...American nurses have faced hardship and challenges in every war period in the relatively short history of the United States.It is no surprise that American nurses have faced hardship and challenges in every war period in the relatively short history of the United States (US). For example, Wood (1972) recounted how nurse volunteers during the civil war not only endured the harsh conditions of the war and cleaned up the unsanitary conditions of the military hospitals, but also fought another war themselves with the male dominated medical profession bent on keeping women away from the battlefield or defining their own profession of nursing. Norman (1999) detailed stories of 77 nurses in World War II who were captured by the Japanese, taken prisoner, and held for three years in a prison encampment in Bataan. In interviewing her aging subjects, she discovered a strength within them that was unmistakable; one that allowed them to survive their dire situation while still caring for other prisoners of war. However, despite this, and the fact that psychologists believed nurses’ education and their experiences had somehow left them immune to the ravages of war, Norman (1999) found that “the opposite was true: they felt too much” (p. 242). This was supported in a study that considered a direct correlation between moral sensitivity and moral distress of nurses in two countries (Ohnishi et al., 2018). Ironically, it is the empathy of nurses that will often cause them to suffer secondary traumatic stress (Bride, Radey, & Figley, 2007).

Also in World War II, some 10,000 American nurses were involved with troops in France, Germany, and Sicily, saving lives and making vital contributions to military medicine (Sarnecky, 1999). However, they too suffered in silence, rising to the occasion time and again, even though they themselves were hurting. It has been this way in war after war; nurses have been willing to put their lives in danger for their charges, work as long or hard as necessary to ensure the injured got the best care they could give. In former years, this stress has been dismissed, with some claiming that nurses do not suffer the stressors of those who are fighting (Lucchesi, 2019). This position is changing and the stressors of nurses in wartime scenarios are becoming more recognized.

In virtually every war in every country, we hear of nurses suffering distress and handling ethical issues.In virtually every war in every country, we hear of nurses suffering distress and handling ethical issues. Generally, this is only documented through stories told by the nurses, mostly after many years have passed since their experiences in an attempt to not lose the memories of their stories (Agazio & Goodman, 2017; Nightingale, 1859/1992; Norman, 1999; Sarnecky, 1999; Sorokina, 1995). This article will discuss some of the ethical issues experienced by nurses during the wars in Iraq and Afghanistan. Though the stories are vastly different from those of their predecessors because of medical and technological advances, the issues remain nearly the same. We will describe some of the ethical dilemmas faced by nurses in a wartime environment, as they were described to the research team.

Background

...every war is different and there is no training for what nurses actually see or do...Since the beginning of civilization, people have been involved in conflict and there have been nurses caring for individuals injured in these conflicts. Nurses have learned triage principles and have been educated about the types of injuries they might see. However, every war is different and there is no training for what nurses actually see or do and how they will process their feelings surrounding the circumstances. Most theory learned in nursing programs is “thrown out the window” when it collides with the reality of war. This does not imply that ethical concerns are set aside, but because of different expectations, they may become more acute and necessitate action that may not coincide with normal professional nursing values. This can create moral distress for nurses.

There is a large body of literature about the moral distress of nurses, but there seems to be a lack of clarity in how it is defined because of its multiple dimensions (McCarthy & Gastmans, 2015; Pauly, Varcoe, & Storch, 2012). Some literature discusses issues nurses may encounter in hospital situations (Bachhuber, Roberts, Metraux, & Montgomery, 2015; Hamric, 2012; McAndrew, Leske, & Schroeter, 2018; Oh & Gastmans, 2015; Whitehead, Herbertson, Hamric, Epstein, & Fisher, 2015). Other literature discusses how moral distress occurs and what types of support nurses need (Burston & Tuckett, 2013; Rathert, May, & Chung, 2016). In many articles, the cause of moral distress is organizational (Corley, Minick, Elswick, & Jacobs, 2005; Wolf et al., 2016) and in others it is individual (Beck, 2011). Johnstone and Hutchinson (2015) contended that the lack of clarity regarding the concept may require nursing to abandon this concept and rethink moral reasoning in nursing.

