Since the inception of the three nurse corps, military nurses have been intimately involved in the care of service members, their families, and civilians. Historically, surges in registered nurse commissions occurred in response to United States (US) involvement in wartime missions. Most recently, more than 6,300 military nurses were actively engaged in the Global War on Terrorism (Operation Enduring Freedom [OEF, 2001-2014], Operation Iraqi Freedom [OIF, 2003-2010], Operation New Dawn [2010-2011], and Operation Inherent Resolve [2014 to present] between 2001 and 2015 (Berry-Cabán, Rivers, Beltran, & Anderson, 2018). Thousands more military and civilian nurses provide ongoing care to wounded service members in military hospitals and treatment centers in the United States daily. At the request of host nations, military nurses are also actively involved in military operations other than war (MOOTW); namely humanitarian and disaster relief efforts (Agazio, 2010; Baxter & Beadling, 2013).

Exposure to trauma, death, violence, threats to personal safety, and ethical dilemmas in austere work environments means that military nurses are at risk for untoward psychological effects...Exposure to trauma, death, violence, threats to personal safety, and ethical dilemmas in austere work environments means that military nurses are at risk for untoward psychological effects capable of impacting their personal and professional lives (Elliott, 2015; Gibbons, Hickling, & Watts, 2012; Gibbons, Shafer, Aramanda, Hickling, & Benedek, 2014; Kenward & Kenward, 2015; Thompson et al., 2014). Short and long term responses to these exposures manifest as depression, anxiety, stress, and moral distress that result in burnout, compassion fatigue, post-traumatic stress, and post-traumatic stress disorder (Adler et al., 2017; Gibbons et al., 2012; Goldstein, 2016). Troublesome is the fact that military nurses must process their own experiences while providing care to those with similar, if not identical, symptoms and experiences (Lester, Taylor, Hawkins, & Landry, 2015).

Troublesome is the fact that military nurses must process their own experiences while providing care to those with similar, if not identical, symptoms and experiences Efforts to describe the psychological effects of military service on active duty, reserve, and National Guard nurses are widely reported in the nursing literature. More importantly, strategies to address and mitigate these effects are emerging and gaining traction. Yet, the implications to stakeholders beyond the confines of the military environment are not apparent. Lessons learned from research about military nurses and nursing practice may be beneficial to entities outside of the military. Therefore, a review of current literature was undertaken to elucidate the psychological effects of military service on nurses’ well-being for the purpose of extending the conversation to nurse leaders in civilian and academic environments.

Review of Literature

Methodology
We performed a literature search of English language articles, published between 2010 and 2019. Using the key words military nurs* and deployment, humanitarian, secondary traumatic stress, post-traumatic stress, post-traumatic stress disorder, PTSD, burnout, compassion fatigue, moral, ethical, or ethical dilemma, articles were retrieved from the Cumulative Index of Nursing and Allied Health Literature (CINAHL), the National Library of Medicine (PubMed), the American Psychological Association (PsycINFO), OVID, ProQuest, and Google Scholar databases. Due to very few articles that discussed the impact of participation in humanitarian missions, date parameters were expanded to locate relevant articles in this domain. We excluded articles that were not published in English, did not include military nurses, or specifically focused on the reintegration experience (post-deployment transition). The reference lists from retrieved articles were further examined for additional sources. A total of 52 articles matched inclusion criteria for this review. Synthesis of current literature was grouped by psychological issue to facilitate a comprehensive understanding.

Military nurses are proud of their service and the opportunity to give back to their country, but acknowledge significant differences between military and civilian nursing practice. Military nurses comprise a small percentage of the total military force in the United States. Yet, their role carries importance as their primary goal is to restore health to ensure a ready force capable of fulfilling missions at home and abroad (Agazio & Goodman, 2017; Defense Health Board, 2015; Kelly, 2010). Military nurses are proud of their service and the opportunity to give back to their country (Boyd, 2017; Finnegan et al., 2016a), but acknowledge significant differences between military and civilian nursing practice. Kelly (2010) argues the military nurses’ obligation to follow orders and participate in battlefield operations “can seem contradictory to the values and beliefs of civilian health care professionals” (p. 639). Participation in deployed, humanitarian, and natural disaster missions results in unforeseen challenges (Goodman, Edge, Agazio, & Prue-Owens., 2013; Kenward & Kenward, 2015), prolonged stress (Agazio & Goodman, 2017; Gibbons et al., 2012; Gibbons, Shafer, Hickling, & Ramsey, 2013; Rivers, 2016), and distress (Agazio, Goodman, Opanubi, & McMullen, 2016; Goldstein, 2016), each of which contribute to psychological effects for military nurses.

