Emerging Standards of Care
Kassandra Snow
NUR 531
May 25th, 2015
Greg Friesz

Emerging Standards of Care
In the United States, it is no secret that there are many differing cultures, ethnicities, religious and racial in an abundance. In the nursing field, we see many differing cultural diversities on a daily basis. Racial, religious, and ethnic differences are mostly easy to spot in the health care world. These differences are readily discussed in nursing education, and education is given on how to provide culturally competent care for many different backgrounds. While this is an amazing thing to have in the nursing world, my question is what about the culture of military Veterans? Veterans are typically overlooked when it comes to the concept of culturally competent care. They have their own way of thinking, own belief systems and even their own language along with the specific mental and addiction health disparities. It is important that nurses do not overlook the rising number of Veterans, and the specific care they need due to the differing culture. Culturally competent care for veterans, any vulnerabilities of the Veteran culture, standards of culturally competent care in the Veterans Administration, application of nursing theory, and solutions for providing culturally competent care for Veterans will be addressed in this paper.
Culturally Competent Care and Standards
The United States is widely known as the “melting pot” of the world, and that comes with many differing cultures, ethnicities, religions and race. Caring for all of these different patients in health care means that the nurse must be educated in many different cultures and how to provide care for them in a respectful and safe manner. There are many different way to define cultural competence when it comes to nursing care. According to Fortier & Bishop (2003), providers have many different ways to bridge barriers to communication and understanding that comes from racial, ethnic, cultural and linguistic differences. Cultural competence includes all of these differences in both interpersonal and organizational interventions and how to achieve the goals of public and clinical health when the differences are notable (p. 3). The Joint Commission (2010) states that cultural competence is the “ability of health care providers and health care organizations to understand and respond effectively to the cultural and language needs brought by the patient to the health care encounter”. The Joint Commission has set forth standards of culturally competent care in organizations that include: valuing diversity, assessing themselves, managing the dynamics of difference, acquiring and institutionalizing cultural knowledge, and adapt to diversity and the cultural contexts of individuals and communities served (p. 1).
The standards mentioned above can most definitely be applied to providing culturally competent care for Veterans. It is clear to see that the culture of Veterans can be classified as transracial. Many differing races, ethnicities, and religious backgrounds all melted into one culture. With all of the differences in clear site, it is hard from a nursing perspective to provide care for every culture at once, but the main culture of all of the patients at the VA is the Veteran culture. According to Convoy & Westphal (2013), military culture is comprised of shared beliefs, values, behaviors and ideals inclusive in defending our nation or national identity. The Veteran culture places a high value on selflessness, loyalty, courage, stoicism, morality, and commitment to society. These values and beliefs transcend all of the differing individual backgrounds of those included in the Veteran culture. It is important that the health care providers and nurses at the VA have cultural awareness of the Veterans, and also awareness of their own attitudes, knowledge of military culture, and personal assessment skills to improve the clinical interaction with the Veterans (p. 592). That is how cultural competent care is provided to Veterans at the VA hospital. Next, I will discuss the population of Veterans and their possible vulnerabilities to receiving care.
Population and Vulnerability
As we all know, the United States has a large amount of military members throughout the world. There is also a large population of military living in the United States. According to Convoy & Westphal (2013), there are 22.7 million military men and women living in the United States. Although there is such a large amount of military veterans in the United States, there is a much smaller amount of those that seek health care through the VA hospitals. Within the Veterans associated with the Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) approximately 56% of discharged Veterans used the health care of the Veterans hospitals (p. 591).
Due to the characteristic of stoicism of military veterans, many do not seek health care or downplay their symptoms when at the hospital. This is the first vulnerability that the military veterans have when trying to receive culturally competent care. If the nurse of health care provider is not familiar with the Veteran culture, then they will miss the opportunity to provide the correct or culturally competent care. This is especially important when the Veteran is seeking care at a facility other than the VA. The nurse must take cues from the patient such as the use of ma’am or sir when speaking to others. This is a huge part of the respect for the Veteran culture. Another clue to the patient being of the military is that of traditional military tattoos. The nurse may just simply ask if the patient has ever been affiliated with the military. The Veteran may downplay their symptoms due to fear of not being eligible for military duties if they are still in the reserves.
A second vulnerability of the Veteran culture is that of Post-Traumatic Stress Disorder (PTSD). According to Hobbs (2008), 18% of OEF/OIF Veterans are currently diagnosed with PTSD. This approximated number may be underreported due to the negative stigma attached to mental disorders and the military culture (p. 338). “Veterans diagnosed with PTSD have a statistically higher than average rate for violent acts, suicide attempts/suicide and substance abuse” (Convoy & Westphal, 2013, p. 593). With that being said, PTSD poses issues to providing care to the Veteran population making them vulnerable to not receiving the care that they need. PTSD can come with spatial issues (Veteran not wanting the nurse to get close to them), anxiety about procedures, and declining treatment in itself due to feeling trapped in the hospital. PTSD will often be overlooked, especially in the emergency room setting where physical concerns take precedence over the psychological.
