Open Journal of Nursing, 2013, 3, 400-403 OJN Published Online September 2013 (
Developing nursing curriculum to facilitate the delivery of
holistic care to the military veteran
Michelle Beckford, Corinne Ellis
Saint Peter’s University, Jersey City, USA
Received 16 April 2013; revised 17 May 2013; accepted 10 June 2013
Copyright © 2013 Michelle Beckford, Corinne Ellis. This is an open access article distributed under the Creative Commons Attribu-
tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Daily media coverage tells the story of challenges
facing returning members of the United States Mili-
tary. H igh rates of suicide, more than twen ty per day,
horrific traumatic injuries necessitating challenging
physical and emotional healing, and lingering post-
traumatic stress disorders warranting the most ad-
vanced methods of treatment are reported daily. As
America recoils from two prolonged oversea wars,
the need for prepared healthcare providers is essen-
tial not only for the Veterans Administration (VA),
but also for civilian based healthcare systems. The
bulk of nursing education literature seems to evidence
a void regardi n g thi s se gment of the population. Wha t
seems like a prime education focus remains yet to be
enacted in most nursing programs. The authors have
responded to this challenge, by creating curricula
developed to increase nursing student awareness of
veterans’ unique needs, and to prepare undergradu-
ate nursing students to provide quality care to veter-
ans. Through the creation of a laboratory simulation
scenario, students learned how to holistically view
and respond to the needs of a veteran client. Debrief-
ing allowed for reviewing the experience and discuss-
ing concerns. Outcomes measured via pre- and post-
testing survey reflected the complexity of patient care
needs. Students were asked to rate their ability to
identify and prioritize appropriate nursing interven-
tions. Anecdotal feedback was positive in that stu-
dents consistently expressed a need to have additional
simulation experiences.
Keywords: Military; Suicide; Spinal Cord Injury;
Nurse Educators are being challenged to evolve with the
changing times; the needs of new graduates are rigorous
and compelling. Curriculum must extend beyond the
didactic to facilitate psychomotor skills and application
to clinical care of patients. C. Rauen [1] suggests a
paradigm shift from an instructor-centered model to a
learning centered model. Simulation can be the means to
this end. In a previous study conducted by the authors,
simulation was found to improve student outcomes.
Attrition rates dropped 14.6% with an added low fidelity
simulation component as compared to cohorts that were
not exposed to simulation in the curriculum. The study
was local and limited in sample size. The purpose of the
current study was to expand upon the use of simulation
by utilizing high fidelity simulation to prepare undergra-
duate nursing students to respond to the unique and
urgent healthcare needs of military veterans.
Current statistics delineate the alarming crisis facing
US veterans returning from Afghanistan and Iraq. For
every veteran killed by enemy combatants, 25 veterans
take their own lives ([2]. A recently established crisis
hotline created by the Department of Veteran’s Affairs
(VA), has documented more than 26,000 calls from
actively suicidal military vets. These data are frighten ing
given the tendency toward underreporting of suicidal
ideation [3]. Veterans with mental illness and substance
use disorders accounted for 32.9 percent of all Veterans
Health Administration (VHA) costs $12 billion [4].
According to the National Alliance for Mental Health
(NAMI), rates of PTSD in veterans of the Iraq and
Afghanistan wars range from 5 to 37 percent, while rates
of depression were found to be as high as 27 percent. The
Veterans’ Administrationhas treated more than 400,000
post 9/11 veterans for mental health problems [5].
To help meet the mental health and recovery needs of
US vets, services and pr ograms geared especially to their
unique needs are going to be required [6]. Senators have
told officials of the VA that they must speed up services
for vets with Post-Traumatic Stress Disorder and other
M. Beckford, C. Ellis / Open Journal of Nursing 3 (2013) 400-403 401
mental health cond itions [7 ]. A report released in January
2013 by the VA identifies report also identified female
veterans and Vietnam-era veterans as two demographic
groups that require extra consideration when it comes to
suicidal behaviors [8]. Keavney [9] notes that there are
22 million vets in the US, a mix of older vets exposed to
Agent Orange during the Vietnam war, vets exposed to
Malaria and Tuberculosis during conflicts in the Middle
East, veterans suffering from traumatic brain injury after
encountering improvised explosive devices, and todays
vets who are living with very serious injuries.
75% of military vets are cared for through the
Department of Veteran’s Affairs, which employs about
45,000 registered nurses. The VA is projecting the need
for even more RNs to address the best care for veterans’
special needs, including post-traumatic stress disorder,
mental-health issues and traumatic brain injuries [10].
Many military personnel will ultimately be treated by
primary care providers in the community and/or in local
hospitals [11]. The VA, the National League of Nursing,
the American Association of Colleges of Nursing and
other industry groups are calling on nursing schools to
take a pledge to do more to educate students on how to
care for veterans and their families [12]. Schools of
nursing are being challenged to provide relevant,
evidence-based content in their curricula. The American
Association of Colleges of Nursing (AACN) has
sponsored Joining Forces, which is a collaboration of
more than 500 nursing schools that are striving to
educate nursing students on best practice methods in
caring for military veterans. As part of this initiative,
educators are encouraged to prepare students to care for
those suffering post-traumatic stress disorder, traumatic
brain injury, depression, and other clinical issues [13].
