiating changes in roles, reestablishing intimacy, and responding to perceived changes in each other (Peebles-Kleiger & Kleiger, 1994).

In a recent study, Agazio, Padden, Throop, Goodman, and Ricciardi (2012) used the stages described by Peebles-Kleiger and Kleiger (1994) to conduct interviews to trace the trajectory of the deployment for military mothers and the separation from their children. Following institutional review board approval, 37 active duty and reserve component women from all three services who had deployed one or more times in OIF/OEF participated in a grounded theory research study. Their interview data are used as the basis of the recommendations provided in this article and will be organized using the stages model. Some of their quotes are included to illustrate the experience in their own words.

Pre-deployment

Most military women know they will be deploying several months before the actual departure date. Some units are deployed together so that members are able to train and prepare ahead of time personally and with their families. Others however may experience a short time line that may cause a high level of stress for the individual as well as for the family in the rush to be ready to leave. Multiple activities must be completed simultaneously beforehand. Before deployment, service members usually participate in training at the duty location and perhaps at a deployment station that may require leaving for several weeks at a time or even relocating early before the actual deployment. On the home front, mothers need to insure that powers of attorney, identification (ID) cards, and care plans are in place for any dependent children. Since 40% of married military women are married to other service members, most expect their spouse to care for the children during her deployment. Many women in the study indicated that they also arranged additional childcare hiring nannies and au pairs, enrolling in a childcare center, or asking family members to share some responsibilities during the deployment. Single parents most often asked their parents, or a parent, to assume responsibility for the children while they were deployed. This meant often relocating children to different cities, away from military resources, sometimes much earlier than the deployment date, to ease integration at new schools or daycare.

NPs encountering military mothers during this period can assist in many ways. Any deploying service member will receive required immunizations and health screening from the military healthcare providers to be cleared for the deployment, but military women may also benefit from seeing their regular healthcare provider to discuss menstrual suppression, contraception choices, and management of any ongoing chronic health issues. This management may include providing enough medication for what is currently a 4- to 6-month usual deployment time frame as it may be uncertain if there will be adequate stock for refilling prescription medications depending on unit location. Many women choose to use a means of menstrual suppression while deployed since management of monthly cycles is difficult in the deployed environment (Trego, 2007; Trego & Jordan, 2010). Supplies are limited, uniform gear is cumbersome, job demands, discomfort because of elements such as heat, sand, and use of portable toilets all combine to make menstruation difficult to manage. Not only can the NP use a predeployment appointment to assess for concerns and issues, but the time can also be used to assess and educate regarding the environmental challenges for personal hygiene. Suggested areas to include in the assessment of the military mother are included in Table 1.

Table 1
Table 1:
Mother screening sample questions: How do you think your relationship has changed with your children and spouse? What do you feel about leaving/being gone/return home?

NPs can also provide guidance if the mother is having concerns related to her child's well-being during the deployment. Deploying mothers report that care should be taken by the healthcare provider to avoid making judgment statements such as “I could never leave my child like that”; “What will you do if you get hurt?”; or “Why don't you consider getting pregnant so you do not have to go?” Questions such as “When do you think you might leave and then return? What have you done so far to prepare? Do you know where you are going and if they have the Internet or e-mail? What can I do to help you? Your child? Your caregiver?” are more helpful and give a sense of genuine concern for the well-being of the military mother and her family.

Selecting and planning reliable care for their children poses increased stress for the mothers during this predeployment period. By identifying parents early who are in the reserves or on active duty, NPs may find it useful to include potential for deployment in the initial and ongoing history so that intervention and education can begin before deployment notification. Providing copies of immunization records, well child appointments and acute/routine physical exams can assist mothers in providing information to designated caregivers (father, grandparent, other relatives), especially those who are relocated elsewhere. Time should be given for mothers to express any concerns they may have personally or in regard to their children. NPs can offer reassurance and strategies the mothers can use to maintain contact and a relationship with their children. In addition, NPs should encourage mothers to reach out in their communities and circle of friends for additional support for their family while they are gone. One mother dubbed this “summoning the village” as she noted “It takes a village to raise a child,” "… I won't say it was easy because it surely wasn't easy, but it was easier because I had my Village People.” This particular mother sent out e-mails to everyone she knew and garnered wonderful help for her husband for respite evenings and weekend carpooling. Her “Village People” and “rescued” her husband on a regular basis. Mothers sometimes need to be reminded that they do not have to “do it all” and to reach out because they will find others who will step up and help out during their absence.