Ethical Issues
Military nurses have two ethical obligations: the patient and the missionMilitary nurses have two ethical obligations: the patient and the mission (Olsen & Gallagher, 2014). Yet, the military and the nursing profession maintain opposing value systems; one is prepared to end human life in pursuit of an objective whereas the other is focused on the life-saving, caring role (Kelly, 2010; Lundberg, Kjellström, Jonsson & Sandman, 2014). This “dual loyalty” to uphold military objectives alongside patient care obligations frequently results in distress and conflict for military nurses (Agazio et al., 2016, p. 235). Reflections from military nurses reveal the disconcerting nature of placing the service member role and responsibilities before or above the nursing role (Chargualaf & Tse, 2017; Haynes-Smith, 2018; Kelly, 2010; Olsen & Gallegher, 2014). Moral dilemmas may occur for military nurses when meeting the obligations of one role leads to a failure to satisfy the obligations of the other role (Olsen & Gallagher, 2014). Kelly (2010) argues that, in some instances, military nurses may violate parts of the International Council of Nurses (ICN) Code of Ethics (ICN, 2012) by following military orders. Swedish military healthcare personnel practicing in combat zones expressed concern that expectations to perform both military and medically related duties may also violate international humanitarian laws (Lundberg et al., 2014).

Nursing practice in the combat environment has received considerable attention due, in part, to the challenges related to patient care and decision making.Nursing practice in the combat environment has received considerable attention due, in part, to the challenges related to patient care and decision making. A secondary analysis of qualitative data from two studies, thematically organized around the ICN Code of Ethics (ICN, 2012), revealed that military nurses encounter ethical issues in all dimensions of practice in the wartime environment (Agazio & Goodman, 2017). Allocation of resources; patient triage; cultural competence and providing culturally competent care; and impartial treatment of patients were identified as key issues in the study. Despite pre-deployment training, military nurses reported feeling unprepared to provide care for polytraumas resulting from mass casualty incidents (Adler et al., 2017; Agazio & Goodman, 2017; Boyd, 2017; Goodman et al., 2013). These feelings may arise from providing care under the constant threat of harm (Gibbons et al., 2012) in environments far different from those in which training and previous practice occurred (Andersson, Lundberg, Jonsson, Tingström, & Dahlgren, 2017; Haynes-Smith, 2018; Kenward & Kenward, 2015).

For some, feelings of unpreparedness resulted in decreased self-confidence and concern over the ability to contribute as a member of the healthcare team in a meaningful way (Boyd, 2017). According to tenets of the Geneva Convention, military nurses are obligated to provide care to enemy combatants and host nation civilians alongside wounded service members (Agazio & Goodman, 2017; Thompson & Mastel-Smith, 2012; Thompson et al., 2014). Military nurses voiced moral distress over their ability to safely care for Iraqi patients due to a lack of trust in interpreters, biases created over a desire to prioritize care to U.S. soldiers, inability to assure the continuity of care, and cultural differences that negatively affected patient care (Finnegan, Lauder, & McKenna, 2016; Goodman et al., 2013).

The emotional impact of care decisions made in the combat environment contributed to moral issues and stress that lingered well beyond the deployment period At times, mission requirements, institutional policies, the environment, or orders received from superior officers prevented military nurses from making the right choice or taking the correct course of action related to patient care (Agazio et al., 2016; Agazio & Goodman, 2017). Patient care and prioritization of that care depended upon prudent allocation of resources in deployment settings. Yet the frequency of traumas and resupply delays often meant that resources were scarce (Agazio et al., 2016, Finnegan et al., 2016a). Military nurses struggled with the ramifications of making life or death decisions that relied on the presence or absence of supplies or risking that supplies may not be available if additional traumas arrive (Kenward & Kenward, 2015). The emotional impact of care decisions made in the combat environment contributed to moral issues and stress that lingered well beyond the deployment period (Agazio et al., 2016; Gibbons et al., 2012).

