According to the Department of Veterans Affairs (VA) (2014a), there are an estimated 22.3 million Veterans living in the United States. Although there are still Korean and World War II Veterans, their numbers have greatly diminished over the past 10 years (U.S. Department of Veterans Affairs, 2014a) and the largest group is now Veterans of the Vietnam era who number 7.4 million. The Vietnam conflict officially began in 1961 and spanned 14 years. This large cohort of Veterans is now reaching or has surpassed 65 years of age, qualifying them for Social Security and Medicare. As a result, it is likely that home care clinicians will be caring for many patients who are Vietnam Veterans. The purpose of this article is to increase home healthcare clinicians' awareness and knowledge of the unique experiences and special healthcare needs of Vietnam Veterans.
Military and Veteran Culture
According to Johnson et al. (2013), military service is a shared experience that transcends the racial, ethnic, and socioeconomic boundaries typically experienced in civilian life. Joining Forces, an initiative launched by First Lady Michelle Obama and Dr. Jill Biden, has helped elevate awareness of the unique needs and experiences of military Veterans and their families (Joining Forces, 2011). As a result, civilian healthcare systems and providers have begun to recognize these unique needs and experiences and how they can affect health (Convoy & Westphal, 2013; Cozza et al., 2014; Johnson et al.; Stanton, 2014).
Military culture has its own language, values and beliefs, rules, and customs and traditions (Hamaoka et al., 2014). Men and women serve in the military in multiple capacities, including Active Duty, National Guard, and Reserves. They come from all ethnic, socioeconomic, and educational backgrounds and can serve in one of five branches: Army, Navy, Air Force, Marines, or the Coast Guard. Each of these branches has a unique subculture. The military structure is hierarchical, with enlisted personnel, warrant officers, and officers. It functions with a chain of command for which authority and responsibility are assigned. Hallmark to this culture are rules that manage risk and create cooperation, interdependence, and self-sacrifice for the group. Emphasis is placed on following the direction of leaders and executing orders without question.
Military culture has the ability to influence health in a positive way but can also create a sense of failure if the Veteran is not able to live up to the standards and values they lived by during their time of service (Convoy & Westphal, 2013). It is important for home healthcare clinicians to be aware of this unique military culture and to learn ways in which to partner with Veterans to manage their health. The engrained culture and behavior of the military experience often stay with Veterans for many years, if not their entire lives. Many Vietnam era Veterans entered the military while still in their teens, especially during the years of the draft (American Foreign Relations, n.d.). Developmentally, they were very impressionable and lacked life experience. In addition, they were exposed to addictive drugs such as heroin, which was cheap and readily available (Horwitz, 2015). Military service is often a defining attribute of a Veteran, even more so if they served during a time of war or were exposed to combat. According to the U.S. Department of Veterans Affairs (n.d.), approximately 48% of Vietnam Veterans reported being exposed to combat. In the same report, approximately 46% reported being exposed to dead, dying, or wounded people.
Knowing if the Veteran served in the Reserves, National Guard, and/or on Active Duty is also important as this may have an impact on their experiences, behavior, and health risks (Stanton, 2014). Reserve and National Guard units, in the Vietnam era, were activated. This created financial and other psychosocial challenges to individuals who had signed on thinking this would be a "weekend warrior" experience that brought in extra money each month, when in fact they were deployed. Reintegration challenges may vary depending on the capacity in which a Veteran served.
The Vietnam War Experience
The Vietnam War (1964-1975) changed society in many ways. It was a long, costly war involving South Vietnam, with the United States as the primary ally, against the communist regime of North Vietnam and its southern allies, the Viet Cong (History.com, 2009). The peak of U.S. involvement in the war occurred in 1969. During the same time, antiwar protests and marches took place as the American people were divided in their support of the war. The Vietnam War had an economic and psychological impact on Americans. The presence of live, unrestricted media in Vietnam impacted societal response in comparison to World War II, when edited films were censored and presented to the public weeks after live events (Hallin, n.d.). As a country, we no longer felt unbeatable. Veterans of this war faced negative reactions from some people who accused them of killing innocent civilians and children (History.com, 2009). Many service members returned home with physical problems from wounds/injuries and environmental exposure to Agent Orange as well as psychological problems from the atrocities that exposure to war and combat can create. Table 1 summarizes the statistics of service members' dispositions serving during that time period.
