military nurse essay

CAREER PATHS

Why Choose a Career as a Military Nurse: Pathways and Rewards

• Last Updated: 10/03/2023

Are you passionate about both nursing and serving your country? If so, a career as a military nurse could be the perfect fit for you. In this article, we will explore the pathways and rewards of choosing a career in military nursing.

As a military nurse, you have the unique opportunity to utilize your nursing skills while also making a difference in the lives of the men and women who serve in the armed forces.

Whether you’re providing critical care on the front lines or working in a military hospital, your role as a military nurse is vital in ensuring the health and well-being of service members and their families.

Benefits of a Career as a Military Nurse

A career as a military nurse offers numerous benefits that make it an attractive option for healthcare professionals. One of the major advantages is the competitive pay and comprehensive healthcare coverage. Military nurses receive a salary that is on par with their civilian counterparts, along with access to quality healthcare for themselves and their families. This financial stability and security can provide peace of mind and a solid foundation for a rewarding career.

In addition to financial benefits, military nurses also have access to specialized training and education. The military recognizes the importance of continuous learning and offers various programs and courses to enhance the skills and knowledge of their nursing staff. This allows military nurses to stay up-to-date with the latest advancements in healthcare and provide the best possible care to their patients.

Another significant benefit of a career as a military nurse is the opportunity for career advancement. The military follows a structured career progression system, providing nurses with clear pathways for growth and promotion. With each promotion, military nurses gain increased responsibility and leadership opportunities, allowing them to make a greater impact within their field. This sense of professional growth and development can be highly rewarding for individuals who are ambitious and driven to excel in their careers.

Pathways to Becoming a Military Nurse

If you’re interested in pursuing a career as a military nurse, there are several pathways you can take to achieve this goal. One option is to join the military as a commissioned officer through a program such as the Nurse Corps.

This program is designed for individuals who have already completed their nursing education and are ready to serve as military nurses. As a commissioned officer, you will receive specialized training in military nursing and be assigned to a healthcare facility within the armed forces.

Another pathway to becoming a military nurse is to join the military first and then pursue your nursing education. The military offers various educational programs, such as the Nurse Candidate Program , which provides financial assistance for individuals who want to become nurses.

Through this program, you can attend nursing school while serving in the military, and upon graduation, you will be commissioned as a military nurse.

Regardless of the pathway you choose, it’s important to meet the requirements and qualifications for military nursing. These typically include having a valid nursing license, meeting age and citizenship requirements, passing a physical fitness test, and undergoing a background check.

Each branch of the military may have specific requirements, so it’s essential to research and ensure you meet the criteria before applying.

Training and Education for Military Nursing

Once you have met the requirements and been accepted into a military nursing program, you will undergo specialized training and education. This training is designed to prepare you for the unique challenges and responsibilities of being a military nurse. It may include coursework in areas such as military healthcare systems, combat casualty care, and leadership development.

In addition to classroom instruction, military nursing training also includes hands-on clinical experiences. This can involve rotations in various healthcare settings, both within military hospitals and in field environments.

These practical experiences provide valuable opportunities to apply your nursing skills in real-world scenarios and gain the confidence and competence needed to excel in your role as a military nurse.

After completing your initial training, you may have the opportunity to pursue advanced education and specialization within military nursing. The military offers a range of educational programs, including master’s and doctoral degrees in nursing.

These advanced degrees can open doors to higher-level positions and allow you to become a subject matter expert in a specific area of nursing.

Roles and Responsibilities of Military Nurses

As a military nurse , you will have a wide range of roles and responsibilities depending on your assigned location and military branch. In a combat or field setting, your primary responsibility may be providing emergency medical care to wounded soldiers or assisting with medical evacuations. This can involve treating injuries, stabilizing patients, and ensuring they receive the necessary medical attention.

In a military hospital or clinic, your responsibilities may include providing routine medical care, administering medications, conducting health screenings, and assisting with surgeries. You may also be involved in preventive healthcare initiatives, such as immunization programs or health education campaigns.

Additionally, military nurses often play a crucial role in disaster response efforts, providing medical support to affected communities during times of crisis.

Regardless of the specific setting, military nurses are known for their adaptability and ability to work under pressure. They must be prepared to handle a wide range of medical situations and make quick decisions to ensure the best possible outcomes for their patients. This requires a high level of clinical competence, critical thinking skills, and a strong dedication to providing quality care.

Rewards and Challenges of Being a Military Nurse

A career as a military nurse offers a unique set of rewards and challenges. One of the greatest rewards is the sense of fulfillment that comes from serving your country. As a military nurse, you have the opportunity to make a direct impact on the lives of service members and their families.

Whether you’re providing lifesaving care on the battlefield or offering compassionate support in a military hospital, your contributions are invaluable and deeply appreciated.

Another reward of being a military nurse is the camaraderie and sense of community that comes with serving in the military. You will be part of a team of dedicated professionals who share a common goal of protecting and serving their country.The bonds formed with fellow military nurses and other healthcare professionals can be lifelong and provide a support system throughout your career.

However, it’s important to acknowledge that being a military nurse also comes with its own set of challenges. Deployments and separations from loved ones can be emotionally difficult, and the nature of the job can be physically demanding and mentally taxing.

Military nurses must be prepared to work in high-stress environments and adapt to rapidly changing situations. It requires resilience, flexibility, and a strong commitment to the mission.

One of the most attractive aspects of a career as a military nurse is the abundance of opportunities for career advancement. The military follows a structured promotion system that rewards nurses for their performance, experience, and education. As you progress through the ranks, you’ll have the chance to take on leadership roles, mentor junior nurses, and contribute to the overall development of the nursing profession within the military.

Pursue Advanced Certifications

Transition into the civilian healthcare sector.

A career as a military nurse can provide a solid foundation for a successful transition into the civilian healthcare sector. The skills, experiences, and leadership qualities acquired in the military are highly valued by employers, making military nurses sought after in the civilian job market. Whether you choose to continue your nursing career within the military or pursue opportunities in the private sector, the skills and experiences gained as a military nurse will set you apart from other candidates.

Support and Resources for Military Nurses

The military recognizes the importance of supporting their nursing staff and provides a range of resources to ensure their well-being and professional development. These resources include mentorship programs, continuing education opportunities, and access to state-of-the-art medical facilities and technology. Military nurses also have access to comprehensive healthcare coverage for themselves and their families, ensuring that their medical needs are taken care of.

Support Programs

The military provides various support programs to help military nurses and their families navigate the unique challenges of military life. These programs may include counseling services, financial assistance programs, and support groups. The military community is known for its strong sense of camaraderie and support, and military nurses can rely on their colleagues and the larger military family for assistance and guidance.

Conclusion: Making the Decision to Become a Military Nurse

In conclusion, a career as a military nurse offers a unique combination of nursing and service to country. It provides the opportunity to make a difference in the lives of service members and their families while utilizing your nursing skills to their fullest potential. The rewards of a career as a military nurse are numerous, including competitive pay, specialized training, opportunities for career advancement, and the sense of fulfillment that comes from serving your country.

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Military nursing

A primer for new recruits.

Cox, Catherine Wilson PhD, RN, CEN, CNE; Wiersma, Gretchen M. DNP, RN, CPN, CNE, CHSE; McNelis, Angela M. PhD, RN, CNE, FAAN, ANEF

At the George Washington University School of Nursing in Washington, D.C., Catherine Wilson Cox is an associate professor, Gretchen M. Wiersma is an assistant professor, and Angela M. McNelis is a professor and associate dean of scholarship, innovation, and clinical science.

The authors have disclosed no financial relationships related to this article.

∗Names have been changed to protect privacy.

This article offers an overview of military nursing and provides three examples that illustrate how nurses can advance their careers within each service.

Considering a career in the military? This article offers an overview of the pros and cons and provides examples that illustrate how nurses can advance their careers in each branch of service.

MILITARY NURSES are crucial to quality healthcare within the United States Armed Forces. The military trains and maintains a nurse workforce that is prepared to deliver care, lead teams, and deploy at any time. Nursing recruits are assigned to the Air Force, Army, and Navy through enlisted commissioning programs, Reserve Officer Training Corps (ROTC) opportunities, and direct commission and recruitment initiatives. The Air Force, Army, and Navy are the only US military branches with their own Nurse Corps. Currently, around 10,000 full-time nurses are on active duty (3,155 in the Air Force, 3,334 in the Army, and 3,537 in the Navy). 1 Among the 8,000 part-time reserve nurses, 2,460 serve in the Air Force, 4,329 in the Army, and 1,316 in the Navy. 1 The Navy supplies healthcare services to the Marines because the Marine Corps is part of the Navy, and the Coast Guard employs civilian nurses. Nurses who are interested in non-military public service can work as nurse officers in the Commissioned Corps of the US Public Health Service. 2

Expectations for military nurses differ from those of their civilian counterparts because military nurses have the dual roles of RN and officer. Moreover, these nurses often deploy into volatile global environments and lead interprofessional teams of care providers, so they must be able to transition into both roles rapidly and competently. This article offers an overview of military nursing and provides three examples that illustrate how nurses can advance their careers within each service.

Benefits and challenges

The benefits of military nursing include being commissioned as an officer, practicing in collaborative environments, honing leadership skills via hands-on and professional development opportunities, learning cutting-edge technology, and traveling within the US and/or abroad. 3 Additional benefits include generous compensation and benefits—for example, 30 paid vacation days annually, low-cost life insurance, a thrift savings plan, and paid sick and maternity leave. Military nurses also receive free on-base housing or tax-free off-base housing allowances, comprehensive medical and dental coverage for both nurses and their dependents, more autonomy in clinical practice than in most civilian jobs, opportunities to pursue a graduate degree at minimal or no cost, and retirement benefits and a military pension after serving for 20 years.

Challenges may include the prospect of deployment, possibly to austere environments, as well as separation from families and friends. Military nurses may also be challenged by the possibility of working long hours without overtime pay, biannual physical fitness tests, and the insecurity of not knowing where the next assignment will be until having “orders in hand.” Undeniably, the ultimate challenge is risking the loss of life in service to one's country. For example, 201 military nurses died in service during World War II, including 16 killed by enemy fire and 13 who died in weather-related flight crashes. 4 Nine Army nurses have died since the start of the Iraq War in 2003. 5

Who can join?

All three services have various age, physical, education, experience, and citizenship requirements. The maximum age requirements for all three branches are predicated on federal law, which allows for full retirement and receipt of benefits after at least 20 years of service. However, age waivers may be available depending on certain circumstances. For example, applicants may be exempt from retirement rules if they work in a specialty with a worker shortage. 6

Physical requirements differ across the services, but in general, all applicants must pass a full physical and mental examination. Given their military role and the possibility of being deployed to an austere environment, nurses who need lifesaving medications such as insulin or nurses with a health disorder that requires constant monitoring would pose a risk. Most applicants are US citizens, but permanent residents may be eligible to serve.

All active duty and reserve military nurses complete a civilian BSN program before they join a Nurse Corps; additional training or experience requirements vary among the three branches. Nurses who join the Nurse Corps via Direct Commission in any of the three branches must also have at least 1 year of RN experience.

ROTC scholarships are competitive scholarships awarded to undergraduate nursing students, and scholarship benefits and requirements vary between the three branches. Students interested in joining as Army and Navy nurses can also apply for either's Nurse Candidate Program.

Other recruitment programs include the Enlisted Commissioning program, which is open to active duty or reserve members of all three services who wish to become officers. The Seaman to Admiral-21 Program is a competitive in-service commissioning program offered exclusively to Navy sailors; the Health Profession Scholarship Program is open to graduate nurses interested in joining the Nurse Corps in any of the three branches.

According to the assignment officers of the three Nurse Corps within the military—Lt. Col. Tracey Gosser (Air Force), Col. Susan Cloft (Army), and Capt. Carolyn McGee (Navy)—about 500 nurses who join each year are prelicensure graduates and another 300 are postlicensure RNs who join the military after working as civilians. Most of the prelicensure recruits come from ROTC programs, which are offered at over 1,700 colleges and universities in the US. These officer-training programs focus on leadership skills as well as communications and ethics. 7 ROTC students reflect a variety of majors, not just nursing.

Although this article does not specifically address recruits to the reserves, it is important to recognize that the three Nurse Corps depend on reservists to meet the demands of a full range of military operations; for example, in military treatment facilities via aeromedical evacuations, on hospital ships, and/or in deployments for global activities. Furthermore, recruitment numbers may decline a few years down the line due to recent consolidation in military medical systems and efforts to cut healthcare provider positions, including those for active duty nurses. 8 It is unknown if the positions will be completely cut, converted to contractor jobs, or shifted to the reserves; however, the demand for military nurses will persist regardless of downsizing and/or consolidation. It is important to recognize that active duty and reserve nurses are complemented by civilian nurses in order to meet health readiness mission requirements of the Armed Forces. 1

Recruitment pathways

Prelicensure recruits in the Air Force attend a 10-week nurse transition program course in one of four US locations, and they complete a 1-year nurse residency program following graduation in one of eight locations in the US or two in Europe. In the Army, all prelicensure recruits attend a 6-month clinical nurse transition program at one of nine locations in the US or one in Europe. For their first tour of duty, new Navy nurse prelicensure graduates are sent to inpatient facilities, each with its own decentralized transition program.

Paths to service: Three examples

Example 1 . Antonio∗ enlisted in the Air Force and became an aerospace medical technician. He was picked up for the Air Force's competitive Nurse Enlisted Commissioning Program (NECP), excelled in his baccalaureate program, earned his BSN, and passed the NCLEX-RN on his first attempt. After graduation, he attended Commissioned Officer Training (COT) in Montgomery, Ala. After COT, Antonio went to Scottsdale Healthcare in Arizona to complete a nurse transition program. Antonio's next assignment was to a nurse residency program at Travis Air Force Base in California, where he stayed for his follow-on tour. Today, Antonio is certified as a critical care RN and is awaiting orders to an overseas duty station.

Example 2 . Michelle became an Army nurse via an ROTC scholarship. She decided to apply for the scholarship to pay for school as well as opportunities for travel and adventure. Upon graduation and after attending required Army medical training, she was commissioned as a second lieutenant, passed her nursing boards, and completed the Basic Officer Leader Course in San Antonio, Tex. She was then stationed at Landstuhl Regional Medical Center in Germany, where after completing the Clinical Nurse Transition Program she officially began her role as both a military officer and a professional nurse. Michelle transitioned into a career as a civilian nurse after 10 years in the Army.

Example 3 . Elizabeth met a Navy recruiter during her senior year of nursing school. She became a Navy nurse via the Direct Commission pathway and attended Officer Development School in Newport, R.I. Her tours included Navy inpatient facilities in Bethesda, Md.; Cherry Point, N.C.; and Portsmouth, Va. Eventually Elizabeth transferred to the reserves and recently retired as a Navy captain. Her military education benefits paid for her master's and doctoral degrees.

Final thoughts

Military nursing is a unique experience that offers nurses the opportunity to be a part of something bigger than themselves. The shared perspective of Air Force, Army, and Navy nurses is that a military nurse uses a “one-team” mentality to care for military service members and their families. Understanding the pathways nurses take to join the military workforce is important for nurse educators and administrators to know in supporting their success.

Air Force; Army; military nursing; Navy; ROTC

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Open access reflecting on the characteristics and values of military nurses: war zone qualitative research, alan finnegan phd, frcn, faan, professor of nursing and military mental health, university of chester, chester, england, hugh mckenna cbe, frcn, faan, professor of nursing, ulster university, coleraine, northern ireland, kath mccourt cbe, msc, frcn, president, commonwealth nurses and midwives federation, london, england; convener, royal college of nursing fellows coordinating committee, london, england.

In 2013, I (AF) was appointed as the first UK Ministry of Defence Professor of Nursing, with an implicit responsibility to lead and support military nurses in undertaking high impact research. Early into this assignment, I deployed into Afghanistan to complete a series of qualitative nursing research studies. This included an exploration into the characteristics and values that military nurses defined as being pre-requisite to successfully undertaking their role in a harsh and demanding environment.

Nursing Standard . 35, 10, 82-85. doi: 10.7748/ns.35.10.82.s39

Published: 30 September 2020

In part, I was motivated through a reflection on principles such as compassion, resilience and clinical competency that are attributed to significant military nursing role models, such as Mary Seacole and Florence Nightingale, and attempting to conduct an empirical study to determine their relevance in a modern setting. This in situ nursing research was novel, and I was indebted to other civilian authors, including RCN Fellows Hugh McKenna and Kath McCourt, who provided their academic expertise and support to ensure that the research was built on strong methodological foundations.

