In 2015, approximately 9.11 million of the projected 21,681,000 veterans in the United States were enrolled in the Veterans Affairs Health Care System (VAHCS) (U.S. Department of Veterans Affairs [USDVA], 2015). The percentage of all veterans receiving health care services at the VAHCS for fiscal year 2014 was approximately 42% (USDVA, 2015). This is an increase over 32% reported for 2008 (USDVA, National Center for Veterans Analysis and Statistics, 2010). Veterans have unique health needs based on their military exposures, which can include chemicals and infectious diseases, environmental influences, impacts of evolving technology and techniques used in combat, the type of military service, physical and psychological trauma, and the remoteness and separation from family and support groups (Johnson et al., 2013). Because less than half of qualified veterans obtain their health services at the VAHCS, it is essential that nurses in both military and civilian tertiary and community settings develop the competencies to successfully identify and address the unique needs of this population (American Association of Colleges of Nursing [AACN], 2012; Johnson et al., 2013; Moss, Moore, & Selleck, 2015).
Educational institutions and health care organizations agree that graduates of nursing programs must be prepared to provide health care to veterans and their families. In 2012, the AACN engaged in an initiative called Joining Forces, which aimed to improve health care for veterans and their families. The Veterans Health Administration is the largest integrated health care system in the United States, with more than 1,700 sites comprising 144 hospitals, 1,211 outpatient sites, 300 veteran centers, and 56 regional offices, serving approximately 8.76 million veterans each year (USDVA, 2015a). This large, integrated, interdisciplinary network is an optimal setting for undergraduate nursing students to gain the knowledge, skills, and attitudes (KSAs) necessary to care for veterans and their families across all settings where health care is delivered.
Moss, Moore, and Selleck (2015) described a veteran-focused competency framework that consisted of 10 Veteran Competencies for Undergraduate Nursing Education (VCUNE). The VCUNE competencies included:
- Military and veteran culture.
- Posttraumatic stress disorder (PTSD).
- Amputation and assistive devices.
- Environmental/chemical exposures.
- Substance use disorders.
- Military sexual trauma.
- Traumatic brain injury (TBI).
- Serious illness, especially at the end of life.
The competency topic areas can “guide faculty in the development of nursing curricula for undergraduate students to ensure that they are prepared to recognize, intervene, and refer Veteran patients and their families who suffer from conditions related to their military service” (Moss et al., 2015, p. 315). The KSAs associated with each competency can be woven into an existing or new curricular map.
Other authors described the unique health care needs of veterans and created Enhancing Veteran-Centered Care: A Guide for Nurses in Non-VA Settings (Johnson et al., 2013), which included two tables to guide the practice of nurses in non-VA settings, one providing “Resources on the VA and Veteran's Health by Topic” (p. 26) and the other a “Veteran-Centered Health History Assessment” (p. 28). In addition, the AACN (2012) provided resources for teaching and learning about veterans in the “Joining Forces: Enhancing Veterans' Care Tool Kit,” which included general resources, resources for veteran/active military nursing students, resources from nursing organizations offering care for veterans, and a variety of publications, webinars, and Web links for educating current and future nurses to care for veterans. These resources and tools can be used by faculty to develop undergraduate nursing curricula to support veteran-centered care competencies.
The community health clinical course (i.e., field work experience) described in this article integrated the guidance for unique health care of veterans by Johnson et al. (2013), the VCUNE competencies (Moss et al., 2015), and the AACN (2012) veteran-centered resources into a unique community health field work experience where students engaged with clients and health care personnel in various settings—all serving veterans and their families. The purpose of the course was that all students became equipped with KSAs to provide holistic relation-centered care to veterans and their families.
Community Health Clinical Components
Approximately 148 junior nursing students per year, in a baccalaureate nursing curriculum situated in an upper midwestern, mixed metropolitan/urban environment completed learning experiences in various community-based settings. In the past 3 academic years (2012–2015), one cohort (20 students per year for a total of 60 in 3 years) focused on the unique health care needs of veterans and their families. Students were selected based on applications that were evaluated on academic achievement and a written assignment describing their interest in the veteran population. The group included 12 male and 48 female students, ranging in age from 21 to 35 years.
