Recent changes in the United States Armed Forces have resulted in an influx of individuals transitioning from the military into civilian communities (National Center for Veterans Analysis and Statistics, 2016). Consequently, nearly 900,000 veterans are enrolled in undergraduate and graduate programs for postmilitary education (Hill, Kurzweil, Pisacreta, & Schwartz, 2019). To expand nursing education and retention of veterans in a Bachelor of Science in Nursing (BSN) program, the Ida Moffett School of Nursing in Birmingham, Alabama, enhanced its program to develop pathways for seamless transitions of veterans into nursing careers. A veteran student's challenge of reintegrating into society while pursuing a college education might be the greatest barrier encountered (Kirchner, Coryell, & Yelich Biniecki, 2014).
Recent literature highlights reintegration strategies that include specializing orientation programs, connecting veterans with one another, training faculty and staff on unique veteran challenges, and offering more counseling and financial aid (Borsari et al., 2017). Nonetheless, a gap exists in the provision of spiritual support to veteran students. As professional nursing embraces spiritual care as a dimension of practice, the Veterans' Bachelor of Science in Nursing (VBSN) pathways aim to develop strategies that reinforce the academic, emotional, and physical needs of the veterans, as well as spiritual. This article describes how mental health providers at the university are collab-orating with the Department of Veterans Affairs (VA) to utilize the Building Spiritual Strength (BSS) intervention to support spiritual well-being in veteran students.
VETERANS' SPIRITUAL HEALTH
Spirituality “is a way of being in the world in which a person feels a sense of connectedness to self, others, and/or a higher power or nature; a sense of meaning in life; and transcendence beyond self, everyday living, and suffering” (Weathers, McCarthy, & Coffey, 2016, p. 93). Spiritual well-being helps organize the physical, psychological, and social aspects of individuals and functions in the psychological empowerment of nursing students (Broujeni & Khademi, 2015). In addition, spirituality may have a protective role in fostering positive psychosocial characteristics for veterans (Sharma et al., 2017).
Combat veterans often encounter spiritual challenges as they confront violence, anguish, and death on a level unfamiliar to civilians. During war, some veterans are tasked with enacting behaviors that in most theistic religions would be considered immoral, such as killing or wounding others. The multifaceted moral environments that can exist in combat areas may overwhelm individuals whose spiritual development is in concrete stages (Litz, Lebowitz, Gray, & Nash, 2017).
Often, soldiers experience moral injury, which Litz et al. (2017) described as profound distress experienced as a result of a violation of personal or ethical belief. The intensity of this distress can influence the veteran's spiritual behavior (Wansink & Wansink, 2013). At times, soldiers who experience traumatic events struggle spiritually. Even in cases that do not involve serious trauma, veterans might grapple with spiritual difficulties due to loss of belonging, predictability, and purpose; veteran students can feel disengaged and struggle to recognize how they are sustaining the greater good (Borsari et al., 2017). Within the veteran population, spirituality, as well as spiritual distress, is displayed in various ways.
Spiritual distress is a state of anguish related to the impaired ability to experience purpose through an affinity with self, others, or a higher power, and is a significant element of moral injury (Litz et al., 2017). Many soldiers enter the military remembering the unequivocal learned commandment, “Thou shall not kill.” Yet during combat, they may see or perform acts that result in death or injury. Soldiers may witness extreme devastation or experience the death of friends. These circumstances can lead to the loss of trust in a higher authority (God). In veterans, this disturbance may present as: feelings of anger, hopelessness, depression, and/or anxiety; difficulty sleeping; belief of abandonment by God; questioning the meaning of life or suffering; sudden doubt in spiritual or religious beliefs; and/or seeking spiritual help or guidance (Litz et al.; Nash et al., 2013).
