As of 2016, only 7% of the population in the United States have served in the military (Bialik, 2017); coincidingly, the United States has seen an increased number of military students currently enrolled in a variety of institutions supported by federal funding (Ford & Vignare, 2015; Kato, Jinkerson, Holland, & Soper, 2016; Keita, Diaz, Miller, Olenick, & Simon, 2015; NASPA Research and Policy Institute, 2013). This may be attributed to an expansion of education benefits, as well as a military drawdown and recent initiatives to transition veterans into health care careers (Bureau of Health Workforce, 2014). Nonetheless, some military students struggle as they shift from the highly structured military environment to a self-directed civilian classroom (Blum, 2015; Ness, Rocke, Harrist, & Vroman, 2014). Because nursing schools also enroll military students, an integrative review was conducted to ascertain the factors that challenge and/or facilitate a military student's transition to the civilian nursing classroom.
Whittemore's and Knafl's (2005) five-step integrative review method (e.g., problem identification, literature search, data evaluation, data analysis, and presentation) was used to critically analyze and synthesize the literature regarding military students because it allowed for the incorporation of various methodologies.
Step One: Problem Identification
Civilian nursing programs educate 100% of undergraduate military nursing students, yet many faculty are unaware of the challenges these students may encounter when they transition to the civilian classroom. Hence, the primary purpose of this integrative review was to ascertain the factors that challenge and/or facilitate a military student's transition to the civilian nursing classroom. A second purpose was to present recommendations so educators can become culturally competent in order to work with this unique student population. Multiple transition theories were explored but Jeffreys' (2015) Nursing Universal Retention and Success (NURS) model was ultimately chosen to provide the conceptual framework for this integrative review because it was specific to nursing students and encompassed multiple factors that affect student success in undergraduate nursing programs.
Step Two: Literature Search
The literature search included articles published in English from 2005 to 2018, and the electronic databases explored were CINAHL®, Scopus®, ERIC™, and Education Source. The search terms included Army, Soldier, Navy, Sailor, Marine Corps, Marine, Air Force, Airman, Enlisted, Enlistee, Military, Training, Corpsman, Corpsmen, Medic, Aerospace Medical Service Specialist, Nurse Corps Medical Enlisted Commissioning Program (MECP), Airman Scholarship & Commissioning Program (ASCP), Army Medical Department (AMEDD) Enlisted Commissioning Program (AECP), Enlisted Commissioning Programs, veteran OR veterans, BSN OR VBSN OR bachelor OR bachelors OR baccalaureate OR postsecondary OR post-secondary, student OR students, nursing OR nurse OR nurses, and campus OR college OR university, attrition, and transition OR transitions OR transitioning. More than 70 articles were included in the final sample, but only 12 of the publications were found in nursing journals or discussed military nursing students (Allen, Armstrong, Saladiner, Hamilton, & Conard, 2014; Allen, Billings, Green, Lujan, & Armstrong, 2012; Cox, 2019; D'Aoust, Rossiter, Itle, & Clochesy, 2016; Donelan et al., 2016; Dyar, 2016; Eddy & Hill, 2005; Hurlbut & Revuelto, 2018; Keita et al., 2015; Morrison-Beedy & Rossiter, 2018; Voelpel, Escallier, Fullerton, & Rodriguez, 2018; Wilkerson, 2015). Additionally, five articles discussed the care of Veterans by nursing students (Carlson, 2016; Kaplan, Murihead, & Zhang, 2017; McMillan et al., 2017; Moss, Moore, & Selleck, 2015; Rossiter, Morrison-Beedy, Capper, & D'Aoust, 2018) and the National League for Nursing (n.d.) has unfolding case studies and teaching strategies for working with Veterans and their families. However, the focus of this integrative review was on military nursing students, not military/Veteran patients. Finally, for the purposes of this article, the terms military student or military nursing student are used, and they encompass four categories (Table 1).
Terms for Military Students
Step Three: Data Evaluation
The final sample included all scholarly literature pulled for this integrative review because each provided context for the subject matter. The sample incorporated opinion pieces, review articles, original research, association perspectives, and books.
Step Four: Data Analysis
Whittemore's and Knafl's (2005) four phases of data analysis were applied. The first phase, data reduction, included developing an overall classification system based on Jeffreys' (2015) NURS model. Data display was the second phase and allowed for the visualization of patterns and relationships via a data matrix. The third phase was data comparison, and it incorporated the use of the data matrix, making it helpful to begin to categorize the data in accordance with the NURS model. The final phase was conclusion drawing and verification; this entailed synthesizing important elements to interpret the data.
