Nursing Care for Veterans

It’s a quiet morning following Presidents Day at the telephone triage center at the James J. Peters Veterans Affairs Medical Center in the Bronx. Nurse practitioner Sophy Koyithara, manager of the center, is relishing the relative calm after weathering the deluge of calls flooding into the center over the long weekend when all VA health facilities throughout the country were closed. On the Monday holiday alone, Koyithara’s team of 13 nurses answered 834 calls from veterans up and down the Eastern Seaboard, dealing with matters ranging from the everyday to the life-threatening. “We got calls from veterans with foot pain and those with questions about medication,” said Koyithara, “and then we had people who were experiencing symptoms of heart attacks and strokes and needed immediate emergency treatment.”

It was during this flurry that Koyithara received a call from a distraught veteran who said he was standing on the edge of a bridge, contemplating jumping to his death. Koyithara kept the man talking on the phone for an hour and a half while the police searched a 200-mile radius for the location of the bridge. Using information the vet had given about where he lived in Pennsylvania, the direction he set out in, and how much gas was in his car, miraculously, the police found the veteran and successfully coaxed him from the bridge. Unfortunately, this kind of call comes in all too often. Nurses at the Bronx VA telephone triage center receive an average of four to five suicide calls a day—nights between 4 p.m. and 7 a.m., on weekends, and during holidays. “The nurses here are our most important resource,” said Koyithara. “They are highly experienced clinically and great communicators who save lives every day.”

At VA health centers as well as in civilian settings throughout the U.S., nurses play an integral role in caring for the nation’s 22 million veterans and 3 million active service and reserve members. This is a diverse population that includes frail, elderly vets who served in World War II, Korea, and Vietnam as well as some 2.8 million U.S. troops who have been deployed since October 2001 to support operations in Afghanistan and Iraq.

The VA is the largest employer of nurses in the nation. Its 90,000 nurse professionals lead primary care teams, work directly with homeless vets, provide screening and treatment for mental health conditions such as post-traumatic stress disorder and substance abuse, and spearhead new efforts to offer health care services to the growing number of women in the military.

“Nurses fit nicely into the model of caring for vets and the military,” said General William Bester, a former chief of the Army Nurse Corps and 32-year veteran who is now senior adviser to the Jonas Veterans Healthcare Program. The Jonas initiative supports doctoral level (PhD and DNP) education for nurses who will be involved in all levels of veterans’ health care, from direct patient care to administration and policy. “By training, nurses are focused on the medical and psychosocial aspects of their patients’ lives, including dealing with family, employment, and other potential sources of stress. They do a wonderful job of communicating, which is one of the strongest benefits they bring to caring for veterans,” added Bester.

The Department of Veterans Affairs is undergoing a major overhaul, spurred by an investigation conducted by the VA’s Office of the Inspector General into improper scheduling practices and long wait times for appointments at a VA facility in Phoenix that led to the deaths of at least 40 veterans. The investigation was extended to 93 other VA facilities, and confirmed that delays and waiting-list problems were widespread throughout the system. The IOG investigators called for “immediate and substantive changes,” writing: “This report cannot capture the personal disappointment, frustration, and loss of faith of individual veterans and their family members with a health care system that often could not respond to their mental and physical health needs in a timely manner.” Other reports, including one by the RAND Corporation, found that in particular “there is a large gap between the need for mental health services and the use of those services” by the increasing number of veterans returning from Iraq and Afghanistan.

In August 2014, Congress passed a $15 billion emergency funding bill that expands access to non-VA health care facilities for veterans unable to receive timely appointments or who live 40 miles or more from a VA medical facility. The bill also includes $5 billion to enable the VA to hire more doctors and nurses and approximately $1.3 billion to finance leases for 27 new VA facilities nationwide. Finally, the increased funding is designed to improve care for victims of post-traumatic stress disorder and military sexual trauma and those suffering from traumatic brain injuries (the so-called “invisible wounds of war” that are more prevalent among veterans who have served in Iraq and Afghanistan).