SPIRITUAL AND PASTORAL CARE NEEDS
A goal of Healthy People 2020 is to increase the percentage of individuals with disabilities who utilize spiritual activities, among others, to improve health (U.S. Department of Health & Human Services, 2019). Although the actual number of U.S. veterans has been declining since 1990, those receiving compensation due to a service-connected disability have increased to approximately 4,743,100 recipients (U.S. Department of Veterans Affairs, 2019a). Many of these veterans are diagnosed with posttraumatic stress disorder. Notably, the number of veterans attending college has more than doubled since 2009 (U.S. Department of Veterans Affairs, 2014), resulting in a student population with diverse disabilities including moral injury. Numerous colleges and universities are unprepared to deal with veterans' unique needs. Previous research has demonstrated that utilizing spiritual beliefs or practices can be a coping mechanism for individuals with physical illness, psychological distress, or traumatic occurrences (Salgado, 2014). As disabilities can influence an individual's purpose, connections, and acceptance (Wasserman, Asch, Blustein, & Putnam, 2016), professionals trained in pastoral care need to be integrated into university support resources.
FOSTERING SPIRITUAL SUPPORT
As research has highlighted spirituality as a coping mechanism, the VA enacted a directive to ensure veterans receive spiritual and pastoral care (U.S. Department of Veterans Affairs, 2019b). Kopacz and Karras (2015) found that veteran students are more likely to seek pastoral care when experiencing psychological distress. To support the spiritual needs of students in the VBSN pathways, university chaplains, counselors, and mental health providers work closely with healthcare providers at the VA.
First, mental health providers with training, experience, or supervision in spiritually integrated care, or chaplains or counselors with specialized mental health training at the university, work with veteran students who present with transitioning challenges. Each student receives an initial consultation and triage service. After an evaluation and limited assessment, the student attends individual therapy sessions. Although the confidential sessions include the integration of spiritual aspects of personal growth, the student sets the tone and chooses when and how to include spirituality in his or her therapeutic work. All interventions are short-term and goal-oriented. Exploratory psychotherapy is implemented as needed. If the student's difficulties cannot be resolved at the university level with the combined efforts of VA providers, the student is referred to an appropriate program or intervention at a local facility.
BUILDING SPIRITUAL STRENGTH INTERVENTION
As a result of the VA-university partnership, several Ida Moffett School of Nursing students participated in the BSS intervention (Harris et al., 2011). This 8-week spiritually integrated group counseling intervention aims to decrease symptoms related to a disability by enabling resolution of spiritual distress. Trained chaplains work with students in weekly 2-hour sessions for 8 weeks.
In the initial session, participants establish group rapport by sharing military and religious histories and identifying personal spiritual development goals, which they document in their BSS workbook. Typical session formats devote time to processing individual content of meditation journals, affording students the opportunity to use feedback from other participants and the chaplain in resolving distress in relationship with a Higher Power. The materials are designed to gradually increase cognitive complexity while addressing spiritual concerns. Meanwhile, the chaplain assesses spiritual developmental issues and sources of spiritual distress.
In later sessions, forgiveness is conferred as an ongoing process of preserving an appropriate connection with one in need of forgiveness instead of a “forgive and forget” method to settling distress. During the final session, the student investigates ways to continue to independently foster his or her spiritual strength. The utilization of BSS affords veteran students the opportunity to use nontraditional providers and services in the community rather than a healthcare setting, therefore reducing the stigma associated with treatment.
Participating veteran students offered feedback on involvement in the BSS intervention. Case studies are presented of two positive outcomes of veteran students from the inclusion of spiritual care interventions. Both of these students welcomed spiritual support to assist them with transitioning into the academic setting. Prior to participating in BSS, each student was failing academically, but after completing the intervention, their grades improved significantly. The BSS intervention provided the opportunity for these transitioning veteran students to explore and reduce spiritual distress which ultimately assisted in their academic success (See Sidebar: Building Spiritual Strength Intervention Benefits).
Veteran student one. J. S., a 1st Lieutenant, was a 25-year-old male in the VBSN pathway, transfer option. Before joining the Army, he completed two semesters at a university. During his first year of military service, J. S. completed Airborne School and joined the ranks of elite paratroopers who set the example for determination and courage. Eventually he was deployed.