Moral distress as a distinct concept in nursing is generally thought to have originated with Andrew Jameton’s (1984) philosophical views of moral distress and ethical dilemmas. He defined moral distress as a clear difference in thinking between a nurse and those in superior positions, whereas an ethical dilemma involves a more global perspective of care and its context. He further differentiated distress into two distinct stages. The first is initial stress, where an individual recognizes there is dissonance between care needed and personal moral convictions. The second is reactive stress, where an individual will respond to the stressor with specific behaviors, which can either be short-lived, or persistent. Since his original writings, Jameton’s philosophical thinking has evolved to a broadened concept that includes nursing within the global environment (Jameton, 2013). Prior to Jameton, moral distress in nursing was described by authors going back to Nightingale (1859/1992), where she stated,

The distress is very legitimate, but it generally arises from the nurse not having the power of laying clearly and shortly before the doctor the facts from which she derives her opinion, or from the doctor being hasty and inexperienced, and not capable of eliciting them. (p. 69)

Her notion seemed to be directly related to role differences between physicians and nurses. This was supported in a later article by Elmer (1909) concluding that well-trained nurses should be listened to, and held in high regard by physicians. He further stated that environment played a significant role in nurses’ distress.

Moral distress...has rarely been studied with nurses in a war zone, during a war.Moral distress as experienced by nurses is well documented and has been studied in multiple settings. However, it has rarely been studied with nurses in a war zone, during a war. While the root causes of moral distress that military nurses experience may remain the same as those described by Hamric et al. (2012), i.e., clinical situations, internal constraints, and external constraints, there are also significant differences in the types of stressors that deployed military nurses face. Fry and colleagues were among the first to begin to develop a model for moral distress in military nurses (Fry, Harvey, Hurley, & Foley, 2002). They described environments that were dangerous; patients who were uncharacteristic; and military triage practices that differed from the norm. They contended that this triad constituted a higher than normal probability for moral distress among military nurses.

Because the wartime environment is entirely distinctive, may be austere, and is often culturally different, ethical issues experienced by nurses may be even more pronounced (Gross, 2004). Moral distress in nurses and the psychological sequelae of war have been extensively studied, but there is a decided lack of literature surrounding ethical issues actually experienced by nurses in war. While there were numerous articles examining caring for patients in a war zone and on humanitarian missions, and these made mention of certain ethical challenges, only one other article from the United States could be found that specifically examined ethical issues of American nurses during war (Agazio & Goodman, 2017). This article will add to this gap by presenting a comprehensive view of ethical issues encountered by nurses in a war zone. The quotations presented are those that best exemplify the themes found in the data. In this article, group and individual participants are numbered in the order in which they appear in the discussion.

Study Methods

The purpose of this study was to describe, through an in-depth qualitative reanalysis of the transcripts, some of the ethical issues that nurses struggled with as they faced caring for patients in a war zone or while deployed. The original intent of our study was to use an interpretive, ethnographic methodology to gather nurses’ first person accounts of experiential learning in caring for wounded service members. Phase 1 of the study contained accounts of nurses (n = 180) who had deployed to war zones and/or on humanitarian missions. Phase 2 (n = 235) of the study aimed to extend the first phase to include care of wounded service members (WSMs) (n = 67) through their rehabilitation and service members’ accounts of their memories of their care experience from point of injury in the combat zone through rehabilitation. We recognized in some cases that WSMs could have fuzzy memories of their initial care. Table 1 depicts aggregated demographic data of the nurses in the Phase 2 of the study.

Table 1: Demographics of Sample

We conducted face-to-face, semi-structured interviews with individuals or small groups aimed at prompting complete accounts of actual caregiving experiences from nurses in various situations of care and the WSMs’ detailed narrative stories about injury, care, and rehabilitation experiences. Institutional review board approval was gained at all study sites and through military channels. Data were collected in private settings within the study institutions and after informed consent. Interviews were audio recorded and field notes taken by the research team members. Additionally, demographic data were collected from participants to include branch of service or work environment, rank, gender, age, education, years of experience, deployment location, and nursing specialty.

