The concern over health disparities for populations has expanded far beyond race and minority status. Healthy People 2020 defines a health disparity as "a particular type of health difference closely linked with social, economic, and/or environmental disadvantage." Health disparities affect groups of people who have systematically experienced obstacles to adequate health care based on categories such as racial or ethnic group, religion, gender, and mental health. This is not an inclusive list as health disparities affect populations other than traditional racial and ethnic minorities (US Department of Health and Human Services, 2015).
US veterans are a population with distinct characteristics and health concerns. The experiences and values of current and former military members and their families are vastly different from those of the civilian population (Redmond et al., 2015). Basic training/boot camp, combat deployment, and exposure to environmental or chemical substances change the way veterans look at their families, communities, and themselves. As a result of these unique life experiences, veterans have very different psychosocial and physical health risks than their civilian counterparts (Cigrang et al., 2014).
Currently, there are more than 21 million living US veterans, but not all receive care at Department of Veterans Affairs (VA) facilities. Only 61 percent of recently separated Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) veterans seek care at the VA. The remaining 39 percent are seen in civilian offices, clinics, and hospitals where their veteran status may not be known or assessed (US Department of Veterans Affairs, 2015). This article describes the unique and distinct culture of veterans and provides resources to assist faculty in teaching culturally competent care. Recognizing veterans as a distinct cultural group is necessary to address needed educational, policy, and practice changes.
VETERANS AS A DISTINCT CULTURE
Culture consists of the shared language, social norms, and ideas of a distinct group of people that are shaped by experience and the environment (Redmond et al., 2013). The expression of culture includes the attributes of language, values, and patterns of behaviors of a distinct group identifiable as its own and based in ideology. People of the same culture typically share distinct achievements over time, often transmitted with symbols, artifacts, and imitation reflective of core values (Kroeber & Kluckhohn, 1952). The use of the term culture is becoming increasingly broad; it is used to denote groups not based on race or ethnic origin, such as individuals belonging to the LGBTQ (lesbian, gay, bisexual, transgender, and queer) or deaf communities.
When a soldier, sailor, airman, or marine enters service, he or she is methodically enculturated into a society different from the civilian world. Learned behaviors, change, and adaptation shape service members, from boot camp until eventual separation. When examining veterans as a distinct culture, it should be recognized that, although some terms may differ slightly among branches of the military, a distinct language among veterans exists. Similar to other cross-cultural phrases, expressions such as chow, mess, MRE (meals ready to eat), and H-U-A (heard, understood, acknowledged) have found their way into the mainstream vernacular.
The values of military members are completely transformed during their initial weeks of service. Although there is slight variability in individual branches of the armed forces, what unifies service members are the embedded values of loyalty, teamwork, and unwillingness to leave a comrade behind (Strom et al., 2012). Military members act as a collective, cohesive unit, always putting the good of the group above the good of the individual. The end result is a strong sense of esprit de corps and camaraderie that sets military members psychologically apart from civilians (Coll, Weiss, & Yarvis, 2011).
The culture adopted during military service remains after the service member separates and takes on veteran status (Johnson et al., 2013). These attributes, values, and behaviors clearly mark veterans as having a unique, often difficult to spot, culture.
IMPLICATIONS FOR THE NURSING CURRICULUM
Cultural competence education in nursing has long been recognized as key to supporting the principles of patient-centered care. However, veterans are not typically categorized by schools of nursing as a diverse population with special health needs. The Accreditation Commission for Education in Nursing (2016) baccalaureate standards, the American Association of Colleges of Nursing (2008), and the National League for Nursing (NLN, 2016) emphasize the role of professional nurses in delivering culturally sensitive care. However, schools of nursing may be overlooking one of our country's largest and most vital cultural groups. There is little evidence to indicate that nursing programs are addressing military and veteran culture as an aspect of cultural competence and an integral piece of patient-centered care. A few articles found in the nursing literature describe exercises involving simulated scenarios (Anthony, Carter, Fruendl, Nelson, & Wadlington, 2012; Beckford & Ellis, 2013; Nye, Keller, & Wrenn, 2013). It is imperative that academicians begin to include culturally competent veteran care in prelicensure nursing program curricula.
First, we must collectively recognize the unique cultural differences that exist among veterans and accept that they differ from our own. Awareness of differences is consistently defined as a key element of cultural competence across models (Shen, 2015). Second, faculty and students must understand the unique psychological and physical impact that military service has on veterans' health status and strive to achieve a strong knowledge base to deliver culturally competent care (Shen, 2015). Veterans' needs may differ by the era of service (e.g., Vietnam, Gulf War), and students must be taught to recognize the symptoms and sequelae of posttraumatic stress disorder, traumatic brain injury, and military sexual trauma. There are increased risks among veterans for suicidality and substance abuse, and students should be taught to screen accordingly.
Finally, curricular integration of educational resources, including the NLN Advancing Care Excellence for Veterans resources (http://www.nln.org/professional-development-programs/teaching-resources/veterans) and AACN's Joining Forces: Enhancing Veterans' Care Tool Kit (http://www.aacn.nche.edu/downloads/joining-forces-tool-kit), should be explored and drive any needed changes. Throughout the country, isolated colleges of nursing are partnering with the VA in a program called the Veterans Affairs Nursing Academic Partnership. This VA-funded program/partnership is an excellent first step in integrating culturally competent veteran care into students' clinical experiences. There are limited numbers of Veterans Affairs Nursing Academic Partnership programs nationwide.
CONCLUSION
Veterans possess the unique attributes of language, values, and behaviors and should be recognized as a distinct group. Recognizing veterans as possessing their own culture is a first step in the provision of culturally competent care. The health care needs of our nation's veterans are well identified in the literature, but it is unclear how culturally competent veterans care is integrated into prelicensure nursing program curricula.
It is critically important that future research determine the resources needed to best educate nursing students. Faculty should utilize the limited resources available and begin to integrate curricular changes to address program gaps. Curricular redesigns should be inclusive of all diverse populations in an effort to increase competence. What is certain is that our nation's veterans, who shouldered the responsibilities of our national defense through their service, deserve care that is patient-centered, culturally competent, and delivered at the hands of nurses who are ready to meet their unique needs.
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