As such, this article is drawn from the only qualitative nursing studies conducted in a War Zone and published in Nurse Education Today. I have been the assistant editor of the journal since 2016.

Characteristics and values of a British military nurse. International implications of war zone qualitative research

Background Between 2001 and 2014, British military nurses served in Afghanistan caring for both service personnel and local nationals of all ages. This paper is from the only qualitative nursing research conducted in situ in Afghanistan, in 2013.

Aim To explore the characteristics and values that are intrinsic to military nurses in undertaking their operational role.

Design A constructivist grounded theory was used. UK Ministry of Defence Research Ethical Committee approval was obtained.

Conduct of work Semi-structured interviews with 18 British armed forces nurses.

Results A theoretical model was developed that identified the intrinsic characteristics and values required to be a military nurse. The nursing care delivered was perceived to be outstanding.

Recommendations Originality, and linked to sustainable development goals in good health and wellbeing and informing quality education.

Finnegan A, Finnegan S, McKenna HP, McCourt K et al ( 2016 ) Characteristics and values of a British military nurse. International implications of War Zone qualitative research. Nurse Education Today. 36, 86-95. doi: 10.1016/j.nedt.2015.07.030

www.sciencedirect.com/science/article/abs/pii/S0260691715003007

Introduction and background

The foundations of modern medicine and nursing are directly correlated in caring for armed forces personnel in times of conflict and war ( Gabriel and Metz 1992 , Medicine and The Military 2020 ). This extends to the formation of the (Royal) College of Nursing (RCN) in 1916 ( Finnegan and Nolan 2012 ).

It was during the Crimean war (1853-1856) that field hospitals were first established. During this war death was common due to yellow fever, dysentery, cholera and tuberculosis ( Gill and Gill 2005 ). It was here, while attending wounded servicemen and delivering care in hostile territories and under dangerous conditions, that Florence Nightingale began to formulate her concepts about nursing ( Nightingale 1859 ). These advancements resonant today with the spotlight on infection control, hospital epidemiology, and hospice care. It was fitting that the network of ‘field’ hospitals quickly set up during the COVID-19 pandemic were given the name Nightingale.

In World War I, military nurses demonstrated extreme flexibility and resilience at clinical, physical, psychological and environmental levels, including caring for local nationals and enemy troops ( Gerolympos 1995 ). Nurses were at risk ( Harper and Brothers 1918 , Hay 1953 ), and their patients were positively influenced by the calm way the nurses went about their duties, while the nurses were inspired by the performance, fortitude and cheerfulness of their patients ( Hay 1953 ). Evidence can be found in the diaries of nursing leaders such as Maud McCarthy who, as matron in chief to the British Expedition Force, had sailed on the first ship to France in 1914 and then maintained her position throughout the entire campaign until 1918. However, few research studies have assessed the effectiveness of the military nurses’ operational role, and a comprehensive literature search identified no published empirical study that explored the core characteristics and values required by military nurses in the operational arena.

In this century, an International Security Assistance Force comprised of British, American and other allied troops were deployed to Afghanistan (2001-2014) in support of a NATO mission and to care for all patients, including local nationals of all ages and captured persons (CPers) ( Simpson et al 2014 ). The major hub for medical activity was Camp Bastion Hospital, which contained multi-national British, American and Danish clinical staff under British command. Coalition patients were quickly repatriated to their home countries. The local population’s progress, rehabilitation, community care and future treatments were through a local healthcare facility outside of the military’s scope of influence.

By 2013, military medical and mental health research were dominated by positivist theories and quantitative research, and no qualitative nursing research had been undertaken in the Afghan/Iraq war zones. In 2013, I (AF) deployed to Afghanistan to collect data for four studies. In addition to this study ( Finnegan et al 2016a ), data were collected on educational and clinical preparation ( Finnegan et al 2016b ), the psychological implications ( Finnegan et al 2016c ), and the role of the mental health team ( Finnegan et al 2014a , 2014b ). Approval for the study was granted by the UK Ministry of Defence Research Ethical Committee.

Interviews were conducted with 18 military nurses based at Camp Bastion Hospital, Afghanistan during June and July 2013. The intent was to accurately reflect the respondent’s interpretation of a wide range of emotions, behaviour, thoughts and beliefs. This led to an emerging theoretical model categorised as: personal values, military skills, scope of practice and clinical leadership. These groupings were responsive to the common dynamic healthcare factors faced by any nurse in relation to manpower, experience, motivation, satisfaction, and the type of casualty with associated ethical issues. I had the support of civilian academics who had military experience and they helped scrutinise the data to ascertain comparators and differences. It is important to recognise that this model was an emerging prototype, and needed testing and further research on its functionality and to consider wider transferability.

Influence and impact

Respondents were volunteers who had made a lifestyle choice to deploy in support of fighting troops. The participants believed that the nursing care delivered in the conflict area was of a very high standard for all patients. They reported a sense of self-worth and pride aligned to strong team integration as being significant positive factors in underpinning the excellent care. Prior experience of this environment helped and made the nurses less likely to be negatively psychologically affected by either the clinical presentation of casualties, high activity levels or the austere environment ( Finnegan et al 2016c ). Senior staff identified the importance of advocacy, being tenacious and backing their judgement to deliver compassionate care. Role modelling and getting to know their staff were important in building a rapport to understand other peoples’ views and aspirations. As with other parts of the nursing workforce, it was important to be conscious of some of the multifactorial stressors, although it was also noted in Afghanistan that many nurses thrived.

Nurses talked of quality care, helping each other, communicating with each other, reminding each other of what is expected, and recognising the qualities that nurses brought to the multi-professional team. An emphasis was placed on patient needs, which were determined through robust communication built on a trusting relationship. These included lessons learned from caring for CPers, where the nurses consciously detached themselves from any legal processes and treated the casualty as a vulnerable patient. Respondents reported that military nurses must have the correct clinical competencies, with skill sets aligned to working within one’s scope of practice. A particular concern was caring for children, with anxiety induced from both a lack of clinical experience ( Finnegan et al 2016c ) and previous negative experiences. Participants found these situations extremely stressful.

The impact of the study at the time was to inform pre-deployment training and advocate the role of practice educators in the operational environment. Due to the unique nature of this research, the study built on homebased military qualitative defence research ( Finnegan et al 2014c ) and I published the challenges, theory and methods used to inform future studies ( Finnegan 2014a , 2014b ).

Current and future relevance

COVID-19 presented nurses with a multitude of challenges, and one means of assessing what is required in the present is to look to the past. Defence nurses face challenges not generally encountered at an equivalent level within civilian practice, and this study demonstrated the essence of compassion and empathy associated with an altruistic motivation to relieve suffering in the harshest of condition. The attributes historically aligned to great military nurses of previous generations were empirically demonstrated as intact in the current workforce, which is particularly poignant in the International Year of the Nurse and the Midwife.

The characteristics identified in our study have been demonstrated in nurses during the COVID-19 pandemic, and there is clear synergy with global workforce demands. Popular descriptions of nurses ‘battling’ the virus and ‘being on the front line’ are used to describe healthcare delivery.

The findings from our study identified that certain themes and categories could be polarised, depending on the circumstances. Nurses focused on their scope of practice, civilian colleagues were intrigued by the leadership skills, while patients and public focused on personal attributes. However, the power of nursing as a profession is built on the amalgamation of these elements to provide the unique characteristic and value of the profession. The research provided military nurses with a framework for a realistic personal development plan to build on their strengths and identify limitations. Also, it supplied selection panels with an additional tool to help the recruitment process and presented a prompt to focus on all the components of being a military nurse, and not just one area, for example, physical fitness.

Given the increasing global migration of nurses, it was hoped this paper could encourage similar occupational models. Due to the sample, the findings were UK-focused, but these nurses were deployed with equal numbers of colleagues from the United States and evidence suggests that lessons learned from War Zone nursing have international military and civilian implications. However, as an emerging model, readers were advised to treat the findings with some caution.

The American Academy of Nursing’s Military and Veteran Family’s expert panel are working with the RCN’s defence forum and nursing academics to further develop nursing research. In 2020, this will be showcased in international events ( Westminster Centre for Research in Veterans, 2020 ), with 14-16 of the conference papers scheduled to be published in a high standard peer review journal in April 2021.

As the only international armed forces nursing-led qualitative research study undertaken during the Afghanistan and Iraq conflicts, this article was an important historical resource. Significant medical advancements have been achieved by translating clinical lessons learned on the battlefield into civilian healthcare. The serious poly-trauma injuries of the Afghan conflict featured orthopaedic problems, including amputations and associated injuries such as burns ( Jansen et al 2012 ) and traumatic brain injuries ( Taylor et al 2012 , Trauma Brain Foundation 2016 ). Yet the exemplary Bastion Hospital healthcare provision ( Care Quality Commission 2012 , Stockinger 2012 ) played a part in saving lives where previously patients would have died ( Hodgetts 2012 ). These experiences informed the development of the National Institute for Health Research/Ministry of Defence-funded Surgical Reconstruction and Microbiology Research Centre ( 2015 ) and the Scar Free Foundation ( 2020 ). In mental health, clinical and nursing initiatives such as assertive outreach, community-based care, crisis intervention ( Artiss 1997 ) and group psychotherapy ( Harrison and Clarke 1992 ) have their origins in the world wars. The lessons learned from the battlefield, can have significant positive influences on military and civilian nursing on a truly international scale. The study demonstrates that despite the ethical and geographical challenges, that quality information can be collected in the harshest of terrains. The originality of the study is embedded in the United Nations’ sustainable development goals of producing evidence to inform good health and well-being and shaping quality education.

By collecting empirical data to inform educational programmes, clinical practice and policy, nursing researchers can help prepare the future generation of nurses. Placing nurses first, with a model that focuses on the requirements of a good nurse, has the potential to lead to better patient care, and improve the quality of their workforce experiences.

Open Acesss

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (see https://creativecommons.org/licenses/by-nc/4.0/ ) which permits others to copy and redistribute in any medium or format, remix, transform and build on this work non-commercially, provided appropriate credit is given and any changes made indicated.

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Deployment experiences of military nurses: A systematic review and qualitative meta-synthesis

Affiliations.

• 1 School of Nursing, Third Military Medical University, Army Medical University, Chongqing, China.
• 2 McGill University, Montreal, QC, Canada.
• 3 Department of Military Nursing, NCO School, Army Medical University, Shijiazhuang, China.
• PMID: 33128266
• PMCID: PMC8359314
• DOI: 10.1111/jonm.13201

Aims: The purpose of this systematic review is to explore military nurses' preparation, deployment and reintegration experiences in order to provide recommendations for effective management of the nursing team.

Background: Nurses provide health care in different settings including community, hospital and the disaster site. Military nurses have a long history of deploying for global health.

Method: A systematic review and qualitative meta-synthesis of studies focusing on the preparation, deployment and reintegration experiences of military nurses was carried out.

Results: Five synthesized findings were concluded: (a) preparing and sharing experience are the key coping strategies; (b) transition from the civilian care to emergency situations; (c) teamwork contributing to team bonding and the growing role of nursing in the medical team; (d) devoting to nursing duty achieves growth; (e) reintegration is not easy and external support matters.

Conclusion: Transition from civilian care to deployment and from structured deployment environment to reintegration poses challenges to nurses, and better preparation, sufficient support enables them to gain growth.

Implications for nursing management: Nurse managers should consider how to sustain a competent and ready nursing team by proposing training protocols to nurses for the potential challenges during the deployment cycle when responding to disasters and public emergencies.

© 2020 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd.

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PRISMA flow diagram of study selection and inclusion process. Source: Moher et al.…

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Competencies of military nurse managers: A scoping review and unifying framework

1 School of Nursing, Third Military Medical University, Chongqing China

Theodora Nomusa Chihava

Jingjing fu, suofei zhang.

To identify competencies of military nurse managers and develop a unifying framework of military nurse managers’ competencies.

Military nurse managers shoulder multiple responsibilities because of duality roles, and they should possess competencies that enable them to manage human and material resources during peacetime and wartime. Therefore, nursing management within military context is demanding, such that a comprehensive understanding of their competencies is needed for effective military nursing management. Although relevant studies have focused on different military branches and different levels of managers, there is no standard evaluation framework.

A scoping review of studies focusing on competencies of military nurse managers from seven databases was carried out.

Nine studies were included in this review, and a framework consisting of six domains of military nurse managers’ competencies was identified: clinical expertise, role model, leadership competencies, human competencies, financial competencies and deployment competencies.

Existing knowledge of competencies of military nurse managers is limited, and a comprehensive understanding of this topic can provide direction for future work.

Implications for Nursing Management

Military nurse managers play substantial roles within the military nursing context. A unifying framework can facilitate personnel recruitment and competency measurement, as well as training protocol development.

1. INTRODUCTION

An increase in health care demands and the ever‐changing health care environment has resulted in nurse managers shouldering most of the responsibility of increasing patient and staff satisfaction (Emmons,  2018 ). Nurse managers at the executive level are in charge of clinical nursing services, strategic planning, administration as well as clinical leadership, while the head nurses or first‐line nurse managers are responsible for patient care activities that occur 24 hr a day in their units (Chase,  2010 ; Duffield, Gardner, Doubrovsky, & Wise,  2019 ; Gunawan & Aungsuroch,  2017 ). Notably, nursing managers are responsible for maintaining the link between an institution's administrative mission and the nurses who provide nursing care in the clinical unit, as well as being in charge of efficient patient care activities by ensuring that subordinate nurses are qualified for the tasks allocated to them. This is one of the reasons why their roles are considered most complex in health care institutions (Chase,  2010 ). Additionally, the leadership style of nurse managers has huge influences on staff members’ turnover and the quality of patient care they deliver; so, they should have the necessary competencies to ensure the smooth running of their units (Pishgooie, Atashzadeh‐Shoorideh, Falcó‐Pegueroles, & Lotfi,  2019 ; Saleh et al.,  2018 ).

Historically, military nurses were indispensable during wars, disasters and United Nations (UN) peacekeeping missions as evidenced by Florence Nightingale when she cared for wounded soldiers during the Crimean War. It is still common practice for military nurses to be deployed in response to natural disasters or epidemics to save human life. The scope of practice for a military nurse is twofold as a soldier and a professional nurse practising in the fluctuating military health care environment and meeting demanding military operational requirements which differs from the nursing environment of civilian nurses (Griffiths & Jasper,  2008 ; Lundberg, Kjellström, & Sandman,  2019 ). When deployed in a disaster area or a combat zone, military nurses deliver medical tasks in an austere environment. One common challenge military nurses face during deployment is to adapt to the dangerous environment which results in fear of the unknown (Rivers,  2016 ; Rivers & Gordon,  2017 ). Military nurses also face ethical dilemmas when facing multiple patients and shortage of supplies (Almonte,  2009 ). This is further confounded by the fact that, at times, military nurse officers lacking experience during deployment are elevated to head nurses of medical missions because of their military rank (Beaumont & Allan,  2012 ). Thus, the management competencies of military nurses differ slightly from those of civilian nurses because of the versatile environment causing physical and psychological strains. Other expectations of a military nurse manager include ensuring the quality and safety of patients and personnel in a complex working environment and acting as a role model who has a positive impact on junior nurses and encourages the team to overcome challenges (Barr, Ferro, & Prion,  2019 ).

To ensure high‐quality patient care, many scholars and institutions have studied and explored leadership and management competencies over the past decades. Among the published assessment tools of competencies of nurse managers, the Chase Nurse Manager Competency Instrument (NMCI) is a valid and reliable measurement scale of nurse managers’ competencies, which was developed by Dr. Chase in 1994 and further validated in 2010, based on the American Organization of Nurse Executive (AONE) Leadership Collaborative Framework and Katz's conceptual framework (Chase,  1994 , 2010 , 2012 ; Katz,  1955 ). The Chase competencies include Chase Technical, Chase Human, Chase Conceptual, Chase Leadership and Chase Financial Management. Further exploration of managerial competencies of first‐line nurse managers through concept analysis by Gunawan and Aungsuroch ( 2017 ) revealed attributes of managerial competencies including self‐development, planning, organising, budgeting, leadership, legal and ethical issue management and health care delivery.