They discussed scarce resources, ethical issues, family concerns, matters related to deployment, and difficulties in care management, among many topics.Interview data were analyzed using the most current version of Atlas.ti, a software program designed to code and store qualitative data. This software allows data coding so that content specific to codes can be further analyzed and synthesized. Codes were developed inductively by the research team. After discussion of transcripts amongst the team, a codebook was developed by selecting interview excerpts that illustrated each code. Ambiguities were discussed until consensus was reached. Though we originally set out to examine how nurses acquired new knowledge related to caring for service members with serious injuries and poly-trauma, we found that stories went far beyond descriptions of how they gained confidence in their skills on the battlefield, or during subsequent care for injured service members. They also provided deep explanations of their experiences regarding what it was like to care for U.S. service members, the enemy, and local foreign citizens. They discussed scarce resources, ethical issues, family concerns, matters related to deployment, and difficulties in care management, among many topics.

For this analysis, we specifically examined all text related to the code “ethical, moral, political challenge” related to the continuum of care of the injured. We found 164 quotations contained within this code. Data from this code was found in 48 of the group and individual interviews and represented 83 of the 235 nurses in the study. Most text surrounding moral distress was confined to nurses’ care and conditions on the battlefield. After analysis of all text related to this code, we identified ethical situation themes of a) resources/allocation; b) military nursing core values; c) nursing code of ethics; d) caring for the enemy; e) caring for civilians; and f) need for follow-up/closing the loop.

Findings

Resources/Allocation
The first theme of Resources/Allocation was multifactorial and related to numbers and types of casualties, severity of injury, and humanitarian efforts. This included resources used to care for severely wounded service members that were thought to have been futile; and resources used on injured enemies, prisoners, on the local civilian casualties, or even on locals seeking care because they knew their own care system was deficient.

Nurses expressed some frustration with differing opinions as to whether massive resources should be used at all cost.Care for Injured Allied Service Members. Service members in the wars in Iraq and Afghanistan saw injuries that would have been non-survivable if not for advances in medicine and definitive care practices. The injured were cared for by highly trained combat medics and nurses right on the battlefield at the point of injury. Once service members reached combat support hospitals, they had already received, in many cases, lifesaving care, but they were still severely injured. Nurses expressed some frustration with differing opinions as to whether massive resources should be used at all cost. This was particularly true when many casualties were received at one time and heart-wrenching triage was necessary. One nurse expressed:

P1: Because out there the theory of triage is reversed: you save the greatest good, not the greatest injured. So if we had to, and there was days that we did, we left somebody in the shade with a corpsman to attend to them, with as much morphine as he needed and kept him comfortable until he died. And sometimes they were still there and we'd go back for them afterwards and we'd throw whatever we had left at them.

Resources for Enemies and Civilians. Many nurses related stories of having to use scarce resources on enemies who had been injured in the same firefight and brought in with WSMs, or civilian casualties who had been in the area. They struggled with the need to use resources that were supposed to be used for Americans. Though they dutifully did what was required, most could not reconcile their actions, particularly because they knew the subsequent care these people would get outside the American hospitals was quite poor. Often these patients were kept for extended periods of time whereas American casualties were stabilized and transported in a matter of a few hours or days.

P1: But the one big discussion that we got into that really became an ethical discussion frequently and even before we went in, but definitely once we started seeing them, was using our supplies on the Iraqis.

G1: Caring for everyone who gets injured, the Iraqi civilians, Iraqi police, Iraqi army, the Americans from all over - our beds were very valuable. So we constantly had to triage and move patients out. This ethical dilemma came up over and over and over again in transporting Iraqi patients, because we had to transport them from Ballad to Baghdad, where they were assessed by the combat support hospital there, and then arrangements were made for them to go into the Iraqi medical system. Well, everybody had an overwhelming feeling that we were sending them to their death by sending them to the Iraqi medical system. So it was an ethical dilemma constantly, when we had to make arrangements to transport these patients out. So we would stabilize them and keep them as long as we can, to give them the best shot at life.

