In 2013, I (AF) was appointed as the first UK Ministry of Defence Professor of Nursing, with an implicit responsibility to lead and support military nurses in undertaking high impact research. Early into this assignment, I deployed into Afghanistan to complete a series of qualitative nursing research studies. This included an exploration into the characteristics and values that military nurses defined as being pre-requisite to successfully undertaking their role in a harsh and demanding environment.
Nursing Standard. 35, 10, 82-85. doi: 10.7748/ns.35.10.82.s39
Published: 30 September 2020
In part, I was motivated through a reflection on principles such as compassion, resilience and clinical competency that are attributed to significant military nursing role models, such as Mary Seacole and Florence Nightingale, and attempting to conduct an empirical study to determine their relevance in a modern setting. This in situ nursing research was novel, and I was indebted to other civilian authors, including RCN Fellows Hugh McKenna and Kath McCourt, who provided their academic expertise and support to ensure that the research was built on strong methodological foundations.
As such, this article is drawn from the only qualitative nursing studies conducted in a War Zone and published in Nurse Education Today. I have been the assistant editor of the journal since 2016.
Background Between 2001 and 2014, British military nurses served in Afghanistan caring for both service personnel and local nationals of all ages. This paper is from the only qualitative nursing research conducted in situ in Afghanistan, in 2013.
Aim To explore the characteristics and values that are intrinsic to military nurses in undertaking their operational role.
Design A constructivist grounded theory was used. UK Ministry of Defence Research Ethical Committee approval was obtained.
Conduct of work Semi-structured interviews with 18 British armed forces nurses.
Results A theoretical model was developed that identified the intrinsic characteristics and values required to be a military nurse. The nursing care delivered was perceived to be outstanding.
Recommendations Originality, and linked to sustainable development goals in good health and wellbeing and informing quality education.
Finnegan A, Finnegan S, McKenna HP, McCourt K et al (2016) Characteristics and values of a British military nurse. International implications of War Zone qualitative research. Nurse Education Today. 36, 86-95. doi: 10.1016/j.nedt.2015.07.030
The foundations of modern medicine and nursing are directly correlated in caring for armed forces personnel in times of conflict and war (Gabriel and Metz 1992, Medicine and The Military 2020). This extends to the formation of the (Royal) College of Nursing (RCN) in 1916 (Finnegan and Nolan 2012).
It was during the Crimean war (1853-1856) that field hospitals were first established. During this war death was common due to yellow fever, dysentery, cholera and tuberculosis (Gill and Gill 2005). It was here, while attending wounded servicemen and delivering care in hostile territories and under dangerous conditions, that Florence Nightingale began to formulate her concepts about nursing (Nightingale 1859). These advancements resonant today with the spotlight on infection control, hospital epidemiology, and hospice care. It was fitting that the network of ‘field’ hospitals quickly set up during the COVID-19 pandemic were given the name Nightingale.
In World War I, military nurses demonstrated extreme flexibility and resilience at clinical, physical, psychological and environmental levels, including caring for local nationals and enemy troops (Gerolympos 1995). Nurses were at risk (Harper and Brothers 1918, Hay 1953), and their patients were positively influenced by the calm way the nurses went about their duties, while the nurses were inspired by the performance, fortitude and cheerfulness of their patients (Hay 1953). Evidence can be found in the diaries of nursing leaders such as Maud McCarthy who, as matron in chief to the British Expedition Force, had sailed on the first ship to France in 1914 and then maintained her position throughout the entire campaign until 1918. However, few research studies have assessed the effectiveness of the military nurses’ operational role, and a comprehensive literature search identified no published empirical study that explored the core characteristics and values required by military nurses in the operational arena.
In this century, an International Security Assistance Force comprised of British, American and other allied troops were deployed to Afghanistan (2001-2014) in support of a NATO mission and to care for all patients, including local nationals of all ages and captured persons (CPers) (Simpson et al 2014). The major hub for medical activity was Camp Bastion Hospital, which contained multi-national British, American and Danish clinical staff under British command. Coalition patients were quickly repatriated to their home countries. The local population’s progress, rehabilitation, community care and future treatments were through a local healthcare facility outside of the military’s scope of influence.
By 2013, military medical and mental health research were dominated by positivist theories and quantitative research, and no qualitative nursing research had been undertaken in the Afghan/Iraq war zones. In 2013, I (AF) deployed to Afghanistan to collect data for four studies. In addition to this study (Finnegan et al 2016a), data were collected on educational and clinical preparation (Finnegan et al 2016b), the psychological implications (Finnegan et al 2016c), and the role of the mental health team (Finnegan et al 2014a, 2014b). Approval for the study was granted by the UK Ministry of Defence Research Ethical Committee.
Interviews were conducted with 18 military nurses based at Camp Bastion Hospital, Afghanistan during June and July 2013. The intent was to accurately reflect the respondent’s interpretation of a wide range of emotions, behaviour, thoughts and beliefs. This led to an emerging theoretical model categorised as: personal values, military skills, scope of practice and clinical leadership. These groupings were responsive to the common dynamic healthcare factors faced by any nurse in relation to manpower, experience, motivation, satisfaction, and the type of casualty with associated ethical issues. I had the support of civilian academics who had military experience and they helped scrutinise the data to ascertain comparators and differences. It is important to recognise that this model was an emerging prototype, and needed testing and further research on its functionality and to consider wider transferability.
