The 2015 US Census identified more than 22.5 million veterans living in the United States.1 Because of the number veterans requiring healthcare, approximately 75% of the veteran population is receiving care at facilities other than the Veterans Health Administration (VHA).2 With the recent extension of the Veterans Choice Program that allows veterans to seek healthcare from non-VHA providers, this number will continue to increase.3
Mental health problems, such as posttraumatic stress disorder (PTSD) and substance use disorder (SUD), can be directly related to a veteran's experiences during their time of service, and the prevalence of PTSD is greater in the veteran population.2,4 Combat-related PTSD is related to experiences where the veteran is exposed to repeated events that reinforce the trauma and make it more difficult to treat and is associated with an increased risk of substance abuse.5,6 Veterans with a dual diagnosis of SUD and PTSD have more severe symptoms and are more difficult to treat.7
Most nurses in the United States will be caring for veterans regardless of where they are employed. Nurses in non-VHA facilities should be equipped with the knowledge, skills, and attitudes (KSAs) related to the specific needs of veterans to optimize care for these patients. A set of 10 care competencies and associated KSAs previously developed to guide in the preparation of nurses to provide care for veterans and their family members was used.8 The KSAs specifically related to PTSD and SUD were used as a basis for this evaluation of the self-perceived readiness of medical-surgical nurses in a non-VHA facility to care for veterans with PTSD and SUD.
Methods and Procedures
This study was approved by a university institutional review board.
Participants and Recruitment
Participants were a convenience sample of nurses in clinical roles employed in 3 trauma units of a large academic medical center in the Southeastern United States. Posters were placed in bathrooms, report rooms, educational areas, and break rooms of all trauma units describing the study and soliciting participation in the study evaluation survey and semistructured interviews.
A survey focused on KSAs related to PTSD and SUD was developed for this study using Likert-style and open-ended response questions. Also collected were participants' age, gender, years registered as a nurse, area in which they work, military service, and experience with veterans.
Survey items were derived from Veteran Competencies for Undergraduate Nursing Education developed to prepare nursing students for veteran care after graduation.8 The 21-item 5-point Likert scale survey developed for this study included 2 competence categories of the 10 original with accompanying KSAs related to PTSD and SUD. For each competency and associated KSA listed in the survey, participants were asked to rate their comfort level in deploying.
Data Collection and Analysis
The survey was administered using SurveyMonkey (SurveyMonkey Inc, San Mateo, California) online survey software. Follow-up emails were sent 2 weeks after the beginning of the survey and then at 1 week prior to closure to encourage participation. Potential correlations between Likert scale KSA responses and demographic characteristics were assessed using Kendall's tau-b coefficient with significance defined as <0.005.
Survey participants were asked to volunteer for an individual semistructured live interview. After providing informed consent, those who participated in the semistructured interview were asked a series of predetermined questions related to their experience with veterans, particularly those with PTSD and SUD.
The overall response rate to the survey was 25% (n = 51) of total population of 203 trauma nurses. Twenty-one nurses volunteered to participate in semistructured interviews. Participants were predominantly female (75% female, 25% male), with mean age of 32.4 years and mean of 9.22 years of experience. Only 2 participants had served in the military, and 62.75% had no experience with veterans, either personally or professionally, or had never worked for the VHA (95.92%). Approximately half (50.98%) asked patients if they were veterans. An overwhelming 96.08% agreed that they could provide more effective care if they knew more about veteran competencies.
Likert Scale Survey Data
Posttraumatic Stress Disorder
Participants were asked to rate their level of KSA from “strongly agree to strongly disagree” on veteran care competencies related to PTSD. More participants agreed (80.4%) than disagreed (11.76%) that they were knowledgeable about the signs and symptoms of PTSD, and 7.8% were undecided. Approximately 44% disagreed that they were knowledgeable about the treatment modalities for PTSD (Table 1).
More participants (51%) reported less competence with assessing PTSD triggers than more competent (35.3%). Additionally, fewer than 30% of participants expressed competence with conducting and interpreting PTSD screening and assessing need and identifying resources for veterans with PTSD (Table 1).
Most participants agreed that they were comfortable expressing support (88%) and conveying empathy (94.1%) for veterans impacted by PTSD (Table 1).
Substance Use Disorder
Participants were asked to rate their level of KSA from “strongly agree to strongly disagree” on veteran care competencies related to SUD. More participants agreed (72.5%) than disagreed (11.76%) that they were knowledgeable about the prevalence and risk factors for SUD among veterans, and 15.7% were undecided. Participants disagreed (47.1%) that they were knowledgeable about the use of SBIRT (screening, brief intervention, and referral to treatment) (Table 2).
Participants reported more skill (82.4%) with recognizing signs and symptoms of withdrawal/delirium tremors than less skill (11.8%) (Table 2). Fewer than 50% of the participants reported confidence in their skill with screening for unhealthy alcohol use using the Alcohol Use Disorders Identification Test (AUDIT-C) and providing brief interventions for those identified as risky or problem drinkers.