Step Five: Presentation
The last step of Whittemore's and Knafl's (2005) integrative review method demanded that conclusions were supported by the evidence. From this step, implications for education, research, and/or practice are shared. In addition, Table 2 provides a list of general resources for educators working with military student nurses, and Table 3 offers recommendations that were derived from the nursing literature.
Teaching Military Student Nurses: General Resources for Educators
Recommendations Based on the Experience of Nursing Programs
Student Profile Characteristics
According to Jeffreys (2015), this category is defined by student demographics, including prior work experience. Hence, the literature supported the concept that military students are valuable assets—because they convey a level of maturity and strong work ethic and are disciplined, bring important life experiences to the classroom, or are team builders—but that they have needs that differ from nonmilitary students (American Council on Education, 2016; Gregg, Howell, & Shordike, 2016; Gregg, Kitzman, & Shordike, 2016; Hart & Thompson, 2016; Hitt et al., 2015; Lighthall, 2012; McBain, Kim, Cook, & Snead, 2012; Ness et al., 2014). For example, many are older, have families, or tend to live off campus and therefore have to commute to school (American Council on Education, 2018). Coll and Weiss (2015) shared 10 strengths that military students bring to the classroom: leadership, team membership and team leadership, diversity, punctuality, flexibility and adaptability, an ability to be self-directed, a possession of outstanding work habits, a commitment to excellence, a global outlook, and an investment in their communities. However, Lighthall (2012) cautioned educators that some military students may not ask for help or will ask questions only as a last resort. Ness et al. (2014) confirmed that military students struggle with developing a self-identity outside of their respective services and that it may be taxing for them to forge a relationship with academic peers or faculty. Finally, Roost and Roost (2014) stated that military students vary in their experiences because a service member who has never deployed will have events that differ from one who has deployed and even those who have deployed may or may not have been exposed to combat.
Voelpel et al. (2018) developed survey instruments to gauge the perceptions of nursing military students regarding the value of support strategies put into place to facilitate their academic success. Another one of their surveys targeted faculty and staff regarding academic and student success. Replicating the surveys with other schools of nursing may be an option for nursing research. Additionally, Dyar (2016) identified the following gaps in the literature regarding nursing research and this student population: nursing students who have deployed to combat zones, as well as the transition of military nursing students to the classroom. Hence, both qualitative and quantitative studies regarding these areas are needed.
Student Affective Factors
According to Jeffreys (2015), this category incorporates cultural congruence whereby students sync their attitudes, values, and beliefs with both the academic environment and the nursing profession. However, nursing faculties vary in their experience regarding how best to acclimatize military nursing students to the classroom. Hence, many would benefit from formalized training focusing on areas related to military culture, common language used, deployments, rank structure, and even negating stereotypes that disproportionately concentrate on a propensity for violence so faculty can become culturally competent to work with military students (Allen et al., 2014; Barnard-Brak, Bagby, Jones, & Sulak, 2011; Bonar & Domenici, 2011; Cass, 2014; Cass & Hammond, 2015; D'Aoust et al., 2016; Elliott, 2015; Elliott, Gonzalez, & Larsen, 2011; Graf, Ysasi, & Marini, 2014; McBain et al., 2012; Osborne, 2014; Wilson, Smith, Lee, & Stevenson, 2013; Voelpel et al., 2018). Furthermore, D'Aoust et al. (2016) reported that their military students felt that faculty did not understand their specific needs, so at the authors' institution a 3-hour university-wide faculty and staff program was developed, taught by student Veterans, and included these topics: Who Is a Veteran, Transition and Reintegration Challenges, Academic Issues, Posttraumatic Stress Disorder (PTSD), Misperceptions, and How to Become an Ally. Attendees then received a sticker they could place on their office doors so that military students could easily identify those who had the training and were most likely to be receptive to their concerns. Taking it one step further, the nursing program then developed a series of online “Got Your Six” training modules for faculty, staff, and clinical partners. Burnett and Segoria (2009) also endorsed faculty online workshops.
Barnard-Brak et al. (2011) and Dyar (2016) wrote that faculty members who have negative feelings about the military may express this, thus alienating military students. Hence, teacher efficacy training programs could raise self-awareness. Furthermore, ideal faculty include those with prior military service because they can role model for the students by providing guidance about transitioning from the service to academia, as well as act as interpreters for faculty regarding military matters (Allen et al., 2012; Wick, Bester, Garcia, & Stoll, 2014). No matter what—if any—accommodations are made for military students, faculty should always maintain high expectations so that students are successful with meeting course goals and objectives, as well as program standards (López, Springer, & Nelson, 2015; Sportsman & Thomas, 2015).