Though they dutifully did what was required, most could not reconcile their actions...Limited Resources of the Foreign Medical System. Many respondents talked at length about some of the frustrations they had with the local medical system of the country. They knew the Americans were capable of providing better care for local individuals than they would have in their own hospitals. Much of the angst felt by our nurses was related to the fact that we were treating and likely saving people who would eventually be sent back to a local hospital unable to provide resources to continue care. They believed they were sending many people out to their deaths by releasing them from the American hospital and the nurses could not reconcile that with their own value system, even though they knew it was acceptable by the local culture.

G1: They usually the University Center wouldn't take a ventilated patient 'cause they didn't have the means - most of the time - well, their nurses weren't really nurses, and the doctors usually worked only days, till like three o'clock in the afternoon, and then they had like a tech working at night, so they never received the care. But I know in Baghdad - we called up on a couple of patients that we sent over to university, and we found within days of sending them over there, they were dead.

G2: It's strange. You just don't understand why. A lot of times - the Iraqi patients - they're very fearful of going to - when you're gonna transfer them to the Iraqi hospital, because they know, if they're Sunni or Shia, that they can die in there, just because of the difference.

They believed they were sending many people out to their deaths by releasing them...Military Nursing Core Values
Military nurses are trained to view themselves as “officers first, nurses second.” From the time they receive initial training in the military, they are taught that mission and need of the military comes first. Nurses were very aware of both responsibilities of being in a war zone, but struggled to reconcile military needs with human suffering. Many had beliefs that they were deploying solely to care for American service members but found themselves spending most of their time caring for Iraqis and Afghanis. This was because American service members were transported to Germany, then back to the United States in a very short space of time, whereas local citizens truly had no place to go. Additionally, when word got out to the villages that the Americans could help them more than their own medical system, they began showing up for care of all types, even non-emergent. To portray American good will to these people, they received care.

G3: Well, we knew we were going to. They go through the whole - everybody gets equal care. And - and you go to war with yourself. Because as a professional, you're gonna give everybody equal care. But as a soldier, it's very tough to treat Iraqis that you know. What we got mostly, as far as Iraqis go, we had a prison.

P3: Geneva Conventions and rules of war that we have to provide that for them, even if they don't provide the same thing for us. But it's just - when you're hands-on, when you're actually taking care of the soldier and taking care of the assailant, then it's a little more - makes it a little more difficult 'cause emotions are involved.

One nurse in particular related a story regarding her welcome home and the angst it caused her because she had gone off to war and was speaking about it to her family, having to defend her actions and her beliefs. She felt like she, herself, was reliving the Vietnam war experience some forty years later.

P4: Okay, so one thing that was hard was my [relative deleted] is very liberal. She’s always out there protesting against the war. She’s the quintessential liberal person, lives out in [location deleted]. Our political views don’t clash, but she always likes to play the devil’s advocate. She’s always saying, “You have to understand,” blah, blah, blah. I remember telling her it was really hard taking care of those EPWs (Enemy Prisoners of War) because the moral and ethical issues I would have. Knowing what they have done was really, really hard for me……… I started crying, I’m like, I cannot believe, I was using a whole lot of profanity at that point. I remember telling her…… “Don’t have that kind of opinion until you get there because you don’t know what you would do in that instance.” I thought I had a very valid point in that because I took care of EPWs. So I said, “Do not judge the Americans, or U.S. for what they did, because you don’t know what you would’ve done in that situation.

Nursing Code of Ethics
Perhaps the most important and expected finding of this study and of the deep dive into ethical issues was that the nurses seemed to have no conflict whatsoever with their roles as nurses. This finding was almost universally relayed by the nurses interviewed. None seemed to have difficulty in reverting back to the reason they became a nurse in the first place and that was human compassion.

P5: And that was the hardest thing I think I've ever done. And - you know what you think you might want to do. But then, what you're supposed to do comes through, and I did take care of him. It was one of the hardest things that I had ever done.

