In 2016, it was reported that there were 18,599,716 veterans of the Armed Forces in the United States (National Center for Veterans Analysis and Statistics, 2018). While these veterans are both men and women of various ages and races, they are predominantly white males, with a median age of 65 years old (National Center for Veterans Analysis and Statistics, 2018). When these veterans leave their military service behind them, many are left with some reminder, either mental or physical, of their time spent in the service. Standard health care as well as care specific to their time as active duty members can be difficult to acquire. Limited locations of care facilities, high demand for services, mental health, and substance abuse all impact the veterans’ ability to achieve overall health and wellness. Additionally, female veterans, while considered a minority still face similar issues, compounded with an overall lack of women’s health services. The system that provides healthcare to our nation’s veterans is often difficult to navigate, frustrating to the patients, and therefore, underutilized. Healthcare providers, especially nurses, must be aware of the challenges faced by veterans to provide quality care and to advocate for their patients effectively. It is also imperative that we advocate for change, to correct the injustice in the system that supports the men and women who have valiantly supported the rights and freedoms we enjoy on a daily basis.
Discussion
In today’s age of modern medicine, 90% of combat injuries are survivable, and an estimated sixteen percent of post-9/11 veterans say they were seriously injured in combat (Pew Social & Demographic Trends, 2011). While standard civilian hospitals and care centers can certainly manage these types of injuries, Veterans Affairs (VA) health centers are more uniquely qualified to address these issues, making them the better choice for care. For many veterans, access to VA care centers is very limited. In Maryland, there are three inpatient Veteran Affairs hospitals, and 11 outpatient care sites that manage approximately four hundred thousand patients (U.S. Department of Veterans Affairs, 2018). The limited number of care sites and a large number of patients needing care causes long wait times for appointments, leaving these veterans untreated or seeking care outside of the VA health system. Waiting for care causes these men and women to have more complex conditions or complications that could have been successfully avoided with earlier intervention. Seeking care outside of the VA health care system is often problematic as well, as communication between VA and non-VA providers can be slow and difficult to coordinate. Non-VA providers may have a difficult time accessing VA records, causing information gaps in the treatment history of the patient they are seeing. While some do have private insurance, as many as 20% or 1.2 million rely solely on the VA system, meaning that care outside of this system is not covered by their benefits (Carla E. Zelaya & Colleen N. Nugent, 2018). Patients who “are low-income, live in rural areas, lack other sources of coverage, and have relatively poor self-reported health status get a higher percentage of care from the VA” (Adler, 2018, p. 298). This implies that the same patient who is waiting for an appointment at a VA facility most likely cannot afford the private insurance that would allow them to seek care elsewhere and/or may live in an area where care cannot be conveniently received. Patients of these VA facilities may also have to travel a great distance for care due to the limited number of locations. All of these factors negatively impact the initiation of care and compliance with follow-up appointments and referrals for additional services causing the patient to go without care that they are in need of and a potential decline in overall health.
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As nurses, it is crucial that we are aware of the struggles these men and women are facing regarding their health care and be open to facilitating care in every way we can. By thoroughly assessing the patient’s current situation, we can get a better overall understanding of their healthcare needs. If we simply hand the referral and appointment card, we may miss that this veteran lacks transportation to the appointment he or she has been waiting for, or that they have a physical, cognitive, or mental health concern that will impede their compliance with care. Enlisting the help of a care manager can help improve the overall quality of care that is being provided. RN care managers utilized in VA facilities work to remove barriers to care, such as transportation or financial concerns, provide education, and help facilitate communication with all providers active in the patient’s care (Alban, Andersen, Beatty, Grubbs, & Sweeny, 2017). By acting as or involving the RN case manager in the care of the veteran client, the nurse can help the client to feel valued, making them more likely to take an active role in their health and to be more receptive to teaching and suggestions. This is crucial to the overall improvement and maintenance of health in all populations, but especially in the veteran population. Additionally, there has been a push from the Commission on Care, supported by many nursing associations to allow “all VA APRNs to practice to the full scope of their education and abilities without physician supervision” (Kentucky Nurse, 2016). This initiative would dramatically decrease the wait times at VA facilities by increasing the number of providers available for appointments. By understanding the current state of the VA healthcare system and the need for reform, nurses are able to advocate for change both at the organizational and federal levels.