After being involved in deadly combat action, J. S. returned to the United States and decided to resume schooling. He was excited to return to college but noticed the same sensation of uncertainty he had felt while overseas. Eventually, he reported having a “broken spirit.” Because he did not “trust” the other students, he did not talk or interact with them.
As the semester progressed, J. S. became increasingly withdrawn. He confided to his peer mentor, “I just feel numb. I constantly think about everything I did wrong as a soldier. I know God is disappointed in me.” With his peer mentor's encouragement, J. S. sought Christian pastoral care from the university's chaplain. The chaplain, realizing that J. S.'s anxiety was causing him much exhaustion, reminded him that Jesus promises relief, rest, and refreshment for the soul: “Come to me, all you who are weary and burdened, and I will give you rest” (Matthew 11:28, NIV). In the following weeks, J. S. completed the BSS intervention through collaboration with the VA. During a follow-up appointment with the university chaplain, he reported several lifestyle changes, including interacting with other veterans who experienced moral injury. He also began exercising, eating healthy, volunteering, and spending more time with loved ones. In the end, J. S. stated, “I found my spiritual strength again!”
Veteran student two. K. W., a Sergeant, was a 34-year-old female in the VBSN pathway, accelerated option. Two years prior to enrolling in the program, she completed a tour in Iraq where her unit screened traffic entering the base, including pedestrians and vehicles. She often was responsible for searching Iraqi women for suicide bomb vests. Once back home, K. W. sometimes relived the events surrounding that frightening period. Because she had completed a bachelor's degree online during her enlistment, she was aware of the academic challenges of college and believed she was ready to tackle this next life journey.
On the first day of classes, K. W. slid into a seat in the back by the door, but as other students crowded in, she began feeling anxious and uncomfortable. The only thing she could think about was that being in a crowd made her a target. Though miles from combat, K. W. continued to anticipate and respond to incidents as if danger was imminent. By midterm, she had become overwhelmed with negative feelings and lost interest in becoming a nurse. She asked, “How can I now help people when I have already hurt so many people?” K. W. was referred to complete the BSS intervention. During a follow-up with a university mental health provider, she reported practicing mindfulness and optimism. She concentrated on the present instead of dwelling on the past and learned to search for the good factors in her life, the things that created joy and a sense of peace or happiness. At the end of each day, she reflected on the good things that had happened in the last 24 hours. K. W. graduated at the top of her class the following year. At her pinning ceremony, she recited what had become her daily solace: “May the God of hope fill you with all joy and peace as you trust in him, so that you may overflow with hope by the power of the Holy Spirit” (Romans 15:13, NIV).
IMPLICATIONS FOR NURSE EDUCATORS
Veteran students are entering nursing programs across the nation. This choice connects them to their future and often to what they perceive as their life's value and purpose. Educators should consider how spiritual well-being appears to influence the development of coping skills and promote social support (Alorani & Alradaydeh, 2018), causing individuals who have experienced traumatic events to begin to view these situations from a positive perspective (Starnino, 2016).
In faith-based nursing schools, often a part of the mission is to nurture students in their faith. Nurse educators working with veteran students who have compromised spiritual well-being are charged with linking these students with their spiritual strength. Students who have not contemplated their beliefs about spirituality may be challenged in addressing patient apprehensions or inquiries in the clinical setting. Providing spiritual support, even through personal reflection and self-analysis, affords veteran students the opportunity to broaden their definition of spirituality. In addition, facilitating the development of the students' beliefs about spirituality promotes engagement in active learning. An awareness exists for nurse educators to respect veteran students' current knowledge, experiences, and positions related to spirituality to support them in being successful in the academic setting.