P5: We did. We talked a lot about it because - from the looks on everyone's faces, everybody had the same feelings. And we talked about the importance of what we had to do, to take care of the patients. That that's our job, and it's not only our job, it's our obligation.

The most poignant story of nursing core ethics came from one Navy nurse, who related a story of caring for a teenaged Taliban who was injured as he set off an improvised explosive device (IED) targeted to Americans. He wound up killing and injuring several Americans. To demonstrate the compassion with which this nurse cared for this patient, we are including the entire story here.

G4: And my first experience with a Taliban soldier from – Taliban bad guy, as they call them – I was given a black eye and a broken bone in my face from an attack from him. And so that was not something I’d been familiar with as a nurse, for as many years as I’ve been. Quite alarming. Didn’t hit him back. But I continued to take care of him for the whole ten days that he was there. And it was a good thing. It reminded me of the oath I took as a nurse, to take care of any patient, anywhere, any time that I was needed to, and it was a challenge, because this particular one was just a boy, and he actually killed two of our American soldiers, so it was – every single bit of strength that I had to take care of him. Being a pediatric nurse, though, I could do it because I focused on the fact that he was a young patient, a young boy, and that’s all he knew. So I gave him 100 percent of care, and I feel very good about that. He taught me a valuable lesson about giving care to someone you didn’t want to…….. And it did make me grow. And who says you can’t still learn as an old nurse. (laughs).

He had a- unfortunately, because he was so young, he had set an IED to explode, and instead of – well, it did explode, and it killed two of our young soldiers, but it also injured himself because he didn’t get away. And he lost a leg, an arm, and was trached, and one eye. So the joke downrange was that I had half of a young boy that attacked me and I couldn’t defend myself. But you know, as I said, it did teach me a valuable lesson, and I think the junior officers that saw how I handled the situation, and that I was willing to take care of him, even though he broke a bone in my face, I was still going to give him the best care and I wasn’t going to back down. I was going to show him that he didn’t scare me, that I was still going to be a nurse and I was still going to be an American.

Yes, actually it did. When he left – whenever you take care of a Taliban, I don’t’ know if you ladies – anybody in here has, but if they’re a detainee, you simply finish taking care of them till they can care for themselves the best way, and you have no one to leave them with. You have to take them to the outside skirts, where it’s safe for you, and leave them, and they have to get where they can get to for safety. So we simply took this man to the outside quarters of the air field and of course he’s blindfolded and has earmuffs on, has no idea where we have brought him from – and it’s for our safety, of course – and we drop him. And so he has to manage to get to safety himself. But knowing that, and how young he was, I know he was probably very strong, but I left him with a sack of water, food, and his bracelet that is for good luck. It’s a religious bracelet that was taken off of him when he first came to our hospital. I gave it back to him. And said goodbye. And he thanked me in English, he said, Thank you, Commander, and the only reason he knew my rank was because the gentleman that rescued me, the MP that rescued me from when he hit me, said Commander, are you okay? And he remembered that. Our name tags are covered. Otherwise he didn’t know my name. But he did know some English and he did understand, so I said to him, Tašakor, which is Thank you. And he looked very puzzled at me. And I told him, You taught me a valuable lesson, even though I don’t think he understood me, I think he did because he saw my eyes. And I did become attached to him, even though he hurt me, but I think that if he made it back, he might say, they’re not as bad as you think. They gave me very good care.

One of the largest sources for conflict from the nurses we interviewed was caring for the enemy...Caring for the Enemy
One of the largest sources for conflict from the nurses we interviewed was caring for the enemy, or those that U.S. soldiers have gone overseas to fight. Nurses had ample opportunity to care for them as well as for prisoners of war. While they showed compassion at every step of the way, they still sometimes had difficulty for numerous reasons. Sometimes the enemy or prisoners mistreated them, sometimes they were caring for an enemy alongside those Americans they had just injured. Some of them parsed out pain medications, so they would have enough for the injured Americans. However, that was rare and the majority of the nurses, though tested in ways they never imagined, also felt a certain pride in the fact that they overcame their fears and disdain. They believed they were able to make a positive difference in the lives of fellow humans and to perhaps sway the enemy perception of American service members.