The lay literature has clearly established the plight of
the military vet. However, there remains a gap in
scholarly nursing journals with regard to how educators
are responding. Therefore the authors have developed
and implemented a curriculum designed to address the
needs of this vulnerable population. Ultimately the
curriculum is intended to prepare undergraduate nursing
students as they enter into practice and to promote safe
practices. The curriculum incor porates concepts of holistic
care, meaning that care addresses physical, mental, emo-
tional, sexual, cultural, social and spiritual needs [14].
Holistic care as it applies to the military veteran, recog-
nizes the need to shift from traditional problem-based
disease care, to person-centered health care [15]. In
accordance with the philosophy of Holistic Enrichment
of Adult Living (HEAL), the aim of this program has
been to improve the preparation of nursing students by
including the use of relevant clinical assessment tools,
addressing the status of client support systems, and
improving communication [16].
This scenario was part of a larger set of simulation
scenarios designed to decentralize mental health concepts.
Decentralization is proposed, not for the purpose of
diluting the importance of mental health, but on the
contrary, to emphasize the need for all nurses to utilize
appropriate psychosocial interventions. In terms of
holistic care, psychological well-being is relevant to all
realms of nursing practice. Mental health assessment and
intervention need to be threaded across all areas of the
nursing curriculum.
The purpose of this project was to create a BSN
curriculum that reflected the mental health needs of
patients not only in acute care psychiatric facilities but
also in medical-surgical disciplines, maternity units, and
community settings. The larger curricu lum was designed
to also cover mental health throughout the lifespan. The
learning objectives were for undergraduate nursing
students to initiate and implement an appropriate mental
status assessment using therapeutic communication, and
also to provide safe care by identifying risk factors and
using critical thinking to establish requisite nursing
interventions. Therapeutic communication is a concept
introduced during the initial theory and clinical courses,
therefore the simulation also served to reinforce those
skills. Simulation of this type discouraged students from
hiding behind clinical tasks in the provision of holistic
care. Most importantly, this simulation was designed to
help students identify and respond to the individual
needs of military veterans. Students were provided
appropriate assessment tools including VA/DoD Essen-
tials for Depression Screening and Assessment in Pri-
mary Care [17].
Students were provided with related didactic lecture
material prior to their scheduled simulation experience.
They were also assigned readings relevant to nursing
research that supported evidenced based practice.
Simulation was a mandatory assigned experience.
Students were placed in pairs to provide care for the
simulated patient. Two faculty members supervised the
simulation, one as a facilitator and one serving behind
the scenes as the voice of the patient. Students were
required to complete a pre-test prior to simulation. The
pretest consisted of a 10 question inventory submitted
anonymously through the survey monkey website.
Questions included 6 true/false questions designed to
measure students understanding of concepts related to
depression, spinal cord injury and care of the military
veteran. One question was dedicated toward dosage
calculation as suggested by QSEN competencies. The
final 3 questions were anecdotal questions in which
students were asked to rate their comfort in prioritizing
care and identifying appropriate nursing interventions.
The exact same questions were formatted into a post-test
Copyright © 2013 SciRes. OPEN ACCESS
M. Beckford, C. Ellis / Open Journal of Nursing 3 (2013) 400-403
and administered following the debriefing session of the
Through the creation of a laboratory simulation
scenario, students learned how to holistically view and
respond to the needs of a veteran client. In the scenario, a
young female veteran experienced depression and
suffered a spinal cord injury as a result of an attempted
suicide. It is an inter media te c are settin g, where th e pati ent
is awaiting transfer to a rehabilitative facility. Students
were expected to utilize the nursing process, perform
psychosocial assessments, and recognize signs and
symptoms of depression. Students were also expected to
prioritize their nursing interventions to provide a safe
and supportive environment. Therapeutic communication
was integral to their approach as they prioritize num-
erous patient needs. Furthermore, students were expected
to provide physical care including positioning, turning, ,
and neurological checks. This scenario was different
from typical nursing simulations in that it progressed
based upon the patient’s verbal and psychosocial
presentation rather than according to significant changes
in physiological patterns. The patient was intentionally
created as a female for the purpose of eschewing the
stereotype of males only in the military and also for the
purpose of increasing the awareness that females in the
military are also at high risk for suicide. Debriefing was
conducted with all assigned students and with the
involved faculty members. Students were encouraged to
voice their concerns regarding their progress as the
scenario unfolded. Faculty reiterated that the simulation
lab allows for a safe place to make mistakes. It is im-
portant to note that this particular population of students
was at the junior level in a B.S.N. program and as such
had not had a course in mental health nursing yet.
