In 2015, there were approximately 22 million veterans living in the United States, representing 7% of the population (U.S. Census Bureau, 2015). Yet, only 27% of veterans seek care in Veterans Affairs (VA) facilities (Bagalman, 2014). Although some nursing students may have opportunities to learn about veteran care through clinical placements in a VA system, it is important that all students be informed of the unique health care needs of this population because of the likelihood they will care for veterans in their future practice settings. These factors highlight the need for undergraduate nursing students to receive better preparation to care for veterans.
There is a gap in the literature about how care for veterans can be incorporated into an already content-laden prelicensure nursing education curriculum (Elliot & Patterson, 2017). Our school of nursing sought to address this need by enriching our undergraduate nursing curriculum with veteran-centric content through a VA Nursing Academic Partnership (VANAP). This article describes the collaborative process used by the school of nursing (SON) and the partner VA facility to identify what nurses competent in veteran care need to know and how to build these competencies into an existing undergraduate curriculum.
VANAPs are education and practice-partnerships between VA facilities and SONs designed to ensure quality veteran care now and in the future. The purpose of VANAPs is to “leverage academic and clinical resources to increase student enrollment, support faculty development, promote innovation in clinical education, develop veteran-centric education and practice initiatives, and increase the recruitment and retention of VA nurses” (Office of Academic Affiliations, Department of Veterans Affairs, 2013, p. 1). The U.S. Department of Veterans Affairs has long championed developing affiliate training partnerships, and the evidence that supports the benefit of a collaboration between academic and practice institutions is growing (Bvumbwe, 2016, Harper et al., 2016, Lloyd-Penza et al., 2019; Roach & Hooke, 2019).
An academic partnership was essential for securing the commitment to enhance the nursing curricula and overcoming the commonly expressed barriers to making changes: lack of time and content-laden curricula (Elliott & Patterson, 2017). In 2013, a VANAP was established between a Portland VA Health care System (VAPORHCS) and Oregon Health Science University (OHSU) SON. Executive leadership from both partners were in full support of the partnership. VANAP faculty and program directors were composed of SON faculty and staff RNs from the VA with faculty appointments at the SON. This blend of clinical and academic RN faculty and program codirectors provided a strong foundation from which to grow the partnership and identified initiatives. Integration of veteran-care education in the baccalaureate curriculum was a priority educational initiative of the partnership.
The VANAP partnership was leveraged to thoughtfully develop the competencies needed by nursing students to provide veteran-centric care. To build curriculum enhancements within the existing undergraduate courses, the partnership used veterans as a population exemplar in a curriculum that stressed population-based nursing as an essential concept that was spiraled through the curriculum.
VANAP faculty conducted a literature review on veteran health care considerations and nursing practice. The search terms used were veterans + population-based care + nurse competency using CINAHL® and PubMed®. An exact number of articles identified by these terms was not retained at the time; however, more than 30 articles and resources were found that illuminated the unique health care considerations and needs of the veteran population. These articles were reviewed completely, and only those articles that addressed a broad and comprehensive focus rather than a singular health care consideration were retained.
A list of recurring themes from the 15 retained articles regarding these unique needs and considerations was compiled. Faculty reviewed the list with veteran-care experts at the VA via email and face-to-face meetings, and also reviewed the national Veterans Health Administration websites regarding veteran health care needs for validation. The list was refined further to contain only care considerations that potentially applied to most, if not all, veterans. For example, knowledge regarding care of veterans who underwent amputation was a theme; however, because it would not be applicable to the majority of veterans, it was eliminated from the list. In contrast, knowledge of military service history and related health risks was a theme that applied to all veterans and was retained in the list. The program directors presented the honed list for review and discussion at the VANAP Strategic Steering Committee, as well as the VANAP Advisory Board comprising VA and SON leadership, nurse directors and managers, veterans, and nursing education experts for discussion and adoption. The result of this process was the adoption of the following eight behavioral competencies for nursing students reflecting competent veteran care:
- Applies knowledge of military culture and the veteran experience to provide care that is veteran patient-driven.