Standards of Culturally Competent Care in the Veterans Administration
The Veterans Administration hospitals are dedicated to providing care to the specific culture of the military Veterans. According to Convoy & Westphal (2013) there are 153 VA hospitals, 773 outpatient VA centers, and 260 counseling centers across the United States (p. 593). In the past, the VA has had issues with being complacent in the care given and rewarded illness rather than promoting recovery. The VA did not recognize PTSD as a diagnosis until 1980, but since 1995 has taken it upon itself to undergo an overhaul to help combat the issues that were notably inhibiting providing culturally competent care (Hobbs, 2008, p. 338). According to Lutwak et. al. (2014), the “VA is committed to providing sensitive, patient-centered, and evidenced-based care to all veterans” (p. 484).
The VA has what we call core values instead of standards for culturally competent care. While the terminology may be different, the intention is the same. According to the U.S. Department of Veterans Affairs (2014), the VA has core values with the acronym of ICARE. These core values stand for Integrity, Commitment, Advocacy, Respect, and Excellence. I believe that the VA is meeting the standards set forth by the Joint Commission mentioned earlier. The respect core value of the VA incorporates the standards of valuing diversity, acquiring and institutionalizing cultural knowledge, and adapting to diversity and the cultural contexts of individuals and communities served at the VA. By ensuring the employees take their care of the veterans seriously, they are providing the culturally competent care. The vulnerability of PTSD diagnosis is being addressed by the VA in a staggering force. My institution has been recognized as one of the best VA facilities for psychiatric care, and we have a unit dedicated to PTSD. With my facility being focused on one culture alone of Veterans, I think that we provide culturally competent care every day. By addressing the particular vulnerable populations within our specific culture, I believe that we are actually going above and beyond the standards put forth by the Joint Commission. I don’t feel that my facility is missing any standards for culturally competent care. Other VA facilities may be lacking behind my facility on the psychiatric element. I feel that if the other VA’s around the country do not have outpatient mental health services, than they need to create some programs to meet the needs of the Veterans.
Impacts of Meeting or Not Meeting Standards
Due to mental illness being one of the primary diagnoses of military Veterans, providing care for those with psychiatric illness is a must at the VA. According to Sebella (2012) “The Office of Inspector General of the U.S. Department of Health and Human Services found that in 2011, 36% of veterans had to wait more than two weeks to access Veterans Administration (VA) care for mental health concerns” (p. 48). This is an alarming number. While the VA is providing care in the mental health forum, increased wait times is not acceptable. “PTSD is recognized as one of the most common disorders experienced by veterans returning home from combat” and not providing timely care for these Veterans can mean a worsening of symptoms and even death (p. 49). Not meeting the standards of culturally competent care can impact the nursing care provided. The nurse may have issues with communication between the patient and themselves. If the nurse is not educated in the culture that they are providing care for, the patient may be less apt to be truthful with the nurse, as previously mentioned. According to Georgetown University (2004), “organizations, and systems are not working together to provide culturally competent care, patients are at higher risk of having negative health consequences, receiving poor quality care, or being dissatisfied with their care” (para. 10). Anger and outbursts may be experienced by the patient towards providers due to being unhappy with treatment. Anger and outbursts are very common in those with PTSD due to hyperarousal (Sebella, 2012, p. 49).
On the other end of the spectrum, meeting culturally competent care standards for Veterans can have a huge impact on the patients overall health outcomes. As mentioned earlier, Veterans don’t always present to the provider with the actual problem they are experiencing, but with other complaints that seem unrelated. This can be due to trust issues or negative associations with the ailment they are experiencing, such as mental illness. Being informed and educated about the military culture and the illnesses common to them, the nurse can pick up on cues that would lead them to the source of the problem. Meeting these culturally competent standards put forth by the Joint Commission could lead to smoother, more efficient care of the Veteran and improve their satisfaction with the VA in general. If satisfaction is increased, the Veteran is more likely to take advantage of the care and resources provided by the VA.
Transcultural Theory
Throughout our education in nursing we have learned many different theories applicable to providing patient care. One of the most applicable theories related to providing culturally competent care is Leininger’s Transcultural Theory. Transcultural Theory was started in the 1950’s by Madeline Leininger after noticing a gap in nursing care that related to providing care to those of differing cultures. This theory is one of the oldest in nursing theories around. It was also the only theory related to caring for cultures and their well-being, illnesses, and death. This theory works with discovering worldwide cultural differences and commonalities. It includes both and inside and outside culture care. The sunrise model is an aspect of the Transcultural Theory of Nursing used to provide culturally competent care. The Sunrise Model has the nursing professional working with the client to determine the aspects of care that need to be met in order to provide safe and effective care based on their culture. The nurse using the model with veterans can “discover factors related to cultural stresses, pain, biases, and even destructive acts as nontherapeutic to clients” (Leininger, 2002, p. 190). By using this model with Veterans, the nurse can get an inside view of the issues in the Veteran culture and how to work to improve the health status of the patients. Leininger’s Transcultural Theory is applicable because it is one of the most holistic viewpoints in nursing theory. After 9/11 “the need for understanding of transcultural violence, terrorism, hatred, and killing of innocent people has increased” (Leininger, 2002, p. 190). These issues directly affect our Veterans over many differing generations and using the Sunrise Model of the Transcultural Theory can help providers and nurses provide the best care for our Veteran culture.