Even thinking outside the box can add to student success. For example, Eddy and Hill (2005) wrote about Hill's deployment to Iraq with her South Dakota Guard Unit and how her nursing faculty worked together to provide didactic content, as well as count clinical hours toward graduation requirements while Hill was still deployed. Allen et al. (2014) offered solutions that focused on progression, retention, and graduation of military students from nursing programs. One of their solutions was to offer innovative education models that reduced redundancy for areas whereby competency has already been validated via the military.
Furthermore, the literature revealed some additional thoughts for faculty to consider when they have military students in their classrooms. First, military students may feel isolated from their peers and may think that faculty do not understand them (Grossbard et al., 2014). Hence, faculty should provide an inclusive atmosphere for all students. Additionally, the majority of military students are assets to the classroom, given their experience with leadership and team building (Hart & Thompson, 2016; Sportsman & Thomas, 2015). Many are global citizens, so faculty are advised to take advantage of a military student's experience. However, military students may not want to discuss their military experience nor reveal that they even have a military background; hence, faculty should provide a classroom environment that is safe by respecting a student's privacy and leaving it up to the student to disclose any prior service (Kirchner, 2015). Furthermore, Dyar (2016) shared six barriers that military students experience and which faculty should remember: stigma (which leads to asking inappropriate questions), peer classmates (without a military background), traditional nursing education (that uses customary pedagogies), personal and financial responsibilities (which result in struggles), and gender (whereby men may have represented the majority in the military but remain the minority in nursing).
According to Jeffreys (2015), this category includes study skills, class attendance, time management, and/or institutional resources. A reoccurring theme in the literature was that military culture emphasizes structure, discipline, and order; this is very different from a typical college student's life (Kirchner, 2015; Naphan & Elliot, 2015; SFVAMC's Veterans Outreach Program at City College of San Francisco, 2013). Further, because they are accustomed to a very organized environment, military students do not respond well to inconsistent or capricious policies (Hitt et al., 2015). Military students also benefit when colleges and universities are prepared to administer to their needs (e.g., centralizing services by offering “one-stop shopping” is one way to accomplish this), provide a welcoming and friendly campus (e.g., “Veteran-friendly”), offer services for previous injuries and disabilities, connect military students with their military peers, and possess great communication plans (Burnett & Segoria, 2009; Cass, 2014; Cass & Hammond, 2015; Church, 2009; Hitt et al., 2015; McBain et al., 2012; NASPA Research and Policy Institute, 2013; O'Herrin, 2011; Osborne, 2014; Romero, Riggs, & Ruggero, 2015; Schiavone & Gentry, 2014; SFVAMC's Veterans Outreach Program at City College of San Francisco, 2013).
According to Jeffreys (2015), this category reflects financial status, family support, childcare concerns, transportation issues, and living arrangements. Financial concerns, including payment delays by the Department of Veterans Affairs (VA), and not graduating on time are the two biggest factors that military students fear (Ackerman, DiRamio, & Garza Mitchell, 2009; McBain et al., 2012). Elliott (2015) drove home the financial concerns of military students by saying that financial hardship predicted increased symptoms of depression and PTSD. Consequently, schools should make military students cognizant of financial aid options that complement their VA benefits. Norman et al. (2015) and Olsen, Badger, and McCuddy (2014) also spoke of financial barriers, and Snyder, Wick, Skillman, and Frogner (2016) found that navigating complex benefits was a barrier to military students.
According to Jeffreys (2015), this category involves anything regarding grades. Bryan, Bryan, Hinkson, Bichrest, and Ahern (2014) wrote that depression may play a stronger role than PTSD when it comes to a low grade point average (GPA) for military students and that the warning signs for academic problems include turning in late assignments, receiving lower test grades than expected but still passing, failing a test, and skipping or choosing not to attend class. Voelpel et al. (2018) shared that test-taking abilities could still be affected despite a variety of tutoring and advisement resources provided to their military students. Durdella and Kim (2012) found that college GPA was negatively associated with students who had prior military service. Because Grossbard et al. (2014) found that lower perceived social support military students receive from the both the faculty and staff negatively correlated with their GPAs, it is imperative for nursing programs to be demonstrative in their support of these students.
