The steady stream of military personnel returning from two decades of conflict in Afghanistan and Iraq following the September 11, 2001 terrorist attacks has posed a formidable challenge to U.S. health care providers – in military hospitals, Veterans Administration facilities, and among the civilian doctors and nurses where the majority of veterans receive medical care.

Meanwhile, the growing number of women in the armed forces report a steady rise in sexual trauma during the time serving the nation.

These are among the special health care needs of active military personnel and veterans being addressed, both on educational and research fronts, at Jefferson College of Nursing, a 130-year-old institution that is part of Thomas Jefferson University, with locations in Philadelphia (Center City campus) and Horsham Pennsylvania (Dixon campus).

While physical injuries might first come to mind when we think of veterans, many issues emerging among the approximately 2 million men and women who engaged in those conflicts involve mental health challenges such as post-traumatic stress disorder (PTSD) and depression and anxiety.

Veterans by nature and training frequently do not report such symptoms to their primary care providers (PCP), yet without treatment the conditions often become more severe – sometimes with tragic consequences. Those with PTSD (representing up to 15 percent of the total veteran population) are considerably more likely to engage in high-risk behaviors including substance abuse. PTSD is associated with significantly increased risk for nervous system, hypertensive, musculoskeletal, circulatory, and digestive diseases; it leads to sleep disturbances, depression, anxiety, suicide, substance abuse, domestic violence and adversely impacts veterans and their families and friends.

While professionals working in military and VA hospitals and clinics are accustomed to dealing with the special needs of those who have experienced combat, many civilian PCP’s lack the knowledge and clinical expertise to feel comfortable developing assessment and treatment plans for that population. That is particularly important when you consider that only 21 percent of veterans receive primary care in VA settings. With the vast majority of veterans receiving care in the civilian system, it is essential for providers to understand the nuances of military culture.

At Jefferson College of Nursing, new elements regarding veteran’s health are being added to the curriculum this year. The goal is to better prepare nurses who will work in civilian care facilities and how they can better assess and address the post-deployment issues of their patients. The initiative is led by Kathleen Gray, DNP, FNP-C, an Associate Professor at Jefferson.

“It is vital that civilian providers take the time to screen for military service and be aware of the nuances of military culture and incorporate this into the care plan by actively identifying and addressing relevant behavior health concerns,” Dr. Gray said. “Look beyond the surface; service members many times will not report mental health concerns due to the stigma, and by virtue of their training.”

Dr. Gray’s veteran-centered element within nursing education begins with learning how specific aspects of military culture (starting with that reluctance among many veterans to talk about their problems) can impact not only the assessment of a condition but also its treatment. The health care provider must seek out the patient’s service history (Where did they serve? What were their experiences, particularly in combat?), identify environmental conditions and similar health risks from their military service, and assess how the sum of that patient’s military experiences has affected their life.

Here, Dr. Gray quotes William Osler (1849-1919), a Canadian physician and one of the four founding professors of Johns Hopkins Hospital: “It is much more important to know what sort of a patient has a disease, than what sort of disease a patient has.”

She adds, “Above all, it is critical to strengthen the provider/patient relationship and build trust.”

A 2009 study found that veterans whose physicians who were more motivated to learn about the military culture’s influence on patient behavior were more satisfied with their medical visits, perceived their physicians to be more facilitative and – again, a key to receiving prompt and effective care – more likely to discuss their challenges.

Dr. Gray’s focus on assuring veterans of more effective care also includes an examination of the special challenges facing the women who today comprise 10 percent of the veteran population. She noted that while there is a plethora of research documenting the psychological challenges of male veterans from that period, there is a significant gap in the literature related to female veterans. This year, she launched a study detailing the experiences of the women who had to adjust to civilian life afterward. Dr. Gray is focusing on the transition from military to civilian life from both a socio-economic perspective and in terms of mental health concerns.

“My goal is to illuminate the challenges that women veterans face as they transition back into civilian life and provide a frame of reference to support and meet the needs of women veterans,” said Dr. Gray, who expects to report her findings in early 2022.

One of Dr. Gray’s students is Romnick Poindexter, who served as a nurse in the U.S. Army for five years and is scheduled to graduate from Jefferson’s DNP – Nurse Anesthesia Program next Spring, “I chose Jefferson to continue my nursing education because of its emphasis on leadership and embracing diversity,” he said. “When I came out of the military it is important to me that the institution I join reflects what I value which is embracing multiple backgrounds, leadership, and diversity. I was trained in the military to be a leader, and Jefferson offers that opportunity.”

Sexual trauma among military personnel and veterans also has been a point of interest and research at Jefferson College of Nursing – particularly for JCN Dean Marie Marino, EdD, RN, FAAN.

Dr. Marino is an advanced practice nurse who served in the US Navy Reserve Nurse Corps. She noted that, since 2011, the Department of Defense has been required to report to Congress annually regarding sexual assaults involving members of the armed forces, and on efforts to improve sexual assault prevention and response programs.

Those annual reports – and other studies – have revealed disturbing trends. For instance, according to data reported in 2021 from the VA’s national military sexual trauma (MST) screening program, 1 in 3 women and 1 in 50 men responded “yes,” that they experienced MST, when screened by their VA provider.

The term military sexual trauma (MST) generally refers to experiences of sexual assault and/or sexual harassment during a service member’s military career. The Department of Veterans Affairs’ definition  is “psychological trauma, which in the judgment of a mental health professional employed by the Department, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment, which occurred while the veteran was serving on active duty or active duty for training”.

“MST is not a diagnosis,” Dr. Marino emphasized. “It is an experience of sexual assault and/or sexual harassment during one’s military service. But an MST experience may cause survivors – and remember, this can include male as well as female service members – to have a broad range of symptoms that predictably and negatively influence their quality of life and longevity.”

She noted that MST is associated with reduced heart rate variability and a subsequent potential for cardiovascular disease and post-traumatic stress disorder (PTSD). MST also is associated with an increased risk for other mental health problems, particularly anxiety disorders that are precipitated from frightening or horrific events.

“It’s important to remember that MST can contribute to substance use or abuse, problems in relationships, and physical health problems such as sexual difficulties, chronic pain, weight gain or eating problems, and gastrointestinal problems,” Dr. Marino said.

After military service, the VA requires health care providers to explore experiences of MST with every veteran. That universal screening, coupled with the growing number of women in the military, means the population of veterans identified as having experienced MST and seeking treatment is expected to continue to increase, according to Dr. Marino.

The definition of MST has been standardized within the military but that’s not true in the civilian sector,” she noted. “Groups such as the Disabled American Veterans and American legion are doing great work to educate veterans and help them find treatment.”

While working to address veterans’ needs, Jefferson College of Nursing also works hard to attract more men and women to take up nursing careers after leaving the armed services. “We find veterans are a great fit for nursing because they are innovative, resilient, team-oriented and accustomed to stressful situations,” JCN’s Dean Marino noted.

Each year, the college gives preference in awarding its Robert/June Eyerly Scholarship to a student who has served in the military or is the descendant of a veteran.

Through the efforts of Dr. Gray, Dr. Marino, and the institution’s broader commitments, Jefferson College of Nursing leads the way to provide the best possible assessments and treatments for American veterans’ physical and mental health challenges – whether in the VA facilities that operate solely to serve them or in the hometown health care facilities where they most often go for care.