Solutions to Help Meet Standards
While the VA is working hard to provide culturally competent care to our Veterans, there are many places that could use improvement in this area. In nursing school, we must take a community care nursing class, a theory class and many others that may hit on the topic of providing culturally competent care. The one cultural group that I do not remember getting any education on is the culture of military veterans. As Hobbs (2008) states, there close to 25 million veterans in population in 2008, but where is the literature in books about providing culturally competent care to the Veteran (p. 340)? I believe that a solution to help nurses provide the safe and effective culturally centered care for veterans must call for a change in nursing education. Whether the nurse works for the VA or not, they will need to recognize a patient that has been affiliated with the military. This is a safety issue for both the nurse and the patient. Educational nursing institutions must change the curriculum to include the culture of military Veterans.
Another solution that could help the VA continue to meet the culturally competent care standards is the PTSD screening. The staff in our mental health department of the VA ask specific questions to our Veterans regarding PTSD, depression, suicidal or homicidal thoughts. The Emergency Department, where I am employed, asks about hallucinations, suicidal, and homicidal thoughts. However, most of our primary care providers for Veterans do not utilize this tool to help raise awareness about PTSD. According to Sebella (2012), there are four different questions that primary care providers should ask the patient as to if they have ever had an experience so frightful in their life that in the past month they:
“1. Have had nightmares about it or thought about it when you did not want to?
2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
3. Were constantly on guard, watchful, or easily startled?
4. Felt numb or detached from others, activities, or your surroundings” (p. 51)?
Using these PTSD screening tool would help identify a classic condition of the vulnerable Veteran population. The screening for PTSD helps meet the standard of valuing diversity and managing the diversity of difference put forth by the Joint Commission as mentioned above.
Conclusion
As nurse leaders in the VA hospitals deliver care to a population and culture that we are very familiar with, many other nurse leaders and providers around this country are not as familiar with the Veteran culture. The Veteran culture seems to be extremely overlooked when it comes to implementing the standards of culturally competent care in the general population. The Veteran culture is very different from many other cultures in this world, but they deserve the competent care that all other cultures receive. The nurse leaders must follow the standards put forth by the Joint Commission and other resources to ensure these are getting met in practice. The use of Leininger’s Transcultural Theory and Sunrise Model will help ensure these culturally important issues are met in the nurse-patient experience. My VA facility has done a great job at following these standards, but there is much improvement that needs to be done within the nursing education world in order to educate future nurses about culturally competent care of the military Veteran. Knowing that there are millions of people throughout this country included in this culture, whom fight for our freedom, it would be very sad to no address the discrepancies in the care of their culture. Just think about this, would you want your cultural preferences forgotten about when you go to your next health care visit?

References
Convoy, S. MSN, RN, PMHNP, Westphal, R.J. PhD., RN, PMHCNS-BC. (2013). The Importance of Developing Military Cultural Competence. Journal of Emergency Medicine, 39(6), 591-594.
Fortier, J.P., Bishop, D. (2003). Setting the Agenda for Research on Cultural Competence in Health Care: Final Report. U.S. Department of Health and Human Services Office of Minority Health and Agency for Healthcare Research and Quality, 3-14. Retrieved from http://archive.ahrq.gov/research/findings/factsheets/literacy/cultural/cultural.pdf
Georgetown University. (2004). Cultural Competence in Health Care: Is it Important for People with Chronic Conditions? Retrieved from https://hpi.georgetown.edu/agingsociety/pubhtml/cultural/cultural.html
Hobbs, K. MSN, RN, CNS-BC. (August 2008). Reflections on the Culture of Veterans. AAHON Journal, 56(8), 337-341.
Leininger, M. (2002). Culture Care Theory: A Major Contribution to Advanced Transcultural Nursing Knowledge and Practices. Journal of Transcultural Nursing, 13(3), 189-192. DOI: 10.1177/10459602013003005
Lutwak, N., M.D., Byne, William,M.D., PhD., Erickson-Schroth, L., Keig, Zander,M.S., M.A., Shipherd, J. C., PhD., Mattocks, K. M., PhD., & Kauth, M. R., PhD. (2014). Transgender veterans are inadequately understood by health care providers. Military Medicine, 179(5), 483-5. Retrieved from http://search.proquest.com/docview/1523896014?accountid=458
Sebella, D. (2012). PTSD Among our Returning Veterans. American Journal of Nursing, 112(11), 48-52. DOI: 10.1097/01.NAJ.0000422255.95706.40
The Joint Commission. (2010). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care A Roadmap for Hospitals. Retrieved from http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf
U.S. Department of Veterans Affairs. (2014). ICARE Core Values. Retrieved from http://www.va.gov/icare/