To the men and women of the U.S. Army, Navy and Air Force Nurse Corps, each of you has elevated the profession of nursing through your unwavering service to our country in times of war and peace. You make the profession of nursing very proud.
Thousands of American citizens have answered the call to defend their country. Countless men and women entered into harm’s way to prevent enemies from reaching the shores of our country. December 7, 1941, millions of America’s sons and daughters once again donned the uniforms of the U.S. Army, Navy, Air Force, Marine Corps and Coast Guard. Across centuries, their mission remained the same: “To support and defend the Constitution against enemies, obey the orders of the President of the United States and obey the orders of superior officers according to Uniform Code of Military Justice.”
Hailing from countrysides or urban areas, they served. Rich or poor, they served. Native born or naturalized citizens, they served. No matter what race, color or creed, they served. From a wide variety of ethnic backgrounds, they came to serve their nation, and serve they did. They served in places called Iwo Jima, Sainte Mère-Église, the Inchon Peninsula, Laos, Cambodia, Kuwait, Baghdad and Kandahar. During times of disaster, they readily and willingly served the needs of their distressed fellow citizens, as well as citizens of the world. Our United States military has been the force behind our freedoms for over 200 years.
While the efforts of the United States military are widely publicized, their culture is often foreign to those outside the sacred bonds of membership. Many individuals who did not serve look upon the military culture with unfamiliar eyes. One such group of “outsiders” may be hospice professionals. Combat devastates the human body through injury and the human psyche by impeding one’s ability to free himself from the impact of the sensory overload that is known as “combat.”
Due to the development of body armor and other protective devices, as well as effective triaging of injuries, innovative trauma treatment and rehabilitation services, many wounded military members survive and return home. For many veterans, their wounds are apparent, but for others, the wounds of battle are often invisible.
In order for healthcare workers to deliver complete care to our veteran population in the hospice setting, education is essential. The manual presents information for hospice care personnel on the culture and ethos of military service, as well as information on post-traumatic stress disorder (PTSD), common health issues experienced by veterans, issues of readjustment to civilian life, the psychosocial issues of combat and a discussion on end-of-life practices for members of the military.
Members of our military deserve the best we, as hospice providers, can offer. In order for us to achieve this task, we must know our veterans. Retired Admiral Mike Mullen said of returning military members:
I fear they do not know us. I fear they do not comprehend the full weight of the burden we carry or the price we pay when we return from battle
In order for hospice providers to care for our veterans, we must make every attempt to know them. “Indeed, through knowing them, we care for them.”
Introduction to the United States Military
Millions of Americans answer our nation’s call for service within the Armed Forces. As healthcare providers, we frequently are asked to care for the healthcare needs of present and past members of our military in hospitals, clinics, physician offices and even in their own homes.
For many hospice providers, the military culture and way of life is foreign and may often be misunderstood. In order to offer our veterans the best possible care, it is important for hospice providers to become familiar with the military culture. The purpose of this manual is to assist hospice providers in delivering culturally competent healthcare to veterans of the U.S. military.
Assessment remains a central tenant of the nursing process. Similar to a health assessment in terms of identifying health-related information, a military service assessment may offer valuable information to the hospice provider on understanding the effect military service had on the patient, both positive and negative.
The first place to begin is with an overview of U.S. military, the five major branches, military culture, as well as a brief overview of the combat missions since World War II to present day.
The U.S. military began in 1775, a year before the Declaration of Independence was signed. The Continental Army, Continental Navy and Continental Marines were established by the Second Continental Congress to defend the new nation against the British during the American Revolutionary War.
Following the signing of the Treaty of Paris in 1784, the War for Independence ended and a new nation began her work. As part of their agenda, the new Congress created the U.S. Army on June 3, 1784; the Army officially recognizes its founding on June 14, 1775. As a provision of power, the Constitution gave Congress the power to declare war, raise and support armies, provide and maintain a navy, and make rules for the government and regulation of the land and naval forces. They named the President of the United States as the military’s commander-in-chief. A few months later, October 13, 1775, a meeting of the Continental Congress in Philadelphia began the U.S. Navy. The Continental Congress voted to adapt two sailing vessels with carriage guns. Each ship, manned with a crew of 80 men, set sail in an attempt to intercept British ships carrying supplies and ammunition for their army.9
In the years since Congress first raised an army, the U.S. military has been involved in numerous conflicts and wars. To gain an appreciation for the experiences of members of the Armed Forces, it is important to familiarize one’s self with the wars many veterans served in. The discussion will begin with World War II because, sadly, no veterans are alive who fought in World War I or any prior conflicts.