Most participants agreed that they were comfortable accepting addiction recovery (92.1%) and conveying a nonjudgmental stance (96%) toward veterans with SUD (Table 2).
Significant correlations were found between knowledge (signs and symptoms [P = .001], risk factors [P = .001], prevalence, consequence and longitudinal course of PTSD [P = .000], treatment modalities for PTSD [P = .000]; and skills [assessing need for resources for veterans with PTSD, P = .001]) and previous experience working with veterans. Participants with no experience working with veterans were less likely to feel confident assessing resources needed and identification of those resources for veterans with PTSD. Participants without prior experience working with veterans were less likely to be confident in their knowledge of signs, symptoms, risk factors, prevalence, consequence, and longitudinal course of PTSD. A significant correlation was also noted between gender and the SUD-related skill of screening for alcohol use. Women were more likely to feel confident using a screening tool for alcohol use than men (P = .005).
Open-Ended Survey Data
The 1st open-ended survey question addressed any previous experience that the nurse had with veterans. More than half of the participants (62.3%; n = 32) had no previous experience working with veterans. Reported experience with veterans varied from personal experiences with family and friends to caring for them as patients in non-VHA settings. The 2nd open-ended question addressed in the survey asked nurses what they perceived as the most important information to take into consideration when caring for a veteran. The participants' responses included having knowledge about their service history, deployment history, combat exposure, and any experiences that the veteran during their service time. Other responses included a desire to know more about their medical history, specifically their mental health, such as PTSD, substance abuse, and emotional well-being. Additionally, participants expressed a need for knowledge of PTSD triggers and screening tools. One participant commented, “Veterans stop opening up when they think no one cares and nothing is being done about how they express their feelings as a person with not just physical needs but emotionally, spiritually, and financially, all want to still be able to help their families.”
Semistructured Live Interviews
There were 21 live semistructured interview participants. Each interview was recorded and transcribed. When participants were asked about their familiarity with the “Have you served” campaign, 90.5% (n = 19) of participants answered that they were not aware of this campaign. Participants were also asked if they inquired about their patient's military status; fewer than half (38.7%; n = 8) admitted to routinely asking their patient about their status.
Some participants (28.6%; n = 6) only asked about military status if patients had military tattoos or were wearing a hat that identified them as a veteran. One participant stated, “If I feel like they look like they have been in the military, or they kind of talk like they have been in the military, I'll just ask are you a veteran or what branch did you serve?” Several participants reported that they had family members who were military, and this helped them to identify their patients as veterans. The remaining 33.3% (n = 7) did not ask about military status. When asked about the reason for not inquiring about military status, a participant responded, “Because it is not required.”
Several participants expressed concern about asking about military status because of fears of PTSD. For example, 1 participant stated, “I think it would depend on their demeanor and how they are acting.” Another participant stated, “I think just sort if maybe the stigma of it, thinking that they have PTSD makes you a little scared. Like maybe, am I gonna trigger something?” Other participants reported that they felt comfortable approaching the question of military status because they had previous experience with veterans.
All participants agreed that veterans require different treatment for PTSD than nonveterans. One participant replied, “I think people who have served need a different type of treatment, and also their families need treatment, and the reason is that because those people have been overseas or somewhere where there's been active war, and because of the struggles they have had, trying to stay alive, and everything that they had to endure, that we do need to give specialized treatment for them.” Several participants agreed that because of their repeated exposures to life-threatening events and time spent in combat a different type of therapy was warranted. All participants also agreed that veterans require different treatment for SUD than nonveterans. One participant stated, “Because it is not just substance abuse like, ‘Oh I just want to take a bunch of pills.’ It may be, ‘Oh I was in the Vietnam War and all my friends died, and now I do not wanna live.’”
This study is an important step toward understanding the perceptions of those who are caring for veterans in non-VHA facilities and their ability to provide veteran-centric care. This project focused on the evaluation of self-perceived knowledge of veteran care competencies by medical-surgical nurses. The results add to the limited body of literature on KSAs associated with veteran care. The results of this study show that medical-surgical nurses perceived they lack skills required to provide care for a veteran with PTSD/SUD. They felt confident regarding their knowledge, but not the skill required to apply this knowledge to practice. They may have been overconfident in their knowledge of PTSD and SUD. This would be consistent with a study finding that clinicians were significantly (92%) overconfident in their perceived knowledge.9
Higher scores related to attitudes, such as expressing support, conveying empathy, and nonjudgmental stances, could be directly related to the actions of nurses in general and not specific to veteran care competencies. Empathy is a key component of the nursing profession and a vital requirement for a healthy provider-patient relationship, and nurses place value on projecting an empathetic persona.10
Only 37.8% (n = 8) of healthcare providers reported inquiring about military service, which was higher than that found in a previous study.11 Nurses admitted to inquiring about military status of their patients only if they recognized them as veterans by their dress or markings. Populations are determined or defined by characteristics of that specific population.12 For military veterans, a hat with the name of their branch of service or tattoos of their military unit or rank identifies them as veterans. This is consistent with previous studies that providers would be aware and inquire about military status only if the patient exhibited certain characteristics.11
Fear of Triggering a PTSD Episode
Nurses overwhelmingly reported a fear of triggering a PTSD episode when eliciting information about a patient's military status. Several nurses expressed concerns over room assignments for patients with PTSD. There were concerns that the alarms heard in the hospital could trigger a reaction. Another concern mentioned related to waking patients from anesthesia or conscious sedation. Nurses are justified in their fear of violence from veterans. Veterans returning from deployment are associated with an increase in episodes of violence, particularly those with mental health issues.13 One study concluded that nurses were being placed in unsafe environments when caring for patients with PTSD.11 Resources, such as a PTSD response team, need to be put in place at healthcare facilities to support nurses who care for patients with PTSD.