- Applies knowledge of military service history and related health risks to provide care that is evidence-based.
- Demonstrates understanding of potential issues and challenges for veterans and their families related to reintegration to civilian life.
- Applies knowledge of higher incidence of mental health issues experienced by veterans.
- Assesses, plans, implements, and evaluates care for disease processes and comorbidities commonly experienced by veterans in diverse settings.
- Assesses, plans, implements, and evaluates community-based programs to promote health in veterans and military families.
- Assesses, plans, implements, and evaluates self-care practices and resources to promote well-being in veteran caregivers.
- Uses information, information tools, and improvement science to monitor outcomes of care and continuously improve the quality of care for veterans and military families.
VANAP faculty began meeting and collaborating with SON key stakeholders, including the undergraduate program director and faculty course leads for the undergraduate program, to discuss the importance of veteran content integration into the nursing program of study, and initial buy-in was achieved. To integrate veteran-care content, it was aligned with both the newly identified competencies and with current undergraduate content. Faculty first examined the curriculum for areas where veteran content was already being taught and ensured alignment of that content with the established competencies. Competency content gaps were identified, and concept-based enrichment activities and experiences were added or modified using a veteran-care lens when appropriate.
Conscious efforts were made to prevent “content creep” and oversaturation of material, and to integrate veteran content into areas that would be a natural fit. To engage students using multiple learning modalities, faculty used veteran-centric case studies, simulations, concept-based learning activities, reading preparation, and lecture. Through the collaborative relationship between the SON and the VA, clinical experts in veteran care provided lectures to nursing students in all levels of the baccalaureate nursing program. These strategies of content integration and lectures exposed students to veteran-specific information while also teaching concepts that could be broadly applied to all populations.
Veteran-centric care content was integrated into the 13 required undergraduate courses and 25% of undergraduate simulation experiences through collaboration and negotiation between the SON and VANAP faculty. To prevent layering additional content in courses, enhancement strategies were used within each existing didactic and clinical course. First, case studies, which are part of every didactic course, were developed with required and optional readings. The case studies encourage students to apply knowledge to practice in the key concepts in every course. For example, in the chronic illness course, a case study about an 80-year-old Korean War veteran and his fall risk/assessment was included as an application case study for safe mobility.
Second, guest lecturers with expertise in veterans' care who were also experts in a content topic for the course were invited to speak. In the leadership course, the Chief Nursing Officer for the VA spoke about nursing leadership from the VA lens. In the mental health course, an expert in suicide prevention was invited to present strategies used in his practice caring for veterans at high risk of suicide.
Third, in the clinical courses that were associated with didactic courses, veteran-specific concept-based learning activities were created to reinforce practice applications for this population. One example of these efforts was incorporated into acute care clinical experiences, where an innovative concept-based clinical learning activity was created for nursing students to identify and educate veterans at risk for amputation. Post-conferences including students from both VA and non-VA clinical areas were integrated into the senior-level population health course, which allowed students who did not have clinical in the VA to learn about veteran care from VA student experiences (Roach & Hooke, 2019).
In simulation, VANAP partnership faculty members worked together to create new scenarios using simulation as a means to fill in gaps or enhance theory and other clinical learning. Adoption and adaptation were used to enhance the curriculum by increasing the number of high-quality veteran simulation scenarios in the simulation database. For example, the highly regarded, previously piloted, and fully developed unfolding cases from the National League for Nursing (NLN): Advancing Care Excellence for Veterans (ACE-V) website has 12 scenarios including different acute and chronic veteran-centric health issues in various settings, which provides many options for OHSU concept-based curriculum (NLN, 2017). Resources used included the U.S. Department of Veteran Affairs VHA website and the American Association of Colleges of Nursing (AACN) Joining Forces Tool-Kit for additional simulation scenarios to adopt as well as up-to-date information to assist in converting previously nonveteran scenarios into veteran-centered cases (AACN, 2012; U.S. Department of Veteran Affairs, 2015). VANAP faculty also provided expert opinions based on real-life veteran nursing care experiences during the debriefing phase for each simulation session, which both enriched discussions and engendered feedback for scenario revisions.
