Background: Specialised care for veterans and military families is needed to respond to the unique health problems they experience. However, specific components of such training have yet to be examined.
Purpose: This investigation aimed to gather feedback from social work and nursing students on their experiences in a veteran-specific clinical placement to determine content for a new inter-professional training program at a large northeastern US university.
Materials and Methods: Two focus groups were conducted, one with master of social work students (n=8) and one with master’s level nursing students (n=4), all of whom had recent clinical placements in a veteran-specific site. A semi-structured interview guide was followed.
Results: Three broad categories of themes emerged from the data: challenges encountered (including challenges related to forming relationships with veterans and in working in the American Veterans Affairs healthcare system); strategies for responding to these challenges; and insights for training future clinicians.
Conclusion: Clinical training programs should consider including content that will both prepare students to work with veterans and military families and to face the challenges that exist in healthcare systems. Specialised training that includes military culture and problems specific to the population may help improve outcomes for veterans and military families.
Keywords: social work, nursing, education, veterans, health care
The recent conflicts in Iraq and Afghanistan have prompted an elaboration of the issues facing service members and families throughout deployment, during reintegration, and following separation from military service1,2. Several countries have committed to providing quality care to veterans and their families3,4. Specialised training has been called for so that clinicians are able to respond to the health and mental health needs arising in the context of military service5,6. Presumably such training would positively impact outcomes for veterans and for military families; however, the potential content of such specialised training has only just started to be examined. In a recent focus group investigation6, veterans and military family members observed that to deliver appropriate care, healthcare providers need to achieve a nuanced military/veteran cultural competency and receive training in the specific health and mental health issues facing veterans and military families.
Most specialised training for social work (SW) and nursing (N) students occurs during an advanced year clinical placement. Such a placement might be in a Department of Veterans Affairs (VA) hospital, a setting that provides care to veterans in the United States. In fact, to accommodate projected increases in demand from OIF/OEF (Operation Iraqi Freedom/Operation Enduring Freedom) veterans7, the VA recently announced plans to add 1900 clinicians8. Students who receive training in the care of veterans and military families may prove to be a vital component in the effective care of veterans in the US and elsewhere.
In spite of the availability of VA care, only about 30% of eligible veterans seek care at VA clinics9. The rest seek care in community-based settings, where there has been a recent push for inquiries about prior military service10. Consequently, clinicians working in any healthcare setting are likely to encounter veterans and military family members during their tenure in the field and may benefit from specialised knowledge about how to best respond to this population, given that military service may cause or exacerbate presenting problems11.
The present investigation sought to gather information from healthcare professionals in training who had a previous clinical placement in a veteran-specific healthcare setting. Participants were asked about their placement experiences and their views on needed pre-placement training. This information was gathered to inform curriculum development and content for a new inter-professional training program in veteran and military family care for graduate SW and N students at a large northeastern US university.
In May 2013, two focus groups were conducted with SW and N students who had completed a recent veteran-specific placement. This research was conducted as part of a larger study that included four additional focus groups (three with veterans and one with military family members) assembled to gather information about their experiences seeking health care and recommendations for training future professionals; these findings are reported elsewhere6.
The names of graduate SW and N students who had completed a veteran-specific placement were provided from their departments. Students were contacted via phone and/or email to determine their interest in participating. Screenings were conducted in person or over the telephone to ensure eligibility and collect demographic information. Students were eligible if they were over age 18, were a current or former SW or N student, and had completed the placement in the past three years.
Reminder calls and/or emails confirmed the date, time, and location of each focus group. Participants received a US$30 gift card and a gas card(s) to offset transportation costs. Study protocol was approved by our university’s Institutional Review Board.
The SW group (n=8) were recent master’s level SW graduates. Six were women and two were men; the median age was 31.5 years (range=23-47); 50% were Caucasian, 25% African American, and 25% indicated two races. Three participants were veterans. VA placements included: behavioural health (25%); Healthcare for Homeless Veterans program (25%); women’s clinic (12.5%); medical SW (12.5%); a geriatric/hospice/rehabilitative care unit (12.5%); and multiple units (12.5%).
The N group (n=4) were female and identified as Caucasian; the median age was 46 years (range=31-55). Two were current students and two were master’s level N graduates. Specialisations included: psychiatric mental health (50%); gerontology (25%); and anaesthesia (25%). Clinical rotations at the VA were consistent with each student’s specialisation. One participant was currently an Army Reservist.
