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Clinical Implications

The majority of previous research on reintegration has focused on combat warriors. Much less is known about reintegration from the vantage point of the nurses who cared for the injured warriors and the innocent civilians who were caught in the horrific chaos of war. Nurses may possess a unique and perceptive insight given the nature of their work and the humanistic and holistic perspectives embedded in their profession.

The findings from our research can be used to encourage meaningful dialogue between military nurses and health care administrators at their various workplaces (military and civilian) to investigate and reflect on how wartime deployment impacts their current and future nursing careers. A lesson can be learned from these veterans because they provide a realistic picture of the reintegration experience. These nurses can be extremely influential in helping other nurses to prepare for deployment to a war zone. The findings in this book inform both military and civilian leadership, as well as families and communities, of the changes that reintegrating nurses have gone through and continue to go through as part of the reintegration process. It is ignorant and unrealistic to assume that nurses will not be changed both personally and professionally as a result of their wartime deployment. The findings presented in this book demonstrate the need for military health care and family advocacy groups to improve outreach services on a regular basis for veterans and their families. Family readiness and outreach services need to make a greater effort and have a more proactive approach to reach all civilian health care facilities that employ nurses who serve in military reserve units. Programs for reservists need to be especially creative and available because reservists often do not reside near a military installation.

Services for all veterans need to include psychological, physical health, social welfare, financial, spiritual, and educational help. A one-size-fits-all approach is inappropriate and problematic in addressing reintegration issues. A more individualized perspective with an open-ended timeline may be key to helping veterans deal with reintegration.

This book expands knowledge about military nursing in war and the sequelae that follow after such service. It elucidates the difficulties encountered upon returning home, such as renegotiating roles, resuming family activities, returning to clinical work, dealing with uncomfortable memories, and addressing possible negative feelings caused by stress, frustration, and disappointment. No one returns to a perfect milieu; even very positive homecomings and seemingly easy reintegrations are not without bumps in the road.

The findings of this current research inform us that it is of paramount importance to have support systems in place to assist military families before, during, and after deployment to address the specific stressors pursuant to each time period. Although the book is concerned with the reintegration process, it goes without saying that reintegration is truly affected by the events that preceded it. It is hoped that future research will build on this foundational work as nurses continue to be deployed to Afghanistan. Some research has led to the development of promising interventions that seem to be beneficial. However, we need to formulate more helpful interventions and specifically address the needs of military nurses to ensure optimal individual and family functioning.

It is important for the American people to hear the stories of these nurses. They not only answered their country’s call to serve; they provided high-quality health care for the warriors defending our nation. These nurses served humankind, providing excellent and compassionate care; even for the enemy when needed. They formed a kinship with the oppressed women of Iraq and Afghanistan and never turned their backs on anyone in need. They had a special place in their hearts for the children of Iraq and Afghanistan. Our nurses cared for so many innocent victims in these two war theaters. Their stories inspired us and gave us an appropriate lens to gain a better understanding of the complex reintegration process.

THERAPEUTIC INTERVENTIONS

It goes without saying that all returning veterans need to be “thanked for their service” by everyone coming in contact with them: their families, social network, community, and workplace. Both military and civilian workplaces need to “rally round the flag” and welcome veterans back. Places of worship should acknowledge their service and embrace their homecoming just as the same faith communities prayed for their safe return while they were deployed.

Military personnel and all present in a war zone face an array of multifaceted stressors on a daily basis. With the constant threat of mass casualty events, nurses had to be on alert 24/7 even if they supposedly had a day off from their regular duty. Thus, nurses were at risk for being injured or being killed even though an attack was less likely to occur at a hospital or clinic. Some nurses volunteered to go “outside the wire” on humanitarian missions specifically directed to help woman and children in nearby villages and towns. The voices of these returning nurses illustrate the need for mandatory mental health screening at homecoming with frequent checkups. Therapeutic modalities and interventions need to be individualized on a case-by-case basis.

Research from the Veterans Administration (VA) and various military services have identified the following factors that increase a service member’s chance of developing posttraumatic stress disorder (PTSD). These factors include: a longer deployment time (especially 9–12 months); more severe combat exposure (deployment to “forward” areas closer to the enemy and seeing others wounded or killed); severe physical injury; traumatic brain injury; lower rank; lower level of education; low morale and poor social support within the unit; not being married; family problems; member of the National Guard or Reserves; prior trauma exposure; female gender; and being from an Hispanic ethnic group (National Center for PTSD, 2015).

According to the VA Office of Public Health and Environmental Hazards, more veterans recently returned are seeking care through the VA than ever before. VA data show that from 2002 through 2009, 1 million troops left active duty in Iraq and Afghanistan and became eligible for VA care. Forty-six percent of these troops sought VA services. Of those veterans who used VA care, 48% were diagnosed with a mental health problem. Yet, many veterans with mental health problems have not availed themselves of VA services. Some reasons given for not seeking help include the following concerns: being perceived as “weak”; being treated differently by others; fear that others would lose confidence in them; lack of privacy; a preference to rely on family and friends; lack of confidence in treatment modalities; the possibility of medication side effects; and problems with access to care such as cost and location of treatment facilities (Veterans Administration, 2010).