Many mothers in the study expressed concerns that children would forget them while they were away, especially for younger aged children.

Now, for me, leaving was extremely difficult because she was two and a half. Anyway, my big fear was that I would leave and come back and she wouldn't remember me.

(Mother of a 13-month-old) I wanted the baby to know who I was. I didn't want her to reject me when I came back. I was worried about how my son would do in school.

These concerns are real and often speak to some feelings of guilt for leaving their children. Having a plan to communicate over the course of the deployment seems to help all of the children, no matter the age, to recognize and reconnect with the mom on her return. A plan can also be made to involve the mothers while they are away and perhaps even to meet the primary caregiver before the deployment. This connection could open the door to begin a relationship with the children's caregiver as this person may also need some emotional support during the deployment.

Providers can also help deploying mothers in identifying the documents that will be needed to maintain access to care especially if the designated caregiver will be using nonmilitary healthcare facilities. Active duty families have access to military facilities worldwide, but reserve component families may primarily have insurance coverage through civilian employment. While activated for deployment, reservists are eligible for Tricare benefits, but this insurance may not be accepted by the child's usual provider. Additionally, if the designated caregiver is a grandparent located away from military facilities, the military parent needs to insure proper power of attorney documents are in place as well as military ID cards, and enrollment in the Defense Enrollment Eligibility Reporting System (DEERS) to insure that the child will have access in the military parent's absence. Several mothers related some situations when they learned their children had been disenrolled causing some additional worries about any injuries or illness that could have happened to require medical care while they were deployed.

My oldest one got dis-enrolled from TRICARE, randomly, this last deployment…he needed to get immunizations to start school. Randomly, he got dis-enrolled from TRICARE, but because he was my dependent, even though his father is active duty, they would not allow him to re-enroll him. He had to scan and email me the application. I had to fill it out and mail it back [from Iraq].

Providing an e-mail or setting up a Skype or other web connection would allow the mothers to reach out regarding any concerns about the child's health and receive anticipatory guidance for normal child development and issues as well as for behavior that may be related to the deployment separation. Depending on location and time zone, a web-based connection could be set up so that mothers could actually participate in the appointment.

Mothers in the study related that during deployment their children had experienced issues in acting out behavior, regression, withdrawal, tearfulness, and sometimes developmental delays such as speech and reading difficulties emerged. They were at a loss to intervene and were upset even after the deployment that many times these issues were not addressed until after they returned. Having a relationship with a provider and a means to communicate would have gone a long way to alleviating concerns and allowed for earlier intervention in these circumstances.

Mothers facing a deployment may sometimes start to distance themselves from their children as a protective mechanism in facing the impending separation and also to allow them to focus upon the upcoming mission in the wartime environment.

And I definitely noticed that once I got my orders I started finding other things, not consciously, but I was suddenly finding other things to do at night when it was time to read them a bedtime story, for example. I would be folding laundry and [husband] would be doing it. And that made me sad in a way, but I just couldn't – I had to distance, almost, a little bit.

Other mothers have expressed difficulty in temporarily relinquishing “control” and their mothering role to either their spouse or caregiver as they deploy. Typical of this concern, one mother described her experience as she prepared to leave:

I was worried that things weren't going to get done to my standard…everything from how are they going to get dressed, what to get fed, their school work, and soccer, music, all that. But I kind of had to tell myself that once I'm away I won't have control over those matters I'll just have to leave it to the folks, to my husband at that time as well as the nanny.