The U.S. military is represented by five branches; the U.S. Army, Air Force, Navy, Marine Corps and Coast Guard. The Army, Air Force, Navy and Marine Corps operate under the direction of the Department of Defense. The Department of Homeland Security directs the Coast Guard, except when directed by the President of the United States. Currently, 1.3 million serve on active duty (U.S. Department of Defense, 2013).
In addition to active duty, the U.S. military has National Guard and reserve components. Approximately, 1.4 million individuals serve in the National Guard or reserves (U.S. Department of Defense, 2011). Members of the National Guard and reserves commonly work one weekend a month and other weeks during the year while maintaining employment outside of the military. These members are often referred to as “Weekend Warriors.” Like their active duty counterparts, the National Guard and reservists maintain assignments in general and specialty areas, unit assignments, ranks and pay grades.
Who is a veteran?
General and widely accepted definitions of a veteran include an individual “who served in the armed forces” or “an old soldier who has seen long service.” Perhaps a more stirring definition of a veteran is “someone who, at one point in his or her life, wrote a blank check made payable to the United States of America for an amount of ‘up to and including my life.’”
For the purpose of obtaining benefits from the Veterans Affairs (VA) Department, a veteran is defined as “a person who served in the active military, naval, or air service, and who was discharged or released therefrom under conditions other than dishonorable” (Moulta-Ali, 2014). For many members of the National Guard and reserves, they are not eligible for VA benefits due to the inability to meet the requirements of active duty and length of service. An exception to this is reserved for Guard or reserve members who were activated for federal military service and served in the Persian Gulf for 12 months (Moulta-Ali, 2014). At the end of the activation period, the service member would be considered to have served on active duty for that period of time. A dishonorable discharge or bad conduct discharge status may exclude a veteran from benefits. See Figure 4 for information on living veterans.
Organization of the military is based on a system of hierarchy. In some instances, members of the military may refer to themselves by their rank or pay grade. Rank is often determined by length of time served and performance. A pay grade is referred to as an E-1 – E-9 for enlisted personnel and O-1 – O-10 for officers.
U.S. Military Service Academies
Admittance into one of the U.S. military academies is a very prestigious honor reserved only for a select few individuals. Excellence in the classroom is only one criterion necessary for admission. The service academies seek individuals with strong leadership potential, who are physically fit and have outstanding character. Thousands of applications are received yearly to the academies. Selection for admission begins with a nomination from a Congressman, Senator, Vice President or President. Applicants to the Coast Guard Academy compete in a direct nationwide competitive process that has no by-state quotas. A service academy scholarship includes four-year education, room and board, pay, exclusive benefits and training.
Once admitted, students undergo hard physical and intensive academic training while increasing their leadership skills for future use when commanding troops. Once a student graduates from a service academy, he or she is commissioned as a second lieutenant (U. S. Army, Air Force and Marines) or ensigns (U.S. Navy and Coast Guard). Graduates must serve at least five years of active duty and an additional three years in the reserves. If the student’s chosen occupation requires particularly extensive training (such as a naval aviator), the tour of duty may be longer. Veterans who are graduates of one of the service academies often view this with great honor and prestige.
The U.S. Military Service Academies include the following institutions:
- The United States Military Academy (USMA) in West Point, New York, founded in 1802
- The United States Naval Academy (USNA) in Annapolis, Maryland, founded in 1845
- The United States Coast Guard Academy (USCGA) in New London, Connecticut, founded in 1876
- The United States Merchant Marine Academy (USMMA) in Kings Point, New York, founded in 1943
- The United States Air Force Academy (USAFA) in Colorado Springs, Colorado, founded in 1954
Rank insignias can often be very confusing for healthcare providers who are unfamiliar with the military rank symbols Figures 7 and 8 offer charts of common rank symbols of the U.S. military.
Cultural Principles of the Military
When caring for members of the military, past and present, it is essential to understand their culture. Members of the armed forces come from various ethnic, religious, educational, economic and political views but they all possess very strong ties to their military culture. Hospice workers must remember that the military culture remains with an individual forever and plays an important part in their thoughts, language, decisions and actions. In reality, the military culture and mindset remains a central component of a person’s identity even during their final days.