However, the competencies identified above do not adequately address the demands for military nurse managers acting as both a nurse and a soldier. As a professional leader in the military, they should meet the military standards such as loyalty, discipline and obeying superior commands no matter the consequences. According to the Army Leader Requirements model, army leaders should have eight core leadership competencies including leading others, extending influence beyond the chain of command, leading by example, communication, creating a positive environment, preparing self, developing others and getting results (Funari, Gentzler, Wyssling, & Schoneboom,  2011 ). Additionally, the Uniformed Services University (USU) develops uniformed medical officers through the Department of Military and Emergency Medicine (MEM) by synthesizing three core competencies, which are leadership, military skills and medical skills (O'Connor, Grunberg, Kellermann, & Schoomaker,  2015 ). There are several studies focusing on competencies of military nurse managers; however, most of them focus on either single branch of military (army or navy), or single level of position (executive level, military nurse officer or head nurse). Thus, there is no unifying framework of military nurse managers’ competencies that can be used as an evaluation standard. To develop this unifying framework that is designed for military nurse managers with dual roles in the military health services, this paper fully and systematically evaluated existing findings of military nurse managers’ competencies to generate a scoping review comprising competencies of military nurse managers and then synthesized the identified competencies with NMCI, the Army Leader Requirements model and the USU MEM Leadership Model to provide a standardized guideline for future military clinical nursing personnel management.

A scoping review and a unifying framework development were undertaken focusing on competencies of military nurse leaders, in the way similar as that developed by Levac Colquhoun & O'Brien ( 2010 ). This methodology provides an overview of empirical and non‐empirical studies focusing on a particular topic and supports summarization of emerging evidence (Arksey & O'Malley, 2005 ; Levac et al., 2010 ). Additionally, a five‐step procedure, including formulating the research question; identifying relevant studies; selecting relevant studies; data charting; and collating, summarizing and reporting results, was taken (Levac et al., 2010 ).

2.1. Formulating the research question

The research question ‘what competencies of military nurse managers have been described?’ was formulated and used to guide this review.

2.2. Identifying relevant studies

‘Nurse manager’ in this review refers to managers at all levels including tactical/direct, operational/organisational and strategic level (VanFosson,  2012 ). Electronic searches were conducted to identify journal articles published in PubMed, CINAHL, EMBASE, PsycINFO, Cochrane Library and Chinese databases including CNKI and Wanfang up to November 2019. Grey literature was also searched in databases including Google Scholar. The following search theme was used: (a) military, or army, or air force, or navy, or warrior, or combat, or armed force, or defense; (b) nurse, or nursing; (c) head, or mid‐level, or manager, or leadership, or executive, or leader; (d) competence, or competency, or competencies.

2.3. Selecting relevant studies

Studies were included in the review if they (a) focused on competencies of military managers at different levels, including executive level, military nurse officer and head nurse; (b) were qualitative studies, quantitative studies, literature review or mixed‐method studies; (c) written in English or Chinese. Studies were excluded if they (a) were case studies, abstracts or citations; (b) were not specifically related to competencies of military managers; (c) publish with language other than English or Chinese. The selection of relevant studies was undertaken independently by two researchers.

A total of ninety studies (Figure  1 ) was yielded and then imported into EndNote X9 (Clarivate Analytics). After duplicates were removed, sixty‐two studies remained. These sixty‐two studies were assessed to determine whether they met the inclusion and exclusion criteria based on the title and abstract. Fifty studies failed to meet the inclusion criteria were excluded. The remaining twelve full‐text studies were retrieved and independently evaluated by two researchers. After careful examination based on inclusion and exclusion criteria, nine studies were remained and included in this review.

Flow chart of search process

2.4. Data charting

Data from all the included studies were extracted and categorized into subgroups by the following headings: author, publish year, country, aim, design, type of nurse manager and all factors that could be identified as being related to competencies of military nurse managers (Table  1 ).

Selected studies, aim, design, type of nurse manager, competencies derived from the studies and which domains of Chase Nurse Manager Competency Instrument the studies address: Chase Technical (T), Chase Human (H), Chase Conceptual (C), Chase Leadership (L) and Chase Financial Management (F)

2.5. Collating, summarizing and reporting the results

This procedure was divided into two stages. Stage one was to structure the competencies retrieved from the literature. When retrieving competencies, it was noted that NMCI was used as a tool in two studies. NMCI included five domains: (a) knowledge of health care environment (Chase Technical); (b) communication and relationship management (Chase Human); (c) professional (Chase Conceptual); (d) leadership (Chase Leadership); and (e) business skills and principles (Chase Financial Management). NMCI is a good framework for developing a comprehensive understanding of identified competencies from the included studies. So, five domains of NMCI were utilized to cross‐check the identified competencies of each study. Stage two was to outline the findings from stage one to develop a unifying framework, combined with NMCI, the Army Leader Requirements model and the USU MEM Leadership Model.

3. FINDINGS

3.1. description of studies.

A total of nine studies, published between 2007 and 2017, were included (Table  1 ).

These researches were undertaken in two countries: the United States ( n  = 7) and China ( n  = 2). The samples consisted of nurse managers from different organisational levels, including executive level ( n  = 1), military nurse officers ( n  = 4) and head nurses ( n  = 4). All the identified competencies were compared with the five domains of NMCI (Table  1 ). Nine studies mentioned competencies identified as Chase Technical, Chase Leadership and Chase Human. Six studies included competencies identified as Chase Conceptual, while four mentioned competencies identified as Chase Financial Management.

3.2. Comparison among military nursing managers of different levels

Anderson ( 2016 ) assessed the top 10 perceived competencies by using NMCI. These competencies matched three domains in the Chase competencies, including Chase Technical, Chase Human and Chase Leadership. Besides this study, eight other included studies also matched competencies in Chase Technical, Chase Human and Chase Leadership. Almost half ( n  = 4) of the eight studies that focused on the head nurse did not identified competencies of financial management, and the other four studies that identified finance relevant competencies with one study focusing on the nurse executive level, while the remaining three studies reviewed the military nurse officer level.

3.3. A framework of military nurse manager's competencies

Based on the competencies identified in stage one, a framework of military nurse manager's competencies was developed. The competencies identified in stage one were summarized into six domains of military nurse manager's competencies: (a) clinical expertise, (b) role model, (c) leadership competencies, (d) human competencies, (e) financial competencies and (f) deployment competencies (see Table  2 ).

Conceptual framework of military nurse manager's competencies

3.3.1. Clinical expertise

Clinical expertise includes clinical knowledge, clinical skills, assessment skills, nursing practice standards, infection control practice and evidence‐based practice, which provides the basis for completing complex multitasking (Anderson,  2016 ; Dai,  2010 ; Funari et al.,  2011 ; Harris,  2007 ; Li,  2007 ; Porter,  2017 ; VanFosson,  2012 ). One unique aspect of clinical expertise in a military nursing context is clinical diversity. Military nurse managers should have multidisciplinary nursing knowledge and skills instead of focusing on one speciality. Clinical expertise can validate a nurse manager's leading role, help the manager to earn respect and influence others (Harris,  2007 ).

3.3.2. Role model

A nurse leader is expected to be a role model for their staff in the way treating patients, family members and other health care team members in a kind and considerate manner (Harris,  2007 ). The term ‘role model’ refers to leading by example and displaying good character. Leading by example requires military nurse managers to exhibit good nursing practice at all times especially when treating multiple and serious‐wounded patients in austere environments (Dai,  2010 ; Harris,  2007 ). Their actions should be grounded in military values and professional ethics by displaying good characters such as dedication, confidence, integrity, loyalty, passion for work and social responsibility (Li,  2007 ).

3.3.3. Leadership competencies

Leadership involves influencing all levels of personnel to accomplish a shared goal, and effective leadership can have a positive effect on patient outcome (Wong, Cummings, & Ducharme,  2013 ). Military nurse managers should have foundational thinking skills, personal journey disciplines, the ability to use systems thinking, succession planning, change management and stress management (Anderson,  2016 ; VanFosson,  2012 ). In detail, they should have the ability to lead a team, collaborate with individuals and organisations in developing a vision, motivating others, making decision, resolving conflicts, solving problems, managing change and stress, as well as being adaptable (Anderson,  2016 ; Dai,  2010 ; Funari et al.,  2011 ; Harris,  2007 ; Li,  2007 ; Palarca,  2007 ; Porter,  2017 ; VanFosson,  2012 ).

3.3.4. Human competencies

Human competencies refer to the ability to work effectively in a medical group and to exert a cooperative effort in the team (Katz,  1955 ). Human competencies include two key components: (a) communication and interpersonal skills and (b) organising. Communication and interpersonal skills can foster a positive clinical environment for patients and profession growth as well as facilitate teamwork and team success. These competencies consist of oral and written communication skills, interdisciplinary communication, communication at all levels, interpersonal skills, team building and maintaining a positive work environment (Anderson,  2016 ; Dai,  2010 ; Harris,  2007 ; Li,  2007 ; Palarca,  2007 ; Porter,  2017 ). Organising is the ability to plan activities and allocate resources including personnel management, staff development and professional development (Anderson,  2016 ; Dai,  2010 ; Harris,  2007 ; Li,  2007 ; Palarca,  2007 ).

3.3.5. Financial competencies

In deployment to a conflict environment, military nurse managers might be provided with limited resources; thus, financial management is a required competency. Financial competencies include knowledge of basic business management practices (financial, supply and budget), formalizing a strategic business plan, financial management skills, budget analysis and management skills, analytical ability, and military medicine business practices (Funari et al.,  2011 ; Palarca,  2007 ; Porter,  2017 ).

3.3.6. Deployment competencies

Military nurse managers are trained to meet demanding military operational requirements during disaster relief, conflicts and peacekeeping missions. Deployment competencies include combat casualty care management, military skills and military cultural competencies (Li,  2007 ; Palarca,  2007 ; Porter,  2017 ; Ross,  2010 ). Combat casualty care management is necessary in caring for highly complex trauma patients such as victims of chemical, biological or radiological terrorism and seriously injured combatants (Ross,  2010 ). Military skills encompass knowledge of the military mission and battlefield, the ability to interact according to military protocols, knowledge of military regulations and survival skills (Palarca,  2007 ; Ross,  2010 ). Military cultural competencies include skills related to interfacing with patients of different cultural background and facilitating cooperation among three military services and civilian services (Ross,  2010 ).

4. DISCUSSION

Military nursing and civilian nursing have many similarities which are determined by the common goals to provide nursing care to patients and to promote health. However, the difference between the two is the mission of military nursing is to provide nursing care and leadership in both peacetime and during contingency operations (D'Angelo et al.,  2019 ; Rivers & Gordon,  2017 ). Additionally, military nurses are required to work in a dynamic world of health care and to meet demanding military operational requirements (Anderson,  2016 ). Moreover, the military nursing context is determined by different working circumstances as the military nurses may work in military clinics, military base hospitals, tents, ambulances, airplanes, ships or alongside deployed troops. Furthermore, a transition from senior nurse to nurse manager might occur during deployment because of the military rank or clinical experience, indicating the importance of military nurse officers being cultivated to be managers from unit level to strategic level. This review aims to explore military nurse managers’ competencies to benefit the recruitment, training and management of military nurse leaders. Nine studies were included in this scoping review, and a unifying framework outlining six domains of military nurse managers’ competencies was developed.

Based on NMCI, the Army Leadership Requirements Model and the USU MEM Leadership Model, clinical expertise, role model, leadership competencies, human competencies, financial competencies and deployment competencies were identified. Army, Navy and Air Force services have unique nursing roles and demands in distinct competencies, and the above‐identified competencies of a military nurse manager were considered from a generic view instead of taking each military branch into account. Working in the military as a nurse manager requires them to sustain excellent performance in various military and health care environments.

Leadership is the ability to guide and manage, to make decisions under pressure or in dealing with unpredictable circumstances and to inspire other team members to follow (Brewer & Ryan‐Wenger, 2009 ). The Army Nursing Leader Capabilities Map clearly defined five key competencies of leadership, including foundational thinking, personal journey disciplines, systems thinking, succession planning and change management (VanFosson,  2012 ). Besides the above five competencies, stress management is also essential to leadership, especially when performing contingency operations (Anderson,  2016 ).

Foundational thinking skills refer to executing the vision, demonstrating evidence‐based decision‐making and developing internal standards, ethics and values while system thinking skills include understanding unit‐level processes and goals, as well as responding to divergent inputs to choose best clinical practices (VanFosson,  2012 ). Additionally, it is important for military nurse managers to understand the commander's missions, visions and to ground their actions of providing soldier‐centred care within military values and nursing ethics. However, dual loyalties can cause ethical problem which is the dilemma between providing nursing care and performing military missions (Draper & Jenkins,  2017 ; Lundberg et al.,  2019 ). Based on the fact that leadership development is a lifetime career goal, from unit level to strategic level (Raimondo, Pierce, & Bruzek‐Kohler,  2008 ; Wilmoth & Shapiro,  2014 ), the personal journey disciplines enable nurse managers to seek self‐development, which includes seeking direct feedback and adjusting, applying new knowledge, setting initial personal, professional and career goals, as well as identifying positive role models (VanFosson,  2012 ). Besides focusing on personal development, military nurse managers should also put their effort into succession planning (Phillips, Evans, Tooley, & Shirey,  2018 ); in detail, they should motivate junior nurses, discover potentials of their staff and prepare themselves for the next leadership level (VanFosson,  2012 ). Personal journey disciplines and succession planning are the guarantees for the stable management of a nursing team from the unit level to the strategic level.

A role model competency is when a military nurse manager becomes a role model by committing themself to their duty, thereby encouraging their core team members to see how their roles contribute to the overall effectiveness of the team (Hughes,  2018 ). This is similar to the actions of Florence Nightingale who successfully led her team during the Crimean war (Stanley & Sherratt,  2010 ). Military nurse managers should lead by example in delivering nursing care, especially when faced with a dangerous work environment, or caring for infectious patients by displaying brave and professional actions grounded in military values and nursing ethics. This will help the managers to gain the loyalty and trust from their team members, as well as to motivate the team to sacrifice their time and energy for the benefit of others. When military nurse managers lead by example, they should also have clinical expertise with diverse clinical capabilities. These are determined by the fact that they are faced with a broad patient population that may be severely injured, suffering from shock, fractures or burns (Finnegan, Lauder, & McKenna,  2016 ; Rivers & Gordon,  2017 ), unlike civilian nurse managers who might focus on one specialty. Additionally, the dynamic changing world of health care requires military nurse managers to possess capabilities of change management and stress management, especially for military nurses who provide medical care in various high‐pressure environments (Anderson,  2016 ; Finnegan, Finnegan, & Thomas,  2014 ). Change management refers to identifying gaps, utilizing evidence‐based practice to initiate changes and adaptability to changes. When military nurse managers are deployed to combat zones or disaster rescue sites, they have to think quickly and clearly make life‐saving decisions. Under such circumstances, they need to take time to decompress from their pressure while relieving the stress of team members.

Military nurse managers should also possess human competencies, as they depend on their subordinates to achieve goals and to complete missions. It is essential for them to have good communication and interpersonal skills as well as organising abilities to motivate their subordinates and to assign tasks, especially when they are facing life‐threatening challenges when deployed in combat zones. For example, health care workers working in armed conflicts should know the importance of internal communication among their team and also consider the local context to prevent putting the team at risk (Baucom, 2017 ). Moreover, qualitative studies of deployment experiences constantly highlight the fact that military nurses felt unprepared to deliver nursing care in an austere environment (Conlon, Wiechula, & Garlick,  2019 ; Finnegan et al.,  2016 ). This means military medical services should put more efforts to continuously teach, develop and prepare military nurses for future missions, either as a team member or as head of a medical team. To overcome these challenges, military nurse managers should be visionary and innovative, together with having competencies of communication skills, interpersonal skills, staff development, personnel management and professional development.

Financial competencies focus on cost–benefit analysis and financial resource monitoring. Military nurse officers might encounter a shortage of supplies in the midst of war, so supply management and improvising are important competencies of a battlefield nurse. The reason why three studies (Dai,  2010 ; Harris,  2007 ; Li,  2007 ) that targeted head nurses did not include any relevant competencies for financial management might be because head nurses working in hospital normally do not have much input on a budget; for example, some nurse managers in public hospitals rely on financial managers to give directions. Knowledge of health care budgets and costs enables nurse managers to adapt to changes in management and to improve nursing care. Therefore, military nurse managers shoulder responsibilities to manage resources during deployment especially in a combat zone, and they need to be educated in financial management by learning financial planning, financial monitoring, financial decision‐making and financial control (Naranjee, Ngxongo, & Sibiya,  2019 ).

Deployment competencies describe that the military medical force is expected to deliver expert medical care to support military operations, and military nurses should medically and physically fit for their role to be deployed on short notice (Kenward, Marshall, & Irvine,  2017 ). Deployment competencies, which are the basic of delivering patient care during deployment, refer to casualty management, military skills and military cultural competencies (Ross,  2010 ). Military nurses should be trained in combat casualty care to care for trauma patients in the battlefield. They should also have advanced capabilities for war wound care, as weapons of war evolve (Puri,  2017 ). Casualty management can be divided into three levels: first aid to wounded soldiers, quality medical treatment in a tactical environment and surgical capability in a military hospital (Andersson, Lundberg, Jonsson, Tingström, & Abrandt Dahlgren,  2017 ). Moreover, military nurses are challenged to have assessment skills, clinical skills, trauma care skills and critical care skills to save lives during military deployment (Agazio,  2010 ; Finnegan et al.,  2014 ).