Having an opportunity to discuss these feelings with a provider would be helpful in, first, venting her feelings as often being unexpressed may just add more feelings of guilt for leaving, and, second, in moving her to some problem-focused coping in setting up alternatives as to how she can continue to “mother” during her physical absence from the home.

As mothers move closer to the deployment date, preparing their children for the separation becomes a paramount concern. Mothers are very careful in crafting their message to reassure children of their love and that they will return home safely. They are also cognizant of the child's developmental level and suggest ways that they will stay in touch with each other during the separation. One mother described the message she gave her children:

I said, “Honey, I'm here because I have to get the bad guys because they want to hurt you and [your brother]. I have to get them put away so that they won't go here and they won't hurt you, but I'm doing this for you, okay? I'm going to be back and I'm going to be home, and I'm going to talk to you every day on Skype just like if I was home. We're going to read, and we're going to talk, and you're going to tell me how your day was.”

Engaging the children in planning for the separation is beneficial. Mothers also noted leaving “reminders” of themselves such as flat Stanley-type standups with their image; pillowcases with their photo; small gifts for the caregiver to use as a surprise memento; DVDs or tapes with storybook recordings and photo books.

I ordered childrens books because [named website] delivers to Iraq, so I ordered … some childrens books and I had…video recording on my camera and I would record myself reading books to her and then, I would send those DVDs back home … so she had a really clear picture of mommy reading a book to her as well.

Providers can use these as suggestions with mothers concerned about the children remembering them in their absence and as ways to actively continue their mothering role. In addition, many resources are available through the Internet that have been developed to help children cope with a parent's deployment (see Table 2). There are also several picture books available for younger aged children as well as novels for school-aged and middleschoolers (see Table 3).

Table 2
Table 2:
Internet resources for deployment and military families
Table 3
Table 3:
Books for younger children about parental deployments

Deployment

At some point in preparing to depart, the deployment date will arrive when the actual separation occurs. At this point, the designated caregivers will assume responsibility for the children while the mothers turn their focus to the work and mission in the deployed environment. Early in a deployment period, or if the location is isolated, communication lines at first may not be as available or reliable, which can increase concerns on the part of the children, caregiver and/or add to the emotional stress for the mothers. Most current deployments do include access to e-mail, Internet-based communication, and phone lines so that many mothers may choose to have daily contact or a scheduled time to contact the family depending on the nature of the unit to which they are assigned. For the mothers in the study, the deployment period was a bittersweet time. Many remarked how difficult it was to miss the child's development and holidays that marked important milestones in their growth and life together.

He started talking, walking, potty training, all that and I missed all of it

When I went to Iraq,…. I missed her first day of kindergarten, losing her first teeth.

Yet, mothers also acknowledged the important work they were doing in the deployment and for their units, patients, host country, and the United States.

It's just the purpose of it and it is our job. Everything my kids get, it comes from the service of my country, so I have to give back to my country. That's how I feel, we're helping each other and this is what we're here for.

During the deployment, communication was critical. Mothers tried to maintain frequent communication and participation, as much as possible, in the life of the family. But at the same time, they recognized that they needed to relinquish “control” so that the designated caregiver could provide the care that they currently could not. This was difficult when they would observe, through Internet-based communication, or perhaps hear comments from friends or family members, of differences noticed in how the children were being cared for while they were away.

I would hear about things over the phone. He [husband] and I were talking—I just tried to let it go and I just had to remind myself that these were not things that were going to kill my children and it needed to not be important because I had to realize that my making an issue of it, it wasn't going to change anything and we—it's just going to be frustrating for me and I'm just going to anger my husband who was doing the best that he could and that wasn't going to be helpful for anybody.

Mothers would also observe care needs and use the Internet to order items such as winter coats and school supplies.