Interviews with 23 military nurses who responded to at least one disaster revealed significant differences in feelings of preparedness during a disaster response versus wartime. Similar issues emerged in a study investigating nursing challenges during a humanitarian mission following the 2004 tsunami in the Indian Ocean (Almonte, 2009). Military nurses reported ethical conflicts related to an inability to provide care to injured persons due to time and resource constraints. Nurses further verbalized feeling inadequately prepared to handle pediatric deaths and the volume of patients requiring care (Almonte, 2009). Common experiences were shared by military nurses participating in missions following other natural disasters (Rivers, 2016; Rivers & Gordon, 2017). Interviews with 23 military nurses who responded to at least one disaster revealed significant differences in feelings of preparedness during a disaster response versus wartime. Functioning in a state of chaos, characterized by many unknowns, and circumstances where military nurses had to “make do” were overwhelming and left the nurses with substantial emotional sequelae (Rivers, 2016). Psychological burden may be decreased if military nurses are provided time to reflect and receive support during the reintegration and recovery period (Rivers & Gordon, 2017).

Compassion Fatigue and Burnout
Compassion fatigue and burnout are widely reported effects of military service. All nurses, regardless of specialty, are at risk for compassion fatigue (Peters, 2018). For military nurses, compassion fatigue and burnout are frequently associated with participation in deployment and humanitarian missions. Yet, inconsistent definitions of both terms, even when isolated to a military context, create challenges to synthesize the results across published studies (Owen & Wanzer, 2014). Two recently published concept analyses sought to define and distinguish the terms (Peters, 2018; Sorenson, Bolick, Wright, & Hamilton, 2017). According to Peters (2018), compassion fatigue involves holistic exhaustion manifested as physical, emotional, and spiritual decline due to an inability to cope or recover from a sustained exposure to stress and suffering. For military healthcare providers, compassion fatigue is an occupational hazard involving feelings of empathy, helplessness, fear, purposelessness, and an inability to identify self-care needs that results in psychological distress (Sorenson et al., 2017). Goldstein (2016) noted the pervasive nature of compassion fatigue involving multilevel distresses manifested through emotions, feelings, and behaviors.

Whereas compassion fatigue tends to have an abrupt onset, the insidious nature of burnout is related to the cumulative effects of occupational stress and leads to emotional exhaustion Whereas compassion fatigue tends to have an abrupt onset, the insidious nature of burnout is related to the cumulative effects of occupational stress and leads to emotional exhaustion (Sorenson et al., 2017). Ayala & Carnero (2013) note that burnout is an extension of compassion fatigue that occurs when coping strategies are insufficient to manage occupational stress over a long period of time.

Across published literature, personal and work-related variables, including leadership support, are associated with compassion fatigue and burnout in military nurses (Adler et al., 2017; Finnegan, Lauder, & McKenna, 2016b). Known sources of stress for military nurses include the physical working environment, particularly during deployments or humanitarian and disaster missions; frequent exposure to trauma or violence; competing role responsibilities; threats to personal safety; individual responses to prolonged stress such as hyperarousal and hypervigilance; and prolonged engagement providing care to injured soldiers (Gibbons et al., 2012; Gibbons et al., 2014; Kenward & Kenward, 2015, Lang, Patrician, & Steele, 2012). Civilian and military nurses share similar manifestations of compassion fatigue including feelings of distress, a negative outlook, decreased morale, changes in work quality, and disengagement from patients (Goldstein, 2016). Triggers associated with compassion fatigue include heavy workloads involving high acuity patients, a lack of support in the work environment, and previous exposure to trauma (Goldstein, 2016). However, military practice environments may contribute additional unique triggers for compassion fatigue not seen in civilian nurses, namely frequent and repeated exposure to polytrauma and death (Goldstein, 2016).

Civilian and military nurses share similar manifestations of compassion fatigue including feelings of distress, a negative outlook, decreased morale, changes in work quality, and disengagement from patients Nurses who deploy during their military career are more likely to experience feelings of burnout (Leners, Sowers, Quinn Griffin, & Fitzpatrick, 2014). Lang and colleagues (2010 & 2012) determined that civilian and military nurses assigned to Army military treatment facilities in the United States and overseas in a deployed environment were moderately burned out. Working long hours was found to be an underlying factor in developing burnout (Lang et al., 2012). In a cross-sectional study of 344 military medical personnel deployed to Afghanistan, more than 30% reported symptoms of burnout (Adler et al., 2017). Burnout was positively correlated to perceived professional stressors; however, burnout was negatively correlated with self-care, team support, general and health-supporting leadership (Adler et al., 2017). Additionally, rank did not protect service members from developing burnout (Adler et al., 2017). Among military nurses in Peru, those who were single, older, and working in the emergency department (ED) were more likely to have higher depersonalization scores, while working in the current department for a shorter length of time was associated with higher emotional exhaustion scores (Ayala & Carnero, 2013). Unlike previous studies, a cross-sectional study of military ED healthcare providers revealed that professional role and previous deployment experience was not associated with burnout or compassion fatigue. This was attributed to a greater exposure to traumas and enhanced training opportunities afforded to ED providers (Cragun, April, & Thaxton, 2016).