A veteran-care curricular integration mapping tool (Table 1) spanning the 3-year nursing program of study was developed to track the content taught and corresponding competency alignment, the course in which it was taught, and the mode of instruction (e.g., didactic, case-based, or simulation). This avoided duplication of veteran-focused content among the courses in the curriculum. The mapping tool also served as a repository for content-related resources and tools for faculty teaching the content. The curricular map outlining these content enhancements is reviewed and updated annually by VANAP faculty.
Veteran-Care Curricular Integration Map
All nurses likely will care for veterans or their family members at some point in their nursing career, and understanding the unique care needs of the veteran population is essential to providing optimal care. Understanding military culture; military sexual trauma; traumatic brain injury; posttraumatic stress disorder; issues facing families and caregivers; complications from exposure to nuclear, biological, and chemical warfare; and physical and mental disabilities as a result of direct combat or exposure to military action were identified as core concepts that needed to be included in nursing education (U.S. Department of Veteran Affairs, 2019). Integrating veteran-centric content into undergraduate nursing curricula equips nursing students to increase knowledge regarding the unique health care needs of veterans and to provide effective care for veterans. Although veterans experience unique health care needs, many of the concepts that were integrated can be implemented across populations, making the content applicable to all nursing students using veterans as a population exemplar.
Strategies to promote a collaborative experience during the development of the content integration process included targeted efforts to promote understanding of the VANAP partnership and its initiatives to all SON undergraduate faculty. VANAP faculty were integrated among the non-VANAP faculty in multiple ways, including co-leading course clinicals and teaching didactic classes, which helped build relationships and credibility and ensure veteran-care content integration. VANAP faculty also facilitated subject matter experts from the VA as guest presenters in theory classes and during lunch and learn presentations open to all faculty and students to further partnership visibility, buy-in, and collaboration.
Other strategies to promote the integration process included the development of the eight veteran-care competencies used to frame competent veteran-centric care. These competencies served as a clear and consistent focus when considering and integrating the curricular enhancements. In addition, veteran-care resources were uploaded to the SON electronic platform, enabling access by SON faculty.
A variety of veteran-centric educational strategies were developed and used to meet existing course objectives with veterans as a population exemplar in a spiraled curriculum. For example, while incorporating 12 scenarios focusing on a number of different acute and chronic veteran-centric health issues in various settings into simulation in the undergraduate nursing curriculum, faculty members worked together with the focus of using simulation as a means to fill in gaps or enhance theory and other clinical learning. In this way, the special needs of veterans could be addressed without adding to the content burden in a course. Continual monitoring and communication within the partnership has been used to maintain the curricular enhancements. The next phase of this educational initiative includes evaluating the impact of veteran-care curricular content integration on student learning, and the faculty and student educational experience.
Veterans are a population with unique health care issues and needs. Integrating veteran-centric content into the baccalaureate curriculum promotes best practices in caring for veterans and their families. Such work will result in more culturally competent nurses practicing both in and outside of VA facilities. Integrating educational strategies that are veteran-focused into existing curriculum requires careful planning and thoughtful staging of the change. Involving stakeholders early in the process, maintaining frequent communication, and integrating collective feedback allows creation of a program that meets student, faculty, and veteran needs.
The strategies used for incorporating veteran-centric care into a curriculum could be used by other nurse educators to integrate and maintain a variety of population-specific curricular enhancements into an undergraduate nursing curriculum. It is important for educators to look for an array of teaching methods and learning activities that can work seamlessly within an existing curriculum to achieve this end. Mapping curriculum and maintaining good communication among faculty are helpful strategies to highlight the enrichment learning activities and to avoid loss of these added elements, especially with faculty turnover. It is also essential to regularly review the created educational strategies to ensure that educators are staying current with practice and providing the most up-to-date material so that students are prepared to effectively care for their veteran patients upon graduation.