Summer plans, one of the weeks of my son's summer fell through, and I just got on the phone and got on the Internet and got him into a computer camp. I called a 1-800 number from Iraq and got him into a computer camp and got that all set up. My daughter outgrew her crib, and I went online and ordered a toddler bed to be delivered. I sent books and stuff to the kids using [the web]. There really isn't an excuse to say you can't be connected when you have the Internet.

Interactions with her personal healthcare provider may be limited during this time, but if available, most would just want to have reassurance that their children were being well cared for, they were healthy, and they were participating in all their usual activities. “Trying to keep life normal” for the children was a theme that emerged in the study with regularity. It was important to the mothers to know that the children were not missing out on sports, extracurricular activities, or family excursions because of her absence.

I'm pretty close to them so even though I was deployed I talked to them a lot and called frequently. My kids would put me on the speakerphone while playing the piano or they would tell me when their spring flowers were out. You know, tried to have a normal life, so to speak … They would tell me what they were doing. They'd draw pictures and send it to me and vice versa. I sent pictures of me in Iraq and showed them as much as I can show them anyway of my daily routine. So I think it helped them sort of gain some amount of insight of what my life is like. It's not like I'm completely absent. In fact, my middle daughter was—how old was she—twelve at the time, and her statement when I got back was, “Mommy, it's as if you never left.”

During the actual deployment, the most important implications for the NP falls with the care of the family, children, and possibly other relatives or friends who may be the designated caregivers … and communicating that care in some way to the deployed mom. For the women in the study it was not unusual for a health concern to arise during the deployment, which only served to intensify feelings of helplessness when they were so far away. Good lines of communication that include the deployed parent make a difference in reassuring them about the quality of care provided.

She had to have two adenoids taken out and tubes put in. That happened while I was gone and of course, that was just horrible because then, of course, you think of all the horrible things that can go wrong even though it's a nothing surgery, but of course, as a mom, all the thoughts of, “She doesn't understand the surgery. She doesn't understand what's going on. She knows that Mom's just not there.” You know what I mean? What was neat, though, is my mom was really good. She's a nurse, too. They took pictures at the hospital and everything. The surgical team had taken a picture with them and her in her little gown and all that kind of stuff, so they were really good. It was, of course, weeks later that I got the pictures, but they even signed a little card and said, “We're taking very good care of [child name].” What a wonderful staff they had. It was just a local, civilian hospital. In that, I knew she was well taken care of. It's just keeping all of those thoughts that your mind wants to [worry about]

When caring for children of a deployed parent, it is important to remember to not only query regarding their reaction (see Table 4), but also to check in with the caregiver, especially those not co-located near military facilities (see Table 5). Normally, at military locations with frequent deployments, family readiness, or support, groups (FRG) are an institutionalized resource offering companionship, support, and information to spouses of deployed service members. For those in communities, or perhaps fathers or grandparents, serving as the designated children's caregivers, the FRGs may not be accessible because of timing, distance, or feelings that they are not included in these predominately female programs. Encounters with the NP may be their only opportunity to express concerns about their deployed wife, daughter, or friend, and about child care issues that they are unsure about. As well, they may also be feeling increased anxiety, stress, or depression from being unaccustomed to providing care as a “single” dad or as a grandparent for an extended period of time. Their own chronic health conditions may be neglected as focus on caring for a dependent child vastly disrupts their regular lifestyle and routine.

Table 4
Table 4:
Child screening sample questions: How do you feel about your mother leaving/being gone/return home? What do you think will change or has anything changed (at school, at home, with friends etc.)?
Table 5
Table 5:
Caregiver screening sample questions: What strategies are you utilizing to de-stress/cope with the additional burdens? How do you feel about child's mother leaving/being gone/return home?

Assessment should include inquiries regarding the children's reaction to the deployment and how they are coping, school and social activities, and behavior. Some children may act out, withdraw, or have sleep difficulties during the deployment, especially younger children who are not able yet to express their feelings verbally. Caregivers too could be experiencing health concerns, sleep difficulties, depression, or just stress overload. They often appreciate a sympathetic ear and perhaps referral to support services if they are indicated. Despite some “bumps in the road," most mothers in the study expressed appreciation for the excellent care provided by their husbands, mothers, mother-in-law, au pair, nanny, or other caregiver and knew their children had been well cared for and loved.