Working long hours was found to be an underlying factor in developing burnout To better understand the pervasiveness of these issues within a military environment, researchers have begun to compare rates of burnout and compassion fatigue between civilian and military nurses. Lang et al. (2010) concluded that military and civilian nurses working in a military treatment facility in the US had moderate levels of burnout, although civilian nurses maintained higher emotional exhaustion and depersonalization scores than military nursing personnel. Routinely caring for injured soldiers and working night shift were further associated with high emotional exhaustion scores, while working shorter shifts resulted in less depersonalization (Lang, Pfister, & Siemens, 2010). Lang et al. (2012) later compared burnout scores for nurses working in the U.S. military treatment facility with deployed military nurses; both groups exhibited burnout. For the deployed nurses in the sample, lack of supportive leadership, inability to provide quality care, difficult relationships between physicians and nurses, and working more than 80 hours were significantly associated with emotional exhaustion (Lang et al., 2012).

Post-traumatic Stress and Post-traumatic Stress Disorder (PTSD)
Post-traumatic stress disorder has been deemed a public health issue among deployed and non-deployed Veterans (U.S. Department of Veterans Affairs, 2018). A recent secondary analysis of data obtained from the National Health Study for a New Generation of U.S. Veterans survey revealed that the overall prevalence of PTSD among deployed and non-deployed veterans serving during the OEF/OIF era was 13.5% (Dursa, Reinhard, Barth & Schneiderman, 2014). Rates of PTSD were substantially higher in veterans who deployed in support of the War on Terror when compared to those who did not deploy (15.8% vs 10.9% respectively; Dursa et al., 2014).

Rates of PTSD in military healthcare providers vary widely Rates of PTSD in military healthcare providers vary widely (Gibbons et al., 2012). Swearingen, Goodman, Chappelle, and Thompson (2017) reported that 14% of military healthcare personnel (military nurses and respiratory therapists) trained to provide treatment to high acuity patients in an aeromedical environment (Critical Care Air Transport Team [CCATT]) met PTSD symptom criteria, as opposed only 4.3% of general aeromedical personnel (AE). This equated to a 3.22 higher likelihood that CCATT members would develop PTSD when compared to AE members. The researchers contended that training and deploying as a group may protect military nurses against developing PTSD (Swearingen et al., 2017). Another study of U.S. military healthcare personnel deployed to Afghanistan determined that 4.3% positively reported symptoms matching PTSD criteria (Adler et al., 2017). Frequently, military nurses are grouped with other military healthcare personal in research investigating PTSD, creating challenges to a clear understanding of the scope of the issue for specific care providers. Qualitative empirical evidence and anecdotal accounts support PTSD as an issue for military nurses (Gibbons et al., 2013; Gibbons et al., 2014; Haynes-Smith, 2018, Nayback-Beebe, 2010).

...training and deploying as a group may protect military nurses against developing PTSD Associations between PTSD and personal or work related variables are widely reported. Like compassion fatigue and burnout, risk factors for PTSD include a lack of social support, repeated exposures to violence and trauma, and moral distress created by ethical dilemmas (Gibbons et al, 2012). Though similar, secondary traumatic stress (STS) manifests unique differences from PTSD. According to Penix, Kim, Wilk, and Adler (2019), secondary traumatic stress is positively associated with combat exposure, professional demands, and burnout, while job performance and connection to family are negatively associated with secondary traumatic stress. Conversely, Swearingen et al. (2017) found no relationship between PTSD symptoms and demographic or occupational factors in a sample of 188 Air Force aeromedical evacuation personnel.

Despite aggressive efforts by military leaders, stigma associated with accessing mental health services and barriers to receiving care remains.Despite aggressive efforts by military leaders, stigma associated with accessing mental health services and barriers to receiving care remains. Among 211 healthcare providers in the U.S. Air Force (USAF), more than half perceived that accessing mental health services would result in a decreased confidence in work abilities by others in the unit and being treated differently by unit leaders. In those who did access services, barriers related to getting time off from work (41%) and difficulty scheduling appointments (21%) were commonly reported (Hernandez, Bedrick, & Parshall, 2014). Hernandez et al. (2014) concluded that officers in the USAF reported more stigma and greater barriers when accessing mental health services compared to enlisted personnel.