While enlisted, members of the military are exposed to a multitude of traumatic experiences that can have both physical and emotional effects that last far beyond their time of active duty. It was reported that 44 percent of post-9/11 veterans had a difficult time readjusting to civilian life (Pew Social & Demographic Trends, 2011). Frequent bouts of irritability or outbursts of anger were reported by nearly half of these veterans and thirty-seven percent are believed to suffer from post-traumatic stress, whether they have received an official diagnosis or not (Pew Social & Demographic Trends, 2011). According to the Substance Abuse and Mental Health Services Administration, “approximately 50% of returning service members who need treatment for mental health concerns seek it, but only slightly more than half who receive treatment receive adequate care” (Substance Abuse and Mental Health Service Administration, 2017). A study performed by Hoge et al also showed a correlation between soldiers who reported experiencing a mild traumatic brain injury and the development of post-traumatic stress disorder (2008). The study found that of the soldiers surveyed who reported suffering an injury with loss of consciousness, 43.9% suffered from post-traumatic stress disorder (Hoge, et al., 2008). Often associated with poor mental health, substance abuse is a significant concern for veterans as well, and according to the U.S. Department of Veterans Affairs, “about 1 in 10 returning soldiers seen in VA have a problem with alcohol or other drugs” (U.S. Department of Veterans Affairs, 2015). Many veterans suffering from post-traumatic stress are also struggling with substance abuse, compounding their need for treatment but also complicating their ability to seek and receive care. Post-traumatic stress and substance abuse problems directly impact the rate of suicidality in veterans, making them twenty-two percent more likely to commit suicide than non-veterans (U.S. Department of Veterans Affairs, 2017). In recent years there has been a significant push to increase awareness about and treatment of mental health disorders, especially in the military population. Stigma, lack of understanding or awareness, career concerns, and logistical challenges have been identified by the United States Government Accountability Office as significant barriers to care (United States Government Accountability Office, 2011). Because post-traumatic stress and substance abuse often contribute to one another, they must be treated concurrently in order for treatment to be effective. While there are currently programs to help veterans battling these diseases individually, patients with these co-existing conditions often do not respond well to treatment aimed only at one issue. Only recently have “dual-diagnosis” programs emerged, as evidence indicates that treating both conditions concurrently leads to overall better patient outcomes. These programs are limited in their numbers, locations, and number of patients that can be accepted, again leaving these patients with few options and declining mental and physical health as a result.
Understanding the unique experiences of these veterans, their lasting psychological effects and the services available to them is essential to providing care to veterans with mental health issues. The VA is trying to address the growing number of patients needing mental health treatment. It is now required that veterans are screened for “PTSD, depression, substance abuse disorders and history of military sexual trauma” when being treated by a primary care provider (United States Government Accountability Office, 2011, p. 15). Many of the primary care clinics that serve veterans now also have mental health providers available on-site. The nurse must constantly assess the mental health of their patients and encourage the use of the mental health services available to them. For the client who is resistant to accepting help or those who are in rural areas, the nurse’s knowledge of appropriate resources is essential. Information about the Veterans Crisis Line, Mobile Vet Centers, and other community programs should be provided and encouraged to those who are at risk (United States Government Accountability Office, 2011). It is also important for the nurse to understand how substance abuse can affect mental health concerns and vice versa. By appreciating that the client struggling with drug or alcohol addiction may also be suffering from a mental health issue, the nurse can ensure that the care is individualized to meet that client’s specific needs.