He [husband] did incredibly well. He learned how to use the community resources. We had a really, really good friend that was stationed in Kansas with him and he used resources to help him manage with taking care of her when he had to—had to be at work for various reasons or study or whatever so he really, truly, truly surprised me. He even learned how to do her hair which—that was—that to me was the kicker, the icing on the cake

Reintegration

Reintegration refers to the time period once the military mother has returned home when both she, and the family, are adjusting to being together once again. Both families and service members count the days until they head back and, to make the date more tangible, use devices such as countdown calendars to track the days. Depending on planning for troop movements, the actual date can be fluid, changing frequently, until the final day for departure is set. This can be hard on families longing to welcome the mothers home again especially when the date changes. Mothers in the study indicated that most of the time they would not report a firm date for the airport arrival until they were boarding the plane so that they would not stress the family, and children, with a roller coaster ride of anticipation. For younger children who had not yet grasped time concepts, they employed “fun” calendars such as a jellybean or kisses jar where the child took one a day and could visualize the time getting shorter as the container emptied. In cases where dates changed, the caregiver occasionally surreptitiously added a few treats to the container so as not to disappoint if the container emptied and mom was not home yet.

They knew that I was coming home soon but they did not tell them the day that I was actually coming home because we weren't sure … we didn't want them counting on a day and then it not happening. I'm told that what happened—I came home at 9:30 at night so they ate dinner and got ready … and they said, “We've got to go get our kisses from Mommy.” They had made sure that there was one each. My older daughter picked up right away. She took her kiss out, she's like, “Wait a minute, there's no more kisses left.”

My husband said, “Well, what does that mean?” She says, “That means Mommy's coming home.” He said, “Yeah.” She says, “When?” He said, “Oh, we're going to the airport right now to pick her up,” and apparently it was just—I just wish they had videotaped it because I didn't actually get to witness that. I always was thinking about that … [and felt] a great feeling.

As going home neared, many deployed service members, as well as family members, started to fantasize about the reunion as a celebration with lots of fanfare, closeness, and joy. In actuality, however, many must travel back through hub locations and after many flight transfers and legs to their journey, arrive tired, late in the evening, and perhaps the first steps back on U.S. soil are not greeted by friends and loved ones. Children may be overwhelmed and become shy and withdrawn with the expectation to recognize and greet their returning mother. Low key approaches, like the situation described above, may work best as these children did not have time to anticipate a certain type of welcome, but were present in the moment with excitement generated just prior to the actual event.

I picked both of them up from school because they didn't even know I was coming back. It was a surprise. I picked my son up from his preschool and he was shocked and I picked my daughter up and she was shocked … when my daughter walked into the office she was just overjoyed and ran to me.

NPs can help families temper fantasized reunion scenarios by providing guidance on how to keep expectations realistic for adults and children. On the home front, providers can help caregivers getting ready to reintegrate mothers into the family and also provide anticipatory guidance in some of the challenges the family might face in the weeks and months after her return.

Mothers in the study related that coming home again triggered fears that they would not be recognized by the younger children, or that the relationships with them would be altered. The mothers also needed to renegotiate their roles in the home since a new routine was usually in place during their absence. As part of reintegration, the military provides briefings to advise returning parents to allow some time to adjust and reestablish their roles before making any changes. NPs can reinforce this message during their interactions early in the mother's readjustment period. Many mothers have related feeling disassociated from their families, almost like a stranger, coming back in to the home where things may have been moved around in their absence and perhaps children look to the other parent or caregiver for their needs out of habit.