Deployment competencies can be gained through medical training, where the military nurse is trained as a professional nurse and as military personnel. Military training includes knowledge of military missions, protocols and regulations, as well as survival skills to be competent to adapt to various environments domestically or abroad. Military nurse managers should train subordinates to have a better understanding of the mission where they are deployed and maintain the physical fitness of junior officers. When deployed, military nurses are put in hostile environments with cultural challenges (Ross,  2010 ). Then, it is essential for military nurse managers to be able to care patients from diverse backgrounds and learn to cooperate with members from different institutions during deployment (Atuel & Castro,  2018 ; Ross,  2010 ). Besides, understanding diverse cultures is the cornerstone of patient care. It is also a substantial competence for military nurse managers to promote effective patient‐centred nursing practices among cross‐cultural contexts (Atuel & Castro,  2018 ; Meyer, Hall‐Clark, Hamaoka, & Peterson,  2015 ).

There are some limitations regarding this scoping review. This review summarized the competencies of military nurse managers identified from nine studies and developed a unifying framework, based on theoretical frameworks including NMCI, the Army Leader Requirements model and the USU MEM Leadership Model. We tried to expand search strategies to search more relevant published studies. However, due to the restricted distribution of relevant military files and language barrier, the resources we could get access were limited.

5. IMPLICATIONS FOR NURSING MANAGEMENT

Military nurse managers play a substantial role in ensuring nursing care quality in their units from disciplined subordinates who are loyal to the military service and nursing profession. They also are in charge of leading nursing team, cultivating junior military nurses, conveying military values and completing military missions. Moreover, the fluctuating nursing context from peacetime to different military missions poses challenge to the military nursing team. Military nurse managers are the core of this team; therefore, a comprehensive understanding of military nurse manager’ competencies and the unifying framework can provide directions to build a strong nursing team. This framework facilitates management of military nurse managers, including personnel recruitment, competency measurement and training protocol development. Additionally, this framework can also provide a basis for training civilian nurse managers to be better prepared for emergency public health event.

6. CONCLUSIONS

Existing knowledge of competencies of military nurse managers is limited, and the framework of competencies of military nurse managers developed in this review took the uniqueness of the military nursing context, as well as the common standard of each military branch and each manager level into consideration. Clinical expertise, role model, leadership competencies, human competencies, financial competencies and deployment competencies are key aspects for characterizing an excellent military nurse manager. A comprehensive understanding of this topic provides direction for future research work and nursing management.

AUTHOR CONTRIBUTIONS

HM, TC, JF, LL and YL made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data. HM, SZ, JT and LL involved in drafting the manuscript or revising it critically for important intellectual content. HM, TC, JF, SZ, LL, JT, LL and YL gave final approval of the version to be published and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content.

ACKNOWLEDGEMENTS

The authors would like to thank Ms Yan Hong from Third Military Medical University and Mr Jinyu Huang from McGill University for writing assistance and language editing of this manuscript.

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Stories from Inside Military Nursing

Mar 30, 2013 | Magazine , Veterans in Nursing

We often say nurses are on the “front lines” of health care, meaning they work closely with patients and become intimately acquainted with the issues those patients face. And while hospitals can seem a lot like trenches sometimes, they are a far cry from the military operations taking place worlds away.

Here, two military nurses share their stories, from the stress of coordinating care in a combat zone to dealing with prejudice and personal growth, all while caring for the men and women serving in the U.S. armed forces.

Joseph D. Hacinas, R.N., M.S.N., C.N.S., P.H.N.

Lieutenant Commander, United States Navy Nurse Corps Last year, 2011, marked my 10th year as a nurse. Those years have been marked by personal and professional accomplishments. However, this was not always the case. In fact, my nursing career was almost never a career to begin with.

After graduating with honors, I had a great sense of pride and confidence. Perhaps I had too much self-confidence. As a result, I failed miserably with my nursing board exam. Worse, I blamed everything and anything but myself. Having failed this exam almost cost me my job and the opportunity to become a commissioned officer in the U.S. Navy. My mentality relied heavily on the fact that I was going to be a nurse. I intended to be an outstanding nurse, just like the hundreds of outstanding nurses of Asian/Filipino descent who came before me.

Yet, I assumed I could pass the nursing board exam without really studying or working for it. Well, lesson learned. An expensive lesson, I should add. Had I not eventually passed my nursing board exam, I would have been looking at an employer recoupment of about $20,000. Ouch! The good news is that I was able to overcome this barrier just in time.

Rookie nurse

I began my career in a military nursing at the Naval Medical Center in San Diego, and my goals were simple: learn as much as possible and don’t make mistakes with potentially dire consequences (e.g., a medication error). Not so different from civilian nursing, really!

I remember that rookie year vividly. Looking back, I am still not sure how I was able to succeed in such a demanding work environment. I was assigned as a staff nurse at a 28-bed medical-surgical unit. By far, we were the busiest nursing unit in our 250-bed facility. Every day was non-stop action. It felt like my heart rate increased by at least 10 beats per minute every time I set foot in the unit. It seemed like we never slowed down—and the tempo was dizzying. I would typically have six patients with an assistant. For any given shift, my duties would consist of AM care, vitals, assessment, medications, and procedures. I also had to coordinate MRI visits, CT consults, and X-ray availability while calling for discharge medications in pharmacy. No matter how physically and mentally prepared I tried to be, it was hard to maintain a sense of control. There were times that I was so stressed I literally made myself sick. Basic nursing skills such as prioritization of patients and critical-thinking skills were learned on the go. I wouldn’t exactly call it chaos. But it was close.

Yet, as crazy as it may sound, I actually did not mind it one bit. It’s the truth. One of the reasons was that I had great mentors around me. I used to look around our nursing unit and realized my nursing colleagues were more than willing to help, no matter what. Perhaps it was our sense of teamwork. Or it could have been our dedication to military nursing and our patients. Whatever it was, it didn’t take me long to realize that I had made the right career move. Unlike my civilian nursing colleagues, I have had the unique opportunity to care for patients who have served and are serving this great nation. It is a feeling like no other. To come in on a daily basis and know that I am part of something meaningful is incredible. This couldn’t have been more evident than after the events of September 11, 2001.

I was actually on my way to work when I heard of the terrorist attacks. Not knowing much at the time, I just remember thinking that my nursing skills were about to become a commodity, whether I was ready or not. It was a fearful and uncertain time for everyone, almost surreal to think that such an attack was even humanly possible. I just remember hearing from my supervisors, “Be ready.” There was a good chance most of us were bound for deployment overseas. Soldiers, marines, sailors, and airmen were counting on us to provide the best patient care possible under all circumstances. As it turns out, I was actually one of the nurses that ended up staying behind during the early stages of the war. Nevertheless, it was professionally fulfilling. It provided a great way for me to contribute. For the next few years, I found myself in various nursing assignments, from California to Japan. I have been blessed to grow professionally and gain a better perspective of my overall purpose as a military nurse.

Military minority

Like some people find their niche in a nursing specialty like pediatrics or oncology, I have found that being a military nurse has its own advantages. I work with an outstanding team. From physicians to social workers, it is a rewarding experience to collaborate and gain a sense of unity. This is especially important as nurses and the rest of the health care team are tasked to care for patients with complex disease processes. More importantly, my service to active-duty patients and beneficiaries truly defines who I am as a nurse. Whether I am teaching a dependent spouse about healthier eating habits or holding a patient’s hand and praying with him before a major surgery, I am there to give it my all. Because, chances are, they would do the same for me. And that alone is what matters most. In a sense, we are more than just a family. We are united as one.

Of course, to say my military nursing career has been nothing but great experiences wouldn’t be entirely accurate. I can recall one incident when caring for a retired military member. He rang his call bell for assistance. When I walked in to his room, he said, “I’m sorry, but I had asked for a nurse.” I politely answered that I would be the one taking care of him for the night. He quickly replied, “No, no, no. I asked for a nurse—the one who has blonde hair, blue eyes, and wears a nice skirt.” Obviously, I could have reacted in a negative manner. Rather, I chose to remain calm and respectfully informed him that not all nurses are females with blonde hair. Somewhat perplexed, the patient quickly changed the topic and turned his attention to the television. I did not feel anger towards that particular patient; all I could think of was trying to find ways to help him understand the evolving nature of nursing, which now consists of men as well as Asian/Filipino nurses like me.

As troubling as that patient’s reaction seemed at first, I truly felt he came to realize that male nurses were more than able and capable of caring for patients like him. Though he never said so directly, I just had a feeling. And if nothing else, I know my serving as his nurse was a concrete example that contradicted his former world-view.

The common thread

Nursing is an ever-evolving profession. And changes in our health care delivery system will happen, regardless. The past 10 years of nursing have taught me valuable lessons. For one, I have learned to remain humble. I have also learned to not take things personally when it comes to patient comments. Granted, some comments are downright ignorant and hurtful. But, I believe there is a common thread and human decency in everyone. As a military nurse, I am proud to be a part of their lives. In particular, I am proud to know that I have been given ample opportunities to touch lives and care for my patients. I never imagined I would be in the position to make an impact on someone’s life. Personally, those few minutes of comforting patients during the worst of times have turned to a lifetime of personal and professional satisfaction.

Yet, as with any profession, nursing is not for everybody. I have friends and colleagues who left nursing. I think some of the more common reasons for doing so were the stress of the patient workload and the lack of support from nursing leaders. Being a minority nurse, my advice is to truly and honestly evaluate one’s dedication and intention before committing to nursing. Nursing is a great and well-respected profession, but it does come with its challenges. For example, there have been times when I feared for my safety when caring for patients with developmental delays and mental instability. In addition, minority nurses may still encounter racial and ethnic stereotypes.

Once, a patient bluntly asked if all Filipino nurses speak Tagalog among one another in front of non-Filipino patients. Taken aback, I informed her that no, that is not the case. They only speak their native language during their off-duty time. In another instance, when reporting to my new supervisor (who happened to be a minority), she said, “I can already see two things that are against you. You’re an Asian and a male.” In the U.S. Navy Nurse Corps, we value diversity and strongly feel that concept results in a better work environment for all of our valued staff members, regardless of their race or color. Yet, we, as a health care organization, also understand that we are at risk for discrimination. The good news is that we have a solid support structure that enhances equal opportunity for all.

I learned there remains a small group of people in the nursing world who are who they are and believe what they believe, and there’s no changing them. More importantly, I learned the value of self-discipline while serving my patients at the most honorable level. Ignorance and immaturity exist in this world, but we, as minority nurses, have more than the power and ability to achieve the highest levels in long, fulfilling careers. We should not and cannot allow minor setbacks to dictate who we can become as professionals—we are simply too valuable to the profession. I have always seen nursing as a rewarding career, personally and professionally. Joining the nursing ranks seemed like a no-brainer. And, in general, my expectations of camaraderie, mentorship, and professional development have been met.

Who knows what the next 10 years will bring? I may pursue other interests such as golfing and traveling across the globe. I may even find myself teaching at a local university. I am okay with the unknown that lies ahead when it comes to my career as a military nurse. The one thing that I am certain about is that I will continue to strive in providing the best patient care. The ability to make a difference in patients’ lives means a lot to me. And sometimes, that is all you need. Here’s to another 10 years!

Artemus Armas, R.N., M.S.H.S, B.S.N, C.E.N.

Major, United States Air Force, North Carolina

I have been an Air Force nurse since January 2002. Before that I was in the National Guard and Army Reserve for 17 years before I went on active duty. In the Guard I was an Army Infantry officer.

During my fourth deployment, I was at the Camp Bastion Joint Operating Base in the Helmand Province of Afghanistan, the fiercest combat zone in Afghanistan at the time I was there. I was in charge of the Aeromedical Evacuation Liaison Team (AELT) at Camp Bastion Joint Operating Base Hospital. The team consisted of a flight nurse (myself), a medical service corps officer, and two radio technicians. We were primarily responsible for providing fixed-wing aeromedical evacuation for NATO forces and sometimes civilians. The team also helped anyone, including civilians, who may need to be seen by a specialist not stationed at Camp Bastion.

AELT responsibilities

The AELT’s key function is transferring patients, such as those with traumatic amputations or other combat injuries, who need more specialized treatment to a different facility. The hospital relies on the AELT to coordinate the patient’s transfer with a medical aircrew (Aeromedical Evacuation Crew, or AEC), which flies the patient from point A to point B. Once the patient is picked up by the AEC and en route to a higher level of medical care, the AELT advises the staff and hospital awaiting the patient’s arrival.

A secondary mission for AELT is providing emergency medical assistance to local nationals and Afghan National Security Theater hospitals. Camp Bastion is a joint hospital, meaning whichever nation’s military is in charge of the hospital collaborates with the other countries working there. When I was there we had the Danish, British, and U.S. military.

Camp Bastion is a Role 3 hospital. Role hospitals break down as follows: Role 1 hospitals are assigned to areas providing basic or initial care; Role 2 are facilities with some surgical capabilities; Role 3 facilities can support trauma care, surgical procedures, and burn care; and Role 4 is advanced medical center care. As the lead medical person on the AELT, I made sure patients were properly prepared for flight. I also trained coalition force physicians, nurses, and medical technicians regarding approved devices, brands, and materials, including pumps, chest tube drainage systems, and traction devices.

I also taught hospital leadership on how our system works, the process of getting a patient to a higher echelon of care; this education included Army, Navy, and Marines. While at Camp Bastion I authored and implemented new policies on moving patients through the theater hospital systems, called the Patient Movement Requirement (PMR). Fortunately, implementing these procedures cut down patient movements errors by 60%.

The AELT took the lead in teaching hospital personnel how to sanitize patients before entering the hospital. We sanitized over 500 ally and enemy casualties (patients), meaning we removed any guns, ammo, or explosives before injured personnel entered the hospital. This was for security, assuring nothing happened to hospital staff and patients.

Through these initiatives and two published articles, my goal was to educate AE crews as much as possible so they would not stress when they saw unfamiliar medications or procedures, while giving a report for patients being moved by the AECs. I also included a quick reference sheet of drugs used by the coalition facility and its U.S. equivalent. By the end of this deployment, my four-person team had moved 313 patients, including 102 battle injuries.

ICU in the sky

On my second deployment that year, I had a five-day notice to get my bags and go, due to an injured person who was deployed. I went to Southeast Asia, where I was in charge of the Aeromedical Evacuation Operations Team. I managed up to eight Aeromedical Evacuation Crews and two Critical Care Air Transport Teams (CCATT).

CCATT is basically an airborne intensive care unit. The team consists of a physician, nurse, and respiratory technician; they transport the most critical patients with the assistance of the AEC. I needed to make sure the crews were ready to fly 24 hours a day, seven days a week, so we could pick up patients in the Area of Responsibility, which covered seven countries. I planned and coordinated training as needed for the crews, from medical guidelines to how to use specialized communication equipment. Mentoring was also a big part of the job, including how to deal with crewmembers and patients, career planning, and writing military reports.

Another big aspect was scheduling AECs, by following regulations regarding when crews could and could not fly. Crews need enough time to recoup and rest to be able to perform their duties on the plane and provide high-quality patient care. Scheduling can sometimes be hectic, because you have crews both on call and on missions.

I also coordinated over two tons of Patient Movement Items to the AOR, while my team also maintained and managed 73 Portable Therapeutic Liquid Oxygen units (patient oxygen). This optimized five AE units and kept them fully mission capable. While there I functioned as a crewmember when personnel were unable to fly due to injury or illness. I flew three missions as part of an AEC and pulled 120 hours of alert status, resulting in the transfer of 18 coalition casualties to advanced care. During increased operations we relocated 12 Aeromedical Evacuation Crew members and two CCATTs to Bagram, Afghanistan, increasing Operation Enduring Freedom capabilities by 20%. The efforts during that time lead our team to win the Expeditionary Aeromedical Evacuation Squadron “Team of the Month.” While deployed, the team safely evacuated over 400 wounded personnel on 180 sorties.

The most important result of all that I do is making sure patients, whether military or civilian, receive the best, most comprehensive care possible throughout the AE system. You need everything: great patient care, equipment, leadership, management, and more. If you just focus on one, the system will not be optimal. It is crucial to be well-rounded on all aspects of the AE system. I am honored that my commanders have seen qualities in me to give me the opportunity to succeed in the positions where I have been placed. My philosophy is to do what is best for the patient and those who take care of them; everything else will fall in place.