There is reluctance on the part of military nurses to identify or admit to feelings of burnout, compassion fatigue, or persistent stress responses over fears about how these symptoms will be perceived by others...There is reluctance on the part of military nurses to identify or admit to feelings of burnout, compassion fatigue, or persistent stress responses over fears about how these symptoms will be perceived by others in the unit, including unit leaders, and the impact such disclosures may have on future military opportunities. Participants in Goldstein’s (2016) study feared appearing weak or incompetent and worried that any attempt to discuss internal struggles resulting from deployments to Iraq or Afghanistan could destroy their military careers. As a result, psychological first aid (PFA) measures were commonly employed by military nurses to cope with perceived stressors (Gibbons et al., 2014). Nurses limited discussion about previous events as a means to compartmentalize negative or traumatic experiences (Gibbons et al., 2014); participated in calming and uplifting activities (Gibbons et al., 2014); actively engaged in self-management activities to enhance self-efficacy (Adler et al., 2017; Gibbons et al., 2014; Kenward & Kenward, 2015); established or reinforced a sense of connectedness to peers and colleagues (Adler et al., 2017; Gibbons et al., 2012; Gibbons et al., 2014; Kenward & Kenward, 2015); and turned to religion and faith (Kenward & Kenward, 2015) to reaffirm a sense of hope (Gibbons et al., 2014).

Exploring Solutions

Differing role expectations, practice environments, decisional influences, perceived preparedness, and competing priorities contribute to negative psychological repercussions for military nurses. The nursing literature has devoted considerable time to define and quantify the “invisible wounds” resulting from military service. This is reflected in the volume of current references informing the review above. Perhaps more importantly, adapting to stressful events and efforts to mitigate psychological effects are less widely reported (Angel, 2016). Some assume that military healthcare providers should be able to manage the psychological consequences of delivering nursing care in dangerous environments simply based on their professional background and training (Finnegan et al., 2016b). Nurse leaders have an obligation to understand and support endeavors that propel military nurses past stress responses to achieve a restored sense of balance and psychological health. This section presents research on spirituality and resilience as possible protective factors, and also explores the phenomenon of posttraumatic growth (PTG).

Nurse leaders have an obligation to understand and support endeavors that propel military nurses past stress responses to achieve a restored sense of balance and psychological health. Spirituality encompasses one’s connectedness to self, others, the environment, and a higher being to find meaning and purpose in life (Gilliland et al., 2010). Ormsby, Harrington, and Borbasi (2016) determined that spirituality and spiritual care may protect military nurses from negative psychological, emotional, or spiritual outcomes resulting from military service in a deployed environment. A phenomenological study of former military nurses revealed that spirituality was an effective way to cope with war-related stressors (Gilliland et al., 2010). Delivering spiritual care is a key component of a military nurse’s practice that facilitates the nurse’s own ability to cope with wartime stressors (Ormsby et al., 2016; Simmons, Rivers, Gordon, & Yoder, 2018). The deployment experience itself did not contribute to a significant change in spirituality (Simmons et al., 2018).

Delivering spiritual care is a key component of a military nurse’s practice that facilitates the nurse’s own ability to cope with wartime stressors Resilience is the ability to process and recover from direct or indirect exposure to trauma (Lester et al., 2015). Spirituality appears to provide some degree of protection against the psychological impacts of military nursing practice; resilience may not sufficiently protect military healthcare providers from deployment related stressors (Gibbons et al., 2012). Among military healthcare providers, nurses who had deployed had decreased resilience contributing significantly to burnout and compassion fatigue (Leners et al., 2014). Yet, the stigma of accessing mental health services and perceived barriers undermine efforts to reduce stress and enhance resiliency in military healthcare providers.

Over the last decade, military leaders have supported and more fully embraced efforts to proactively build resiliency skills... Among Air Force nurses and technicians, Hernandez, Morgan, and Parshall (2016) determined that while mean resilience scores were high, participants reported a moderate amount of stress. Further, there was a positive correlation between stigma and perceived stress and a negative correlation between stigma and resilience (Hernandez et al., 2016). Over the last decade, military leaders have supported and more fully embraced efforts to proactively build resiliency skills through Provider Resilience Training (PRT) and the early identification of burnout or compassion fatigue attributed to a lack of resilience (Lester et al., 2015). However, current training efforts may not sufficiently meet military healthcare provider needs (Leners et al., 2014).