Students had rich learning opportunities across the spectrum of care at the many veteran-centered programs provided by the VAHCS (USDVA, 2015a). Most learning activities were prearranged by the nursing instructor; however, students could plan independent activities based on their personal interests (with instructor approval) if the activities were community based and focused on veterans. The student-centered learning outcomes included:
- Students will apply evidence-based knowledge to provide optimal care for patients and families in the community.
- Learners will holistically assess patient needs to provide safe, ethical care in collaboration with patients, families, and other health care providers within the context of the community.
- Students will recognize the value of providing care that is individualized, compassionate, and in concert with the patient's cultural values, beliefs, and the community in which they live.
- Learners will implement behavior change and patient education strategies to promote health and manage illness in relationship to the unique needs and abilities of individual and families.
- Students will adapt nursing care interventions to the needs of the patient and the resources available in the community.
The nursing student group focused on veteran-centered care met the learning outcomes, as well as addressed many of the competencies and unique health care needs of veterans described by Moss, Moore, and Selleck (2015) and Johnson et al. (2013). The applied pedagogical approach focused on three educational models, including the andragogical model (Knowles, 1984), the transformative model (Mezirow, 1991), and the appreciative inquiry model (Cooperrider & Whitney, 2005). The clinical experiences for students are described in the following paragraphs.
Adult Day Health Center (ADHC)
The ADHC provides a therapeutic day program to approximately 35 veterans who reside in the community. Students spent one day at the ADHC. Eligible veterans attend two times per week, from 9 am until 3 pm. Veterans attending ADHC have a variety of chronic health concerns (e.g., dementia, Parkinson's disease, diabetes, TBI, cardiovascular disease, and mental health diagnoses). ADHC promotes health and independent living and provides respite time for family caregivers. The interdisciplinary team includes RNs, a recreational therapist, a physical therapist, a music therapist, certified nursing assistants (CNAs), and a nurse practitioner. Students directly observed team communication and collaboration, were exposed to community-based resources available to veterans and families, and became aware of the complex health care needs managed in the community.
Community Resource and Referral Center
Students spent one morning at this unique setting working alongside a RN, interacting with homeless veterans. In 2014, 49,933 homeless veterans (8.6% of the total homeless population) were identified (National Alliance to End Homelessness, 2015). Although this represents a decrease in the number of homeless veterans, they remain overrepresented in the total homeless population. The Community Resource and Referral Center supports homeless veterans and those who are at risk of becoming homeless. The focus is on health promotion, disease prevention, advocacy, and social justice. Students engaged in the care of a vulnerable population and learned about community resources for homeless veterans.
Home and Community Care (HCC)
Home and Community Care (HCC) provides care to veterans with chronic health conditions who reside at home or in other community-based settings. Students spent one day at HCC, during which they were paired with a member of the interdisciplinary health care team and shadowed them on home visits. HCC begins the day with a meeting where team members discuss and create individualized holistic treatment plans for their clients, which provided students with another opportunity to observe interdisciplinary team work. During home visits, students discovered firsthand the significance of building trusting relationships with clients by being present and listening to their concerns. They described the difference between providing care in an acute care setting and on the client's “own turf.” A critical lesson learned was the importance of refraining from judgment, especially when providing care in the client's home.
MOVE!® Weight Management Program
Students attended the MOVE! Weight Management Program once during the clinical experience. This comprehensive national program focuses on helping veterans improve their health by consuming a healthy diet and being active. It is estimated that approximately seven of 10 veterans receiving services at the VAHCS are overweight or obese (USDVA, n.d.). MOVE! aims to screen every veteran for obesity and customize a personal weight management plan. Students learned about common health concerns associated with obesity, communicated with veterans coping with complex weight management issues, and observed public health nursing interventions such as surveillance, screening, case finding, case management, health teaching, counseling, collaboration, and referral and follow up (Minnesota Department of Health, 2001).