While deployed as an AELT, I lead our team with a program called “Soldiers’ Angels” ( www.soldiersangels.org ). We would collect items such as books, food, soap, clothes, music, and blankets from people throughout the United States to give to personnel living in austere conditions and patients who needed supplies in the hospital. We ended up distributing over $50,000 in products to over 500 patients, 24 units, and 12 Forward Operating Bases. Recently, I was honored with two awards: The Air Force Flight Nurse of the Year and Nurse of the Year. When my commander informed me I won, I was shocked. It is an honor just to win one . I had learned my commander had put a Flight Nurse of the Year package in for me when I was deployed to Southeast Asia, but I never expected to win. I gave her my information and didn’t think of it again until I won. It was a shock to both of us when I also won the Nurse of the Year. However, though I say “I” in describing all these events, I truly could not have done it alone. The team makes it happen—I just tried to lead them in the right direction.

Getting the opportunity to be a flight nurse has been the most satisfying job I have had thus far in my nursing career. Being a flight nurse in the Air Force has given me opportunities to be an effective leader and make an immediate difference for those I have taken care of that I would not have had as a nurse in a clinic or hospital. Like the rest of the nation, the Air Force needs more nurses and the AF Flight Nurse community needs even more, as a specialty. I would recommend this life to anyone who likes adventure, leadership opportunities, and enjoys taking care of our wounded warriors.

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Article Contents

Introduction, what is mhe, mhe and nurses (and other ahp), pan-profession education and training for mhe, acknowledgments, conflict of interest statement, data availability, clinical trial registration, institutional review board (human subjects), institutional animal care and use committee (iacuc), individual author contribution statement, institutional clearance (approved or does not apply).

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Military Healthcare Ethics: Making It Relevant to the Whole Military Care Team

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Chiu-Yi Lin, Martin C M Bricknell, Alan F Brockie, Janet Clair Kelly, Military Healthcare Ethics: Making It Relevant to the Whole Military Care Team, Military Medicine , Volume 188, Issue 1-2, January-February 2023, Pages 21–24, https://doi.org/10.1093/milmed/usac321

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This article notes the significant increase in academic papers and policy guidance on the subject of ethical practice in military healthcare over the past two decades. This is usually within the domain of “military medical ethics,” linking medical ethics as applied to the medical profession (doctors) with ethics as applied within the military (primarily from the perspective of officers). This article argues that this, highly elitist, perspective disenfranchises the majority of the military healthcare team who are nurses and allied health professionals and serve across the entire rank spectrum. We suggest that the subject should be reframed under the banner “military healthcare ethics” to include the concepts within military medical ethics but to emphasize the obligations of all military health professionals to comply with legal, regulatory, and ethical guidance for the practice of healthcare in the military environment. We recommend that the subject should be included in the curricula for education and training for all military health professions across their whole career.

There has been an increase in the academic debate on the ethical aspects of the practice of healthcare in the military environment over the past two decades across a range of topics. 1 This subject is usually summarized within the domain of “military medical ethics (MME),” linking medical ethics as applied to the medical profession (doctors) with ethics as applied within the military (primarily from the perspective of officers). This article argues that this, highly elitist, perspective disenfranchises the majority of the military healthcare team who are nurses and allied health professionals (AHPs, including dentists, veterinarians, pharmacists, physiotherapists, and non-professionally qualified personnel, e.g., “medics”) and serve across the entire rank spectrum. We suggest that the subject should be reframed under the banner “military healthcare ethics (MHE)” to include the concepts already within MME but to emphasize the obligations of all military health professionals to comply with legal, regulatory, and ethical guidance for the practice of healthcare in the military environment that apply to them. We recommend that the subject should be included in the curricula for education and training for all military health professions across their whole career.

Ethics is the foundation of professional practice, especially in healthcare. Ethics sits at the interface between law (what must be done) and morality (norms of behavior within a community). 2 In most countries, the professional titles of doctors, nurses, paramedics, pharmacists, etc., are regulated by the law based on certification of qualifications and competence by regulatory bodies, such as the General Medical Council, Nursing and Midwifery Council, and the Health Professions Council in the UK or their U.S. equivalents. Professional associations, such as the British Medical Association, Royal College of Nursing, College of Paramedics, or their U.S. equivalents, provide guidance on ethics for members and may have authority to sanction those whose practice falls below these standards. Military ethics is grounded in national and international law. For military health professionals, the Geneva Conventions and other forms of International Humanitarian Law are especially important. In practice, healthcare professionals in the armed forces may have to reconcile compounded and complex principles, combining healthcare practice in a military context with their professional duties and health professional codes—so-called “dual loyalty” between the military profession and the healthcare profession. 3 Obligations to national security and to support the military missions/objectives are key duties for military personnel. 4 However, the obligation to take care of patients purely on the basis of clinical need is the primary duty of a military health professional and underpins the rights and responsibilities attributed to protection as a non-combatant under the Geneva Conventions. These laws and ethics apply to all military health professionals. 5

In addition to academic attention, MHE has been the subject of policies or guidance published by international organizations over the last 10 years. The International Committee of the Red Cross published “Ethical principles of health care in times of armed conflict and other emergencies” in 2015 in conjunction with the International Committee of Military Medicine (ICMM) and other international bodies. 5 It has more recently published further documents under the Healthcare in Danger project; “Protecting healthcare: Guidance for the Armed Forces,” and “The Responsibilities of Health-Care Personnel Working in Armed Conflicts and Other Emergencies.” The WHO has recently published “A guidance document for medical teams responding to health emergencies in armed conflicts and other insecure environments.” 6 In parallel, the U.S. DoD published Department of Defense Instruction (DoDI): 6025.27 Medical Ethics in the Military Health System. 7 Our recent review of the academic literature in military medicine has identified many recurrent topics in MME including “medical rules of eligibility,” protection of healthcare in war, care of detained persons, professional obligations as a non-combatant, oversight of biomedical research and innovation, consent, and confidentiality. 1 All these documents and topics are relevant to every member of the military health team, not just doctors. Thus, the subject should be considered to be “MHE” not “MME.”

The boundaries of practice between professional groups within clinical teams in Western healthcare have become increasingly blurred. Indeed, the armed forces have often led the way in creating a more flexible clinical workforce with a clear lineage to the workforce challenges for health systems during war, leading to the development of nurse anesthetists, physician assistants, and paramedics. Leadership roles within military medical services have become more “profession agnostic” with nurses, physician assistants, and Medical Service Corps officers filling General Officer roles in some countries that were previously the sole domain of doctors.

For this article, we searched the publications that had been collated for our bibliometric review of the whole subject of MME for those related to nursing. Only 66 studies (of 633) seemed to be specifically related to MME in nursing. One study identified six themes underpinning ethical dilemmas reported by U.S. Military nurses who had served in Iraq or Afghanistan: resources/allocation, military nursing core values, nursing code of ethics, caring for the enemy, caring for civilians, and needs for follow-up/closing the loop. 8 Another study combining thematic analysis of narratives of the experiences of U.S. military nurses emphasized their professional obligation to people requiring nursing care based on their professional values within the context of shortage of resources. 9 A Canadian study of the ethical issues faced by a mixed profession group of 50 military healthcare workers identified four categories of ethical challenges they had faced: resource scarcity; historical, cultural, or social expectations of different patient groups; policies and agendas, principally “medical rules of engagement;” and the potential tension of dual loyalty. 10 A smaller study among Swedish military medical personnel has similar findings in that there were ethical tensions with working in an organization with a military purpose, but their “caring instinct” takes primacy. They also noted the challenge of limited resources. 11 These findings replicate similar studies that have examined ethical dilemmas faced by senior UK military doctors deployed to Afghanistan 12 or the Ebola crisis in Sierra Leone in 2014. 13 However, the experiences reported by nurses tend to emphasize the impact of these issues on their experience of direct patient care reflected by their specific role as nurses. We were unable to find any studies that looked at the experiences or ethical dilemmas faced by military medics. This would seem to be a significant oversight given their exposure to the most visceral violence of war.

We argue that there is clear evidence that military medical leaders, doctors, and nurses report ethical challenges associated with their role on military operations. Many authors link this to “moral distress,” and there might be a causative link to “moral injury” for some military health professionals. We also suggest that many topics are predictable and common across all professional groups within the military healthcare team. Therefore, there is an implicit obligation for ethics to be taught as a core component of military specific education for all military healthcare workers in order to prepare them for their role both on deployment and in garrison healthcare. This should be a combination of generic education on common principles in MHE and cover the behaviors and decisions that would be illegal or unethical by reference to key documents that apply to all military healthcare workers. In addition, there might be a need for education in MHE that covered topics specific to each professional group within the military healthcare team including the regulations or guidance that apply to them. Such education might need to be augmented as an individual progress through their career and take on more leadership or policy responsibilities.

Some institutions have developed educational courses/training in MME, such as the ICMM Centre of Reference for Education on International Humanitarian Law and Ethics, the U.S. DoD Medical Ethics Centre (DMEC), and the King’s College London Centre for Military Ethics (KCME). The ICMM Centre runs an annual course and workshop on MME to support military health professionals to make legal and ethical decisions in military context. The DMEC, under the USU, is responsible for the DoD Medical Ethics Program across the U.S. Military Health System. It has recently released a Smartphone App, the DMEC Bioethics Mobile Application. The KCME, nested within the School of Security Studies, bridges education on military ethics for military personnel and MHE for military health professionals. Recognizing the importance of scenario-based small group learning to influence attitudes and behaviors in ethics education, the KCME has developed an innovative Smartphone App embedding 52 scenarios related to MHE into digital playing cards (which are also available in a physical version). 14 This teaching tool has been widely used in many training courses in various countries such as the UK, Ghana, Greece, and Canada. We reiterate the call to arms made by Hooper et al. in 2015 to better prepare the next generation of military healthcare professionals by embedding some training in MME in early professional education. 15 There might be an opportunity to develop a common curriculum for MHE applicable to many military health services that cover the key topics that have been identified in the academic literature.

This article argues that MHE is an important topic for inclusion in the education and training curricula for all health professionals in the armed forces based on emerging evidence of common ethical challenges across most military healthcare professions, particularly in conflict settings. Unfortunately, most of the academic debate in MME and MME training/education seems to be doctor-centered. This neglects the contribution made by nurses and AHPs to military healthcare (including dentists, veterinarians, pharmacists, physiotherapists, and non-professionally qualified personnel, e.g., “medics”). We argue that changing the term “MME” to “MHE” could shift perceptions of the subject into one that encompasses the whole military health team. We also suggest that the military medical community should undertake research into the experiences of military medics to complement the studies into doctors and nurses.

The author would like to thank Centre for Conflict & Health Research, King’s College London for their supports.

MB is partially funded through the UK Research and Innovation GCRF Research for Health in Conflict developing capability, partnerships and research in the Middle and Near East program (R4HC-MENA) ES/P010962/1. CL is funded by the King’s Together Seed Fund for interdisciplinary research.

None declared.

Not applicable.

C.L. and M.B. drafted the original manuscript. M.B., A.B., and J.K. reviewed and edited the manuscript.

It does not apply.

Bailey Z , Mahoney P , Miron M , Bricknell M : Thematic analysis of military medical ethics publications from 2000 to 2020—a bibliometric approach . Milit Med 2022 ; 187 ( 7–8 ): e837 – 45 .doi: 10.1093/milmed/usab317 .

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Olsthoorn P : Dual loyalty in military medical ethics: a moral dilemma or a test of integrity . BMJ Military Health 2019 ; 165 ( 4 ): 282 – 3 . doi: 10.1136/jramc-2018-001131 .

Bricknell MC , Miron M : Medical ethics for the military profession . Rev Cient Gen Jose Maria Cordova 2021 ; 19 ( 36 ): 851 – 66 .doi: 10.21830/19006586.814 .

ICRC : Ethical principles of health care in conflict and emergencies . Available at https://www.icrc.org/en/document/ethical-principles-health-care-conflict-and-emergencies , published 2015 ; accessed February 3, 2022 .

World Health Organization : A guidance document for medical teams responding to health emergencies in armed conflicts and other insecure environments . Geneva : World Health Organization . Available at https://apps.who.int/iris/bitstream/handle/10665/341858/9789240029354-eng.pdf ; accessed September 20, 2022 .

Department of Defense Instruction (DoDI) 6025.27 : Medical ethics in the military health system . Available at http://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/602527_dodi_2017.pdf?ver=2017-11-08-130043-890 ; accessed September 20, 2022.

Kenny DJ , Kelley PW : Heavy burdens: ethical issues faced by military nurses during a war . Online J Issues Nurs 2019 ; 24 ( 3 ): doi: 10.3912/OJIN.Vol24No03Man01 .

Agazio J , Goodman P : Making the hard decisions: ethical care decisions in wartime nursing practice . Nurs Outlook 2017 ; 65 ( 5 ): S92 – 9 .doi: 10.1016/j.outlook.2017.06.010 .

Williams-Jones B , de Laat S , Hunt M , et al. : Ethics in the field: the experiences of Canadian military healthcare professionals . Ethics and the Armed Forces/Ethik Und Militär 2015 ; 1 : 31 – 6 .

Lundberg K , Kjellström S , Jonsson A , Sandman L : Experiences of Swedish military medical personnel in combat zones: adapting to competing loyalties . Mil Med 2014 ; 179 ( 8 ): 821 – 6 .doi: 10.7205/MILMED-D-14-00038 .

Bernthal EM , Draper HJ , Henning J , Kelly JC : ‘A band of brothers’—an exploration of the range of medical ethical issues faced by British senior military clinicians on deployment to Afghanistan: a qualitative study . BMJ Military Health 2017 ; 163 ( 3 ): 199 – 205 .doi: 10.1136/jramc-2016-000701 .

Draper H , Jenkins S : Ethical challenges experienced by UK military medical personnel deployed to Sierra Leone (operation GRITROCK) during the 2014–2015 Ebola outbreak: a qualitative study . BMC Med Ethics 2017 ; 18 ( 1 ): 1 – 3 .doi: 10.1186/s12910-017-0234-5 .

Miron M , Bricknell M : Innovation in education: the military medical ethics ‘playing cards’ and smartphone application . BMJ Military Health 2021 . bmjmilitary-2021-001959.doi: 10.1136/bmjmilitary-2021-001959 .

Hooper CR , Ryan J , Pelham E , Mannion S : Military medical ethics: a call to regulatory and educational arms . Med Confl Surviv 2015 ; 31 ( 1 ): 13 – 20 .doi: 10.1080/13623699.2015.1013391 .

Author notes

The views expressed in this material are those of the authors and do not reflect the official policy or position of the UK Government, the Ministry of Defense, or King’s College London.

• ethics, medical
• health personnel
• military personnel
• patient care team
• principles of law and justice
• military health

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Military Nursing Pros and Cons Consideration Essay Sample

Whenever men and women in the military are sent out to war, there is no surety or certainty to their eventual state of livelihood or death; there is a surety that they will be taken good care of physically, psychologically and emotionally, and military nurses, also known as navy nurses, are delegated to this duty.

The nurses have an enormous duty of compassionately restoring to appropriate health both the soldiers and harmless civilians affected by the war, but is it worth the pain, psychological and emotional trauma that these nurses go through in their line of duty. This paper will critically analyze the concept of military nursing, stating its history, development over the years, giving accounts from a few military nurses and conclude on its worth and importance.

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The military nursing concept was non-existent until the year 1901. This is when the United States government in an attempt appointed civilian nurses into the Army Nurse Corps; an organization that has existed to date delegating nurses who take care of the country’s Army men. The Navy Nurse Corp created in 1908 followed it, and as the name suggests, it delegates nurses who take care of the of nation’s Navy men. The third wing of the military nurses corps in the United States of America is the Air Force Nurse Corps mainly concerned with the nurses who take care of the men in the Air Force. In her book, They Called Them Angels: American Military Nurses of World War Two; Jackson gives first hand account of the nurses who provided care to the military men fighting the Second World War. She refers to them as angels because that is what they practically were; they helped restore back to health the injured. In most of their sheer emotional accounts, these nurses had a duty to look beyond their own person and provide care to the various military personnel. During this era, they provided physical, emotional, and psychological treatment to the wounded individuals. What these nurses do is to look after the soldiers, marines, pilots, and sailors back to robust health both in the field and in hospitals. They carry out their work in clinics, community health centers, intensive care units, and operating rooms within hospitals. During the Second World War and the Vietnamese War, most of the military nurses were just sent out as educators and community health practitioners to go teach and train the local community and “heal”/ nurse the wounded (Pain & Pride 3).

