Transitions Are Hard: A Look at Military Nurses and Their Volunteer Support Organization ()
1. Introduction
Military transitions are challenging, whether from wartime to peacetime missions or uniformed military service to civilian/veteran life (Markowitz et al., 2023). Suicide rates are higher, in fact double in transitioning US military than the general population (Hoffmire et al., 2022). This led Veteran Affairs (VA), and the Veterans Health Administration (VHA) to make suicide prevention (Ullman et al., 2021), comprehensive support, healthcare access and quality a national priority. Suicide prevention is one of six actively managed research portfolios in the VHA, Traumatic Brain Injury (TBI), Pain and Opioids, Gulf War Illness, military exposure, and precision oncology being the other five (DVA, DHA, R&D, 2024).
US military functions are carried out by two groups, the combat sector prosecutes the Nation’s wars, while the combat support sector preserves the fighting strength both in times of peace and war. Currently, approximately 108,000 support jobs are in healthcare (36,000 officers, 72,000 enlisted) making up 12% of the active component (Defense Health Care, 2023). Of the 200,000 servicemembers transitioning out of military service a year, a percentage of them will have served in the health professions and of that, a percentage will have been military nurses (Health.mil, 2021).
Military nurses support combat missions but differ from their combat and combat support peers in that while maintaining Solider, Sailor, or Airmen skills, their primary focus is on preserving the fighting strength through battlefield and peacetime medicine. Studies have found military nurses are significantly impacted by wartime experiences (Doherty & Scannell-Desch, 2015; Hopkins-Chadwick, 2012; Mark et al., 2009; Rivers et al., 2013). Non-military nurses are also significantly impacted and suffer an increased suicide rate relative to non-healthcare workers (Olfson et al., 2023; Davidson et al., 2024). In addition to well-documented military identity, military nurses also have the added identity as military nurse.
In July 2022, Senator Angus King, called for an increase in tracking military occupations saying, “I know [military researchers] have got data by service and sex and everything, but I’ve never heard or seen anything related to job specification,” he said in an interview with Military Times (Shane, 2022). “It seems like something we need to know. If you’re seeing similarities in job titles and job responsibilities, then you know where to focus the attention.” There is a gap in what we know about transitioning and military jobs. In other words, that we currently know about suicide prevention may be underinformed regarding military jobs and in this case military nursing.
2. Background and Significance
2.1. Unmet Needs
Markowitz et al. (2023) surveyed 783 post 9/11 Veterans to examine relationships between post-discharge strains, resentment, depression, and risky behaviors. Surveys revealed that unmet needs upon military separation coupled with loss of military identify were associated with risky behaviors and that the effect of identify loss and unmet discharge needs were mediated by depression and resentment towards civilians. The investigators concluded that the study “highlighted the importance of helping veterans meet their post-discharge needs and adapt to changing identity, in order to reduce the risk of emotional and behavioral problems” (Markowitz et al., 2023). In a sample of 1469 Veterans, Schafer et al., (2024) found that social contribution was the strongest protective factor against suicide (beta = −0.039, t = −15.59, p < 0.001) followed by social integration (beta = −0.13, t = −4.88, p < 0.001), concluding that social contribution could be a treatment for suicide reduction and prevention. The investigators used the Social Well-Being Questionnaire to measure social contribution and integration. The questions on the sub scales were: “I have something valuable to give to the world”, “my daily activities do not produce anything worthwhile for my community,” “I have nothing important to contribute to society”. “I don’t feel I belong to anything I would call a community”, “I feel close to other people in my community”, and “my community is a source of comfort”.
Veterans relate the need to re-establish relationships, make new friends, and maintain friendships after military service (Sayer et al., 2011). When needs are unmet there is a feeling of isolation and loneliness (lack of belonging). Veterans also relate a need to be productive (usefulness), to continue learning, and to develop and to use skills in valued roles and involvement in community activities (Gorman et al., 2018). In addition, past and present military members express concerns over meeting their own health and developmental needs (Gorman et al., 2018). Russell & Russell (2018) found that identity and perceived meaning that military service was beneficial to society were contributing factors to well-being in people and tested their theory in relation to veteran service organization (VSO) involvement. Being a member of and actively engaging in a VSO led to reduced social isolation through identity even if participation in the organization was low. Less isolation and positive meaning through VSO involvement (be a member and participating) even led to lower posttraumatic stress symptoms (Russell & Russell, 2018).