A semi-structured interview guide was developed to elicit feedback on participants’ placement experiences. Participants were informed that the investigators were seeking: “…to learn from you about how to better prepare social workers and nurses to meet the healthcare needs of veterans and their families.”
Among the issues queried were the student’s level of preparation for working in a veteran-specific setting, challenges encountered, whether knowledge of military culture would be important to work effectively with this population, and what should be taught prior to placement.
Two separate groups were held, organised by discipline, to maximise utility for the programs being developed in the respective schools. Each 90-minute group was facilitated by a 2-3 person team. Group content, including assent, was audio-recorded. To protect participants from perceived risk associated with sharing their views, no facilitator had an academic or supervisory relationship with any participant.
Qualitative descriptive content analysis12 was used to analyse transcript data following transcription and verification. This method is appropriate when the phenomena under investigation are complex13 and have not been previously studied. One researcher (BKL) performed initial analyses. Codes were refined by soliciting feedback from research team members who had facilitated focus groups or were familiar with the transcripts.
Three categories of themes emerged: challenges students encountered; responses to these challenges; and recommendations for future pre-placement training.
Challenges in Veteran-Specific Settings
The challenges that SW and N students described in their placements involved issues encountered working with veterans and military family members and issues related to the VA healthcare system.
Forming relationships with veterans and military family members. Students from both disciplines noted difficulties in forming professional relationships with veterans, particularly building trust, rapport, and empathetic connection. One N student remarked, “…one challenge I noticed was building trust, having veterans trust me enough to … open up in front of me.” Another N student affirmed this concern, “It takes a lot of work to build rapport with them.”
According to SW participants, clients were often concerned about whether their providers would be able to relate to or empathise with them. Many SW students noted that veterans often asked trainees if they were veterans themselves. Some students were, in fact, veterans and noted that it did not necessarily facilitate rapport. One student explained, “I’m a veteran; not a combat veteran…some of them didn’t think I was able really to quite relate to their experiences.”
A parallel process took place with military family members: they were reticent to trust someone who did not have first-hand experience. One SW student noted:
I think my biggest challenge—and sometimes it was the veterans, but…sometimes even more so with the family—was: “how do you know?” Because I’m not a veteran. I’m not married to a veteran. I sometimes had a challenge of breaking through, “how can you be the one counselling us when you really haven’t been in our shoes at all?”
Another SW student explained, “military families would become emotional or angry at us because we don’t understand what’s going on.”
The second group of challenges that students noted were imposed by the procedures or policies of the VA healthcare system. These challenges frustrated students because they were seen as a threat to providing quality care.
Inadequate time allocation. Several SW students explained that the time they were given to perform their duties was insufficient. One student remarked:
…we had to do a full assessment in 15 minutes and figure out what kind of services that veteran needed in a short amount of time, and then actually had to write a [progress] note. For me that was a challenge because you can’t possibly assess anybody in 15 minutes and give them a diagnosis…
They also commented on the challenge of completing clinical documentation within 24 hours of client contact, per VA policy.
Limited medication options. N students did not comment on time limitations, however they did voice concerns about apparent medication limitations. One explained, “There were some medications that were not allowed at all, that if you were under any other health plan, they would have been covered.” Another, who specialised in anaesthesia, remarked, “…in anaesthesia there was always kind of a shortage of [propofol]…That’s a drug we use day in and day out.” N students seemed bewildered by some of the differences between the VA system and other healthcare systems.
Rules that limit veterans’ eligibility for services. Several students noted that the VA system imposes eligibility restrictions. One SW student explained,
I would say one of the biggest challenges I had was, you have to have an honourable discharge to be able to receive services. Some of the veterans…didn’t have an honourable discharge, but they were some of the neediest people. A lot of drug and alcohol and mental health needs. It was hard just having to turn them away…and trying to refer them to other services.
Rules that limited hiring students after graduation. N students also expressed frustration with some of the VA’s policies, in particular the requirement of at least one year of post-degree experience before they will be considered for VA employment. Although N students expressed a desire to work for the VA, one student explained that it was unlikely that she would seek employment there:
I’ve got to tell you that where I’m at right now, I probably won’t change after a year of experience; I won’t try to apply. Whereas if I had been allowed to [apply] right out of school, I definitely would have. I’m kind of sad about that.