Retention will be measured at a six-month interval sub-
sequent to this simulation by administering the same
Students entered into each scenario with a high degree of
confidence as evidenced by their pretest ratings. It is
likely that students had no t realized the co mplexity o f the
scenario and/or the psychosocial aspects of care. Students
favorably rated their own ability of identify symptoms
relevant to appropriate assessments for each scenario as
evidenced by pretest questionnaires. In some scenarios
students were more in need of coaching and facilitation
when patients initiated emotionally charged discussions
or self disclosed serious issues such as deliberate attempt
to hurt oneself. Students by and large were able to
accurately provide safety measures related to suicidality,
and were also competent in recognizing presenting
symptoms of depression. Students were noticeably para-
lyzed in respond ing to the hopeless attitude of the p atient.
Not all students recognized that the patient was in fact a
military vet. The authors suspect that the students
misunderstood the patient’s demand for self-reliance,
wanting to be left alone, and overall stoic demeanor as
uncooperativeness rather than the common mind set of a
military vet. Students voiced surprise that the scenario
included a female as a military veteran.
De-briefers emphasized to students that these were
new experiences in which they were not necessarily
expected to know exactly how to respond, thereby a true
opportunity for learning in a safe environment. Students
still rated themselves as not comfortable in providing
holistic care to a patient with a spinal cord injury nor
able to prioritize interventions for safe care with the
same population as evidenced by post-testing. Lower
scores on self assessments in the post-test may reflect the
complexity of learning needs and further substantiates
the need for teaching this content.
Students are rarely engaged in sensitive topics of
discussion during actual clinical rotations. Therefore
simulation affords the opportunity to standardize such
experiences and allows for feedback prior to exposure in
actual clinical settings. Students do not have their
psychiatric nursing rotation until the fall semester of
their senior year and therefore were not expected to
diagnosis as part of the scenario, but were expected to be
able to communicate effectively, to provide safety mea-
sures, and to recognize the need for collaboration and/or
need for referrals. In debriefing sessions, students voiced
appropriate concerns about being caught off guard by
patient concerns and not knowing how to respond. It is
worth noting however that students in the junior class
had back to back scenarios over two consecutive weeks
and those students voiced improvement in their
communication skills and were noticeably more respon-
sive in problem solving with patient. Additionally, the
authors suggest that this simulation will serve as the
perfect segway as students transition into the fall of their
senior year in which they enroll in mental health nursing.
Anecdotally students identified an ability to transfer
knowledge between simulations in lab to patient care in
clinical setting. Students consistently have requested the
opportunity to participate in more simulated scenarios.
The authors have addressed a gap in the literature with
regard to simulation in psychiatric nursing while simul-
taneously creating a timely curriculum. Simulation in
nursing is not new, however the scenario created in this
simulation is unique. It encompasses a psychosocial
focus along with traditional physical care. The focus is
on therapeutic communication and emotional well-being.
This type of simulation enables students to address the
patient in a more comprehensive manner. Simulation
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M. Beckford, C. Ellis / Open Journal of Nursing 3 (2013) 400-403
Copyright © 2013 SciRes. OPEN ACCESS
offers standardized clinical experiences for the purpose
of teaching critical concepts that students are unlikely to
encounter. It allows for additional patient care scenarios
of varying acuity in an era when short-term care facilities
have shorter length of stay. Simulation has the added
benefit of debriefing, which allows for reflection and
inquiry. Simulation allows for the introduction of specific
population needs such as the care of military veterans.
Curriculum needs to evolve to meet the changing needs
of society. The VA has a backlog of over 897,000 claims
for disability benefits related to mental health [2]. Nurses
need to be well equipped to provide comprehensive care
in all settings, understanding the unique needs that each
patient may present. There is an imperative to provide
safe care for those who protected the safety of our
country. Future endeavors will be to measure knowledge
retention at a six-month interval following the simu-
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thinking skills. You can’t throw the book at them. Criti-
cal Care Nursing Clinics of North America, 13, 93-103.
[2] Haiken, M. (2012) Service dogs offer hope for veterans
coping with depression.
[3] Haiken, M. (2013) Suicide rate among vets and active
duty military jumps—Now 22 a day.
[4] Health Affairs (2011) First comprehensive report on the
Department of Veterans Affairs’ Mental Health Treat-
ment System.
[5] National Alliance for Mental Health (2012) Parity for
patriots: The mental health needs of military personnel,
veterans and their families.
[6] American Society for Suicide Prevention (2013) 2013
legislative priorities, veterans and military families.
[7] Mental Health in America (2011) Mental health in the
Headlines. Senators tell VA to speed up mental health
[8] Briggs, B. (2013) 22 veterans commit suicide each day:
VA report.
[9] Keavney, E. (2013) Caring for veterans.
[10] Wood, D. (2010) Preparing nurses to care for today’s
[11] Hatfield, S. (2012) Improving healthcare for veterans &
military families.
[12] Thayer, K. (2012) Nursing schools seek to improve train-
ing on ve ter an ca re . Coll ege s sign o n to j oini ng for ce s na-
tional initiative.
[13] American Association of Colleges of Nursing (2013)
Support joining forces.
[14] Thornton, L. (2013) What is holistic nursing?
[15] Goldman, E. (2012) Holistic medicine is military’s new
marching order.
[16] Holistic Enrichment of Adult Living (2013) Our veterans:
Navigating in a chaotic health care system.