The VA estimates that some 11 to 20 percent of veterans who served in Iraq or Afghanistan suffer from post-traumatic stress disorder in a given year, and that 30 percent of Vietnam veterans have experienced the disorder in their lifetimes. According to General Bester, 1 million vets have been diagnosed with one or more mental health problems while 50 percent of those have been diagnosed with at least two disorders. This large volume of psychological illness plays out in escalating suicide figures: In 2014, there was a 44 percent increase in suicides in male veterans under the age of 30 and an 11 percent increase in females in the same age bracket. An average of 22 veterans commit suicide each day.

Mental health nurses play an important role in dealing with the increase in mental health problems and related concerns among veterans. For example, there are 1.4 million veterans at risk of homelessness due to poverty, poor living conditions, and lack of support networks. Ellen Flanagan, works with homeless vets every day as part of the Housing First Assertive Community Treatment team at the VA’s New York Harbor Healthcare Center in Brooklyn. Her outreach team, which includes a peer counselor who is a veteran himself, finds homeless vets living on the street or in the park and works to get them into permanent housing as a first step toward recovery.

“We have one vet in her early fifties who lives on the street, is delusional, and refuses to come to the clinic to get services,” said Flanagan. “She thinks she is actually working in the park, so we do street outreach for her, going to the park or train station or wherever she’s staying. I do a psychiatric evaluation, provide meds, and we offer to bring her to transitional housing.”

The team works in partnership with New York City’s Department of Homeless Services and can procure Section 8 vouchers for veterans, which can be used to pay rent in select apartments around the city. So far the woman has refused housing, so the regular visits continue. “We make sure that she’s safe and bring her food, blankets, clothing, and gloves, just trying to gain her trust,” said Flanagan.

It takes time, but there are successes. One homeless vet went from the streets to transitional housing in a shelter for veterans and eventually moved into a Section 8 apartment. Flanagan’s team connected him to a Harbor Healthcare VA clinic, where he has access to health services and support groups, including one that provided job training. The veteran received help with substance abuse and began taking psychiatric medication to treat his underlying mental illness. “Eventually he entered a work therapy program and got a job working at the VA,” said Flanagan. The team still visits the vet weekly and has even helped him find furniture and supplies for his apartment.

The VA health care system deploys team care for veterans, homeless and otherwise, by linking each vet with a designated care unit, a model similar to many medical homes in civilian health care. The focus is on providing long-term collaborative care that aims at treating the whole patient, not just separate illnesses or conditions. The emphasis is on wellness and preventive care as well as linking vets to supportive services in mental health, job training, and for the frailest patients, home-based primary care.

According to Kathleen Capitulo ’02, PhD, FAAN, chief nurse executive at the Bronx VA, “Nurses practice in an interdisciplinary team, coordinating complex care, including telehealth.” In home-based primary care, for example, nurse practitioners serve as the primary provider and RNs coordinate all of the care, furnishing follow-up and feedback to vets in their homes. “We put all primary care into this team model four years ago and have been very successful,” said Capitulo. “We have seen a decrease in hospital admissions for patients and do a fabulous job of keeping people out of hospital, with higher patient satisfaction compared to the private sector.”

Capitulo, whose career focused on women’s health and maternal child health before she joined the VA, extended the team-based care approach to the women’s health program at the Bronx VA and the VA community practice in White Plains, N.Y. Women currently make up 8.1 percent of all living veterans and comprise some 14.5 percent of service members in active duty and 18 percent of the reserves. “The VA has been responsive to the unique needs of female veterans, recognizing that the one-size-fits-all approach doesn’t fit women,” said Capitulo. “Women have shared with us that while they are equal, their needs are different.” An expert in qualitative nursing research, Capitulo facilitated focus groups with female veterans and providers to improve care, services, education, and the design of the new women’s health clinic. There is a separate, child-friendly waiting room for women; five-day-per-week coverage for gynecology; a full spectrum of gynecological surgery; and soon, on-site mammography. James J. Peters is one of two VAs in the nation to have a pediatrics clinic, providing well child care and immunizations to children.