It is important to note that the National Center for PTSD does not provide direct clinical care, individual referrals, or benefits information. However, they provide a wealth of written and media materials to aid veterans and their families to educate themselves about PTSD and the reintegration experience in general, which will lead to procuring care.

With the greatest majority of nurses in both war theaters being women, the National Center for PTSD in its literature states that women are more than twice as likely to develop PTSD as men (10% for women and 4% for men). In addition, sexual assault is more likely to cause PTSD than many other events. Women with PTSD are more likely to feel depressed and anxious, whereas men with PTSD are more likely to have substance abuse problems (National Center for PTSD, 2015).

Although some caregiver suffering or “emotional labor” may be inherent in the nursing role, some can be reduced by a supportive leadership, understanding coworkers, and a general sense of appreciation (Hochschild, 1983). Also, nurses need to focus on their own mental health and well-being so that they can continue providing quality care and find meaning and satisfaction in their work.

There are several therapeutic interventions mentioned in the literature to aid returning veterans and their families in the reintegration process. Some focus on the returning veteran, others on the couple relationship, and others on family resiliency. There is never a “one size fits all” model.

One therapeutic intervention, about which the authors feel strongly for all nurses preparing for deployment as well as a refresher course for those at the beginning of the reintegration process, is mindfulness training. Mindfulness is the capacity to intentionally bring awareness to present-moment experience with an attitude of acceptance, openness, honesty, and curiosity. It is being awake to the fullness of life at that immediate time as witnessed by the five senses (Kabat-Zinn, 1996, 2001, 2006, 2009).

Mindfulness training can reduce psychological, emotional, and physiological stress. It can also improve empathy, compassion for others, satisfaction with life, and enhance one’s overall sense of well-being. Being mindful does not mean altering or stopping one’s thinking or purposefully trying to relax. Yet, many people who practice mindfulness on a regular basis report feeling calm, relaxed, and peaceful. Mindfulness meditation can soothe a distracted mind and increase one’s sense of feeling grounded.

Many parents, who are juggling a military career as well as childcare responsibilities, describe a feeling of “being on automatic pilot” as they try to reintegrate after deployment. Their bodies operate in a routine manner at work as their minds are somewhere else, often anticipating future events or ruminating over past events. This way of functioning limits how life is experienced both at home and at work, and affects the quality of relationships and one’s decision-making abilities. It can also increase feelings of stress and lead to anxiety and depression. Mindfulness practices incorporated into one’s daily life can help end negative self-talk, pessimistic thinking, and needless worrying. A conscious shifting of the mind to present-moment experience can interrupt a chain of unhelpful, counterproductive thinking patterns that are detrimental to one’s sense of well-being.

Research in the field of neuroscience has indicated that mindfulness practices enhance brain function in the areas responsible for problem solving, while modulating the areas that identify emotions such as fear and anger. Mindfulness practices enhance one’s ability to assess situations and circumstances with greater attention and a clearer focus so one can respond appropriately without a quick thoughtless reaction. Although mindfulness practices are relevant for both deploying nurses and reintegrating nurses, their applicability has broad implications for all humans for that matter.

Historically, mindfulness-based stress reduction (MBSR) can be traced to Jon Kabat-Zinn in 1979. His seminal training program was developed to reduce chronic pain in patients. His offered a structured 8-week program which included a variety of stress-reduction exercises geared to increase one’s capacity to become more mindful. Its core practices included mentally tuning-in to body sensations, gentle yoga, and breathing awareness. Research examining the effects of MBSR found improvements in the health and well-being of patients who had been suffering from chronic pain.

As a result of the aforementioned training program and the media attention surrounding its success, mindfulness-training programs escalated throughout the United States. In addition, these training programs did not remain just in the clinical sector, but spread to many populations such as athletes, corporate leaders, performers, and educators.

When we consider the nursing profession, mindfulness can foster increased awareness and less distraction in the clinical setting. Mindful practitioners can communicate using better listening skills and speaking abilities. They can deal more effectively with stress because of more efficient coping mechanisms. Mindfulness can also decrease the rate of burnout within the profession.

With military personnel reintegrating after wartime deployment, mindfulness can help them to see things more clearly and with a calmer demeanor. It can help interrupt the cycle of overwhelming thoughts and feelings that often bombard newly returning veterans. Similarly, mindfulness can enhance communication with family, friends, coworkers, and patients. It is a lifelong process that can be developed and cultivated throughout the life span.

Suggestions for practicing mindfulness in daily life include the following steps:

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