With the wars in Afghanistan and Iraq currently drawing toward an end, more veterans will enroll in education programs. Universities and colleges must be prepared with programs designed to meet veteran students' needs. Many veterans view going to college as a chance to do something productive for their minds and bodies and give them a mission and opportunity to advance in life. Because veterans face spiritual challenges while transitioning to civilian roles, professionals experienced in pastoral care are an essential part of the support system. During combat, foxholes provide protection for soldiers; however, once veterans are out of the foxhole and enter the academic setting, others are tasked with providing appropriate support. Collaboration between providers trained in spiritual care at the university and in the healthcare system further strengthens the needed assistance (United States Government Accountability Office, 2014). Without the distinctive provision of pastoral and spiritual support, many veteran students will fail to find their spiritual strength, as well as academic success.
Building Spiritual Strength Intervention Benefits
Unlike other psychotherapeutic methods for treating posttraumatic stress disorder (PTSD), Building Spiritual Strength (BSS) focuses on spiritually integrated interventions for military trauma survivors who are managing PTSD and moral injury. During the eight weekly BSS group sessions, participants identify spiritual conflicts that cause them to feel distress. Once these conflicts are recognized, participants are helped to find and develop spiritual resources (Harris et al., 2011).
The BSS intervention is nondenominational and open to all who wish to attend. Researchers have documented that the intervention helps reduce symptoms of PTSD (Harris et al., 2011). People of cultural or ethnic minorities may benefit more, as studies on spiritual coping for trauma victims have shown that such persons often are more religious than Caucasians, more likely to see spirituality as part of their healthcare, and more likely to use religious coping mechanisms (Taylor, Chatters, & Jackson, 2007).
Harris, Erbes, and Usset (n.d.) created BSS as one means of reducing frequent consequences of spiritual distress, moral injury and lower mental health resilience and to help mitigate the loss of support from one's family and faith community. The intervention is designed to assist veterans to use their current faith resources to recognize and resolve spiritual concerns while maintaining spiritual functioning. The program provides opportunities to explore and lower spiritual distress and help reduce religious strain. Spiritual distress may manifest as feeling alienated from one's Higher Power; as shame, guilt, or fear related to sin or perceived sin; or as expectations of punishment from or abandonment by a Higher Power.
Involvement in a supportive group of individuals who have experienced similar situations provides significant social support—something that enhances recovery. The support group environment also is beneficial for veterans who might avoid mental health treatment because of stigma but would attend a support group for veterans at a local religious organization (Harris et al., 2011).
As participants complete the BSS intervention, they are able to self-evaluate progress on their spiritual goals and plan how to continue personal spiritual development.—Karen Schmidt, BA, RN, JCN Contributing Editor
Alorani O. I., Alradaydeh M. F. (2018). Spiritual well-being, perceived social support, and life satisfaction among university students. International Journal of Adolescence and Youth
, 23(3), 291–298. doi:10.1080/02673843.2017.1352522
Borsari B., Yurasek A., Miller M. B., Murphy J. G., McDevitt-Murphy M. E., Martens M. P., ..., Carey K. B. (2017). Student service members/veterans
on campus: Challenges for reintegration. The American Journal of Orthopsychiatry
, 87(2), 166–175. doi:10.1037/ort0000199
Broujeni R. B., Khademi Z. (2015). The relationship between spiritual well-being and psychological empowerment in nursing
students. Development Strategies in Medical Education
, 2(2), 75–82.
Harris J. I., Erbes C. R., Engdahl B. E., Thuras P., Murray-Swank N., Grace D., ..., Le T. (2011). The effectiveness of a trauma focused spiritually integrated intervention for veterans
exposed to trauma. Journal of Clinical Psychology
, 67(4), 425–438. doi:10.1002/jclp.20777
Harris J. I., Erbes C. R., Usset T. (n.d.). Building Spiritual Strength: Evolving treatment for PTSD and moral injury/spiritual distress
. PowerPoint Presentation at Minneapolis VA Health Care System. Retrieved from https://slideplayer.com/slide/12182805/
Hill C. B., Kurzweil M., Pisacreta E. D., Schwartz E. (2019). Enrolling more veterans at high-graduation-rate colleges and universities
. Retrieved from https://sr.ithaka.org/publications/enrolling-more-veterans-at-high-graduation-rate-colleges-and-universities/
Kirchner M. J., Coryell L., Yelich Biniecki S. M. (2014). Promising practices for engaging student veterans
. Quality Approaches in Higher Education
, 5(1), 12–18.