Students were oriented to the VAHCS home Telehealth program by spending time with a RN providing remote care to patients. The program is voluntary, free to the veterans, and staffed by nurses. VA Telehealth services utilize informatics technologies to deliver case management services to veterans with chronic diseases. Common health concerns followed via Telehealth services include diabetes, congestive heart failure, chronic obstructive pulmonary disease, depression, and PTSD. Patients collect and submit health data and RNs make necessary adjustments to medications and treatments outside of the acute care or clinic settings. RNs may also refer for additional care based on the veteran's unique needs. Providing easy access to an RN for case management and health education in situations where travel would be complicated or ill advised has the potential to improve the health status of veterans, as well as to decrease cost. Students identified the autonomy of RNs as they performed their full scope of professional nursing practice and were exposed to health informatics used to improve individual and population health outcomes.
Additional Learning Activities
Students broadened their perspective of community health/ public health nursing through engaging in additional learning activities that focused on health promotion and disease prevention rooted in the Cornerstones of Public Health Nursing (Minnesota Department of Health, 2007). Most students completed independent teaching–learning projects and explored personal areas of interest related to veteran-centered care and presented findings to students in the group and several invited VA employees. Topics of interest included PTSD, suicide, homelessness, chronic pain, stress, and nursing interventions such as motivational interviewing used in care management, smoking cessation education, using the secure messaging system to deliver individually focused health teaching, and using social marketing to deliver health promotion messages to veterans and their families. In these teaching–learning activities, students identified health concerns of the veteran population, developed their database search skills, and applied evidence to practice.
Enrichment activities were added to the field work experience when they became available. Examples of these were attending a guided tour of the National Cemetery that exposed students to the care provided to veterans after their demise, as well as the support paid to family and friends of the deceased; viewing and discussing a documentary on gay, lesbian, bisexual, and transgender issues in the veteran population; attending a presentation called “Caring for Our Wounded Warriors”; vaccinating people at the annual VAHCS influenza clinic; and attending VA events such as the Care Giver Support Fair, Pain Awareness Day, or the Diversity Fair. Also, a guest speaker facilitated a discussion of the VAHCS' role in emergency response and disaster management at the local, national, and international level. Students increased their knowledge of military culture and the health needs of veterans and their families by partaking in these activities. Specifically, students learned about the administrative structure of the VAHCS, including services and benefits available to veterans, the branches of military service, and the described camaraderie among veterans. Examples of health needs discussed in postclinical conferences included PTSD, homelessness, stress management, gender concerns, drug and alcohol misuse, chronic diseases related to military service, and suicide. Increase in knowledge was measured via an informal survey that revealed increased comfort in speaking to veterans about their service, as well as increased confidence in providing care to them.
The early postclinical discussions were rich, as students attended different sites from each other and were interested in hearing about upcoming experiences. Later in the course, discussions became even more meaningful as more students had attended a particular placement and they were familiar with the site and the population served. Students applied theoretical content, such as the Cornerstones of Public Health Nursing (Minnesota Department of Health, 2007), the QSEN competencies (QSEN Institute, n.d.), and the public health nursing interventions (Minnesota Department of Health, 2001) to what they were observing or participating in during field work. Collectively, theoretical content focused on the health priorities of populations at the individual/ family, community, and systems levels; was grounded in the principles of social justice; promoted holistic health strategies based on evidence; and centered on collaboration with the client, their families, and relevant stakeholders.
Integration of the Veteran Competencies for Undergraduate Nursing Education
The five field work experiences combined with the additional learning activities and the postclinical discussions exposed students to eight of the 10 veteran competencies as established by Moss et al. (2015), including the following: military and veteran culture, PTSD, environmental/chemical exposures, substance use disorders, TBI, suicide, and homelessness (Table). Depending on exposure to clients in various settings, students learned about an additional competency, amputation, and assistive devices. In the current settings, students are less likely to be exposed to cases of military sexual trauma and serious illness especially at the end of life, unless a client to whom they are assigned or making a home visit had these health care issues.