Posttraumatic growth is defined as positive psychological changes resulting from a past traumatic experience (Tedeschi & Calhoun, 2004). More than a coping mechanism to a perceived crisis, PTG may be described as an outcome or ongoing process characterized by growth, self-improvement, meaningful relationships, and an appreciation for life (Tedeschi & Calhoun, 2004). More recently, investigation of PTG in military service members was undertaken (McLean et al., 2013; Tsai, Sippel, Mota, Southwick, & Pietrzak, 2016). According to Tsai et al. (2016), consistently high or increasing PTG is associated with exposure to a greater number of traumatic events, greater purpose in life, and a sense of spirituality in U.S. military veterans. The researchers concluded that sustained personal growth occurred in those with ongoing traumatic exposures and active PTSD symptomatology, while a lack of PTSD symptoms, an active lifestyle, and altruism result in decreased PTG (Tsai et al., 2016). These findings are consistent with those of a study of recently deployed Air Force medical personnel which found a direct relationship between increased healthcare stress and PTG (McLean et al., 2013). McLean et al. (2013) suggested that military healthcare providers’ moral compass and inherent resolve to protect, care, and heal in an altruistic manner are factors which enhance PTG.

Military research was the first to describe the psychological effects of nursing practice resulting from participation in wartime, humanitarian, and disaster missions. Military research was the first to describe the psychological effects of nursing practice resulting from participation in wartime, humanitarian, and disaster missions. Due to the pervasive psychological sequelae, recommendations to reduce the impact and facilitate adaptation have been reported in the military literature. However, the utility of the results and recommendations gleaned from research about military nurses and other healthcare providers is not limited to a military context. It is proposed that civilian and academic leaders utilize the conclusions and recommendations derived from military research to inform and improve practice for all nurses.

Implications for Civilian Nursing Practice

Nurses working in civilian environments also report significant psychological effects resulting from professional nursing practice. Nurses working in civilian environments also report significant psychological effects resulting from professional nursing practice. Managing acutely ill patients requiring complex care, violence in the work environment, inadequate role preparation, and insufficient resources contributes to feelings of stress and distress (Henderson, Kamp, Niedbalski, Abraham, & Gillum, 2018; Shaw, Abbott, & King, 2018). Often, the same outcomes of prolonged stress in military nurses, including PTSD, burnout, and compassion fatigue, are frequently reported by civilian nurses (Cañadas-De la Fuente et al., 2015; Nolte, Downing, Temane, & Hastings-Tolsma, 2017; Spence-Laschinger et al., 2019; Upton, 2018). Although specific contributing factors may differ for civilian and military nurses, the impact on nursing practice is no less relevant.

As in civilian nursing practice, the patient is the primary responsibility of the military nurse Drawing parallels between military and civilian nursing research may lend credence to the transferability of research findings and recommendations. As in civilian nursing practice, the patient is the primary responsibility of the military nurse (Agazio & Goodman, 2017). Moral dissonance and distress occur when military role expectations interfere with the nurse-patient relationship or when the environment of care is not in alignment with personal and professional values (Agazio & Goodman, 2017; Finnegan et al., 2016b; Goodman et al., 2013). As suggested by Thompson et al. (2014), ethical dilemmas while caring for insurgents may be similar to caring for prisoners or gang members who have committed horrible crimes or drunk drivers whose actions have taken lives. Civilian nurses struggling to maintain the sanctity of the nurse-patient relationship in the face of mounting environmental, financial, and resource challenges may find solace in the experiences of military nurses. Individual and organizational interventions, described in military research, should be explored for transferability to civilian nurses and the civilian work environment.

Resiliency and Spirituality
The military has focused on building resiliency for a number of years in response to emotional consequences of participation in war. On an individual level, methods reported by military nurses during deployment to reduce stress, burnout, and compassion fatigue could be used upon return or by nurses in civilian settings experiencing similar challenges. Storytelling (Maiocco & Smith, 2016), journaling (Rivers & Gordon, 2017), and practicing coping strategies such as mindfulness (Stanton, Parker, McDougall, & Eyer, 2017) are just a few examples. In addition, building spiritual literacy (Ormsby et al., 2016) and spiritual resiliency (Simmons et al., 2018) may contribute to increasing overall resiliency in stressful situations.