Health Issues of Vietnam Veterans
The most common ailments for Vietnam Veterans are listed in Table 2 and occupational exposures related to this war are summarized in Table 3. Unique to this era of Veterans was their exposure to Agent Orange and other herbicides and the high prevalence of hepatitis C, posttraumatic stress disorder (PTSD), and homelessness, all of which will be reviewed in this article.
Agent Orange
Although used in other conflicts, Agent Orange is the hallmark environmental health-related issue for Vietnam Veterans. From 1962 to 1971, the U. S. military used this chemical as an herbicide to eliminate forest cover to expose North Vietnamese and Viet Cong troops, as well as to destroy their crops. Agent Orange has been linked to multiple health issues (Johnson et al., 2013; Richards, 2011). Table 4 lists the most common issues that have been linked to Agent Orange to date. The Department of Veterans Affairs offers a free Agent Orange registry program for anyone who has an unexplained health problem that could be linked to exposure to Agent Orange. It is important to know that Veterans who were exposed to Agent Orange and who have developed Type 2 Diabetes Mellitus are eligible to receive VA healthcare and disability compensation (U.S. Department of Veterans Affairs, 2015a).
Hepatitis C
Hepatitis C has become a major health issue for military Veterans in the United States, but particularly for Vietnam era Veterans (Waters, 2003). Although the cause of its prevalence is uncertain and under study, there is a possible relationship to immunization with jet injectors, intravenous drug use, or military-related blood exposures (U.S. Department of Veterans Affairs, 2015b). According to Waters, rapid evacuation, high rates of casualty survival, and blood transfusions before hepatitis C screening was a standard of care may have exposed Veterans to the virus. The VA has a program in place for any Veteran wishing to be tested. Identified risk factors include but are not limited to: using needles to inject drugs, blood transfusion prior to 1992, healthcare worker exposure to blood or bodily fluids prior to 1992, or being tattooed prior to 1992 (U.S. Department of Veterans Affairs, 2004). More information can be located on the VA Web site (http://www.hepatitis.va.gov).
Hepatitis C is treatable (U.S. Department of Veterans Affairs, 2015b). Multiple factors are taken into consideration when determining what treatment a particular person will need. There are several different medications currently approved for treatment of hepatitis C and the duration of treatment ranges from 12 weeks to as long as 48 weeks. Managing side effects of the various medications is a major issue with this patient population. Most patients will have serum ALT (alanine aminotransferase) and viral load (hepatitis C virus ribonucleic acid level or hepatitis C RNA level) levels checked approximately every 4 weeks or more while on treatment to monitor effects of the medication (U.S. Department of Veterans Affairs, 2015b). Patients should be educated on how to prevent exposure of family members and friends to the virus, as that is a potential risk.
Posttraumatic Stress Disorder (PTSD)
Veterans exposed to combat and related combat trauma are at higher risk for developing PTSD (National Institutes of Health Medline Plus, 2009). It is estimated that 30% of Vietnam Veterans have had PTSD at some point over their lifetime. Symptoms include nightmares, irritability, anger, flashbacks, and sleep disturbances (Johnson et al., 2013). PTSD was not a new issue for Veterans of this era; however, Veterans who served during this time had different experiences during war that potentially impacted the increase in prevalence of this condition. Advances in air transportation and medical care provided closer to the war zone led to the survival of more wounded or injured soldiers than with previous wars. Therefore, more war Veterans returned home with disabilities and traumatic experiences. Another difference in the Vietnam era compared to previous wars was that soldiers returned home much faster, creating greater adjustment difficulties, coined "culture shock." In addition, Veterans of this era returned home to an antiwar climate, which compounded the already stressful reintegration post deployment.