Much like the double trauma exposure nurses experience (primary and vicarious) in caring for battlefield casualties, military nurses are likely to experience all the above unmet needs in addition to the burdens of being caregivers.
2.2. Transition Risk Factors
The Centers for Disease Control and Prevention (CDC) Social-Ecological Model (SEM) provides a framework to organize risk and protective factors. Elnitsky, Blevins, Fishers & Magruder (2017) adapted the SEM to the military population. A strength of the Elnitsky et al. (2017) adapted ecological model is that it explains factors at multiple levels (individual, Interpersonal, community, and societal) offering a thorough way of understanding what is at play. As evidenced by the 15 years of research reviewed by Elnitsky et al. (2017), an intervention at any one level can impact other levels and all reintegration work benefits from being contextually grounded. When reintegration (from deployment to non-deployment and military service to after military service) is not going well the following are the risk factors at work. At the individual level, psychological & physical risk factors notably, psychological stress, moral injury, substance use and abuse, difficulties in adjustment and coping, and increased tolerance to pain, pain, functional impairment, and problems with sleep are found. Culture risk factors include disconnection (reverse culture shock) & public stereotypes when moving from identity group to new group. Productivity risk factors are unemployment, under-employed, employed outside of desired area. At the interpersonal Level, relationship risk factors encompassing, lack of veteran friends and dissatisfaction with family and friend relationships and social networks shows up. At the community level, health systems risk factors such as acceptability, poor quality healthcare and access to healthcare are problematic. Work & school risk factors include acceptability and access issues as well as negative community attitudes toward past servicemembers. At the societal level, social policy, media, and research reports that emphasize risk factors can be damaging. When taken altogether there are many risk factors across all levels of the ecological model that can result from unmet needs leading to less-than-optimal transition outcomes add to that the unique role of military nurses and the effect could be magnified.
In the 2021 report “Risk and Protective Factors Across Socioecological Levels of Risk for Suicide: An Evidence Map”, the Department of Veteran Affairs summarize 63 studies (Ullman et al., 2021), only five examined military occupations; categorizing them as combat or combat support. Two of the five found no association. There is little healthcare occupation or specifically military nurse data that can be used to describe or understand military nurse risk factors. It is possible that military nurses respond in kind as the whole with nuances related to their unique role within the military system and subsequent veteran status but not yet adequately explored. What is evident is that overall risks are largely related to social and identify factors, one option to mitigate this risk could be an organization that meets social and identify needs.
2.3. Role of Organizations in Transition Support
Core functions of Veteran Service Organizations (VSO) are to provide a community network, to inform, to provide supportive programming, and to advocate (Thomas et al., 2017). Needs can be met when organizations provide an opportunity for peer-to-peer informal social support, emotional support, information, advice, practical assistance, and clarity deciphering experiences (Russell & Russell, 2018).
When you consider that people who use peer-to-peer social support tend to be more inquisitive, share more personal insight, engage in more conversation, and provide more advice, peer-to-peer social support might be better than therapy, Russell & Russell (2018) found that identity and perceived meaning that military service was beneficial to society were contributing factors to well-being in present and past military members and tested their theory in relation to veteran service organization (VSO) involvement. Being a member of and actively engaging in a VSO led to reduced social isolation through identity even if participation is low. Also, the degree that present and past servicemembers identify with an organization is related to positive meaning of service even if they are not that involved in the organization. Lastly, less isolation and positive meaning through VSO involvement (be a member and participating) led to lower posttraumatic stress symptoms (Russell & Russell, 2018).
2.4. A Discipline Specific Organization
The Army Nurse Corps Association (ANCA) is a 501(c)19 nonprofit organization formed in 1977 by a group of retired Army Nurse Corps officers who desired to promote camaraderie and close ties in Army nurses and establish a means of communication by, for, and about Army nurses. ANCA is a voluntary membership organization consisting of Army nurses who are Active Duty, Reserve, and National Guard, whether currently serving, previously served, or retired. Members have voting rights, and any member may hold elective office in accordance with established criteria. All members are welcome to serve in other volunteer capacities and on the various committees of the organization. All are encouraged to support fellow officers. ANCA provides nursing scholarships in baccalaureate and graduate nursing education and nursing anesthesia programs, provides seed grants for nursing research and evidence-based practice initiatives, and money for publication of nursing research findings, funds members’ nursing specialty certifications, documents and preserves Army Nurse Corps (ANC) and ANCA history, assists members of the public with ANC historical questions, and assists nurse researchers with ANC-related studies, volunteers time, talent and resources in support of ANC and ANCA projects and endeavors, and publishes a quarterly newsletter, The Connection, and maintains an on-line membership roster to facilitate networking and communication among members. ANCA also conducts a biennial convention and participates in ANC events and celebrations and other ANCA/Community events (e-anca.org).