As a consequence, highly talented N staff may not seek employment at the VA. SW students did not report a similar limitation.
Compartmentalised training. Students from both groups also noted that they felt isolated due to the way the VA is structured, and thereby missed opportunities to experience the full array of people and health concerns in the veteran population. For example, one N participant explained, “I didn’t get a lot of exposure to female primary care there. I had very few patients that were women.”
Responses to Challenges
Although participants were not expressly asked to discuss how they adapted to the demands of their placements , a number of strategies were spontaneously described, suggesting that the VA is unique among healthcare systems and future students would benefit from knowing how to respond to common challenges.
Using supervision and informal consultation. Students are not expected to know everything upon entering the placement, however it is important for students to be aware of the limits of their own knowledge. One SW student explained, using his own military service as an analogue, “…you have to be assertive, and you have to be honest. The one thing about being in the military is that if you don’t know something, you’d better say you don’t know it.”
Students from both disciplines valued developing knowledge and used supervision as a means to close information gaps. One N student commented:
…don’t be afraid to ask questions. Ask the questions and ask for explanations of things, because so many times when it gets super busy or the [preceptor] is just trying to get from one patient to the next and get through the day, you’re wondering about stuff and you don’t get enough of a chance to talk about it and find out why they did something or why they said something.
A SW student elaborated, “I had a wonderful preceptor… [she] would make time almost every shift to sit down with me…I would write things down during the day to ask her at the end of the day.”
Consultation with other staff was another way SW students had their questions answered in the moment and without waiting for scheduled supervision. As one SW student explained, “If I had problems and [my preceptor] wasn’t around, I made connections with other social workers… and we would just talk with them.” Another added:[The] connections that you make [with other clinicians are useful] so that if you do run into a problem and you can’t get in touch with your preceptor, [then] you know someone else who might be aware or knowledgeable about that situation.
A SW participant affirmed that staff seemed open to students seeking impromptu consultation, “It’s a city. It really is. It’s a huge city and the staff responds very well to people that were asking questions.”
Use supplemental readings. Although all students reported using supervision to great benefit, it appeared that N students were less likely to use informal consultation. Instead, they reported turning to articles or other resources to supplement their knowledge. Reading materials were either supplied by a preceptor or independently located.
Learn as you go. Students also stressed that to adjust to the challenges one had to be prepared to both learn and adapt on the job. One SW student noted that this was akin to her own military experience:
In the Air Force, we called it ‘on the job training.’ It’s basically learn as you go and create what we call ‘standard operating procedure,’ but you create your own based on your notes and your experiences. You create your own little guide so that should something similar come up again, then you’ll better know how to respond.
Learn to tolerate discomfort/be tenacious. Students from both disciplines also explained how they had to learn to tolerate the discomfort that accompanies being a novice in a demanding setting. As one SW student related,
My preceptor said, ‘get comfortable with the discomfort.’ …I just remember feeling so unconfident, like I didn’t know what I was walking in to… You’re set with a situation and you just do something and you learn from it…Did I know that going in? No, but do I think it made me a better social worker? Absolutely.
Another student, commenting on being transparent and genuine as a strategy to overcome difficulties in forming professional relationships with patients, advised:
If you show your passion, that you want to work with them too, and that you’re willing to … listen to them, they respond very well to that. Instead of just kind of sitting there … not knowing what they’re talking about. They pick up on that instantly. So just having a will to listen to them and let them know: “I may not have been through what you’ve been through, but I really want to sit here and listen to what you have to say.”
Students also explained the importance of tenacity. This sentiment often emerged in response to the challenges they encountered and to the steep learning curve required in a placement where missteps are inevitable. One student advised, “If you’re not willing to get bumped and bruised in the process, to jump in, to ask questions, to be ready to get dirty a little bit, this might not be the placement for you.”
Recommendations for Pre-Placement Education
Students from both disciplines provided recommendations concerning what they thought should be taught (or taught more comprehensively) prior to the start of a placement.
