CULTURALLY COMPETENT CARE FOR VETERANS

Military service members, their families, and veterans have unique needs that require a culturally competent approach to healthcare services. There are approximately 18 million veterans as well as 2.1 million military service members in the United States. Approximately 6% of Americans have been in or are currently in the military (Inoue et al., 2023).

Combat and military experiences directly and indirectly impact veterans’ health and well-being. It is important to recognize how military experiences may be associated with different adverse outcomes in order to provide quality interventions and support services.

The key elements of military culture include:

• Chain of command
• Strict routine and structure
• Respect for authority and oneself
• Strength (not asking for help)
• Honor (used to being trusted)
• Aggression (faster, harder, louder, meaner)

Health Disparities and Health Risk Factors

Health disparities unique to the veteran population include increased comorbidities and the mental and physical effects of trauma experienced during their service. Disparities can vary according to the sex, race, sexual orientation, age, and socioeconomic status of the veteran (Tran & Huang, 2022).

Results from a study conducted in 2019 found that 53% of 10,000 veterans who participated in the study had chronic physical health conditions. In the same study, 33% of veterans had chronic mental health conditions. The most common chronic health conditions included:

• Chronic pain
• Sleep problems
• Anxiety
• Depression
  (Horrom, 2020)

POSTTRAUMATIC STRESS DISORDER (PTSD)

Approximately 2% to 17% of veterans experience combat-induced PTSD, a mental health condition that may occur as a result of their military service. Some veterans may have difficulty being able to identify or talk about the emotional or cognitive characteristics of PTSD. Reports of insomnia may indicate the need to investigate whether the veteran is experiencing PTSD symptoms. It is important to take a thorough and detailed history, since the diagnosis of PTSD is reliant on the patient’s history (Inoue et al., 2023).

SUICIDE

Over 6,000 veterans die by suicide in the United States each year. One study calculated that veterans comprise 17.8% of known suicide cases, and suicide rates for veterans are 1.5 times the rate of the general population. Veterans are at a particularly marked risk for suicide in their first year after being discharged from military service. Although the Department of Defense and the Veterans Administration (VA) have attempted to reduce the suicide rate for veterans through preventive programs, the suicide rate for veterans has remained the same since 2012 (Inoue et al., 2023).

SUBSTANCE USE DISORDERS

Alcohol use disorders are the most common substance use disorders among veterans and military service members, and more than half (56.6%) of veterans consume alcohol. An estimated 27% of veterans smoke tobacco, and 24% of veterans have opioid prescriptions. Mental health conditions such as PTSD and depression, as well as deployments, combat, and becoming a civilian after military service, may contribute to the development of substance use disorders in veterans and military service members (Inoue et al., 2023).

Best Practices for Culturally Competent Care for Veterans

Best practices for culturally competent care of veterans include avoiding common stereotypes about the veteran population, caring in a trauma-informed manner, understanding and being sensitive of the multiple comorbidities of veterans, and understanding the long-term effects that military culture may have had on the patient.

UNDERSTAND THE UNIQUENESS OF EACH INDIVIDUAL VETERAN

There is no conventional identity for a veteran. Not all veterans are older, served during wartime, were injured or have a disability, or are male. Likewise, not all those who served in the military self-identify as “veterans”; thus, healthcare professionals may ask, “Were you in the military?” instead of “Are you a veteran?”

Culturally competent care includes an awareness of common stereotypes about the veteran population, which include:

• All veterans are in crisis.
• All veterans have posttraumatic stress disorder and/or substance use issues.
• All veterans served in combat.
• All veterans have access to Department of Veterans Affairs (VA) healthcare.
• All veterans are homeless.
• All veterans want to be thanked for their service.
  (CalVet, n.d.)

PROVIDE TRAUMA-INFORMED CARE

Many veterans experience trauma before, during, and after their military service. This trauma can contribute to mental health conditions such as PTSD and military sexual trauma (MST). In addition, veterans have more anxiety, depression, and mental distress than nonveterans, and female veterans have higher rates of mental health conditions than male veterans. An estimated one third of female veterans have experienced MST. Veterans who have experienced trauma may act irritable and anxious.

Caring in a trauma-informed manner includes:

• Deflecting common triggers such as crowded areas, loud noises, or unanticipated physical touching that may lead to disturbing thoughts, extreme emotions, or flashbacks
• Obtaining consent at all times prior to making physical contact. Explain what you intend to do, such as “To take your blood pressure, I need to place this cuff on your arm. Is that okay?”
• Creating a relationship of trust through your actions. Be reliable, compassionate, and honest while providing care.
• Addressing the patient’s comments, concerns, and questions in a way that does not rush
• Not appearing to confront the patient when talking about noncompliance. Do not say, “You could lose a foot if you don’t get your blood glucose levels under control.” Instead, say, “I understand that monitoring your blood glucose levels can be hard because [what the patient stated was their concern]. Let’s work together to come up with a realistic plan to get your blood glucose levels on track because it’s really important that they are controlled.”
• Providing a safe environment in case a patient becomes distressed. State calmly, “Let’s work on how to help you feel safe. How can I help?”
  (Tran & Huang, 2022)

USE SENSITIVITY WHEN ADDRESSING COMORBIDITIES

Veterans experience more comorbidities than the nonveteran population. Because of this, a veteran is more likely to have a complicated medical history that may include physical, psychological, or substance use disorder. Sensitivity is important when addressing the healthcare needs of a patient with comorbidities.

Addressing comorbidities in a sensitive manner includes:

• Using people-first language, which is a way of communicating with people with disabilities by focusing on the person first, instead of the disability. For example, a veteran who is in a wheelchair is not referred to as “handicapped” but instead as a person with a disability.
• Understanding that environmental exposures the veteran experienced could be contributing to the comorbidities. For example, veterans of the Vietnam and Korean wars may have been exposed to Agent Orange, a chemical linked to cancer, diabetes, ischemic heart disease, and Parkinson’s disease.
  (Tran & Huang, 2022)

BE AWARE OF THE LONG-TERM EFFECT MILITARY CULTURE CAN HAVE ON THE PATIENT

A veteran may experience long-term effects of military culture throughout the rest of their life. In military culture, the needs of the group are prioritized over the needs of the individual. Military members are also taught to follow the “chain of command” leadership structure. Because of this, some patients who are veterans may not prioritize self-care, could have mixed feelings about the care they are receiving, and may not think their needs are as important as someone else’s. To address this, the clinician must listen carefully to what the patient has to say without being judgmental, and must relay compassion in the eye contact and body language used when communicating. One example of this is to listen and make eye contact when the patient is talking about something that is bothering them instead of charting on the computer as they speak (Tran & Huang, 2022).