- American Association of Colleges of Nursing. (2012). Enhancing veterans' care faculty tool kit. https://www.aacnnursing.org/Teaching-Resources/Tool-Kits/Veterans-Care
- Bagalman, E. (2014). The number of veterans that use VA health care services: A fact sheet. https://www.fas.org/sgp/crs/misc/R43579.pdf
- Bvumbwe, T. (2016). Enhancing nursing education via academic–clinical partnership: An integrative review. International Journal of Nursing Sciences, 3(3), 314–322.
- Elliott, B. & Patterson, B. (2017). Joining forces: The status of military and veteran health care in nursing curricula. Journal of Professional Nursing, 33(2), 145–152.
- Harper, D.C., Moore, R.L., Cleveland, C., Miltner, R.S., Froelich, K., McGuinness, T., Waldrop, J., Fogger, S., Davis, A.H. & Selleck, C.S. (2016). Transforming veterans' health care through academic-practice partnerships. Nursing Outlook, 64(5), 424–430.
- Lloyd-Penza, M., Rose, A. & Roach, A. (2019). Using feedback to improve clinical education of nursing students in an academic-practice partnership. Teaching and Learning in Nursing, 14(2), 125–127.
- National League for Nursing. (2017). Advancing care excellence for veterans (ACE.V). http://www.nln.org/professional-development-programs/teaching-resources/veterans-ace-v
- Office of Academic Affiliations, Department of Veterans Affairs. (2013). VA nursing academic partnerships request for proposals. http://www.va.gov/oaa/docs/VANAP_RFP_2013_2014.pdf
- Roach, A. & Hooke, S. (2019). An academic-practice partnership: Fostering collaboration and improving care across settings. Nurse Educator, 44(2), 98–101.
- U.S. Census Bureau. (2015). Veteran statistics: Oregon. https://www2.census.gov/library/visualizations/2015/comm/vets/or-vets.pdf
- U.S. Department of Veteran Affairs. (2015). Exposure related health concerns. https://www.publichealth.va.gov/exposures/health-concerns.asp
- U.S. Department of Veteran Affairs. (2019). Health needs and conditions. https://www.va.gov/health-care/health-needs-conditions/
Veteran-Care Curricular Integration Map
|Course No.||Course Title||VANAP Competencies||Additions to Content||Resources||VA Contact||SON Contact|
|NRS 321||Chronic Illness II||1–8||Introduction to Chronic Illness: includes
Introduction to veteran-centric mental health issues
Mental Health: depressive disorders, bipolar disorders, anxiety disorders, schizophrenia, and related psychotic disorders; suicide; homelessness||PowerPoint® presentation: Introduction to Chronic Illness II
Embedded PDF of Introduction to Chronic Illness II slide presentation
Internet resource for veterans and mental health focus: https://www.mentalhealth.va.gov/||Jane Doea, RN, VA faculty||John Doea, RN, SON faculty|
|1–7||Anxiety||PowerPoint presentation: Anxiety and Obsessive Disorders
Embedded PDF of Anxiety and OCD slide presentation
Embedded PDF of Anxiety Rodney case study||Jane Doea, RN, VA faculty||Sarah Smitha, RN, SON faculty|
Additional veteran resource added for students Winter 2017 (PTSD: National Center for PTSD) https://www.ptsd.va.gov/index.asp||Brief introduction to trauma-related disorders
Embedded PDF of PTSD slide presentation
Internet resource for veteran and mental health focus: NPR (2015) “Behind Bars, Vets With Post Traumatic Stress Disorder (PTSD) Face a New War Zone, With Little Support Website” (http://www.npr.org/2015/11/05/454292031/behind-bars-vets-with-ptsd-face-a-new-war-zone-with-little-support)||Jane Doea, RN, VA faculty; Sarah Smitha, RN, SON faculty||Sarah Smithc, RN SON faculty|