3. Methods
3.1. Purpose
The purpose of this study was twofold 1) using already generated data, determine the desired support from an existing discipline specific military and veteran organization and 2) using semi-structured interviews, further explore selected identified needs that were unclear in the survey.
3.2. Data Collection
Survey data was collected via SurveyMonkey Inc. The survey analysis plan was submitted (March 2023) to Central Office Veteran Health Affairs (VHA), and University of Texas (UT) Health at San Antonio’s IRBs and was determined to be exempt research.
As part of ongoing strategic planning efforts, ANCA periodically surveys Army Nurses and ANCA members. Surveys are tailored to reflects current ANCA interests. In 2023, ANCA sent a survey to all active and lapsed members. Invitations to complete the survey were also posted on the ANCA Facebook page and ANCA group page, and the ANC Mentorship Facebook page as well as ANCA Linked-in page. Two hundred and eighty-three surveys were completed and returned. Respondents were asked to rate the ANCA core missions by order of importance followed by 5 open ended questions.
Question 1: What is ANCA doing well?
Question 2: How does ANCA support you at your stage of your career?
Question 3: What could ANCA do better to support Army Nursing?
Question 4: What actions can ANCA do to recruit new members?
Question 5: What can ANCA do better to retain members?
Those who indicated that they would be willing to participate in an interview on the survey were contacted via email to schedule an interview. All interviews were via Teams with investigators and one subject. Interviews took approximately 1 hour and were audio/video taped and transcribed. Themes identified that needed further clarification were used to construct sample questions and are listed in Table 1.
Table 1. Interview questions.
Theme |
Question |
Possible follow-up question |
Advocate for the importance of nursing care |
Can you tell us about how important advocating for nursing care is? |
What are some ways that ANCA does this well, or maybe not so well? |
Seek more partnerships |
Can you explain what kind of partnerships make sense? |
How do you think ANCA should solicit partnerships? |
Coach and mentor each other more |
Have you experienced coaching or mentoring in ANCA? Can you give some examples? |
How can ANCA coach and mentor better? |
Become more localized |
What do you think the respondents meant by becoming more localized? |
What would being more localized look like? |
Support transitioning ANCs including those who didn’t’ retire |
What do/did you need/want in transition and in some cased retirement from the military? |
Do you think length of service is related to type and amount of support desired? |
Be inclusive, make it more personal |
Have you or someone you know felt not included in ANCA? If so, what do you think made you/them feel that way? |
How can we make ANCA more personal? |
3.3. Data Analysis
Descriptive statistics were used to analyze answers to demographic questions and responses to closed ended questions. Use of an inductive paradigm with a content analysis method was used to code then identify themes in the respondents’ survey for open ended answers. An interpretive paradigm with a hermeneutic phenomenology approach was used to analyze semi-structured interview data. Of note, a hermeneutic-phenomenological method of investigation demands the use of multiple instruments to gather data on participants‟ experiences, interpretations, and understandings. Extensive, wide-ranging gathering of data is necessary for “a thorough appraisal” (Slavin, 2007), therefore this project occurred over two phases.
Phases:
In the first phase survey data was analyzed.
Based on phase1 analysis, semi-structured interviews of a sub-set of the survey population were conducted.
3.4. Trustworthiness and Rigor
Trustworthiness was addressed by IRB review, Investigators credentials, and purposive sampling. Credibility was addressed by triangulation (more than one source: survey, interviews more than one investigator), member/participant checking and peer debriefing, exporting data directly from the SurveyMonkey output survey. Information about context, fieldwork, findings, and conclusions provided sufficient detail to ensure transferability. Confirmability was be addressed by maintaining an audit trail.
4. Results
Respondents (n = 278) were mostly current members (73%), female (78%) and retired (77%). Twenty-three% were reservists, 20% former members, 12% Active duty, 4% 33 and younger, and 21% were Male. The respondents were mostly members, regular army, female, retired LTCs and COLS (67%) and over 68 years old.