Female veterans face an additional set of problems with the VA healthcare system. Often, there are limitations set on gender-specific care that are based on male-dominated diagnosis criteria (Concord & Armstrong, 2018). Many female veterans are unsure of the services offered to them or their eligibility for them and for this reason, are seeking care within the VA health network, but also outside of the network in community health facilities (Concord & Armstrong, 2018). The wartime experiences and the physiological and psychological responses of female veterans are markedly different from their male counterparts. Female veterans of the wars in Iraq and Afghanistan are reported to be about three times more likely to experience symptoms of PTSD than males, making it imperative that their healthcare providers are consistently assessing for depression, PTSD symptoms, poor coping mechanisms such as substance abuse and suicidal ideation, as these often go unreported (Concord & Armstrong, 2018). They are also less likely to disclose concerns about their mental health without prompting due to fear, embarrassment, or concerns for their children (Concord & Armstrong, 2018). The civilian healthcare provider who is not familiar with the specific needs of the female veteran may not know that these issues need to be readdressed frequently. Many VA health centers have a limited availability or lack of gynecologic care providers within their facilities, making it all but impossible for these women to receive reproductive care. Strenuous activity and heavy gear often contribute to overactive bladder, pelvic organ prolapse, and bladder pain syndrome, conditions that a civilian provider would consider an abnormal finding, but a trained VA provider may see the significance of its origin and implications for additional concerns. Many female veterans also struggle with infertility, which is now considered a disease and a documentable disability (Concord & Armstrong, 2018). VA Specialists are limited and scattered across the nation, coverage is often varied and may be non-existent for non-military spouses, making this area of women’s health care a significant challenge. For these women who are accessing care outside of the VA network, it is essential that there be clear and effective communication between VA and civilian providers to ensure that the patient receives high-quality, holistic care. As previously discussed, communication with the VA can be challenging at times, leaving the health and well-being of these female veterans at risk.
The nurse caring for the female veteran in a civilian facility may not be aware that their patient is in fact a veteran. Many do not disclose that they are a veteran unless asked so it is essential that nursing staff evaluate each new patient for military status. The website www.haveyouserved.com was created by the American Academy of Nurses and offers a variety of questions to ask and behaviors to observe when assessing a client with a military background. It also provides links for veterans to each state's Department of Veterans Affairs and other resources that can be provided to the patient. By recognizing that the female patient being evaluated is also a veteran, we can ensure that they receive highly individualized care, based on their specific needs and experiences from their time of service. It has also been suggested that by asking questions about a woman’s military service and occupation, the nurse can improve communication with the patient and gain a better awareness and appreciation of their service (Concord & Armstrong, 2018). The nurse can then use this information to tailor the care that is being provided so that the female veteran feels safe and comfortable, decreasing the stress placed on the patient. This increased communication with the patient will also allow the nurse to better recognize new or worsening signs of mental illness that may be missed where there is not a strong nurse-patient relationship.
Conclusion
While many changes have already happened within the VA healthcare system, many more are still needed. It will take a significant amount of time for those changes to be successfully implemented and many of our nation's veterans simply do not have the kind of time to wait. Nurses must ensure that they are thoroughly assessing their patients, providing appropriate resources, advocating for their patients, and encouraging them to take an active role in their health care. In all cases, but especially with the veteran client, we must recognize and try to understand the unique circumstances that have brought them to their current state and manage their care in a caring and compassionate manner. Appropriately identifying barriers to care and working to remove them or provide workarounds to help the patient receive the care they need is an essential skill of the nurse working with veteran patients. By utilizing resources available to us such as the RN case manager, we can help to ensure that all aspects of the patients’ care have been addressed and that they are receiving holistic care for their physical and mental health needs. As a nurse, having a working knowledge of the resources that are available to the veteran client can also help them to have a better understanding of what is out there and available to them, again increasing the likelihood of the patient taking an active role in their health care. This knowledge can also help the nurse see where there is a continued need for change and improvement. Seeing this situation firsthand, the nurse can better advocate for policy change, increased funding where it is needed, and overall reform of a flawed system, intended to provide care for the men and women who have stood up to serve and protect a country that is essentially letting them down when they need it the most.
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