Meeting the Needs of Women Veterans in Civilian Primary Care Practices

Problem/Purpose:Women are the fastest growing segment of the veteran population—approximately 1.8M are currently serving in the armed forces and 220,000+ have deployed in support of the wars in Iraq and Afghanistan. Women are now eligible to perform duties in more than 90% of all military career fields. Women in the military have steadily progressed from serving in support roles to serving in combat support roles to ultimately evolving to women currently serving with men, not only in combat zones, but in wars where there is no defined frontline, thus placing them in the direct line of fire. Due to the influx of women serving during this latest conflict and the increase in the number of women veterans seeking care in Veteran Administration (VA) clinics requiring a wide variety of physical and psychological health services, women veteran health issues have become a population of interest for the VA and theDepartment of Defense (DoD).

The DoD has prioritized programs to address rising rates of veteran homelessness, divorce, and suicide. The Institute of Medicine (IOM) and Congress have indicated a need for increased funding for educating health care providers to care for veterans to minimize enduring military service related physical and psychological co-morbidities. These issues appear to be increasing amongst the women veteran population. According to a study conducted by the VA, women veterans are “2.1 times more likely to be homeless than their nonveteran counterparts” and regardless of age or race, all women veterans are at an increased risk form homelessness4. In 2010, the Pentagon acknowledge concern regarding the divorce rate of women in the military—7.8% of women as compared to 3% of men in the military. The rates of divorce among women in the enlisted corps are estimated to be slightly higher at approximately 9%. Finally, according to a 2015 VA report, the risk of suicide for women veterans ages 18-29 is 12 times the rate of non-veteran women. Between 2000 and 2010, suicide claimed the lives of more than 170,000 veterans of which suicides among female veterans rose by 40 percent during the decade. A study conducted by the VA looked at the differences between male and female OEF/OIF/OND veterans and VA healthcare utilization for mental and physical health services and results showed that women had more visits to primary care and mental health clinics as well as higher use of community care outside the VA.

The realization that women veterans’ healthcare needs are inherently different than male veterans and an increase in women veterans seeking care in the civilian sector has created a need for increased knowledge and expertise regarding identification of women veterans in civilian healthcare practices as well as a need for continuous improvement and evaluation of women veteran specific services. Studies show that less than 20% of all veterans are actually seen in the VA Health care system by providers who are aware and knowledgeable about their patient’s military status and possible service connected risk factors and exposures. This leaves roughly 80% of veterans, many of whom are women, receiving care in the civilian sector where military status and women veteran specific healthcare needs are unknown to providers.

Fredricks et al., 2015 concluded that more than half of the 141physician respondents they surveyed were not comfortable discussing health-related exposures and associated risks experienced by veterans and more than half expressed unfamiliarity with referral/consultation services available to veterans. There is a lack of knowledge regarding the military, the military culture, and the effect of military service on the overall mental and physical health of veterans, in particular women veterans, which leaves the veteran at a significant disadvantage in regards to their overall healthcare needs. Women veterans have unique physical and psychological healthcare needs that vary from their male counterparts and it is important that civilian healthcare providers are educated on the importance of screening women for military service and are aware of the unique healthcare needs of this population.

Methods:This study will pilot test a 42-item survey amongst a minimum of 100 APRNs who are members of the AANP. The sample will include APRNs who are at least 18 years or older. We will recruit from AANP by posting recruitment e-flyers through the AANP lists serv. The survey link will be included on the recruitment materials. Data will be collected from an online survey posted on Qualtrics and all data will be collected anonymously.

Results:The study is currently in progress. To our knowledge this will be the first study looking at the knowledge and comfort level of Advanced Practice Registered Nurses caring for women veterans in civilian clinical practice. Based on data from the Fredricks et al. study, the investigators on this study hypothesizes that knowledge and comfort level of APRNs regarding caring for women veterans will have less knowledge and a decreased comfort level in regards to women veterans specifically than veterans as a whole.

Discussion:The Joining Force campaign developed by First Lady Michelle Obama and Dr. Jill Biden challenged colleges of nursing around the country to work to improve the healthcare of our veterans. To date over 660 nursing programs in all 50 states have joined forces to included veteran centric healthcare issues into nursing and advanced practice nursing curriculum with several colleges including specific needs of military families in their curriculum. In 2012, the American Academy of Nursing launched the “Have You Ever Served in the Military” campaign to meet the needs of veterans receiving care in the civilian health care system. While much work has been done, much work is still needed. APRNs are on the frontlines of healthcare often working in clinics, hospitals, and community agencies, and may be the first to encounter a woman veteran in crisis or experiencing physical and/or psychological co-morbidities secondary to their military service. Due to the potential correlation between military service and physical and psychological comorbidities, it is imperative for all healthcare providers to screen women patients for a history of military service and to be educated provide appropriate care and the knowledge regarding resources and referrals available to women veterans in the community. Prompt identification and treatment is imperative to decrease deleterious health consequences related military service and to improve the care women veterans receive in the civilian sector.

Meeting the Needs of Women Veterans in Civilian Primary Care Practices will help assess the knowledge gaps of Advanced Practice Registered Nurses (APRNs) in regards to women veteran health issues. Data gained will be used to promote early identification of women veterans in civilian clinical practice where upwards of 80% of veterans receive their care. This study will help bridge the knowledge gap of civilian providers regarding military service related risk factors and co-morbidities as well as knowledge regarding referral sources/resources in the community that would improve health outcomes of women veterans and their family members. This study has the potential to decrease the impact of homelessness, post-traumatic stress, military sexual trauma, suicide, and other co-morbidities women veterans’ experience.

Conclusion: The number of women veterans in this country has increased significantly since the onset of OEF/OIF/OND. They have answered our nation's call to defend our country. Sadly, by doing so, many are at risk for service connected physical and psychological health issues that go undetected in civilian healthcare facilities due to the lack of knowledge and comfort level of civilian healthcare providers. There is a lack of knowledge regarding the military, the military culture, and the effect of military service on the overall mental and physical health of veterans, in particular women veterans, which leaves the veteran at a significant disadvantage in regards to their overall healthcare needs. Women veterans have unique physical and psychological healthcare needs that vary from their male counterparts and it is important that civilian healthcare providers are educated on the importance of screening women for military service and are aware of the unique healthcare needs of this population. It is imperative that APRNs understand the need to screen every patient, especially female patients, for a history of military service as well as receive education and training regarding the unique healthcare needs of women veterans; their risk of trauma, subsequent PTSD and other psychological co-morbidities; identification of physical co-morbidities secondary to military service; and have access to evidence-based clinical practice in the civilian sector where most women veterans receive care. This study will close the gap surrounding knowledge deficits by providing colleges of nursing, state licensure boards, veteran healthcare related stakeholders, and national agencies and provide data and guidance for inclusion of evidence based veteran centric healthcare, to include women veteran specific healthcare, into education, training and certification programs for APRNs.