Just coming back into the family, all the roles that my husband had to pick up and then to acknowledge all the work that he had done and then to slowly fix them up without making him feel like he wasn't doing it the right way or something along those lines. I wanted to get home and get integrated as quickly as I could, … but I had to make sure that my husband didn't feel like I was doing it because it was something that he had failed to do …

Many experience an awkward time during this early period at home. Children may need extra reassurance that mom is not leaving again anytime soon and physical closeness and cuddling. Mothers in the research study related that some of their children experienced some sleeping difficulties, clinginess, and anger with them initially or perhaps preferred the other parent, but others felt the separation made their bond with their children stronger and more resilient.

If I'm gone for any period of time, she's a lot more clingy when I get back, you know, up under me all the time, doesn't really want to leave, you know, wants to sleep in my bed, that kind of thing.

The literature also notes some of the contradictory findings regarding the effects of deployments on children. Flake, Davis, Johnson, and Middleton (2009) noted that children reacted using more internalizing behaviors such as whining, being anxious, and more frequent crying while, in their research, Chartrand, Frank, White, and Shope (2008), noted children aged 3 and above demonstrating higher externalizing behaviors (acting out, school issues) for those whose parent was deployed in comparison to children whose parent was not currently deployed. Since effects on children are not clear cut, NPs seeing children after a parental deployment need to remain vigilant to behavioral issues for early intervention and possible referral.

But when I came back, he just wasn't adjusting well and was having these horrific tantrums and just all kinds of issues. Couldn't leave him for any length of time, even during the day for daycare was hard. So, we had him screened and then subsequently he was diagnosed not only with ADHD, but Oppositional Defiant Disorder, Bipolar as well.

The mother's health too can be affected by the intensity of the deployment experience. Mothers in the study reported nightmares, quick anger, feeling disassociated from family and work, and sadness. Service members receive information about posttraumatic stress disorder (PTSD) and postdeployment adjustments in briefings prior to reintegration, but denial and stigma may prevent them from seeking help as they readjust to stateside life. NPs are in a key position to identify stress symptoms and provide necessary intervention and/or referrals to help with their readjustment and prevent more serious repercussions such as suicidal thoughts or domestic violence.

Once I got over there and I got very busy in the job I had, it was very high stress and I got mad a lot because of the stress. So while I was over there I was afraid of bringing that anger back and having the temper and the short fuse and all of that with my kids. And I just had to keep that in my head that it's completely different situations

Going back to work could also be difficult as it seemed that life had gone on while they were away and they no longer felt like they were part of the team or that there was not an acknowledgement of what they had experienced while away.

I wasn't reintegrated at the end of the two weeks. And I sort of felt—I felt really kind of lost and purposeless … I didn't expect it to be so painful …

NPs can help by reinforcing that the women are experiencing a normal reaction and adjustment, while also staying alert to the possibility of more serious adjustment difficulties and posttraumatic stress symptoms. Sometimes it takes encouragement for the women to seek professional intervention and reassurance that they are not weak for doing so.

Conclusion

While military families have some of the same issues to deal with as nonmilitary ones, military life and deployment can place strains on families and stress existing support systems. Deployment of military mothers offers many intervention points for NPs. Predeployment, mothers need reassurance, anticipatory guidance, and a plan for their personal health while they are deployed. During deployment, the NP's focus may shift to care of the children and their caregiver insuring that all remain physically and emotionally healthy. During reintegration, NPs are in a key position to recognize and intervene early for posttraumatic stress, and the readjustment of the family. Understanding the deployment trajectory and the issues that may arise during each phase provides the NP sensitivity in recognizing and individualizing assessment of the military family. Women want to serve their country, but they also want to make sure their children are well cared for and their families are safe. NPs are in an ideal position to help.

Acknowledgments

This research was sponsored by the TriService Nursing Research Program, Uniformed Services University of the Health Sciences; however, the information or content and conclusions do not necessarily represent the official position or policy of, nor should any official endorsement be inferred by, the TriService Nursing Research Program, Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government.

References

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Keywords:

Military; women; deployment; children; qualitative research; grounded theory

© 2013 American Association of Nurse Practitioners