Kopacz M. S., Karras E. (2015). Student service members and veterans
who access pastoral care for the purposes of mental health support. Journal of American College Health
, 63(7), 496–501. doi:10.1080/07448481.2014.923430
Litz B. T., Lebowitz L., Gray M. J., Nash W. P. (2017). Adaptive disclosure: A new treatment for trauma, loss, and moral injury
. New York, NY: Guilford Press.
Nash W. P., Marino Carper T. L., Mills M. A., Au T., Goldsmith A., Litz B. T. (2013). Psychometric evaluation of the moral injury
events scale. Military Medicine
, 178(6), 646–652. doi:10.7205/MILMED-D-13-00017
National Center for Veterans
Analysis and Statistics. (2016). Profile of post-9/11 veterans: 2014
. Retrieved from https://www.va.gov/vetdata/docs/specialreports/post_911_veterans_profile_2014.pdf
Salgado A. C. (2014). Review of empirical studies on impact of religion, religiosity and spirituality
as protective factors. Journal of Educational Psychology
, 2(1), 121–159. doi:10.20511/pyr2014.v2n1.55
Sharma V., Marin D. B., Koenig H. K., Feder A., Iacoviello B. M., Southwick S. M., Pietrzak R. H. (2017). Religion, spirituality
, and mental health of U.S. military veterans
: Results from the National Health and Resilience in Veterans
Study. Journal of Affective Disorders
, 217, 197–204. doi:10.1016/j.jad.2017.03.071
Starnino V. R. (2016). When trauma, spirituality
, and mental illness intersect: A qualitative case study. Psychological Trauma: Theory, Research, Practice, and Policy
, 8(3), 375–383. doi:10.1037/tra0000105
Taylor R. J., Chatters L. M., Jackson J. S. (2007). Religious and spiritual involvement among older African Americans, Caribbean blacks, and non-Hispanic whites: Findings from the national survey of American life. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences
, 62(4), S238–S250. doi:10.1093/geronb/62.4.s238
United States Government Accountability Office. (2014). VA education benefits: VA should strengthen its efforts to help veterans make informed education choices
[GAO-14-324]. Retrieved from https://www.gao.gov/assets/670/663152.pdf
U.S. Department of Health & Human Services, Office of Disease Prevention and Health Promotion. (2019). Health-related quality of life & well-being
. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/health-related-quality-of-life-well-being
U.S. Department of Veterans
Affairs. (2014). Who are today's student veterans?
[VA Campus Toolkit.] Retrieved from https://www.mentalhealth.va.gov/studentveteran/studentvets.asp
U.S. Department of Veterans
Affairs. (2019a). Veterans Benefits Administration Annual Benefits. Report fiscal year 2018
. Retrieved from https://www.benefits.va.gov/REPORTS/abr/docs/2018-compensation.pdf
U.S. Department of Veterans
Affairs. (2019b). Spiritual and pastoral care in the Veterans Health Administration
. Retrieved from https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=4299
Wansink B., Wansink C. S. (2013). Are there atheists in foxholes? Combat intensity and religious behavior. Journal of Religion and Health
, 52(3), 768–779. doi:10.1007/s10943-013-9733-y
Wasserman D., Asch A., Blustein J., Putnam D. (2016). Disability: Health, well-being, and personal relationships. In E. N. Zalta (Ed.), Stanford Encyclopedia of Philosophy
. Retrieved from https://plato.stanford.edu/archives/win2016/entries/disability-health
Weathers E., McCarthy G., Coffey A. (2016). Concept analysis of spirituality
: An evolutionary approach. Nursing Forum
, 51(2), 79–96. doi:10.1111/nuf.12128