Military culture. Many students in both groups reported that it would have been useful to have training in military culture before starting their placements. One SW student observed, “There needs to be a class on military culture not only to explain the basics, the acronyms, but also…the functions of the different branches…that would help the students be prepared… and not feel so timid.” Another added, “Because it’s a kind of culture all its own and they all have this bonding thing,” referring to the camaraderie and cohesion that develops among service members. A N student, who was also a military officer, added, “I was shocked at everything that soldiers have to do… the boot camp they go through… the sacrifices they make… I think it would be good to learn more about it.” Of note, students observed that pre-placement training in military culture might accelerate the development of rapport with veterans.
Issues specific to veterans. Students also reported that it would have been helpful to be better grounded in the literature and clinical practice concerning the psychological issues that afflict veterans. N students recommended deepening their knowledge of PTSD, including co-morbidities, and how it may interact with other treatments, like anaesthesia. One N student remarked: “In the classroom, they need to go over a little bit more about PTSD…it was mentioned but not a lot was explained.”
Additionally, students voiced their desires to know more about how specific issues manifest in the veteran population, such as how the effects of grief, loss, and psychopathology are experienced. One SW student suggested, “Adding a grief and loss component…[and] teaching students to understand…[that] it may not just be PTSD, it could be loss of a lifestyle, loss of a limb…things like that.”
In this study, graduate SW and N students were asked to share the challenges they had encountered during clinical placements with veterans and military families and insights for training future students. This information was sought to inform curriculum development, joint course content, and an inter-professional seminar for two new programs to train N and SW students to work with veterans and military families. Qualitative content analysis identified three categories of themes: challenges students encountered; responses to these challenges; and insights for training future students.
Both groups of students commented on the challenge of building trusting relationships with veterans. Veteran and family concerns about whether students without personal military experience can understand or be empathetic was a common barrier to establishing this relationship. Students also reported vexing issues with the VA system itself. SW students were frustrated by the limited time afforded to perform assessments and process required forms. N students were frustrated by the unavailability of some medications, possibly due to the integrated formulary14,15, which required them to identify alternatives. N students were particularly aggrieved that the VA would allow them to train at their facilities but deny them consideration for immediate employment following graduation. The rationale eluded students given the VA’s recent commitment7 to increase mental health staff. Students may be better prepared to navigate these challenges if they are apprised of them in pre-placement training.
Challenges that students encountered were often attenuated by the working relationship between the clinical preceptor and the student. SW students were supported by virtue of having access to both their preceptors and other clinical staff. N students did not identify consulting with their preceptor as a solution to the challenges they encountered; off-site reading also filled knowledge gaps. It should be noted that N students came from different training programs and preceptors’ approaches may differ among these specialties. Students from both disciplines acknowledged that clinical placement with veterans requires that students meet challenges head-on to provide quality care.
Students in both groups concurred that military culture should be included in pre-placement graduate curricula. They suggested that an understanding of the background, experiences, and basic needs of this population would facilitate the patient/provider relationship. These findings echo sentiments of veterans and military family members who, in a recent report6, indicated that practitioners in training should receive instruction in military/veteran culture, veteran-specific health and mental health issues, empowering and supporting veterans, and addressing needs of military families. Future research should establish if increased clinician knowledge in this domain is associated with changes in patient satisfaction and quality of care.
Although students were not queried about their experiences with inter-professional care, several reports16, including one from the US government17, have called for the expansion of such care as an optimal way to respond to the unique concerns of veterans and military families. Results from this study can inform the content of clinical training programs, especially when combined with other studies highlighting learning outcomes associated with veteran clinical placements that have an inter-professional component18. Complementary pre-placement classroom learning, including training related to interdisciplinary care, may optimise outcomes and should be investigated.
Strengths of the present study include its timely focus on veterans and their families, its focus on the training needs of two central healthcare professions with international counterparts, and the potential of its findings to enhance the education of future practitioners. However, several limitations should be noted. The small sample size, especially of the N student group, requires that results be interpreted with caution. Moreover, because of N student subspecialties, each experience may be more unique to the individual and not representative of the cohort. Students were also recruited from SW and N training programs in one northeastern US university, and placements had been at one VA; consequently, the gaps in training and challenges in the placement setting may be specific to the US, the student’s school, and/or the placement.
As the results of this study suggest, students who aspire to work with veterans and military families should expect challenges related to establishing rapport and the constraints imposed by contexts in which care is delivered. Focussed pre-placement education, supervision, and on-the-job training should attenuate these and other challenges students encounter. Specialised training may be one important step towards improving outcomes and realising the international commitment to provide quality care for veterans and military families3,4.