Culture may be described as a system of knowledge shared by a certain group of people. Culture is essentially a way of life for a group of individuals that often focuses on tradition being passed from one generation to another. Due to its sustaining importance within communities, culture often becomes a central focus of the mind that readily distinguishes members of one group or category of people from another.
Diversity exists within the U.S. military. All races, religions, geographic and ethnic origins, and economic and educational levels are represented within the ranks of the military. Once a member of the military, the expectation is that the cultural differences are cast aside in order to achieve a united and focused military committed to preserving and protecting the U.S. and its citizens at all costs, including death.
The military is the system of hierarchy based upon relationships between ranks and branches. Often perceived as rigid, military hierarchy and rank creates a harmonious atmosphere due to the established norms and expectations (Kapoor, Comadena & Blue, 1996). The organization of the military revolves around a chain of command. A chain of command is the line of authority by which decisions are made and orders are carried out.
The military culture is deeply entrenched in tradition, honor and careful planning in order to minimize failure and loss of human lives. When encountering members of the military, caregivers must recognize the importance of the cultural elements that reside within veterans. Additionally, hospice providers must recognize the differences that exist between the different branches, or subcultures, of the military. The most important question a healthcare provider can ask is, “Have you ever served in the military?” By asking this simple question, hospice workers can begin a very good relationship with the patient. First, and most importantly, asking this question sends the message that you care about the veteran. Secondly, asking the question establishes the veteran’s identity. 19
Thirdly, this may open the door for the patient to discuss negative feelings or concerns he/she has kept inside for a long time.
Typically, membership in a particular branch of the military causes great pride in those who served within. Many members possess the opinion that their branch of service is the best among the entire military. While many members of the military find pleasure in making jokes and poking fun at the various military branches, they are fully committed to support and sustain their military comrades. An additional point to remember regarding the use of nicknames for branches is that veterans will freely call branches or their members by nicknames, but may frown upon a non-military member doing so. In other words, refrain from using any name other than the official title of a military branch or a member of that branch when speaking about them. Examples of this may be referring to a Marine as a “jar head” or a sailor as a “tin can soldier.”
Cultural Assessment of Veterans
An accurate assessment of a patient’s military history is very valuable. Through gaining knowledge of the patient’s military experiences, the good and the bad, the healthcare provider can identify actual or potential physical or psychological issues, enhance therapeutic communication and establish a trusting relationship with the patient and their family members. Sometimes veterans have special rooms or areas within their homes set aside to display memorabilia. These special areas are very important to veterans, and the healthcare provider may be invited into these special spaces. If you have been invited into this area, it is essential that you treat this experience with respect and honor. This area serves as a place for veterans to remember their lost buddies and talk about their experiences. This, for many veterans, is a shrine to their military service. Healthcare providers may experience a change in the mood of the veteran when they enter this room or area. Be prepared to acknowledge the veteran’s service and deal with tears or other emotions as he/she remembers his or her experiences.
The Branches of the U.S. Military
As previously mentioned, the branch of service a veteran served within becomes a central part of who they are. Veterans tend to take on characteristics, language, culture or philosophy of their specific branch of service. It is not uncommon to see veterans wear T-shirts or hats that indicate a specific branch of service. Veterans, for the most part, are very proud of their service. The following information offers basic information on each of the service branches.
The U.S. Army began in 1775. Since that time, the Army’s mission is to fight wars and provide land dominance promptly and whenever necessary. The Army’s principal responsibility is for land-based military operations but also has aviation components.
- The largest branch of the U.S. military
- Members are referred to as “soldiers”
- Deployment cycle is approximately 2–3 years and 1–2 years at their home base
- In the Iraq and Afghanistan war, soldiers have been deployed to the region several times
- The official Army song is titled “The Army Goes Rolling Along”
- The Army motto is “this we will defend”
- Core values of the U.S. Army are loyalty, duty, respect, selflessness, honor, integrity and personal courage
- Warrior Ethos: “I will always place the mission first. I will never accept defeat. I will never quit. I will never leave a fallen comrade.”
The U.S. Navy recognizes October 13, 1775 as the date of its official establishment, when the Second Continental Congress passed a resolution creating the Continental Navy.