Military research recommends reassessment of healthcare providers at regular intervals...Military research recommends reassessment of healthcare providers at regular intervals, which would serve the civilian community of healthcare providers well (Lester at al., 2014; Sargent et al., 2016). Researchers suggest re-conceptualizing training programs to be more realistic and better prepare nurses to care for highly complex patients in all environments (Andersson et al., 2017; Boyd, 2017). One approach used in the U.S. Army to assist military healthcare providers was to build programs that teach about compassion fatigue and burnout, reinforce self-assessment of health, and support positive steps towards well-being (Lester et al., 2015). Curricula included development of self-care plans, counseling, and ways to strengthen social networks with others who share similar burdens of service as a healthcare provider. Of note, the U.S. Army developed programs in a variety of formats and lengths to meet initial and ongoing needs with the intent to be comprehensive over time, not just a single training. Civilian organizations could build similar programs with training to support those experiencing compassion fatigue, burnout, or secondary traumatic stress. In addition, Lester et al. (2015) propose the use of technology and mobile phone applications, such as the Provider Resilience app, that enhance self-awareness and build resiliency. The effectiveness of education and training is enhanced when providers are able to work in stable environments, with adequate resources, leadership support, and reasonable workloads.

Creating Healthy Work Environments
...nurses who serve in reserve and National Guard roles deserve respect and support upon return from missions, whether war zone or MOOTW.First and foremost, nurses who serve in Reserve and National Guard roles deserve respect and support upon return from missions, whether war zone or MOOTW. Stanton et al. (2017) reported that nurses returning to their civilian roles perceived managers and supervisors, with no military exposure, as generally insensitive to those serving in the military or deployments. Conversely, military nurses entering civilian roles also expressed frustration due to varying role expectations and difficulty fitting in with old jobs and peer groups due to a change in worldview (Elliott, 2015; Elliott et al., 2016). A solution to this is for civilian nurses and leaders to engage with military and veteran nurses to learn about their experiences, as well as how those experiences may influence them upon return. Nurses who deploy from any status may require a year or more after return to make meaning of their experiences (Gibbons et al., 2012; Elliott, 2015) and to reach a point of readiness to move forward (Maiocco & Smith, 2016). Returning or entering a supportive work environment can foster successful reintegration.

From military research, suggestions to reduce hours worked to no more than eight per day and rotating nurses to day shift may provide a necessary change and more interaction with staff, which may alleviate burnout or compassion fatigue (Lang et al., 2010). In addition, monthly unit debriefings could serve as an avenue to discuss difficult patients or situations that might lead to nurse burnout and compassion fatigue. Hospital-wide veteran support groups may be one solution to provide ongoing emotional support to veterans. This model could also be used for others experiencing high stress in the work place.

A number of recommendations in the military research literature focus on promoting self-care practices...A number of recommendations in the military research literature focus on promoting self-care practices, which may reduce stress, compassion fatigue, and burnout. Adler et al. (2017) and Penix et al. (2019) found that health-promoting behaviors by leaders was associated with lower burnout and STS levels respectively. Penix et al. (2019) suggest that promoting emotional self-care and positive feedback contributes to a supportive, healthy, work environment, which may also reduce STS. Further, a team care approach, whereby peers on the unit provide support to team members, as described by Alder et al. (2017), may reinforce a sense of belonging and work engagement, which is transferable to other contexts outside of the military.

Implications for Civilian and Academic Nurse Leaders

Psychological effects of military service may linger well beyond the actual deployment period or service commitmentPsychological effects of military service may linger well beyond the actual deployment period or service commitment (Elliott, 2015; Goldstein, 2016). This is a particularly important consideration as the military continues to withdraw from combat environments and war-torn countries. The influx of active duty, reserve, and National Guard nurses returning to or seeking new civilian employment, or pursuing advanced nursing degrees, means that civilian and academic leaders must be knowledgeable about military culture and the effect(s) of military service. Ongoing efforts to assess, debrief, and train nurses to identify and effectively manage negative outcomes are needed to support and facilitate a smooth transition (Lang et al., 2010; Lester et al., 2015).

In those returning from deployment, a state of chaos is common. Transition from a collectivist military culture, defined by teamwork and conformity, to a civilian environment which values individualism is challenging for nurses (Cozza, Goldenberg, & Ursano, 2014; Elliott et al., 2016). For many, the transition to civilian nursing practice is influenced by residual psychological effects of military service and feelings of grief related to a loss of military identity and lifestyle (Elliott et al., 2016). In those returning from deployment, a state of chaos is common. These nurses work to fit into civilian culture while also attending to feelings of guilt related to decreased compassion (Elliott, 2015). Elliott and colleagues (2016) noted that military nurses in transition underwent simultaneous work-role, personal, and psychological transitions culminating in the reconstruction of a personal and professional identity. Challenges associated with the transition experience may be present for up to one year.