In some of the focus groups, more than half the women said that they had witnessed or experienced military sexual trauma (MST). The team now includes a social worker—a retired New York City police officer with experience in the sex-crime unit—who provides counseling in groups and for individuals. “Our job is to provide a healing environment for those who have experienced MST.”

A significant number of nurses and nurse leaders in the VA health care system have served in the military themselves. Still, the VA health care system does not require that a veteran’s past service history be part of his or her electronic health record, so adverse events that may be related to that service may be missed. That’s why veterans often arrive for appointments at VA hospitals and clinics wearing baseball caps, T-shirts, and jackets emblazoned with logos that let doctors and nurses know what war they’ve fought or served in. Providers are even less inclined to ask about prior service when veterans seek care outside of the VA. In a given year, only 27 percent of veterans receive their care from the VA. The rest are likely to use civilian hospitals, clinics, and private offices. This is especially common for recent veterans of the Iraq and Afghanistan conflicts who served in the reserves and return to their homes in small towns far from military bases and VA clinics or centers.

Dennis Graham ’93 ’08, PhD, believes this needs to change. A Vietnam vet who recently retired as director of the nurse practitioner program at Memorial Sloan Kettering Cancer Center, he feels strongly that a patient’s experience as a veteran can play a major role in an illness, especially a serious one. During their service, veterans may have been exposed to radiation, Agent Orange, anti-malarial drugs, or noxious fumes linked to cancer or immune system disorders. Those who served in Iraq and Afghanistan may have respiratory conditions linked to open-air burn pits, may have experienced traumatic brain injury from improvised explosive devices, or be suffering from posttraumatic stress disorder or sexual trauma. “I asked a patient during a pre-op admission if he had served in the military and he said that he had been in the Korean War,” said Graham. “He told me he still has dreams about it. His wife added that he is restless at night. I reported this to the surgical team and nursing staff. After surgery, the patient had an episode of severe hallucinations and night terror. The psychiatry service was consulted, but they were unaware of his veteran status. I told them about his service in Korea and his reports of dreams and nighttime restlessness and they changed his therapy. Not knowing his experience as a combat veteran could have led the psychiatric team to treat for postoperative delirium and not night terror.”

The American Academy of Nursing recognizes the importance of identifying veterans in civilian health care settings and has launched a national initiative centered on the question, “Have you ever served in the military?” According to Cheryl Sullivan, CEO of the academy, the organization distributes a pocket card that leads nurses through a series of questions that include: “Have you or someone close to you ever served in the military—when did you serve; what was your job in the military; did you experience enemy fire or combat; or do you know if you were exposed to chemicals or gases?” Sullivan says that because nurses are “health care’s equivalent to boots on the ground,” they are in a position to make sure that this vital information is obtained and recorded, potentially helping improve the health care provided to the nation’s veterans and their families.

The “Have You Ever Served” initiative is part of a larger commitment to veteran care from the nursing profession. More than 150 of America’s nursing organizations and over 450 nursing schools in 50 states and territories are part of the Joining Forces effort spearheaded by the White House and First Lady Michelle Obama to better serve the nation’s veterans and their families. Nursing leaders have committed to educating current and future nurses on how to recognize and care for those suffering from combat-related conditions and symptoms. According to the American Nurses Association, this effort is expected to reach more than 3 million nurses in nearly every health care setting and every community in America. As an example of the effort’s thrust, the American Nurses Foundation recently launched a web-based post-traumatic stress disorder toolkit that is available to all registered nurses, and describes how to identify, assess, and refer veterans suffering from the condition.

Nursing research is at the heart of developing new evidence-based treatments and interventions for the invisible wounds of war, such as post-traumatic stress disorder as well as the more visible injuries and conditions of battle. In the clinical arena, nursing emphasizes communication, intimate contact with patients, and a dedication to treating the whole person. When combined with training to better understand military culture, an ability to listen and respond without judgment, and respect for military service, these attributes render nurse professionals essential participants in improving care for those who have put themselves in harm’s way.