Most of the accounts from those who worked both in the Vietnamese and in Second World War are horrific. They worked under abhor able circumstances, with communities that had singularly little idea and information about healthcare. They put the military and local community’s health interest before hand; worked tirelessly to nurse them back to health. Sometimes they lacked enough facility nevertheless provided the best healthcare they could. An article published in the American Nursing Journal in April 1951; Military Nursing-1951 gives a story about the work done by military nurses in a hospital Fitzsimons during the Korean War. In this story, there were too many casualties with a shortage of nurses to handle them, and this ends in a question; are military nurses overworked or pushed beyond their capacity? It is for a fact that nursing need personal sacrifice, and there is a great need for one to be psychologically prepared for what lies ahead of them. For the military nurse, however, the future is uncertain; the numbers of causalities to be dealt with on a daily basis are obviously not predictable (Kathi 2-6)

In one of the letter sections in an issue of the American Nursing Journal; one fan of the journal commented on a need for many to enroll as military nurse corps. His point of encouragement is that there are better remuneration and chances of advancing in rank. Yes, military nursing provides a better package with a free dental and health insurance package. However, what happens when most of these nurses return to their home country when the war is allover? They are faced with a lot emotional and psychological trauma of the vivid memories and pictures of the patients that they treated and counseled during the war. A military nurse Payne who served in the Vietnamese War accounts how they were not allowed to talk about their experience in Vietnam; “Our country didn’t welcome us back”, she said. “We had to be quiet about our time here. It was a pretty lousy thing the U.S. did to our generation. They shoved us under the rug; we were an embarrassment and so we were ignored”, (Payne 1). It is an undisputable fact that military nursing is a more than impressive concept. The is issue is who welcomes them back when they return from the war, which counsels them or helps them forget about the pain, trauma, anger and the horrific moments they had when in the battlefield taking care of both the civilians and wounded soldiers? The military nurses have a huge duty of compassionately restoring to good health both the soldiers and harmless civilians affected by a war (Pain & Pride 1). They do this with a loving heart and so much compassion; the main question at hand is who provides care to them when they return. This might have changed over the ages from the time of the Second World War when they were not even allowed to talk about their experiences, and that is a positive thing because they too need to be counseled and relieved of the psychological trauma that they experience in their dangerous line of duty (Wolters Kluwer Health).

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Medicine on Screen

Films and Essays from NLM

The Army Nurse

Read the Essay    |   Go to NLM Digital Collections    |   Watch on YouTube    |   Read Transcript

Historian David Cantor looks at five films about nursing produced between the 1940s and 1970s. In the mid-20th century, American nursing leaders produced and deployed the motion picture as a modern tool of education, training, and recruitment. Hundreds of films were made, including informational, newsreel, and training movies for a variety of audiences. This title was intended for a variety of audiences—including servicemen, nurses, and potential recruits to nursing—and carries a reassuring message about the skill and effectiveness of the Army nursing service…. Read the Essay

Warning: These films contain explicit images of disease and intrusive medical treatment. Viewer discretion advised.

Supplementary materials, stills from the army nurse.

Other Films Featured in the Essay “Screening the Nurse: Film, Fear, and Narrative from the 1940s to the 1970s”

In the Collections of the National Library of Medicine

Nlm historical audiovisuals collection.

Career , ca.1958: The story of three Native American women attending the U.S. Public Health Service Indian School of Practical Nursing in Albuquerque, New Mexico.

The Nurse Combats Disease , 1962: With the aid of drawings, this film describes the nurse’s role in the prevention of disease, with emphasis on factors that lead to disease transmission and how to interrupt that chain.

NLM Prints & Photographs Collection

View the related online exhibition Pictures of Nursing: the Zwerdling Postcard Collection .

NLM Rare Book Collection

Tradition and Destiny of the U.S. Army Nurse Corps , ca. 1949 is a detailed, illustrated, 52 page booklet about all aspects of the U.S. Army Nurse Corps.

States regularly issued guides and manuals for public health nurses, such as this Manual for Public Health Nurses , from the state of Iowa in the late 1940s.

Related Resources from the National Library of Medicine

Pubmed central full-text journal articles.

Explore current, full-text journal articles on nursing education .

Florence Nightingale: The Mother of Nursing , 2015

Nursing: A Key to Patient Satisfaction , 2009

The Importance of Nursing Research , 2009

PubMed for Nurses

This brief tutorial , designed specifically for nurses, provides an introduction to searching the biomedical journal literature using PubMed.

Circulating Now: The Blog of the NLM History of Medicine Division

The Forgotten Frontier: Nursing Done in Wild Places

How to Become a Nurse and How to Succeed, ca. 1892

Faye Glenn Abdellah: Nurse, Officer, Educator

Nurses on the Cutting Edge

External Resources

National institute of nursing research (ninr)  — est. 1986.

The mission of the National Institute of Nursing Research (NINR) is to promote and improve the health of individuals, families, communities, and populations. NINR supports and conducts clinical and basic research and research training on health and illness across the lifespan to build the scientific foundation for clinical practice, prevent disease and disability, manage and eliminate symptoms caused by illness, and improve palliative and end-of-life care.

NIH Library Subject Guide: Nursing

This guide provides access to nursing, biomedical, clinical trial, evidence based practice, and research instrument databases; drug and pharmaceutical resources; e-books; patient education resources; and professional societies of special interest to NIH Clinical Center and IC nurses.

Nursing at the NIH Clinical Center

Clinical Research Nursing is nursing practice with a specialty focus on clinical research. It includes care provided to research participants, as well as activities to support protocol implementation, data collection and research participant protection.  In addition to providing and coordinating clinical care, clinical research nurses have a central role in assuring ongoing maintenance of informed consent, integrity of protocol procedures and accuracy of research data collection.

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• OJIN Homepage
• Table of Contents
• Volume 24 - 2019
• Number 3: September 2019
• Ethical Issues Faced by Military Nurses

Heavy Burdens: Ethical Issues Faced by Military Nurses during a War

Dr. Kenny received a BSN from the University of Northern Colorado; a Master’s degree in Education from Boston University and MSN from Vanderbilt University; and a PhD in Nursing from the University of Massachusetts, Amherst. She is an Associate Professor at the Helen and Arthur E. Johnson Beth-El College of Nursing and Health Sciences at the University of Colorado, Colorado Springs and held the college’s inaugural Carole Schoffstall Endowed Professorship. She is a Fellow in the American Academy of Nursing and on numerous boards and committees dedicated to serving veterans. Dr. Kenny is a retired Lieutenant Colonel from the U.S. Army Nurse Corps and has a program of research with military and veterans, particularly female veterans. She has authored and co-authored numerous articles related to veteran issues.

Dr. Kelley received an AS from Northeastern University, a BSN from American University, a MS from Boston University School of Nursing with a specialty in gerontology, a Post-master certificate in Family Primary Care from Northeastern University, and PhD in nursing from the Catholic University of America. Dr. Kelley is board certified as a Family and Gerontological Nurse Practitioner, a Fellow of the American Academy of Nurse Practitioners and the American Academy of Nursing. She is a Professor of Nursing and the Director of the Veterans to Bachelor’s in nursing program, Duquesne University School of Nursing, Pittsburgh, PA. She is a retired Navy Captain who has held various leadership, clinical, and research positions. Her research interests are in the areas of clinical knowledge development and continuity of care of wounded service members, evidence-based practice, health promotion and diabetes self-care management. Dr Kelley is an executive board member, Navy Safe Harbor Foundation which is dedicated to supporting the recovery of seriously wounded, ill, and injured Sailors, Coast Guardsmen, and their families by assisting them with resources not currently provided by government or community resources.

• Figures/Tables

American nurses have faced hardship and challenges in every war period in the relatively short history of the United States. This study was an in-depth reanalysis of a two-phase larger study of uniformed service nurses caring for service members injured in the conflicts in Iraq and Afghanistan. In this second phase, a qualitative descriptive study, 235 nurses and 67 wounded service members were interviewed in face-to-face discussions about their caring and care experiences. The article offers background information, discussion of the study methods , and presents some of the ethical issues faced by deployed nurses who were caring for the injured service members and injured/ill civilians during conflicts in Iraq and Afghanistan. Study findings revealed six themes that emerged directly from the data, providing a comprehensive picture of the many issues faced by these nurses. The stories of the nurses are used to illustrate many of their ethical dilemmas. We offer discussion with implications and recommendations for training and subsequent post-deployment care of these nurses. This article adds to the growing body of literature in the field of military nursing ethics.

Key Words : military nursing, ethics, nursing, Afghanistan, Iraq, military personnel, nurses, war, wounded patients, military, prisoners of war, hospital systems, moral distress, ethical decision-making

...American nurses have faced hardship and challenges in every war period in the relatively short history of the United States. It is no surprise that American nurses have faced hardship and challenges in every war period in the relatively short history of the United States (US). For example, Wood ( 1972 ) recounted how nurse volunteers during the civil war not only endured the harsh conditions of the war and cleaned up the unsanitary conditions of the military hospitals, but also fought another war themselves with the male dominated medical profession bent on keeping women away from the battlefield or defining their own profession of nursing. Norman ( 1999 ) detailed stories of 77 nurses in World War II who were captured by the Japanese, taken prisoner, and held for three years in a prison encampment in Bataan. In interviewing her aging subjects, she discovered a strength within them that was unmistakable; one that allowed them to survive their dire situation while still caring for other prisoners of war. However, despite this, and the fact that psychologists believed nurses’ education and their experiences had somehow left them immune to the ravages of war, Norman ( 1999 ) found that “the opposite was true: they felt too much” (p. 242). This was supported in a study that considered a direct correlation between moral sensitivity and moral distress of nurses in two countries ( Ohnishi et al., 2018 ). Ironically, it is the empathy of nurses that will often cause them to suffer secondary traumatic stress ( Bride, Radey, & Figley, 2007 ).

Also in World War II, some 10,000 American nurses were involved with troops in France, Germany, and Sicily, saving lives and making vital contributions to military medicine ( Sarnecky, 1999 ). However, they too suffered in silence, rising to the occasion time and again, even though they themselves were hurting. It has been this way in war after war; nurses have been willing to put their lives in danger for their charges, work as long or hard as necessary to ensure the injured got the best care they could give. In former years, this stress has been dismissed, with some claiming that nurses do not suffer the stressors of those who are fighting ( Lucchesi, 2019 ). This position is changing and the stressors of nurses in wartime scenarios are becoming more recognized.

In virtually every war in every country, we hear of nurses suffering distress and handling ethical issues. In virtually every war in every country, we hear of nurses suffering distress and handling ethical issues. Generally, this is only documented through stories told by the nurses, mostly after many years have passed since their experiences in an attempt to not lose the memories of their stories ( Agazio & Goodman, 2017 ; Nightingale, 1859/1992 ; Norman, 1999 ; Sarnecky, 1999 ; Sorokina, 1995 ). This article will discuss some of the ethical issues experienced by nurses during the wars in Iraq and Afghanistan. Though the stories are vastly different from those of their predecessors because of medical and technological advances, the issues remain nearly the same. We will describe some of the ethical dilemmas faced by nurses in a wartime environment, as they were described to the research team.

...every war is different and there is no training for what nurses actually see or do... Since the beginning of civilization, people have been involved in conflict and there have been nurses caring for individuals injured in these conflicts. Nurses have learned triage principles and have been educated about the types of injuries they might see. However, every war is different and there is no training for what nurses actually see or do and how they will process their feelings surrounding the circumstances. Most theory learned in nursing programs is “thrown out the window” when it collides with the reality of war. This does not imply that ethical concerns are set aside, but because of different expectations, they may become more acute and necessitate action that may not coincide with normal professional nursing values. This can create moral distress for nurses.

There is a large body of literature about the moral distress of nurses, but there seems to be a lack of clarity in how it is defined because of its multiple dimensions ( McCarthy & Gastmans, 2015 ; Pauly, Varcoe, & Storch, 2012 ). Some literature discusses issues nurses may encounter in hospital situations ( Bachhuber, Roberts, Metraux, & Montgomery, 2015 ; Hamric, 2012 ; McAndrew, Leske, & Schroeter, 2018 ; Oh & Gastmans, 2015 ; Whitehead, Herbertson, Hamric, Epstein, & Fisher, 2015 ). Other literature discusses how moral distress occurs and what types of support nurses need ( Burston & Tuckett, 2013 ; Rathert, May, & Chung, 2016 ). In many articles, the cause of moral distress is organizational ( Corley, Minick, Elswick, & Jacobs, 2005 ; Wolf et al., 2016 ) and in others it is individual ( Beck, 2011 ). Johnstone and Hutchinson ( 2015 ) contended that the lack of clarity regarding the concept may require nursing to abandon this concept and rethink moral reasoning in nursing.

Moral distress as a distinct concept in nursing is generally thought to have originated with Andrew Jameton’s ( 1984 ) philosophical views of moral distress and ethical dilemmas. He defined moral distress as a clear difference in thinking between a nurse and those in superior positions, whereas an ethical dilemma involves a more global perspective of care and its context. He further differentiated distress into two distinct stages. The first is initial stress, where an individual recognizes there is dissonance between care needed and personal moral convictions. The second is reactive stress, where an individual will respond to the stressor with specific behaviors, which can either be short-lived, or persistent. Since his original writings, Jameton’s philosophical thinking has evolved to a broadened concept that includes nursing within the global environment ( Jameton, 2013 ). Prior to Jameton, moral distress in nursing was described by authors going back to Nightingale ( 1859/1992 ), where she stated,

The distress is very legitimate, but it generally arises from the nurse not having the power of laying clearly and shortly before the doctor the facts from which she derives her opinion, or from the doctor being hasty and inexperienced, and not capable of eliciting them. (p. 69)

Her notion seemed to be directly related to role differences between physicians and nurses. This was supported in a later article by Elmer ( 1909 ) concluding that well-trained nurses should be listened to, and held in high regard by physicians. He further stated that environment played a significant role in nurses’ distress.

Moral distress...has rarely been studied with nurses in a war zone, during a war. Moral distress as experienced by nurses is well documented and has been studied in multiple settings. However, it has rarely been studied with nurses in a war zone, during a war. While the root causes of moral distress that military nurses experience may remain the same as those described by Hamric et al. ( 2012 ), i.e., clinical situations, internal constraints, and external constraints, there are also significant differences in the types of stressors that deployed military nurses face. Fry and colleagues were among the first to begin to develop a model for moral distress in military nurses ( Fry, Harvey, Hurley, & Foley, 2002 ). They described environments that were dangerous; patients who were uncharacteristic; and military triage practices that differed from the norm. They contended that this triad constituted a higher than normal probability for moral distress among military nurses.

Because the wartime environment is entirely distinctive, may be austere, and is often culturally different, ethical issues experienced by nurses may be even more pronounced ( Gross, 2004 ). Moral distress in nurses and the psychological sequelae of war have been extensively studied, but there is a decided lack of literature surrounding ethical issues actually experienced by nurses in war. While there were numerous articles examining caring for patients in a war zone and on humanitarian missions, and these made mention of certain ethical challenges, only one other article from the United States could be found that specifically examined ethical issues of American nurses during war ( Agazio & Goodman, 2017 ). This article will add to this gap by presenting a comprehensive view of ethical issues encountered by nurses in a war zone. The quotations presented are those that best exemplify the themes found in the data. In this article, group and individual participants are numbered in the order in which they appear in the discussion.

Study Methods

The purpose of this study was to describe, through an in-depth qualitative reanalysis of the transcripts, some of the ethical issues that nurses struggled with as they faced caring for patients in a war zone or while deployed. The original intent of our study was to use an interpretive, ethnographic methodology to gather nurses’ first person accounts of experiential learning in caring for wounded service members. Phase 1 of the study contained accounts of nurses ( n = 180) who had deployed to war zones and/or on humanitarian missions. Phase 2 ( n = 235) of the study aimed to extend the first phase to include care of wounded service members (WSMs) ( n = 67) through their rehabilitation and service members’ accounts of their memories of their care experience from point of injury in the combat zone through rehabilitation. We recognized in some cases that WSMs could have fuzzy memories of their initial care. Table 1 depicts aggregated demographic data of the nurses in the Phase 2 of the study.

Table 1: Demographics of Sample

We conducted face-to-face, semi-structured interviews with individuals or small groups aimed at prompting complete accounts of actual caregiving experiences from nurses in various situations of care and the WSMs’ detailed narrative stories about injury, care, and rehabilitation experiences. Institutional review board approval was gained at all study sites and through military channels. Data were collected in private settings within the study institutions and after informed consent. Interviews were audio recorded and field notes taken by the research team members. Additionally, demographic data were collected from participants to include branch of service or work environment, rank, gender, age, education, years of experience, deployment location, and nursing specialty.