Clinical Sites Exposure to Veteran Competencies for Undergraduate Nursing Education (VCUNE) Competencies
Application of Theoretical Models of Education
The pedagogical approach applied in the veteran-centered community health clinical course focused on andragogy and the transformative and appreciative inquiry models. Knowles (1984) suggested five principles of adult learning in the andragogical model, which included (a) learners are involved in the planning and evaluation of learning, (b) experiential learning is critical, (c) learners seek relevance of learning to a future career path, (d) learning is task centered or problem centered, not content centered, and (e) motivation to learn is internal, not external. These principles applied to the clinical course described in this article. For example, students were self-directed in planning evidence-based teaching projects and independent teaching–learning activities based on personal interests. In addition, students participated in experiential learning relevant to future career paths at the five sites. Finally, students critically analyzed (verbally at postclinical conferences and in written work submitted for critique) KSAs related to encounters in the clinical settings. Knowles (1984) described the ideal learning environment as respectful, collaborative, supportive, and open. Together, faculty and students sought to create this type of learning community.
Transformative learning theory also applied to this field work experience. Mezirow (1991) articulated a developmental learning process in which learners shifted personal perspectives. The shift occurred within the context of experience, reflection, and discourse. The majority of students began with limited KSAs regarding the health care needs of veterans living in the community. The VAHCS sites provided a wide variety of experiences that were discussed in postclinical meetings and provided opportunities for increased knowledge and perspective shifts. In addition to discussions, the clinical reflection assignment allowed students to contemplate and describe KSAs gained from clinical experiences.
Finally, elements of the appreciative inquiry model (Cooperrider & Whitney, 2005) were relevant to this community health clinical course. The appreciative inquiry model is a positive strengths-based approach. Effective learning was more likely to occur when the strengths of the learner and a positive teacher–student relationship were emphasized. Faculty and students brought a “diverse set of assets, strengths and resources,” which represent a “positive core” (Cooperrider & Whitney, 2005, p. 9). The core was the foundation on which to build relationships during the 7 weeks of the experience. During postclinical discussions and the final seminar, a nonjudgmental atmosphere prevailed in which open and honest dialogue was encouraged and all comments were welcomed. Erroneous assumptions were challenged, and critical analysis was the norm. Expectations were that students engaged in the discussions, and the input of all participants was respected and valued.
Evaluation of Student Learning
Formal data regarding student learning of veteran-centered content were not collected. However, formative and summative anecdotal information was gathered in the learning experiences during participation in weekly postclinical discussions and after the community-based veteran-centered clinical course had been completed. Three noteworthy themes stood out in the conversations. The first theme came from statements made by students with increased descriptions of the wide array of resources and supportive services that are available to veterans and their families through the VAHCS. The second theme centered on increased expressions of the complex health care needs of veterans in community-based settings. Finally, students frequently recognized the autonomous nature of the community health nursing role and the importance of collaboration with other health care professionals to meet the needs of veterans.
Along with participation in postclinical conferences, student knowledge gained in the experience was evaluated via written assignments (i.e., a windshield survey, a clinical reflection, and an evidence-based teaching–learning presentation and written paper). Students were provided with guidelines and rubrics specific to each assignment. The completed written assignments provided faculty the data to informally measure increased KSAs related to veteran-centered care.
A standardized clinical evaluation tool completed at the end of the experience documented the achievement of student learning outcomes. Student performance was measured based on five criteria, including effectiveness, affect, safety, initiative, and efficiency. Specific behaviors for each of the criteria are listed on the evaluation tool. For example, in the area of effectiveness, students are evaluated on active engagement during discussions and contribution to projects. In the area of affect, self-awareness is evaluated, whereas in the area of safety, students must follow the policies of the guest agency and maintain client confidentiality. Students were required to receive a score of 3 in each of the criteria to successfully pass the clinical.
Students were informally surveyed following completion of a variety of clinical experiences at the junior level of a prelicensure nursing curriculum, which included the veteran-centered community health clinical. The survey results revealed that most students felt more confident in asking veterans about their service, providing care to them, and having more knowledge of benefits and services for veterans. Graduates of the baccalaureate nursing curriculum who seek employment at the VAHCS are invited to participate in an individual, face-to-face interview. During the interview, graduates were asked several questions about their experiences as students. Graduates were welcomed to discuss any aspects of the experience in the curriculum, including the veteran-centered community health clinical experiences. Graduates who have been interviewed commented on the complexity of veteran health issues and the wide variety of resources and supports for veterans in the community.
