Nursing

The health disparities among veterans residing in rural areas are a growing concern. Currently, 39% of veterans enrolled in and eligible for care by the Veterans Health Administration (VHA) live in rural areas (Hawthorne & Suh, 2009). Many of these veterans have combat-related injuries, increasing the risk for mental health issues (Taber & Hurley, 2009). However, extended travel distances and financial barriers are known to have a negative impact on a veteran’s care. Thus, initiatives to increase veterans’ accessibility to quality mental health services are essential to provide optimal care for veterans in rural areas. Fortunately, psychiatric nurses possess the unique training to assist in improving the quality of care of this population.

Psychiatric nurses must not lose sight of the unique needs of specialty groups within the larger group of veterans, such as those in rural areas. Challenges to meeting the needs of this group and helping them overcome their barriers must be viewed in a different light. For example, as previously noted, the current system of access to VHA services includes extended travel. However, this travel is made more complex for rural veterans because of the limited transportation systems within those areas, as well as a decreased number of people within those areas who can provide assistance with transportation. Although resources may be available through the VHA to support travel for services, if the mechanisms for the actual travel—taxis, buses, or other public transportation systems—are not available, then the barrier still exists.

Over the past decade, the VHA has developed a national system of programs to serve veterans with mental illness. One program, Mental Health Intensive Care Management (MHICM), is designed for veterans with serious mental illnesses and severe functional impairment. Participation in the program requires that veterans are inadequately served, have high hospital use, and are clinically appropriate for outpatient status. MHICM provides resources for nurses to travel to various areas to provide services to veterans. Nurses who serve these patients are stationed at VHA systems in urban areas because many of the service systems located in rural areas have been closed. However, the distance that MHICM nurses can travel from their base is limited, resulting in an even further decrease in access for the most rural veterans. Six percent of veterans benefitting from such programs live in small, rural towns, and 3% of those are in isolated rural areas (Mohamed, Neale, & Rosenheck, 2009); thus, there is still a need for veteran services in rural areas.

Mental health is the second-largest area of illness for which Operation Enduring Freedom/Operation Iraqi Freedom veterans seek treatment (Zoroya, 2007). Because of geographical isolation, many strategies to support mental health care for veterans in rural areas are limited. Given this challenge, creative thinking is required to improve their quality of care. Some rural communities may have social, religious, or other kinds of groups that would be willing to provide transportation and other services to rural veterans, and psychiatric nurses must be prepared to seek out and contact those groups. However, in doing so, another unique aspect related to this specialty group must be kept in mind, and that is the sensitive and cautious approach needed to establish relationships in the rural community.

Because advanced practice psychiatric nurses (APPNs) are more likely than psychiatrists to reside in rural areas (Hanrahan & Hartley, 2008), they have the potential to provide a solution to the mental health care barriers experienced by these veterans. An APPN who lives within the community is better able to establish necessary rapport while tapping into the available resources. Furthermore, APPNs have the ability to provide veterans with specialty care, decreasing the need to travel to urban areas to receive treatment. However, to effectively combat this issue with the assistance of APPNs, the number of nurses within this specialty must increase, and their scope of practice must be expanded.

Although most rural VHA systems have been closed, most rural communities still have a Veterans Service Representative who usually has an office housed in a federal building in the area. Because the representative will most likely be a member of the rural community, this person is another resource who can assist with establishing relationships within the community. This individual can also provide information about local groups that could potentially provide services, such as assistance with travel and nonprofessional intervention strategies. Because of geographical seclusion, many strategies to support mental health care for veterans in rural areas are limited. For example, what if part of the treatment plan was to join an exercise group or a gym to increase social skills? Many rural areas may have only basic businesses such as a grocery store or service station, so how can one make use of such a strategy? Perhaps the representative can inform the veteran of local groups or churches that have exercise classes. Again, psychiatric nurses are challenged to think about how to implement such strategies—despite geographic isolation—to meet the needs of this group of veterans. Although resources may be limited, the need for services in rural areas is not.

Stephanie D. Wynn, DNP, RN-BC,
PMHNP-BC
Assistant Professor

Roy Ann Sherrod, DSN, RN
Professor

JoAnn S. Oliver, PhD, RN, ANP-BC, CNE
Assistant Professor
The University of Alabama
Capstone College of Nursing
Tuscaloosa, Alabama