They discussed scarce resources, ethical issues, family concerns, matters related to deployment, and difficulties in care management, among many topics. Interview data were analyzed using the most current version of Atlas.ti, a software program designed to code and store qualitative data. This software allows data coding so that content specific to codes can be further analyzed and synthesized. Codes were developed inductively by the research team. After discussion of transcripts amongst the team, a codebook was developed by selecting interview excerpts that illustrated each code. Ambiguities were discussed until consensus was reached. Though we originally set out to examine how nurses acquired new knowledge related to caring for service members with serious injuries and poly-trauma, we found that stories went far beyond descriptions of how they gained confidence in their skills on the battlefield, or during subsequent care for injured service members. They also provided deep explanations of their experiences regarding what it was like to care for U.S. service members, the enemy, and local foreign citizens. They discussed scarce resources, ethical issues, family concerns, matters related to deployment, and difficulties in care management, among many topics.

For this analysis, we specifically examined all text related to the code “ethical, moral, political challenge” related to the continuum of care of the injured. We found 164 quotations contained within this code. Data from this code was found in 48 of the group and individual interviews and represented 83 of the 235 nurses in the study. Most text surrounding moral distress was confined to nurses’ care and conditions on the battlefield. After analysis of all text related to this code, we identified ethical situation themes of a) resources/allocation; b) military nursing core values; c) nursing code of ethics; d) caring for the enemy; e) caring for civilians; and f) need for follow-up/closing the loop.

Resources/Allocation The first theme of Resources/Allocation was multifactorial and related to numbers and types of casualties, severity of injury, and humanitarian efforts. This included resources used to care for severely wounded service members that were thought to have been futile; and resources used on injured enemies, prisoners, on the local civilian casualties, or even on locals seeking care because they knew their own care system was deficient.

Nurses expressed some frustration with differing opinions as to whether massive resources should be used at all cost. Care for Injured Allied Service Members . Service members in the wars in Iraq and Afghanistan saw injuries that would have been non-survivable if not for advances in medicine and definitive care practices. The injured were cared for by highly trained combat medics and nurses right on the battlefield at the point of injury. Once service members reached combat support hospitals, they had already received, in many cases, lifesaving care, but they were still severely injured. Nurses expressed some frustration with differing opinions as to whether massive resources should be used at all cost. This was particularly true when many casualties were received at one time and heart-wrenching triage was necessary. One nurse expressed:

P1: Because out there the theory of triage is reversed: you save the greatest good, not the greatest injured. So if we had to, and there was days that we did, we left somebody in the shade with a corpsman to attend to them, with as much morphine as he needed and kept him comfortable until he died. And sometimes they were still there and we'd go back for them afterwards and we'd throw whatever we had left at them.

Resources for Enemies and Civilians . Many nurses related stories of having to use scarce resources on enemies who had been injured in the same firefight and brought in with WSMs, or civilian casualties who had been in the area. They struggled with the need to use resources that were supposed to be used for Americans. Though they dutifully did what was required, most could not reconcile their actions, particularly because they knew the subsequent care these people would get outside the American hospitals was quite poor. Often these patients were kept for extended periods of time whereas American casualties were stabilized and transported in a matter of a few hours or days.

P1: But the one big discussion that we got into that really became an ethical discussion frequently and even before we went in, but definitely once we started seeing them, was using our supplies on the Iraqis. G1: Caring for everyone who gets injured, the Iraqi civilians, Iraqi police, Iraqi army, the Americans from all over - our beds were very valuable. So we constantly had to triage and move patients out. This ethical dilemma came up over and over and over again in transporting Iraqi patients, because we had to transport them from Ballad to Baghdad, where they were assessed by the combat support hospital there, and then arrangements were made for them to go into the Iraqi medical system. Well, everybody had an overwhelming feeling that we were sending them to their death by sending them to the Iraqi medical system. So it was an ethical dilemma constantly, when we had to make arrangements to transport these patients out. So we would stabilize them and keep them as long as we can, to give them the best shot at life.

Though they dutifully did what was required, most could not reconcile their actions... Limited Resources of the Foreign Medical System . Many respondents talked at length about some of the frustrations they had with the local medical system of the country. They knew the Americans were capable of providing better care for local individuals than they would have in their own hospitals. Much of the angst felt by our nurses was related to the fact that we were treating and likely saving people who would eventually be sent back to a local hospital unable to provide resources to continue care. They believed they were sending many people out to their deaths by releasing them from the American hospital and the nurses could not reconcile that with their own value system, even though they knew it was acceptable by the local culture.

G1: They usually the University Center wouldn't take a ventilated patient 'cause they didn't have the means - most of the time - well, their nurses weren't really nurses, and the doctors usually worked only days, till like three o'clock in the afternoon, and then they had like a tech working at night, so they never received the care. But I know in Baghdad - we called up on a couple of patients that we sent over to university, and we found within days of sending them over there, they were dead. G2: It's strange. You just don't understand why. A lot of times - the Iraqi patients - they're very fearful of going to - when you're gonna transfer them to the Iraqi hospital, because they know, if they're Sunni or Shia, that they can die in there, just because of the difference.

They believed they were sending many people out to their deaths by releasing them... Military Nursing Core Values Military nurses are trained to view themselves as “officers first, nurses second.” From the time they receive initial training in the military, they are taught that mission and need of the military comes first. Nurses were very aware of both responsibilities of being in a war zone, but struggled to reconcile military needs with human suffering. Many had beliefs that they were deploying solely to care for American service members but found themselves spending most of their time caring for Iraqis and Afghanis. This was because American service members were transported to Germany, then back to the United States in a very short space of time, whereas local citizens truly had no place to go. Additionally, when word got out to the villages that the Americans could help them more than their own medical system, they began showing up for care of all types, even non-emergent. To portray American good will to these people, they received care.

G3: Well, we knew we were going to. They go through the whole - everybody gets equal care. And - and you go to war with yourself. Because as a professional, you're gonna give everybody equal care. But as a soldier, it's very tough to treat Iraqis that you know. What we got mostly, as far as Iraqis go, we had a prison. P3: Geneva Conventions and rules of war that we have to provide that for them, even if they don't provide the same thing for us. But it's just - when you're hands-on, when you're actually taking care of the soldier and taking care of the assailant, then it's a little more - makes it a little more difficult 'cause emotions are involved.

One nurse in particular related a story regarding her welcome home and the angst it caused her because she had gone off to war and was speaking about it to her family, having to defend her actions and her beliefs. She felt like she, herself, was reliving the Vietnam war experience some forty years later.

P4: Okay, so one thing that was hard was my [relative deleted] is very liberal. She’s always out there protesting against the war. She’s the quintessential liberal person, lives out in [location deleted]. Our political views don’t clash, but she always likes to play the devil’s advocate. She’s always saying, “You have to understand,” blah, blah, blah. I remember telling her it was really hard taking care of those EPWs (Enemy Prisoners of War) because the moral and ethical issues I would have. Knowing what they have done was really, really hard for me……… I started crying, I’m like, I cannot believe, I was using a whole lot of profanity at that point. I remember telling her…… “Don’t have that kind of opinion until you get there because you don’t know what you would do in that instance.” I thought I had a very valid point in that because I took care of EPWs. So I said, “Do not judge the Americans, or U.S. for what they did, because you don’t know what you would’ve done in that situation.

Nursing Code of Ethics Perhaps the most important and expected finding of this study and of the deep dive into ethical issues was that the nurses seemed to have no conflict whatsoever with their roles as nurses. This finding was almost universally relayed by the nurses interviewed. None seemed to have difficulty in reverting back to the reason they became a nurse in the first place and that was human compassion.

P5: And that was the hardest thing I think I've ever done. And - you know what you think you might want to do. But then, what you're supposed to do comes through, and I did take care of him. It was one of the hardest things that I had ever done. P5: We did. We talked a lot about it because - from the looks on everyone's faces, everybody had the same feelings. And we talked about the importance of what we had to do, to take care of the patients. That that's our job, and it's not only our job, it's our obligation.

The most poignant story of nursing core ethics came from one Navy nurse, who related a story of caring for a teenaged Taliban who was injured as he set off an improvised explosive device (IED) targeted to Americans. He wound up killing and injuring several Americans. To demonstrate the compassion with which this nurse cared for this patient, we are including the entire story here.

G4: And my first experience with a Taliban soldier from – Taliban bad guy, as they call them – I was given a black eye and a broken bone in my face from an attack from him. And so that was not something I’d been familiar with as a nurse, for as many years as I’ve been. Quite alarming. Didn’t hit him back. But I continued to take care of him for the whole ten days that he was there. And it was a good thing. It reminded me of the oath I took as a nurse, to take care of any patient, anywhere, any time that I was needed to, and it was a challenge, because this particular one was just a boy, and he actually killed two of our American soldiers, so it was – every single bit of strength that I had to take care of him. Being a pediatric nurse, though, I could do it because I focused on the fact that he was a young patient, a young boy, and that’s all he knew. So I gave him 100 percent of care, and I feel very good about that. He taught me a valuable lesson about giving care to someone you didn’t want to…….. And it did make me grow. And who says you can’t still learn as an old nurse. (laughs). He had a- unfortunately, because he was so young, he had set an IED to explode, and instead of – well, it did explode, and it killed two of our young soldiers, but it also injured himself because he didn’t get away. And he lost a leg, an arm, and was trached, and one eye. So the joke downrange was that I had half of a young boy that attacked me and I couldn’t defend myself. But you know, as I said, it did teach me a valuable lesson, and I think the junior officers that saw how I handled the situation, and that I was willing to take care of him, even though he broke a bone in my face, I was still going to give him the best care and I wasn’t going to back down. I was going to show him that he didn’t scare me, that I was still going to be a nurse and I was still going to be an American. Yes, actually it did. When he left – whenever you take care of a Taliban, I don’t’ know if you ladies – anybody in here has, but if they’re a detainee, you simply finish taking care of them till they can care for themselves the best way, and you have no one to leave them with. You have to take them to the outside skirts, where it’s safe for you, and leave them, and they have to get where they can get to for safety. So we simply took this man to the outside quarters of the air field and of course he’s blindfolded and has earmuffs on, has no idea where we have brought him from – and it’s for our safety, of course – and we drop him. And so he has to manage to get to safety himself. But knowing that, and how young he was, I know he was probably very strong, but I left him with a sack of water, food, and his bracelet that is for good luck. It’s a religious bracelet that was taken off of him when he first came to our hospital. I gave it back to him. And said goodbye. And he thanked me in English, he said, Thank you, Commander, and the only reason he knew my rank was because the gentleman that rescued me, the MP that rescued me from when he hit me, said Commander, are you okay? And he remembered that. Our name tags are covered. Otherwise he didn’t know my name. But he did know some English and he did understand, so I said to him, Tašakor, which is Thank you. And he looked very puzzled at me. And I told him, You taught me a valuable lesson, even though I don’t think he understood me, I think he did because he saw my eyes. And I did become attached to him, even though he hurt me, but I think that if he made it back, he might say, they’re not as bad as you think. They gave me very good care.

One of the largest sources for conflict from the nurses we interviewed was caring for the enemy... Caring for the Enemy One of the largest sources for conflict from the nurses we interviewed was caring for the enemy, or those that U.S. soldiers have gone overseas to fight. Nurses had ample opportunity to care for them as well as for prisoners of war. While they showed compassion at every step of the way, they still sometimes had difficulty for numerous reasons. Sometimes the enemy or prisoners mistreated them, sometimes they were caring for an enemy alongside those Americans they had just injured. Some of them parsed out pain medications, so they would have enough for the injured Americans. However, that was rare and the majority of the nurses, though tested in ways they never imagined, also felt a certain pride in the fact that they overcame their fears and disdain. They believed they were able to make a positive difference in the lives of fellow humans and to perhaps sway the enemy perception of American service members.

G5: I think what a lot of nurses don't realize is, you hear in the States that you get to take care of Americans. And that's great. You get to serve your own people, so to speak. And then you go over there, and you're like, okay, I'm here to serve my American soldiers, they're over here, they're fighting the war, so I'm here to take care of them. And then when you're faced with – you just shot my American soldier. And I'm American. So we got a lot of insurgents that we had to take care of, and it was a whole lot to have to face that patient and know that – I have to give him optimum care, I have to give him just like an American soldier. P6: And – I turned to walk away, and he said, you know, some of the prisoners have changed their minds about Americans. Because of the compassionate care they received. And I turned around – I was like – really? And he said, yeah, they actually gave up information about – like – where booby traps were set, and stuff. So in the end, it ended up saving all lives, not just American lives but – children and Iraqis and – and I just thought that was the neatest thing in the world to hear, because it was so hard and so much work, and so – spiritually challenging at times and – then to hear that it actually made a difference to be kind and compassionate. P7: …..as well, that was in our compound – which was also challenging for us, and some of our people didn't like the idea of having to take care of Iraqis that were terrorist and were utilizing all our supplies, and they had nowhere to go. My edict to my staff was: These people are injured. Humanity-wise, we need to take care of them. I don’t care who they are, what they did or anything else. That is what we need to do.

Caring for Civilians Nurses never balked at having to care for local civilians who were either injured as collateral damage or ill, but they wavered because most of the time it was a long-term commitment. Sometimes they cared for them for months, trying to get them to a point where they could possibly survive outside the American hospital walls. The medical system in those countries was not as sophisticated as it is in this country, nor did it have the resources to care for injured people for the long-term. Their facilities were as overtaxed as the American hospitals, but we welcomed these people. The people knew this and seemed to flock to the hospitals for whatever care they could get.

G6: I mean, their culture is so different than ours. But he was such a long-term patient and we did that for him, too. So the nurses got to where we were looking into, how could we continue to receive these air mattresses and stuff for these patients, because the Iraqi patients pretty much get stuck there. There's no where [sic] to send them. If you want 'em to survive. It becomes a real, real nursing issue. And an ethical issue.

However, the culture of the people sometimes also conflicted with their own sense of survival and the nurses began to wonder why they were spending so much time and resources on people who did not share American values.

G2: Knowing that it was futile care, a lot of it, because they don't care. About survival the way we do. (Arabic phrase), “As God wills.” They won't do anything. God wills it, it’ll happen, and that means if I don't have to do anything, I don't have any responsibility for the outcome.…….

Yet at the same time, nurses had difficulty with overuse of American resources on local civilians, especially when bed space was in short supply, or resources were not available for American casualties. The nurses knew that triaging locals out of the hospital could very well be a death sentence for them. They often spoke about the compassion they felt for these civilians or children who, through no fault of their own were suffering because of a war.

P8: ….yet when you see these starving people who are in such need, your heart goes out to them and you think, well, somebody's gotta help. What are you gonna do these people are starving, and it's not just because of the two years of war. And then when you have people who've never had calcium in their diets so their bones are osteoporotic at 40 – their wound healing is terrible, you have 90-pound men as an average. And the men walk down the hallway and you can see every bone. They look like they belong in a concentration camp and you – it breaks your heart to see human beings in such need, and struggle with how to take care of them, but that wasn't – our job is [sic] to provide long-term care, so it was real hard ethically. Where do you draw the line in saying, okay, we're gonna send you home now. We're gonna send you to an Iraqi hospital, after we did all this work to save your life, and now you may die in an Iraqi hospital, but we're not a long-term rehab center. You know. What do we do?

One of the more difficult things for nurses was caring for injured service members...then not knowing the outcome of their work. Need for Follow-Up/Closing the Loop One of the more difficult things for nurses was caring for injured service members, putting every ounce of their energy into saving them for transport out of the country, then not knowing the outcome of their work. They expressed the need for more follow-up for those who made it through transport, because they believed it would validate their work. However, this was not often the case and all they could do was wonder about the outcome. They believed that was one of the continuing questions they asked themselves when they remembered a certain patient. Sometimes they wondered if saving some of the individuals from horrific injuries was going to be seen by the patient and his/her family as “worth being saved from.” These were not the typical patients who had received their care in the States prior to deployment, so they wondered about the long-term disability of patients, both physically and mentally.