Treatment for PTSD
Inconsistent with previous studies, all participants expressed the need for veterans to have a specialized treatment plan including physical and psychological modalities to promote the best outcomes for veterans being treated with PTSD. Studies have found that veterans respond better to individual-based or a combination of individual-based and group-based psychotherapy by those who were familiar working with veterans.14 Consistent with previous studies was the thought that veterans were exposed to traumatic experiences, and this increased their risk of PTSD. Exposure to traumatic combat increases the probability of PTSD more so than exposure to any other type of trauma.6
Posttraumatic Stress Disorder/Substance Use Disorder
Nurses in this study felt that the increasing numbers of SUD were directly related to the veteran's experience during combat. For the veteran population, substance abuse may be their attempt to self-medicate or deal with problems associated with their military services, such as physical injuries or mental disorders.15 Nurses reported that they felt as though those with PTSD used alcohol or drugs to deal with their memories of combat and fallen comrades. Self-medication of PTSD symptoms with alcohol or other drugs is prominent.16 Consistent with previous studies, nurses felt that there was a relationship between patients experiencing a PTSD episode and an increase in the use of alcohol or other substances. There is a direct relationship between exacerbation of PTSD and subsequent increase in substance abuse.16 Many nurses expressed an interest in learning how to recognize signs and symptoms of PTSD and resources for those identified as having PTSD. Educating medical-surgical nurses on how to recognize and appropriately refer these patients is key to the development of an appropriate treatment plan.
Despite the effort to educate nursing students about the unique needs of veterans by integrating the content into nursing schools, more than 90% of nurses interviewed had no knowledge of the “Have you ever served in the military?” campaign. This campaign was part of Joining Forces, a national effort led by Michelle Obama and Jill Biden to ensure that veterans are identified and receive appropriate care.17 Following this effort, nursing and medical schools pledged to add curricula addressing military and veteran health care.18 Unfortunately, findings from this study suggest that translation to practice in a non-VHA setting is still not optimal.
In this study, while nurses expressed knowledge of PTSD and SUD in the veteran population, they did not feel confident transferring this knowledge to skill in practice. Non-VHA facilities need to make identification of veterans and assessment of service-related conditions routine. Based on the findings of this project, there is a deficit in the skill related to care for veterans with PTSD/SUD. Educational programs can provide information on the efforts to improve veteran care such as Joining Forces and the “Have you served?” campaign, to give nurses in non-VHA settings tools for recognizing their patient as a veteran and providing optimal care for this population. Additional needed content includes information on areas of recognized knowledge deficits such as treatment modalities for PTSD and use of SBIRT, early interventions for SUD, and conducting/interpreting PTSD screens and assessing need/identifying resources for veterans with PTSD. The use of an immersive simulation with unfolding case studies involving care of a veteran could improve confidence in skills on caring for patients with PTSD/SUD. Further research to identify areas needing additional education is warranted.
There were several limitations associated with this study. There was a relatively low response rate to the email survey resulting in a small sample size (25%; n = 51) from a convenience sample. Participants were recruited from 1 patient care domain (trauma) in a level 1 trauma center in an urban setting that was near a large Veterans Affairs Medical Center. Additionally, only 2 of the 10 veteran care competencies were evaluated in this project. This limits the generalizability of the findings. Further studies are needed to fully evaluate the perception of veteran care competencies in different settings.
A large portion of the veteran population will be treated in non-VHA healthcare facilities. The ability to care for this special population is paramount to the delivery of optimum Veteran care. Findings from this study suggest that nurses caring for veterans in non-VHA facilities do not identify veterans or assess for service-related conditions, including PTSD and SUD. Non-VHA facilities should make identification and assessment for service-related conditions routine for fully informed care. Lack of education regarding the “Have you served” campaign, fear of triggering a PTSD episode, and skill deficits in intervention deployment in veteran care are issues that need to be acknowledged in non-VHA facilities. These results are a useful starting point for further evaluation of veteran care competencies and development of programs that can allow for veteran-centric care. Education and training programs related to veteran care competencies will improve quality of care for the veterans in non-VHA facilities.
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