It was necessary to ensure that the learning experiences at the VAHCS meshed with those of the non-VA–focused students because this was a community clinical section of 20 students per academic year in a unique cohort of a much larger body of students taking the same course at other sites. The academic faculty made many contacts with VA personnel, became familiar with the learning opportunities at the VAHCS, and carefully considered learning outcomes and the integration of experiences from various VAHCS opportunities to accomplish this task. This was a first-time experience for the VAHCS having a specific VA-focused student cohort in such a course; thus, the sites and preceptors also had to become familiar with course learning outcomes and create appropriate student rotations with assistance from the faculty. It was necessary for faculty to orient and focus the students about the unique aspects and needs of the veteran population in their brief seven week rotations while still meeting all other course learning outcomes. This required the faculty to do considerable front work initially and to be willing and adaptable to accept and utilize feedback from the nursing students and the VAHCS preceptors and sites to continuously improve the course over ensuing semesters.
The early indicators are that this community health field work experience will be sustainable into the future. The academic institution and clinical partner remain committed to working together to provide meaningful learning opportunities to students. Clearly, this clinical course provided a wide range of veteran-centered experiences and prepared undergraduate nursing students to care for veterans and their families. Students completed the experience with increased KSAs for veteran-centered care, an increased awareness of the resources and support available to veterans and their families, and a beginning orientation to the VAHCS.
- American Association of Colleges of Nursing. (2012). Joining forces: Enhancing veterans' care toolkit. Retrieved from http://www.aacn.nche.edu/downloads/joining-forces-tool-kit
- Cooperrider, D. & Whitney, D. (2005). Appreciative inquiry: A positive revolution in change. San Francisco, CA: Berrett-Koehler.
- Johnson, B.S., Bodiab, L.D., Freundl, M., Anthony, M., Gmerek, G.B. & Carter, J. (2013). Enhancing veteran-centered care: A guide for nurses in non-VA settings. American Journal of Nursing, 113(7), 24–39. doi:10.1097/01.NAJ.0000431913.50226.83 [CrossRef]
- Knowles, M.S. (1984). Andragogy in action: Applying modern principles of adult learning. San Francisco, CA: Jossey-Bass.
- Mezirow, J. (1991). Transformative dimensions of adult learning. San Francisco, CA: Jossey-Bass.
- Minnesota Department of Health. (2001). Public health interventions: Applications for public health nursing practice. Retrieved from http://www.health.state.mn.us/divs/opi/cd/phn/docs/0301wheel_manual.pdf
- Minnesota Department of Health. (2007). Cornerstones of public health nursing. Retrieved from http://www.health.state.mn.us/divs/opi/cd/phn/docs/0710phn_cornerstones.pdf
- Moss, J.A., Moore, R.L. & Selleck, C.S. (2015). Veteran competencies for undergraduate nursing education. Advances in Nursing Science, 38, 306–316. doi:10.1097/ANS.0000000000000092 [CrossRef]
- National Alliance to End Homelessness. (2015). Fact sheet: Veteran homelessness. Retrieved from http://www.endhomelessness.org/library/entry/fact-sheet-veteran-homelessness
- QSEN Institute. (n.d.) Competencies: Prelicensure KSAS. Retrieved from http://qsen.org/competencies/pre-licensure-ksas/
- U.S. Department of Veterans Affairs. (2015). Veteran's Health Administration. Retrieved from http://va.gov/health/
- U.S. Department of Veterans Affairs. (n.d.). VA research on obesity. Retrieved from http://www.research.va.gov/topics/obesity.cfm
- U.S. Department of Veterans AffairsNational Center for Veterans Analysis and Statistics. (2010). Selected research highlights. Retrieved from https://www.va.gov/vetdata/docs/QuickFacts/Reports-slideshow.pdf
Clinical Sites Exposure to Veteran Competencies for Undergraduate Nursing Education (VCUNE) Competenciesa
|Clinical Site||VCUNE Competency|
|Adult Day Health Center||a, b, c, d, e, g, h|
|Community Resource and Referral Center||a, b, c, d, e, g, h, i|
|Home and Community Care||a, b, c, d, e, f, g, h, j|
|Telehealth||a, b, c, d, e, g, h|
|Move!® program||a, b, c, d, e, f, g, h|