Recent literature has also linked PTSD to traumatic brain injury (TBI), demonstrating that Veterans diagnosed with a TBI typically have comorbid conditions of PTSD (or other mental health issues) and pain (Cifu et al., 2013). According to the U.S. Department of Veterans Affairs (2015c), approximately 12% of Vietnam Veterans wounded in combat experienced TBI. Because the relationship between PTSD and TBI was not known during the Vietnam era, returning Veterans may not have been properly treated. Long-term effects of this are unknown. Studies to further investigate the PTSD-TBI relationship are being conducted. Support from family and society can play an important role in mitigating PTSD symptoms (Price, 2014). The Department of Veterans Affairs is working to ensure Veterans with TBI are assessed and treated. More information can be obtained on the VA Web site (http://www.ptsd.va.gov/).
Homelessness
Although most home healthcare clinicians do not care for patients who do not have a residence, they may care for homeless Veterans temporarily living with a family member or friends, or Veterans who may be at risk for homelessness. According to the National Coalition for Homeless Veterans (n.d.), about 12% of the adult homeless population are Veterans and almost half of the homeless Veterans are from the Vietnam era. A referral to the home care agency social worker should be made for any Veteran who is homeless or is in danger of homelessness. The U.S. Department of Veterans Affairs (2014b) has several programs and initiatives to combat this issue and a list can be found by visiting their Web site (http://www.va.gov/homeless/).
Women Who Served During Vietnam
Women are often referred to as "Invisible Veterans" because their contributions to the military went essentially unrecognized by society until the 1970s (U.S. Department of Veterans Affairs, 2011). Approximately 7,000 women served during the Vietnam War (U.S. Department of Veterans Affairs, 2011). Of those who served, close to 90% were nurses. These military nurses were exposed to combat in a different way than in previous wars. Many were exposed to high volumes of patients, with multiple injuries, and a large number of casualties. It is estimated that, of the women who served in this conflict, 26% have or have had PTSD, with another 21% having partial PTSD symptoms over the course of their lifetime (Price, 2014). Military sexual trauma (MST) and PTSD are both concerns for this population, although men can also experience MST. More information can be obtained from the VA Web site (http://www.mentalhealth.va.gov/msthome.asp). Over the past 2 decades, the VA has launched several initiatives to improve access and quality of care provided to women Veterans, including research specific to their needs. More information can be located on the VA Web site (http://www.womenshealth.va.gov/).
Assessing if Your Patient is a Veteran
Prior to admitting a patient to home care services, a clinician may be able to determine if he or she is a military Veteran if it has been documented in the medical record. If not, the first thing you can do upon entering a home is to listen and look for clues that your patient may be a Veteran. He or she may address you as "sir" or "ma am" even though you are likely younger. The presence of tattoos or other memorabilia around the home may also give you a clue that the patient has prior military experience. This can be a great way to initiate the conversation about being a Veteran. According to Convoy and Westphal (2013), the first step in assessing if a patient is a Veteran is to simply ask "have you had any experience in the military?" This question should be inserted into the assessment when other demographic information is being collected and/or confirmed. "The assessment of Veteran status is a safety issue in which there are real health risks for Veterans that, if not properly included within the treatment plan, may result in serious short and long term health consequences for Veterans and their families" (Stanton, 2014, p. 664). Once this has been established you can follow up by asking if, to their knowledge, their military experience has had any long-term impact on their health.
Engaging Veterans about their military experiences may be useful in assessing and developing a plan of care (Seligowski et al., 2012). The U.S. Department of Veterans Affairs (2015d) has compiled and posted on their Web site a Military Health History Pocket Card for Clinicians, which has assessment questions they recommend for trainees and clinicians. Refer to Table 5 for additional questions that you might consider asking a Veteran when establishing a relationship and Table 6 for additional resources. Johnson et al. (2013) also compiled a Veteran-Centered Health History Assessment, which can be a useful tool for those who have minimal exposure to the Veteran population but want to learn more about how to enhance Veteran-centered care.
Once you have established that your patient is a Veteran, pay particular attention to signs of specific challenges or health issues discussed in this article. Explore what actions the patient has or has not taken to resolve any potential military-related health concerns. Determine if further assistance may be required beyond the scope of your home care agency, such as a referral to the Department of Veterans Affairs. Discuss this option with your patient so that they may take part in decisions regarding their healthcare needs.