Transitioning to academia is also a complex and challenging experience (Chargualaf, Elliott, & Patterson, 2017; Chargualaf, Elliott, & Patterson, 2018). Identity reformation, recognized as a change in self-perception resulting from a merge of differing knowledge, values, and norms, was apparent in military nurses who transitioned to the nurse faculty role (Chargualaf et al., 2017). Military nurses endured a state of dissonance when they encountered inaccurate perceptions of military service members; incongruent military and academic value systems; and insufficient support during the transition period (Chargualaf et al., 2017). Deans can facilitate a smoother transition by providing continuing education for faculty. This education can serve two purposes, engaging faculty with peers with prior military service and students who are veterans.

In the academic setting, nurse educators teaching students who are veterans may find value in a deeper understanding of military cultural influences and an appreciation of the lasting effects of serving that are capable of influencing learning and successful matriculation. No research was located to inform the experiences of military nurses returning to higher education. However, research on student who are veterans in general suggests that they also navigate multiple transitions; particularly the intersection of civilian and academic cultures (Patterson, Elliott, & Chargualaf, 2019). Participants in this recent study were able to see how nursing could fill the void from leaving military service by joining an effort greater than themselves; they discovered their new purpose (Patterson et al., 2019). In both cases, leadership skills brought from military service assisted military nurses during the transition (Chargualaf et al., 2017; Chargualaf et al., 2018).

...military nurses who transition to civilian clinical and academic environments bring their military values and experiences to their new roles. Remaining abreast of current military nurse research maintains benefits for military, civilian, and academic leaders. While this review focused on the psychological effects of military service on nurses, it also highlighted that civilian nurses share similar outcomes from professional nursing practice. Further, military nurses who transition to civilian clinical and academic environments bring their military values and experiences to their new roles. Issues may arise if nurse leaders are not familiar with the unique characteristics of veterans or military culture; both of which can influence the ways in which care is provided and care outcomes (Elliott et al., 2016; Gibbons et al., 2012). Civilian leaders should be aware of the unique contextual influences on military nursing practice (Meyer, Writer, & Brim, 2016), inquire about nursing experience in the military (Maiocco & Smith, 2016), and understand that certain experiences increase the risk of negative psychological effects.

Invisible effects of military service should not deter leaders from considering nurse veterans to fill vacancies in civilian healthcare environments. Military nurses are an invaluable asset to the nursing profession. Their experiences as military nurses can support efforts to help others make meaning of military service and the effects of deployment (Elliott, 2014; Elliott, 2015), support others transition between military and civilian environments (Chargualaf et al., 2017; Elliott et al., 2016), and advocate for other military nurses enduring the same or similar psychological effects. Their leadership attributes add value to any nursing role in the civilian sector. Further, the experiences of military nurses can inform nursing curricula and provide a foundation for discussions about moral and ethical dilemmas faced by nurses. Finally, we hope that this review promoted a greater understanding of the benefits of hiring veteran nurses into civilian nursing practice and academic roles.

Conclusion

Building a resilient workforce, within both military and civilian care settings, is imperative for nurse retention and satisfaction. Military service can expose nurses to a number of psychological, emotional, spiritual, and physical stressors. The purpose of this review was to illuminate the psychological effects of military service on nurses’ well-being, so that lessons learned from military nurse research might be interpreted for and used by nurse leaders in civilian and academic environments. Building a resilient workforce, within both military and civilian care settings, is imperative for nurse retention and satisfaction. Ultimately, a resilient workforce can contribute to positive patient outcomes. To accomplish this, healthcare organizations must educate leaders to recognize nursing-related stress, create healthy work environments, and promote positive health behaviors so that military and civilian nurses alike are well supported and positioned to deliver high quality nursing care.

Authors

Katie A. Chargualaf, PhD, RN, CMSRN
Email: KatieCh@usca.edu

Dr. Katie Chargualaf is a certified medical-surgical nurse and military spouse. Currently an Assistant Professor at the University of South Carolina Aiken, in Aiken, South Carolina, Dr. Chargualaf teaches leadership and management in a traditional pre-licensure nursing program as well as the RN-BSN program. She maintains programs of research related to military nurses, Veterans, transition to practice, nurse retention, evidence-based practice, and post transplantation patient outcomes.

Brenda Elliott, PhD, RN, CNE
Email: brenda.elliott@wilson.edu

Brenda Elliott PhD, RN, CNE is an Adjunct Professor in the School of Nursing at Wilson College in Chambersburg, Pennsylvania. She served as a Nurse Corps Officer in the United States Army from 1994–1998. Her research and publications are in the areas of military nursing, veterans, home care, and wound/ostomy management. She serves as the column editor for the Joining Forces column in MedSurg Matters!