G5: I think what a lot of nurses don't realize is, you hear in the States that you get to take care of Americans. And that's great. You get to serve your own people, so to speak. And then you go over there, and you're like, okay, I'm here to serve my American soldiers, they're over here, they're fighting the war, so I'm here to take care of them. And then when you're faced with – you just shot my American soldier. And I'm American. So we got a lot of insurgents that we had to take care of, and it was a whole lot to have to face that patient and know that – I have to give him optimum care, I have to give him just like an American soldier.

P6: And – I turned to walk away, and he said, you know, some of the prisoners have changed their minds about Americans. Because of the compassionate care they received. And I turned around – I was like – really? And he said, yeah, they actually gave up information about – like – where booby traps were set, and stuff. So in the end, it ended up saving all lives, not just American lives but – children and Iraqis and – and I just thought that was the neatest thing in the world to hear, because it was so hard and so much work, and so – spiritually challenging at times and – then to hear that it actually made a difference to be kind and compassionate.

P7: …..as well, that was in our compound – which was also challenging for us, and some of our people didn't like the idea of having to take care of Iraqis that were terrorist and were utilizing all our supplies, and they had nowhere to go. My edict to my staff was: These people are injured. Humanity-wise, we need to take care of them. I don’t care who they are, what they did or anything else. That is what we need to do.

Caring for Civilians
Nurses never balked at having to care for local civilians who were either injured as collateral damage or ill, but they wavered because most of the time it was a long-term commitment. Sometimes they cared for them for months, trying to get them to a point where they could possibly survive outside the American hospital walls. The medical system in those countries was not as sophisticated as it is in this country, nor did it have the resources to care for injured people for the long-term. Their facilities were as overtaxed as the American hospitals, but we welcomed these people. The people knew this and seemed to flock to the hospitals for whatever care they could get.

G6: I mean, their culture is so different than ours. But he was such a long-term patient and we did that for him, too. So the nurses got to where we were looking into, how could we continue to receive these air mattresses and stuff for these patients, because the Iraqi patients pretty much get stuck there. There's no where [sic] to send them. If you want 'em to survive. It becomes a real, real nursing issue. And an ethical issue.

However, the culture of the people sometimes also conflicted with their own sense of survival and the nurses began to wonder why they were spending so much time and resources on people who did not share American values.

G2: Knowing that it was futile care, a lot of it, because they don't care. About survival the way we do. (Arabic phrase), “As God wills.” They won't do anything. God wills it, it’ll happen, and that means if I don't have to do anything, I don't have any responsibility for the outcome.…….

Yet at the same time, nurses had difficulty with overuse of American resources on local civilians, especially when bed space was in short supply, or resources were not available for American casualties. The nurses knew that triaging locals out of the hospital could very well be a death sentence for them. They often spoke about the compassion they felt for these civilians or children who, through no fault of their own were suffering because of a war.

P8: ….yet when you see these starving people who are in such need, your heart goes out to them and you think, well, somebody's gotta help. What are you gonna do these people are starving, and it's not just because of the two years of war. And then when you have people who've never had calcium in their diets so their bones are osteoporotic at 40 – their wound healing is terrible, you have 90-pound men as an average. And the men walk down the hallway and you can see every bone. They look like they belong in a concentration camp and you – it breaks your heart to see human beings in such need, and struggle with how to take care of them, but that wasn't – our job is [sic] to provide long-term care, so it was real hard ethically. Where do you draw the line in saying, okay, we're gonna send you home now. We're gonna send you to an Iraqi hospital, after we did all this work to save your life, and now you may die in an Iraqi hospital, but we're not a long-term rehab center. You know. What do we do?