Four of the five core pillars (history, education and scholarship, research and evidence-based practice, and leadership) were rated as very important while outreach-ambassador program was rated as important. So of the five core pillars of the organization, members and former members rated 4 of the 5 with the top rating and 1/5 with one less than the top rating.
4.1. Results of Open Questions
When asked “What is ANCA doing well?” Responses were grouped into the following categories: Keeping members informed/communicating was #1, followed by #2 connecting members/generations, then #3 remembering our heritage & keeping the history of the Corps. Other activities noted that ANCA is doing well were providing professional development and learning opportunities, executing the convention and luncheons, recognizing excellence with awards, offering scholarships/grants, and using social medical to connect and communicate. One member said, “Just the fact that ANCA exists is something.” When asked “How does ANCA support you at your stage of your career?” Respondents in no order, noted, keeps me informed, up to date, and connected, gives me a feeling of pride, supports research and scholarships, is a lifeline to my history and values, provides conventions/reunion opportunities, reminds me of my service, allows me to share my experiences, provides an opportunity for me to support others. Question #3 “What could ANCA do better to support Army Nursing?” resulted in the following themes, be more visible, become more localized, support transitioning ANCs including those who didn’t retire, coach and mentor each other more, share history more, see more partnerships, push the message of the importance of nursing care. In response to question #4 “What actions can ANCA do to recruit new members?” get serious about marketing, offer incentives, engage, and get local were the themes. Finally, for question #5 “What can ANCA do better to retain members?” be inclusive, keep it local, provide prompts, make it more personal, dues, keep conventions and cruises, conduct exit surveys, some people wish it was still Retired ANCA were identified. One member said, “What is important to members is having connections, obtaining advice/mentorship, somewhere to obtain resources, help with projecting career, maybe introduce hobbies for mental wellbeing.”
Results of semi-structure interviews.
4.2. Advocacy
When asked about the “advocate for the importance of nursing care theme”, interviewees responded that ANCA (requiring a minimum of baccalaureate) is well positioned to be an advocate and noted that advocacy has become overshadowed by emphasis on education. Advocacy was defined as promoting Nurses and the profession by teaching and modeling as well as articulating Nurses unique contributions to healthcare teams while explaining how our practice can help mitigate disease, prevent unnecessary admissions, and address the needs of organizations and patients. Advocacy also meant defining the profession and teaching new nurses to distinguish it from just a technical skill. It was suggested that regions become involved in advocating to their governors, at the state level to emphasize the importance of having the nurses’ voice on legislative changes related to nursing care. Advocacy could also mean offering more Clinical Continuing Education Units (CEUs).
4.3. Partnerships
Interviewees were asked, can you explain what kinds of partnerships make sense and how should ANCA solicit them? For Regions of ANCA that were involved in local Universities it was suggested that discussing the importance of nursing, promoting values, and military opportunities to students was appropriate. Under the umbrella of military Officers of America (MOAA) is the MOAA Uniformed Services Nurse Advocates (MUSNAVC) that combines Army, Navy, Air Force, and public health nurses. Other recommendations was to partner with other military healthcare alumni organizations such as the Silver Caduceus Association (SCA) a “social, informational and philanthropic association whose purpose is to promote the history and traditions of the Army Medical Service Corps (MSC), to enhance continuing education and to support social and recreational activities to its members” (https://www.silvercaduceusassociation.org/about). In general groups that support advanced practice nursing, as well as educated professional nurses was proposed along with partnerships with federal and state organizations like the Red Cross and Texas Nurses Association. Groups of people were suggested for potential partnerships such as Filipino nurses and non-nurses such as physical therapists, dietitians, and oncology are also suggested. To solicit partnerships, it’s suggested to contact the organizations leaders and invite them to meetings or discussions, attend health fairs, attend the Triservice Nursing Research Program (TSNRP) meetings and the National Association of Clinical Nurse Specialists (NACNS). Some said, ANCA’s role in these partnerships is unclear, but it could involve co-sponsoring events.