G7: And I think – I just got the thing, too, that we saw some horribly wounded people. I know it's not for us to decide, but were we really doin' them any favors, with the massive injuries – maybe we should have let 'em – some of 'em go. I mean, I had one guy who had two drains in his head, an ICP monitor and half his skull was out. I don't know how he did but I'm just like – the long-term prognosis – like I say, we don't know how they end up doin'. Or they're missin' both their legs and one arm, long-term. Are we really doin' them any favors. G8: I couldn’t tell you – I mean, I couldn’t recognize any of the Americans that I took care of over there ‘cause you have ‘em for such a short period of time, and everything is so rushed, and you don’t see ‘em lookin’ their normal, I mean, you see him intubated, and they’re sedated, and they’re usually swollen and puffy and full of fluid that we’ve pumped in, and you don’t remember anybody’s names. There’s so many that you just don’t remember. And then you feel bad because you come over here and – like I’ll see burn patients, I’m like – I wonder if I took care of him, or I wonder if I took care of this one. So it’s kinda – and you feel like – I feel like I should remember – that I should remember their names, or that I should remember something.

...both male and female nurses who deployed to Iraq and Afghanistan displayed a strength that may have surprised even them... The findings of moral distress and ethical issues in this study support the literature, but not in the same ways reported in previous articles. We found that many earlier studies presented certain aspects of ethical issues, but not a comprehensive picture ( Mark et al., 2009 ; Scannell-Desch & Doherty, 2010 ; Thompson & Mastel-Smith, 2012 ). Our findings both support and expand on two important findings from an earlier study where the authors described ethical dilemmas regarding care for Iraqi patients and their transfer of care to a local facility ( Goodman, Edge, Agazio, & Prue-Owens, 2013 ). In that study, Goodman et al. described nurses as feeling distressed about caring for Iraqi patients, but only that they felt bad about having to care for them. Our study provided a more detailed look at the nurses’ feelings, and sometimes how they dealt with them.

This study supported the results of a study finding by Thompson and Mastel-Smith ( 2012 ) that nurses reported both a personal difficulty, but yet an inner satisfaction of caring for the enemy as human beings and doing their part to promote goodwill. However, this care was not without personal consequences, such as feelings of guilt over conflict within themselves. Nurses in this study expressed the notion that this difficulty made them stronger and better able to see both sides of war. Like the Civil War women described by Wood ( 1972 ), both male and female nurses who deployed to Iraq and Afghanistan displayed a strength that may have surprised even them and a willingness to care for fellow humans, no matter the side.

Limitations

Initial coding of the qualitative data occurred with a coding framework that was developed during a research team meeting following a detailed discussion and agreement by the entire team. All transcripts were reviewed, discussed and coded consistent with code definitions. For this article, the code and quotations for “ethical, moral, political challenge” were extracted and text then analyzed and synthesized into the above themes. This required interpretive syntheses and it is possible that some bias may have been introduced. However, this was mitigated by the use of “bracketing” during synthesis. Every attempt was made to ensure that themes remained as close as possible to the intent of the nurse participant descriptions. Additionally, results, though comprehensive for the context of this study, are not generalizable to nursing in all war scenarios.

The nurses made it evident that...they were proud of themselves and how they handled wartime situations. It was clear that ethical dilemmas experienced by nurses in this study were unlike anything they had ever encountered in previous assignments. They relayed both negative and positive dilemmas to the research team in a level of detail not tainted by the passage of too much time. Even though many stories will retain their detail for these nurses, some will fade and some details will be forgotten. This is precisely why it was so important to capture these stories as soon as possible after deployment.

The nurses made it evident that despite the dilemmas they faced, they were proud of themselves and how they handled wartime situations. They believed they continued to provide the best care they could for service members, enemies, and civilians alike. They did not hesitate to make what they considered to be the “right decision.” However, at the same time, they continued to question the necessity and ethics of war itself. But they knew their purpose and will defend their right to be a part of it and serve the country by doing what their profession and their country required of them.

P8: And so it kept life in perspective, and – I think the only – conflicted part I feel about the whole thing is, I'm more confused than ever, how I feel about the war. I had my opinion set when I went over there, and I just thought I'd focus on my job, to take care of the troops. That's every – all the politics are not my problem. My job is to take care [sic] of the wounded. And the problem is, I still don't know that we're gonna solve anything.

Nurses should be informed about types of ethical challenges they may face and offered suggestions and coping tools before deployment. Based on the results of this study, the authors suggest that uniformed nurses going to countries of conflict or on humanitarian missions are provided with open and honest communication about the types of patients they will encounter. Additionally, nurses should be provided more in-depth training of the culture of those countries and how best to handle patients who may be openly hostile to them. Nurses should be given basic in-country patient care language, such as “Where is your pain?”, “It is not time yet for more pain medication” or other specific words important to patient care, such as “medicine”, “drink”, and “urinate”, and “blood.” Nurses should be informed about types of ethical challenges they may face and offered suggestions and coping tools before deployment. They should be provided with mental healthcare resources during deployment and after return home, so that they can deal with concerns openly and without fear of retribution or loss of promotion opportunities. In summary, nurses should not simply be sent to a war zone, or on a humanitarian mission, with an expectation to handle issues as best they can.

Authors’ Note : This research was sponsored by the TriService Nursing Research Program, Uniformed Services University of the Health Sciences; however, the information or content and conclusions do not necessarily represent the official position or policy of, nor should any official endorsement be inferred by, the TriService Nursing Research Program, Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government.

Deborah J. Kenny, PhD, RN, FAAN Email: [email protected]

Patricia Watts Kelley, PhD, FNP-BC, GNP-BC, FAANP, FAAN Email: [email protected]

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September 30, 2019

DOI : 10.3912/OJIN.Vol24No03Man01

https://doi.org/10.3912/OJIN.Vol24No03Man01

Citation: Kenny, D.J., Kelley, P.W., (September 30, 2019) "Heavy Burdens: Ethical Issues Faced by Military Nurses during a War" OJIN: The Online Journal of Issues in Nursing Vol. 24, No. 3, Manuscript 1.

• Article September 30, 2019 Psychological Effects of Military Service: Applying Research to Civilian & Academic Environments Katie A. Chargualaf, PhD, RN, CMSRN; Brenda Elliott, PhD, RN, CNE
• Article September 30, 2019 The Nursing Profession in Jordan: Military Nurses Leading the Way Rowaida Al Maaitah, DrPH, MPH, RN ; Daad Z Shokeh, MSc, APN, RN ; Saba A. Al-Ja'afreh, RN, MSc
• Article January 07, 2020 Commissioned Corps Deployments & Family Resiliency Janice Marie Arceneaux, DNP, APRN, FNP-C, CMSRN; James LaVelle Dickens, DNP, APRN, FNP-BC, FAANP; Wanza Bacon, MBA, BSN, RN
• Article September 30, 2019 A New Approach to Preparing Nurses for War: The Army School of Nursing Gwyneth Milbrath, PhD, RN, MPH
• Article September 30, 2019 Air Force Executive Nurse Leaders: Expanding Nursing Leadership During 1995-1999 Lauren Brackett, BS, MSN; Robie Victoria Hughes, DNS, MSN, MA, RN, CENP

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• Copy URL https://www.pbs.org/newshour/politics/fact-checking-warnings-from-democrats-about-project-2025-and-donald-trump

Fact-checking warnings from Democrats about Project 2025 and Donald Trump

This fact check originally appeared on PolitiFact .

Project 2025 has a starring role in this week’s Democratic National Convention.

And it was front and center on Night 1.

WATCH: Hauling large copy of Project 2025, Michigan state Sen. McMorrow speaks at 2024 DNC

“This is Project 2025,” Michigan state Sen. Mallory McMorrow, D-Royal Oak, said as she laid a hardbound copy of the 900-page document on the lectern. “Over the next four nights, you are going to hear a lot about what is in this 900-page document. Why? Because this is the Republican blueprint for a second Trump term.”

Vice President Kamala Harris, the Democratic presidential nominee, has warned Americans about “Trump’s Project 2025” agenda — even though former President Donald Trump doesn’t claim the conservative presidential transition document.

“Donald Trump wants to take our country backward,” Harris said July 23 in Milwaukee. “He and his extreme Project 2025 agenda will weaken the middle class. Like, we know we got to take this seriously, and can you believe they put that thing in writing?”

Minnesota Gov. Tim Walz, Harris’ running mate, has joined in on the talking point.

“Don’t believe (Trump) when he’s playing dumb about this Project 2025. He knows exactly what it’ll do,” Walz said Aug. 9 in Glendale, Arizona.

Trump’s campaign has worked to build distance from the project, which the Heritage Foundation, a conservative think tank, led with contributions from dozens of conservative groups.

Much of the plan calls for extensive executive-branch overhauls and draws on both long-standing conservative principles, such as tax cuts, and more recent culture war issues. It lays out recommendations for disbanding the Commerce and Education departments, eliminating certain climate protections and consolidating more power to the president.

Project 2025 offers a sweeping vision for a Republican-led executive branch, and some of its policies mirror Trump’s 2024 agenda, But Harris and her presidential campaign have at times gone too far in describing what the project calls for and how closely the plans overlap with Trump’s campaign.

PolitiFact researched Harris’ warnings about how the plan would affect reproductive rights, federal entitlement programs and education, just as we did for President Joe Biden’s Project 2025 rhetoric. Here’s what the project does and doesn’t call for, and how it squares with Trump’s positions.

Are Trump and Project 2025 connected?

To distance himself from Project 2025 amid the Democratic attacks, Trump wrote on Truth Social that he “knows nothing” about it and has “no idea” who is in charge of it. (CNN identified at least 140 former advisers from the Trump administration who have been involved.)

The Heritage Foundation sought contributions from more than 100 conservative organizations for its policy vision for the next Republican presidency, which was published in 2023.

Project 2025 is now winding down some of its policy operations, and director Paul Dans, a former Trump administration official, is stepping down, The Washington Post reported July 30. Trump campaign managers Susie Wiles and Chris LaCivita denounced the document.

WATCH: A look at the Project 2025 plan to reshape government and Trump’s links to its authors

However, Project 2025 contributors include a number of high-ranking officials from Trump’s first administration, including former White House adviser Peter Navarro and former Housing and Urban Development Secretary Ben Carson.

A recently released recording of Russell Vought, a Project 2025 author and the former director of Trump’s Office of Management and Budget, showed Vought saying Trump’s “very supportive of what we do.” He said Trump was only distancing himself because Democrats were making a bogeyman out of the document.

Project 2025 wouldn’t ban abortion outright, but would curtail access

The Harris campaign shared a graphic on X that claimed “Trump’s Project 2025 plan for workers” would “go after birth control and ban abortion nationwide.”

The plan doesn’t call to ban abortion nationwide, though its recommendations could curtail some contraceptives and limit abortion access.

What’s known about Trump’s abortion agenda neither lines up with Harris’ description nor Project 2025’s wish list.

Project 2025 says the Department of Health and Human Services Department should “return to being known as the Department of Life by explicitly rejecting the notion that abortion is health care.”

It recommends that the Food and Drug Administration reverse its 2000 approval of mifepristone, the first pill taken in a two-drug regimen for a medication abortion. Medication is the most common form of abortion in the U.S. — accounting for around 63 percent in 2023.

If mifepristone were to remain approved, Project 2025 recommends new rules, such as cutting its use from 10 weeks into pregnancy to seven. It would have to be provided to patients in person — part of the group’s efforts to limit access to the drug by mail. In June, the U.S. Supreme Court rejected a legal challenge to mifepristone’s FDA approval over procedural grounds.

WATCH: Trump’s plans for health care and reproductive rights if he returns to White House The manual also calls for the Justice Department to enforce the 1873 Comstock Act on mifepristone, which bans the mailing of “obscene” materials. Abortion access supporters fear that a strict interpretation of the law could go further to ban mailing the materials used in procedural abortions, such as surgical instruments and equipment.

The plan proposes withholding federal money from states that don’t report to the Centers for Disease Control and Prevention how many abortions take place within their borders. The plan also would prohibit abortion providers, such as Planned Parenthood, from receiving Medicaid funds. It also calls for the Department of Health and Human Services to ensure that the training of medical professionals, including doctors and nurses, omits abortion training.

The document says some forms of emergency contraception — particularly Ella, a pill that can be taken within five days of unprotected sex to prevent pregnancy — should be excluded from no-cost coverage. The Affordable Care Act requires most private health insurers to cover recommended preventive services, which involves a range of birth control methods, including emergency contraception.

Trump has recently said states should decide abortion regulations and that he wouldn’t block access to contraceptives. Trump said during his June 27 debate with Biden that he wouldn’t ban mifepristone after the Supreme Court “approved” it. But the court rejected the lawsuit based on standing, not the case’s merits. He has not weighed in on the Comstock Act or said whether he supports it being used to block abortion medication, or other kinds of abortions.

Project 2025 doesn’t call for cutting Social Security, but proposes some changes to Medicare

“When you read (Project 2025),” Harris told a crowd July 23 in Wisconsin, “you will see, Donald Trump intends to cut Social Security and Medicare.”

The Project 2025 document does not call for Social Security cuts. None of its 10 references to Social Security addresses plans for cutting the program.

Harris also misleads about Trump’s Social Security views.

In his earlier campaigns and before he was a politician, Trump said about a half-dozen times that he’s open to major overhauls of Social Security, including cuts and privatization. More recently, in a March 2024 CNBC interview, Trump said of entitlement programs such as Social Security, “There’s a lot you can do in terms of entitlements, in terms of cutting.” However, he quickly walked that statement back, and his CNBC comment stands at odds with essentially everything else Trump has said during the 2024 presidential campaign.

Trump’s campaign website says that not “a single penny” should be cut from Social Security. We rated Harris’ claim that Trump intends to cut Social Security Mostly False.

Project 2025 does propose changes to Medicare, including making Medicare Advantage, the private insurance offering in Medicare, the “default” enrollment option. Unlike Original Medicare, Medicare Advantage plans have provider networks and can also require prior authorization, meaning that the plan can approve or deny certain services. Original Medicare plans don’t have prior authorization requirements.

The manual also calls for repealing health policies enacted under Biden, such as the Inflation Reduction Act. The law enabled Medicare to negotiate with drugmakers for the first time in history, and recently resulted in an agreement with drug companies to lower the prices of 10 expensive prescriptions for Medicare enrollees.

Trump, however, has said repeatedly during the 2024 presidential campaign that he will not cut Medicare.

Project 2025 would eliminate the Education Department, which Trump supports

The Harris campaign said Project 2025 would “eliminate the U.S. Department of Education” — and that’s accurate. Project 2025 says federal education policy “should be limited and, ultimately, the federal Department of Education should be eliminated.” The plan scales back the federal government’s role in education policy and devolves the functions that remain to other agencies.

Aside from eliminating the department, the project also proposes scrapping the Biden administration’s Title IX revision, which prohibits discrimination based on sexual orientation and gender identity. It also would let states opt out of federal education programs and calls for passing a federal parents’ bill of rights similar to ones passed in some Republican-led state legislatures.

Republicans, including Trump, have pledged to close the department, which gained its status in 1979 within Democratic President Jimmy Carter’s presidential Cabinet.

In one of his Agenda 47 policy videos, Trump promised to close the department and “to send all education work and needs back to the states.” Eliminating the department would have to go through Congress.

What Project 2025, Trump would do on overtime pay

In the graphic, the Harris campaign says Project 2025 allows “employers to stop paying workers for overtime work.”

The plan doesn’t call for banning overtime wages. It recommends changes to some Occupational Safety and Health Administration, or OSHA, regulations and to overtime rules. Some changes, if enacted, could result in some people losing overtime protections, experts told us.

The document proposes that the Labor Department maintain an overtime threshold “that does not punish businesses in lower-cost regions (e.g., the southeast United States).” This threshold is the amount of money executive, administrative or professional employees need to make for an employer to exempt them from overtime pay under the Fair Labor Standards Act.

In 2019, the Trump’s administration finalized a rule that expanded overtime pay eligibility to most salaried workers earning less than about $35,568, which it said made about 1.3 million more workers eligible for overtime pay. The Trump-era threshold is high enough to cover most line workers in lower-cost regions, Project 2025 said.

The Biden administration raised that threshold to $43,888 beginning July 1, and that will rise to $58,656 on Jan. 1, 2025. That would grant overtime eligibility to about 4 million workers, the Labor Department said.

It’s unclear how many workers Project 2025’s proposal to return to the Trump-era overtime threshold in some parts of the country would affect, but experts said some would presumably lose the right to overtime wages.

Other overtime proposals in Project 2025’s plan include allowing some workers to choose to accumulate paid time off instead of overtime pay, or to work more hours in one week and fewer in the next, rather than receive overtime.

Trump’s past with overtime pay is complicated. In 2016, the Obama administration said it would raise the overtime to salaried workers earning less than $47,476 a year, about double the exemption level set in 2004 of $23,660 a year.

But when a judge blocked the Obama rule, the Trump administration didn’t challenge the court ruling. Instead it set its own overtime threshold, which raised the amount, but by less than Obama.

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