Strategies for Working With Veterans
There are several things a home care clinician can do when working with a military Veteran. First, it may be helpful for the clinician to examine his or her own attitudes and beliefs about the military and Veteran culture and how those could potentially impact the care provided (Hamaoka et al., 2014). It may also be important to do a self-assessment of what one knows about the military and Veteran culture, resources, and opportunities to learn more. Many resources can be found on the Internet. You could also learn from patients who are Veterans by listening to their stories. Although not an exhaustive list, Table 6 provides a starting point of resources a clinician may want to explore to learn more about Veterans. Colleges and Universities are beginning to offer courses or post bachelors certificates in Veteran's healthcare for clinicians who have an interest in continuing their education in this specific area (Drexel University, 2015; University of Colorado, 2015).
Acknowledging military experience is important. It is one way the clinician can broach the conversation and let the patient know that you recognize this may have an impact on the person, their emotional well-being, or health status. According to King, as cited in Cozza et al. (2014, p. 17), setting clear goals and expectations for the visit and episode of care are good ways to approach Veterans because they are accustomed to step-by-step instruction, checklists, and standard operating procedures from their military service. Identifying and finding ways to leverage strengths and skills they may have acquired during military service may promote a positive outlook versus focus on illness and vulnerability. According to a study on correlates of life satisfaction, establishing rapport that affords an older Veteran control of his or her care can potentially reduce overall distress (Seligowski et al., 2012).
Functional status is especially important to assess in this population of older adults. As previously discussed, air evacuation and advances in medical care made it possible for severely injured soldiers to return to the United States alive. Thus, lingering war injuries may have a compounding impact on functional status later in life. In a study conducted by Villa et al. (2002), it was found that Vietnam Veterans were predisposed to more reported difficulties in activities of daily living (ADL) and instrumental activities of daily living (IADL) compared to Korean and Gulf War Veterans. In some cases they reported equal or more difficulty in these same tasks compared to World War II Veterans. Vietnam era Veterans who served in Vietnam compared to those who served during the same time period outside of Vietnam reported having more service-related disability and poorer perceived health (Brooks et al., 2008). Although this seems logical, in this same study, there was no difference in reported ADL impairments between those that served in Vietnam versus those that served in other locations during the war. With this information, it is critical that a complete functional status assessment is completed, as patient report alone may not be accurate.
With the passage of the Affordable Care Act (ACA), eligibility for VA benefits was expanded to include previously ineligible Veterans, who served during a time of war or conflict (U.S. Department of Veterans Affairs, 2015e). This is important to know as home care clinicians engage with this population because they may have insurance options that were not previously available to them, especially those Veterans not yet eligible for Medicare. The ACA also allows Veterans to seek alternative care outside of the VA.
If you identify that your patient is a military Veteran, explore whether or not they utilize VA for health services or other Veterans' benefits (Johnson et al., 2013). If they do utilize VA services you should ask exactly what they use so that your care complements services they may already be receiving. If they do not utilize VA services and you think they may benefit from or qualify for them, it may be helpful to consult with your agency social worker. Contacting a local VA hospital or other Veteran service organization such as the American Legion (http://www.legion.org/) or Vietnam Veterans of America (http://www.vva.org/) may be useful to provide assistance in helping Veterans get healthcare and other services they need. Getting the family involved may also be necessary; the VA Web site contains much of the information a Veteran would need, including "how to," FAQ sheets, and other useful information. Veterans who require regular assistance of another person for personal functions such as eating, dressing, bathing, and/or toileting may be eligible for Aid & Attendance and Housebound benefits (Fausone, 2014; U.S. Department of Veterans Affairs, 2015f).
Conclusion
Military Veterans, especially those who served during the Vietnam era, have had life experiences very different from most U.S. citizens. As clinicians practicing in a home care setting, there is an opportunity to connect and establish rapport with these individuals and their families in meaningful ways. Developing awareness of the military and Veteran culture has the potential to improve patient safety and satisfaction. It also has the potential to improve patient outcomes by providing home care clinicians with the necessary tools to engage this population in meeting their special healthcare needs.
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