- Its mission is to train and equip combat-ready naval forces capable of winning wars, deterring aggression and maintaining freedom of the seas
- The official Navy song is titled “Anchors Aweigh”
- Official hymn is “Eternal Father Strong to Save”
- No official motto exists but “non sibi sed patriae” (not for self, but for fatherland) is often used
- Members are referred to as “sailors”
- Core values of the U. S. Navy are honor, courage and commitment
- They specialize in crisis response, special operations, evacuations and humanitarian operations
- The Navy also supports the U.S. Marine Corps by providing transportation for deployment destinations
U.S. Marine Corps
The history of the U.S. Marine Corps (USMC) begins with the founding of the Continental Marines on November 10, 1775 to conduct ship-to-ship fighting, provide shipboard security and discipline enforcement, and assist in landing forces.
- They serve as an expeditionary force in readiness, and conduct expeditionary and amphibious operations, as well as close air support for ground troops
- Members are referred to as “Marines”
- The official USMC song is the “Marines’ Hymn”
- Core values include honor, courage and commitment
- An all-purpose, fast response task force, capable of quick action in areas requiring emergency intervention
- They believe there is “no such thing as a former marine” (once a marine, always a marine)
- Semper fidelis (always faithful) became the motto of the USMC in 1883. It guides marines to remain faithful to the mission at hand and to the Corps
U.S. Air Force
The U.S. Air Force (USAF) became a separate military service on September 18, 1947. Prior to 1947, the responsibility for military aviation was divided between the Army (for land-based operations) and the Navy for sea-based operations from aircraft carrier and amphibious aircraft.
- Their mission is “fly, fight and win …in air, space and cyberspace”
- Members are referred to as “airmen”
- Their motto is “aim high, fly, fight and win”
- Their official USAF song is “The U.S. Air Force”
- They are responsible for conducting military operations in the air and space
- They defend the nation by deploying aircraft to fight enemy aircraft, bombing enemy targets, providing reconnaissance and transporting other armed forces
- Their core values include integrity, service before self and excellence in all we do
U.S. Coast Guard
The history of the U.S. Coast Guard goes back to the Revenue Cutter Service, which was founded on August 4, 1790 as part of the Department of the Treasury. The Revenue Cutter Service and the U.S. Life-Saving Service were merged to become the Coast Guard on January 28, 1915. Upon the declaration of war, and when the Congress or President directs, the Coast Guard operates as a service in the Department of the Navy.
- They safeguard the nation’s maritime interests in the heartland, in the ports, at sea and around the globe
- The official song of the U.S. Coast Guard is “Semper Paratus”
- Members are known as “guardians”
- Their motto is “semper paratus,” meaning “always ready”
- Core values include honor, respect and devotion to duty
Reservists and National Guards
The U.S. military is also made up of reserve and National Guard components of the major branches of service. The reserve component includes the U.S. Army Reserves, U.S. Navy Reserve, U.S. Marine Corp Reserve, U.S. Air Force Reserve and U.S. Coast Guard Reserve. National Guard and Air National Guard forces are the only two military elements comprising the National Guard. Members of the National Guard and reserves are often referred to as “citizen soldiers.”
Members of the National Guard and reserves tend to possess dual identities (Griffith, 2011). Many members live and work within non-military communities, spend one weekend/month in training and attend a two-week training exercise once a year to fulfill their service obligation to their National Guard or reserve units.
- Many service members who are no longer members of the active duty component chose to serve in the Reserves.
- May be eligible to receive VA benefits.
- In times of war, frequently called upon for active duty. When activated, he or she is considered an active duty service member.
- Called upon to support efforts abroad or to fill positions stateside that have been left vacant by deployed, active duty personnel.
- Made up of the Air National Guard and the Army National Guard. • May be eligible to receive VA benefits.
- Serve both state and national governments.
- In times of war, frequently called upon for active duty. When activated, he or she is considered an active duty service member.
- National Guard Combat trained and can be deployed overseas, as well as their home communities.
This manual is for reference purposes only and the manual cannot be sold or reproduced without the approval of AseraCare or the author.The purpose of this manual is to assist with the education of AseraCare hospice providers on the care of the U.S. veteran population. While the author has researched information, the reader must understand that each veteran possesses individual opinions, experiences and thoughts on the subjects addressed within the manual. Additionally, the author does not claim expertise in the areas of the culture of the military, care of the veteran or military history. The author has made every attempt to present the military in an unbiased manner.