One of the more difficult things for nurses was caring for injured service members...then not knowing the outcome of their work.Need for Follow-Up/Closing the Loop
One of the more difficult things for nurses was caring for injured service members, putting every ounce of their energy into saving them for transport out of the country, then not knowing the outcome of their work. They expressed the need for more follow-up for those who made it through transport, because they believed it would validate their work. However, this was not often the case and all they could do was wonder about the outcome. They believed that was one of the continuing questions they asked themselves when they remembered a certain patient. Sometimes they wondered if saving some of the individuals from horrific injuries was going to be seen by the patient and his/her family as “worth being saved from.” These were not the typical patients who had received their care in the States prior to deployment, so they wondered about the long-term disability of patients, both physically and mentally.

G7: And I think – I just got the thing, too, that we saw some horribly wounded people. I know it's not for us to decide, but were we really doin' them any favors, with the massive injuries – maybe we should have let 'em – some of 'em go. I mean, I had one guy who had two drains in his head, an ICP monitor and half his skull was out. I don't know how he did but I'm just like – the long-term prognosis – like I say, we don't know how they end up doin'. Or they're missin' both their legs and one arm, long-term. Are we really doin' them any favors.

G8: I couldn’t tell you – I mean, I couldn’t recognize any of the Americans that I took care of over there ‘cause you have ‘em for such a short period of time, and everything is so rushed, and you don’t see ‘em lookin’ their normal, I mean, you see him intubated, and they’re sedated, and they’re usually swollen and puffy and full of fluid that we’ve pumped in, and you don’t remember anybody’s names. There’s so many that you just don’t remember. And then you feel bad because you come over here and – like I’ll see burn patients, I’m like – I wonder if I took care of him, or I wonder if I took care of this one. So it’s kinda – and you feel like – I feel like I should remember – that I should remember their names, or that I should remember something.

Discussion

...both male and female nurses who deployed to Iraq and Afghanistan displayed a strength that may have surprised even them...The findings of moral distress and ethical issues in this study support the literature, but not in the same ways reported in previous articles. We found that many earlier studies presented certain aspects of ethical issues, but not a comprehensive picture (Mark et al., 2009; Scannell-Desch & Doherty, 2010; Thompson & Mastel-Smith, 2012). Our findings both support and expand on two important findings from an earlier study where the authors described ethical dilemmas regarding care for Iraqi patients and their transfer of care to a local facility (Goodman, Edge, Agazio, & Prue-Owens, 2013). In that study, Goodman et al. described nurses as feeling distressed about caring for Iraqi patients, but only that they felt bad about having to care for them. Our study provided a more detailed look at the nurses’ feelings, and sometimes how they dealt with them.

This study supported the results of a study finding by Thompson and Mastel-Smith (2012) that nurses reported both a personal difficulty, but yet an inner satisfaction of caring for the enemy as human beings and doing their part to promote goodwill. However, this care was not without personal consequences, such as feelings of guilt over conflict within themselves. Nurses in this study expressed the notion that this difficulty made them stronger and better able to see both sides of war. Like the Civil War women described by Wood (1972), both male and female nurses who deployed to Iraq and Afghanistan displayed a strength that may have surprised even them and a willingness to care for fellow humans, no matter the side.

Limitations

Initial coding of the qualitative data occurred with a coding framework that was developed during a research team meeting following a detailed discussion and agreement by the entire team. All transcripts were reviewed, discussed and coded consistent with code definitions. For this article, the code and quotations for “ethical, moral, political challenge” were extracted and text then analyzed and synthesized into the above themes. This required interpretive syntheses and it is possible that some bias may have been introduced. However, this was mitigated by the use of “bracketing” during synthesis. Every attempt was made to ensure that themes remained as close as possible to the intent of the nurse participant descriptions. Additionally, results, though comprehensive for the context of this study, are not generalizable to nursing in all war scenarios.

Conclusion

The nurses made it evident that...they were proud of themselves and how they handled wartime situations.It was clear that ethical dilemmas experienced by nurses in this study were unlike anything they had ever encountered in previous assignments. They relayed both negative and positive dilemmas to the research team in a level of detail not tainted by the passage of too much time. Even though many stories will retain their detail for these nurses, some will fade and some details will be forgotten. This is precisely why it was so important to capture these stories as soon as possible after deployment.