According to Jeffreys (2015), this category denotes psychological outcomes related to stress and satisfaction. Church (2009) reported that the three signature injuries from the Global War on Terrorism were physical injuries, traumatic brain injury (TBI), and mental health issues. Consequently, the literature is replete regarding psychological concerns for military service members/Veterans. Smith (2012) addressed the specific psychological barriers of female Veteran students as well. Regarding self-harm, Blosnich, Kopacz, McCarten, and Bossarte (2015) found that military students had higher odds of self-harm than their civilian peers. However, Bryan and Bryan (2015) reported no difference between traditional versus military students, although Native American military students may be in a high-risk subgroup for suicidal thoughts and behaviors. Rudd, Goulding, and Bryan (2011) also addressed mental health issues and self-harm via the results of a national survey that explored psychological symptoms and suicide risk.
Because military personnel are frequently deploying in arduous conditions for long periods of time and may have been exposed to trauma, they are at risk for PTSD, behavioral health issues, and TBI (Barnard-Brak et al., 2011; Bonar & Domenici, 2011; Campbell & Riggs, 2015; Elliott, 2015; Elliott et al., 2011; Ellison et al., 2012; Kato et al., 2016; López et al., 2015; Ness, Middleton, & Hildebrandt, 2015; Ness et al., 2014; Ness & Vroman, 2014; Schonfeld et al., 2015; Smith, Vilhauer, & Chafos, 2017; Smith-Osborne, 2012; Widome, Kehle, et al., 2011; Widome, Laska, Gulden, Fu, & Lust, 2011). Concerning alcohol abuse, the drinking behaviors of all college students is a public health concern, and because the military has a history of drinking rituals it is postulated that alcoholism could also affect a military student's success in higher education (Barry, Whiteman, Wadsworth, & Hitt, 2012; Grossbard et al., 2014; Widome, Laska, et al., 2011).
Whitley, Tschudi, and Gieber (2013) revealed the results of a symposia whereby college administrators, military students, and advocates for Veterans recognized the need to be equipped to handle possible behavioral and physical health needs. They offered 12 recommendations for supporting the health needs of military students as follows (Whitley et al., 2013, pp. 3–4):
- Develop a plan to destigmatize support services so military students will access them.
- Provide a welcoming environment and “warm hand-offs” to resources (e.g., the registrar, academic advisors).
- Hire learning specialists to teach the skills necessary to promote academic success.
- Provide adequate accommodations for Veterans with PTSD and/or attention deficit disorders (e.g., offer a quiet testing environment).
- Hire experienced and trained counselors who are themselves veterans.
- Provide peer mentors.
- Establish support groups to help multiple military students at the same time.
- Invest in hiring and/or training support group leaders to have professional facilitators who know how to put participants at ease.
- Provide a drop-in center with trained peer counselors.
- Have multiple entry points to group resources, including both formal and informal groups.
- Establish a central information resource to collect all information about military students, as well as coordinate events.
- Develop and implement a comprehensive student Veteran orientation, including a handbook with a list resources.
Outside Surrounding Factors
According to Jeffreys (2015), this category pertains to events outside of the academic environment including regional, national, and international events. When military students deploy during an academic year, McBain et al. (2012) advocated that institutions have policies in place to refund tuition, allow students to complete a course upon return to the classroom, and, above all, be flexible in order to minimize any administrative obstacles faced by military students returning from a deployment. This is especially important because there are federal laws that protect military students who miss classes because of military orders (U.S. Department of Education, 2017). Also, providing non-traditional options for deployed military students to complete course work while meeting the course goals and objectives reveals the faculty's recognition that these students are constantly balancing dual obligations that their nonmilitary peers do not have: service to their country, as well as earning their nursing degree (Hitt et al., 2015). It may also indirectly improve their performance and lead to their retention in the nursing program (Wilson et al., 2013).
Professional Integration Factors
According to Jeffreys (2015), this final category is comprised of any factors that allow nursing students to interact with their peers, faculty, and nursing professionals. It can be a stressful life transition to academia, so one protective factor for any debilitating effects is social support, as well as encouragement from one's own military unit (Campbell & Riggs, 2015; Elliott, 2015; Ellison et al., 2012; Kato et al., 2016; Wilson et al., 2013). Additionally, because military culture is steeped in traditions including friendly rivalries (e.g., “Go Navy, Beat Army”) and peer support, these students feel more comfortable with each other and prefer to engage in collaborative work with their fellow military peers (Burnett & Segoria, 2009). O'Herrin (2011) conveyed that military students may even benefit from a designated space (e.g., a Veteran lounge) so that they have the opportunity to connect with their military peers when feeling overwhelmed but also noted that social isolation from the academic community is not the goal of military-specific endeavors. Finally, Coll and Weiss (2015) emphasized the importance of strong faculty advisement to support military students in higher education.