Mentorship Considerations
Mentorship was a popular topic that brought up personal histories and histories of organizations that engage in formal and informal mentorship programs. There were some concerns with mentorship centered around lack of bandwidth for mentors, generational distancing, lack of a clear framework for growth, mutual goal setting and the risk of credibility issues surfacing when a mentor lacks life skills, as it undermines their ability to care for others. It was suggested that being more visible out int eh community by doing more community support and being active in associations could help bridge the gap in finding those willing to be mentors. Finally, it was proposed that ANCA directly address coaching and mentoring in the strategic plan and consider investing in a Coaching/Mentorship Program Lead for the organization.
4.4. Be More Localized
ANCA divides the globe up into regions to serve their geographically separated members. However, the regions are vast and offer challenges for Region Directors who are volunteers to hold events and travel to where members are living. There is a convention every two years that with the purpose of brining the members together in one place but by in large most interactions are virtual. Interviews recognized these challenges and reflected on lessons learned from past practices. One interviewee noted that the local ANCA program doesn’t only need to be run by one person for an extended period; it also needs to be built by that person and then handed on to another person. Characteristics of local program leads included begin highly energetic and focus on organizational growth and be willing to tap into the Department of Defense officers of into public affairs in different locations. Again, Universities are mentioned in the context of promoting local activities by organizing events, such as community health fairs, including blood pressure screenings, blood sugar checks, and diabetes education; to promote community building and the military. Recommendations for the organization included board selection local chapter leads, creating succession plans, and a lead play book.
4.5. ANCA Support after Service
There was specific feedback about the question so clarifying what ANCA should do for after service support. It was suggested that the support should be shaped by generating a list of individuals who have transitioned out of the military in the last three, five, or 10 years, compared to those who retired, and gather them to discuss their transition process and identify the biggest shocks and hurdles then use webinars to focus on transition issues (refer to transcripts of semi-structured interviews for topics). A guiding principle would be to be there upon transition but check back in 3 - 6 months later. Another opportunity would be to work with MOAA to increase content related to transitioning nurses.
4.6. Inclusion & Personal
A theme that emerged from the phase 1 analysis seemed unclear, words like inclusion and be more personal appeared but actions to take to address these desired functions were not included. During the interviews participants talked about the challenges of a large organization and mentioned using local chapters to make it more personal and attract more people by promoting regular communication and updates (by checking up on one another and modeling that behavior). One participant talked about even though Army nurses are considered people that could break through the societal barriers, it still depends on the personality, level of self-development and being comfortable with people that are different than themselves. The importance was endorsed noting that there is a need for diverse opinions and insights and that feedback from different generations can inform information delivery preferences.
5. Discussion and Implications
The results of this study echo previous study findings regarding the importance of meeting the need for connection, social interaction and growth identified by military veterans (Shafer et al., 2024, Flack & Kite, 2021). Misca et al., (2023) in studying transitioning military personnel receiving mental health services in the UK, highlighted the need for appropriate support to be in place before and during and after leaving the service that included social connectedness. Angel et al. (2018) tested a community-based model for harnessing positive social networks to enhance enrichment outcomes in military veterans reintegration to civilians and found that participation (n = 597), 81% reported increased life satisfaction, 64% reported 70% reported better network building of professional contacts. Lack of connection can lead to loneliness. Ex-military report loneliness and social isolation after leaving the military service (Guthrie-Gower & Wilson-Menzfeld, 2022). Schafer et al., (2024) found that loneliness or lack of connection is significance related to substance use and suicidality in Veterans (rs = 0.33 - 0.42, ps < 0.01). Loneliness was also shown to be a significant risk factor in a sample of 710 Israeli adults for Post Traumatic Stress Disorder (Levi-Belz et al., 2024).
6. Limitations
This was a retrospective analysis of a survey that was constructed for the sole purpose of membership satisfaction, so the investigators were constrained by the questions that were asked and the way that they were asked for phase 1. Phase 2 had a small sample size and was not sample to saturations.
7. Conclusion
Military and Veteran Army Nurses who are past and present members of ANCA desired connecting, communicating, and preserving history and felt that ANCA was sufficiently meeting those needs but also desired an emphasis on inclusion and personalization as well as increased efforts in the areas of establishing partnerships, punching up social and career networking opportunities and providing after service support for those who were in the healing professions.
Disclaimer
The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.
NOTES
*Denise Hopkins-Chadwick, PhD, RN; Samantha Elbel, MSN, RN; Hue Mang, MSHS, RN; Amanda Joy Anderson, PhD, MPA, RN.