The nurses made it evident that despite the dilemmas they faced, they were proud of themselves and how they handled wartime situations. They believed they continued to provide the best care they could for service members, enemies, and civilians alike. They did not hesitate to make what they considered to be the “right decision.” However, at the same time, they continued to question the necessity and ethics of war itself. But they knew their purpose and will defend their right to be a part of it and serve the country by doing what their profession and their country required of them.

P8: And so it kept life in perspective, and – I think the only – conflicted part I feel about the whole thing is, I'm more confused than ever, how I feel about the war. I had my opinion set when I went over there, and I just thought I'd focus on my job, to take care of the troops. That's every – all the politics are not my problem. My job is to take care [sic] of the wounded. And the problem is, I still don't know that we're gonna solve anything.

Nurses should be informed about types of ethical challenges they may face and offered suggestions and coping tools before deployment.Based on the results of this study, the authors suggest that uniformed nurses going to countries of conflict or on humanitarian missions are provided with open and honest communication about the types of patients they will encounter. Additionally, nurses should be provided more in-depth training of the culture of those countries and how best to handle patients who may be openly hostile to them. Nurses should be given basic in-country patient care language, such as “Where is your pain?”, “It is not time yet for more pain medication” or other specific words important to patient care, such as “medicine”, “drink”, and “urinate”, and “blood.” Nurses should be informed about types of ethical challenges they may face and offered suggestions and coping tools before deployment. They should be provided with mental healthcare resources during deployment and after return home, so that they can deal with concerns openly and without fear of retribution or loss of promotion opportunities. In summary, nurses should not simply be sent to a war zone, or on a humanitarian mission, with an expectation to handle issues as best they can.

Authors’ Note: This research was sponsored by the TriService Nursing Research Program, Uniformed Services University of the Health Sciences; however, the information or content and conclusions do not necessarily represent the official position or policy of, nor should any official endorsement be inferred by, the TriService Nursing Research Program, Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government.

Authors

Deborah J. Kenny, PhD, RN, FAAN
Email: dkenny@uccs.edu

Dr. Kenny received a BSN from the University of Northern Colorado; a Master’s degree in Education from Boston University and MSN from Vanderbilt University; and a PhD in Nursing from the University of Massachusetts, Amherst. She is an Associate Professor at the Helen and Arthur E. Johnson Beth-El College of Nursing and Health Sciences at the University of Colorado, Colorado Springs and held the college’s inaugural Carole Schoffstall Endowed Professorship. She is a Fellow in the American Academy of Nursing and on numerous boards and committees dedicated to serving veterans. Dr. Kenny is a retired Lieutenant Colonel from the U.S. Army Nurse Corps and has a program of research with military and veterans, particularly female veterans. She has authored and co-authored numerous articles related to veteran issues.

Patricia Watts Kelley, PhD, FNP-BC, GNP-BC, FAANP, FAAN
Email: kelleyp@duq.edu

Dr. Kelley received an AS from Northeastern University, a BSN from American University, a MS from Boston University School of Nursing with a specialty in gerontology, a Post-master certificate in Family Primary Care from Northeastern University, and PhD in nursing from the Catholic University of America. Dr. Kelley is board certified as a Family and Gerontological Nurse Practitioner, a Fellow of the American Academy of Nurse Practitioners and the American Academy of Nursing. She is a Professor of Nursing and the Director of the Veterans to Bachelor’s in nursing program, Duquesne University School of Nursing, Pittsburgh, PA. She is a retired Navy Captain who has held various leadership, clinical, and research positions. Her research interests are in the areas of clinical knowledge development and continuity of care of wounded service members, evidence-based practice, health promotion and diabetes self-care management. Dr Kelley is an executive board member, Navy Safe Harbor Foundation which is dedicated to supporting the recovery of seriously wounded, ill, and injured Sailors, Coast Guardsmen, and their families by assisting them with resources not currently provided by government or community resources.