Respondents were volunteers who had made a lifestyle choice to deploy in support of fighting troops. The participants believed that the nursing care delivered in the conflict area was of a very high standard for all patients. They reported a sense of self-worth and pride aligned to strong team integration as being significant positive factors in underpinning the excellent care. Prior experience of this environment helped and made the nurses less likely to be negatively psychologically affected by either the clinical presentation of casualties, high activity levels or the austere environment (Finnegan et al 2016c). Senior staff identified the importance of advocacy, being tenacious and backing their judgement to deliver compassionate care. Role modelling and getting to know their staff were important in building a rapport to understand other peoples’ views and aspirations. As with other parts of the nursing workforce, it was important to be conscious of some of the multifactorial stressors, although it was also noted in Afghanistan that many nurses thrived.
Nurses talked of quality care, helping each other, communicating with each other, reminding each other of what is expected, and recognising the qualities that nurses brought to the multi-professional team. An emphasis was placed on patient needs, which were determined through robust communication built on a trusting relationship. These included lessons learned from caring for CPers, where the nurses consciously detached themselves from any legal processes and treated the casualty as a vulnerable patient. Respondents reported that military nurses must have the correct clinical competencies, with skill sets aligned to working within one’s scope of practice. A particular concern was caring for children, with anxiety induced from both a lack of clinical experience (Finnegan et al 2016c) and previous negative experiences. Participants found these situations extremely stressful.
The impact of the study at the time was to inform pre-deployment training and advocate the role of practice educators in the operational environment. Due to the unique nature of this research, the study built on homebased military qualitative defence research (Finnegan et al 2014c) and I published the challenges, theory and methods used to inform future studies (Finnegan 2014a, 2014b).
COVID-19 presented nurses with a multitude of challenges, and one means of assessing what is required in the present is to look to the past. Defence nurses face challenges not generally encountered at an equivalent level within civilian practice, and this study demonstrated the essence of compassion and empathy associated with an altruistic motivation to relieve suffering in the harshest of condition. The attributes historically aligned to great military nurses of previous generations were empirically demonstrated as intact in the current workforce, which is particularly poignant in the International Year of the Nurse and the Midwife.
The characteristics identified in our study have been demonstrated in nurses during the COVID-19 pandemic, and there is clear synergy with global workforce demands. Popular descriptions of nurses ‘battling’ the virus and ‘being on the front line’ are used to describe healthcare delivery.
The findings from our study identified that certain themes and categories could be polarised, depending on the circumstances. Nurses focused on their scope of practice, civilian colleagues were intrigued by the leadership skills, while patients and public focused on personal attributes. However, the power of nursing as a profession is built on the amalgamation of these elements to provide the unique characteristic and value of the profession. The research provided military nurses with a framework for a realistic personal development plan to build on their strengths and identify limitations. Also, it supplied selection panels with an additional tool to help the recruitment process and presented a prompt to focus on all the components of being a military nurse, and not just one area, for example, physical fitness.
Given the increasing global migration of nurses, it was hoped this paper could encourage similar occupational models. Due to the sample, the findings were UK-focused, but these nurses were deployed with equal numbers of colleagues from the United States and evidence suggests that lessons learned from War Zone nursing have international military and civilian implications. However, as an emerging model, readers were advised to treat the findings with some caution.
The American Academy of Nursing’s Military and Veteran Family’s expert panel are working with the RCN’s defence forum and nursing academics to further develop nursing research. In 2020, this will be showcased in international events (Westminster Centre for Research in Veterans, 2020), with 14-16 of the conference papers scheduled to be published in a high standard peer review journal in April 2021.
As the only international armed forces nursing-led qualitative research study undertaken during the Afghanistan and Iraq conflicts, this article was an important historical resource. Significant medical advancements have been achieved by translating clinical lessons learned on the battlefield into civilian healthcare. The serious poly-trauma injuries of the Afghan conflict featured orthopaedic problems, including amputations and associated injuries such as burns (Jansen et al 2012) and traumatic brain injuries (Taylor et al 2012, Trauma Brain Foundation 2016). Yet the exemplary Bastion Hospital healthcare provision (Care Quality Commission 2012, Stockinger 2012) played a part in saving lives where previously patients would have died (Hodgetts 2012). These experiences informed the development of the National Institute for Health Research/Ministry of Defence-funded Surgical Reconstruction and Microbiology Research Centre (2015) and the Scar Free Foundation (2020). In mental health, clinical and nursing initiatives such as assertive outreach, community-based care, crisis intervention (Artiss 1997) and group psychotherapy (Harrison and Clarke 1992) have their origins in the world wars. The lessons learned from the battlefield, can have significant positive influences on military and civilian nursing on a truly international scale. The study demonstrates that despite the ethical and geographical challenges, that quality information can be collected in the harshest of terrains. The originality of the study is embedded in the United Nations’ sustainable development goals of producing evidence to inform good health and well-being and shaping quality education.
By collecting empirical data to inform educational programmes, clinical practice and policy, nursing researchers can help prepare the future generation of nurses. Placing nurses first, with a model that focuses on the requirements of a good nurse, has the potential to lead to better patient care, and improve the quality of their workforce experiences.
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