Transitioning from military medics to registered nurses

Introduction

The USA is projected to face a shortage in the nursing profession. Factors such as the aging population, the aging nursing workforce, the lack of sufficient staffing, the high turnover observed in nursing, and the increase in access to health care due in part to the Patient Protection and Affordable Care Act, significantly contribute to the accelerating nursing shortage.¹ The nursing shortage is expected to reach 260,000 registered nurses (RNs) by 2025.² Research shows that by 2030, the most profound shortages are expected in California and Florida, translating into 109,779 and 128,364 RN jobs, respectively.³ Despite the projected shortage, Florida is expected to see a 23% growth of its nursing workforce by 2022,⁴ while the US Bureau of Labor Statistics projects a 19% growth of the nursing workforce nationwide from 2012 to 2022.⁴ Nonetheless, the supply of nurses will be insufficient to meet the corresponding demand. This translates into a demand for 530,000 additional RNs throughout the USA.¹ Therefore, capitalizing on prior clinical education, experience, and skills of military personnel to fill these jobs could significantly help to reduce the projected nursing shortage nationwide, particularly in the State of Florida.

Indeed, Army and Air Force medics and Navy corpsmen possess exceptional clinical skills and are highly trained to render state-of-the-art care. Through education and training provided by the Joint Special Operations Medical Training Center, a complete range of US Special Operations Command medics have a comprehensive clinical foundation and a “solid understanding of the knowledge and skills required to provide treatment, regardless of the conditions.”⁵ The clinical training military personnel receive, and their accumulated experiences, allow them to perform a broad spectrum of services, such as primary care, emergency and urgent care, disaster relief, and public health. Training and education of military medics is based on curriculum similar to that used to train the civilian nursing workforce. Military medics and corpsmen endure a rigorous process of work evaluation that follows performance measurement based on competency.⁶

However, the civilian world is unaware of the quality of clinical training and education that medics and corpsmen receive, leaving a large portion of the potential health care workforce unexploited. At Fort Sam Houston, 12,500 men and women are trained every year to become combat medics, Navy corpsmen, and Air Force medical technicians.⁷ Additionally, more than 50,000 well-trained men and women were discharged from service between 2006 and 2010.⁸ Despite the strong levels of clinical training and experience they possess, many military medics face barriers to transitioning into the civilian workforce, especially the nursing workforce. Nonetheless, they make quality candidates to fill nursing jobs, particularly after being discharged from the military with their health care experience and with additional nursing education. The State of Florida is home to 13 military bases and 1.6 million veterans. Wartime veterans make up 75% of Florida’s 1.2 million total veteran population. California, Texas, and Florida are the states with the largest veteran populations,⁹ and many of these veterans are military medics.

The Iraq and Afghanistan Veterans of America, a veteran empowerment organization, purports that veterans including military trained medics that attempt to transition into the civilian health care workforce face several barriers. Veterans encounter difficulty translating their military education and training into applicable civilian attributes to secure gainful employment.¹⁰ State government legislation further compounds this issue by imposing enrollment in additional courses to obtain licensure in nursing. Also, male medics encounter a sex-specific barrier as they defy the perception that nursing is a woman’s profession.⁶ Therefore, eliminating these barriers would significantly assist military medics to transition into the civilian nursing workforce, thereby reducing the projected nationwide nursing shortage in the years to come. Under the aegis of Florida International University (FIU), Nicole Wertheim College of Nursing and Health Sciences (NWCNHS) is circumventing barriers to recruit, retain, and graduate transitioning veteran medics and corpsmen as Bachelor of Science in Nursing (BSN)-prepared RNs who reintegrate into the civilian workforce.

Florida International University and Nicole Wertheim College of Nursing and Health Sciences

FIU is a public, federally designated Minority Serving Institution, and a Carnegie-Designated Doctoral Research Extensive University. Located in Miami, Florida, FIU is accredited by the Southern Association of Colleges and Schools. Its strategic plan emphasizes health, focusing on educating health professionals, and serving urban and international health needs. FIU’s commitment to diversity, as exemplified in a city that is largely Hispanic and foreign-born, reflects a commitment to develop culturally and linguistically competent students from ethnically diverse backgrounds.¹¹

The NWCNHS is an academic unit of FIU that hosts a culturally diverse faculty (49.4% minority) with expertise in research, clinical practice, and teaching that is able to address the varied learning styles and needs of a diverse student body. NWCNHS’s mission emphasizes the preparation of “diverse health care professionals to serve as providers and leaders in the delivery of high quality, accessible, culturally competent, and compassionate care within a highly technological and global environment.”¹² Completing a BSN nursing curriculum provides graduates with the unique ability to focus care on not just the physical but the psychosocial, behavioral, and spiritual needs of patients and families, reflective of the framework of patient-centered culturally competent care upon which the NWCNHS is based.¹³ Recognizing the military experience as its own cultural entity, the Veteran Bachelor of Science in Nursing (VBSN) students’ patient-care approach is augmented by this additional insight and thereby prepares students to address and impact disparities in health care locally and globally. FIU students are 61% Hispanic, 15% White, 13% Black, 4% Asian/Pacific Islander, and 7% other minorities.¹¹ FIU’s students are similar representations of the diversity of the Miami-Dade County population comprising 85% racial and ethnic minorities, many of which (66%) are foreign-born and reside in this underserved region.¹⁴

The VBSN program

The VBSN program is funded for 4 years in the form of a cooperative agreement between FIU and the US Health Resources and Services Administration. The purpose of the VBSN project is to develop, implement, and evaluate a Nurse Education, Practice, Quality, and Retention VBSN program at the NWCNHS. The VBSN program’s main objective is to build upon the unique leadership skills, clinical education, and training of military medics and corpsmen to ensure successful completion of the BSN curriculum. The program will increase and diversify the nursing workforce by recruiting, retaining, and graduating 90+ veteran medics and corpsmen over the course of 4 years. Students are recruited via word of mouth, advertisements in military publications, and use of social media. Of the three graduates the program has produced since its inception in the spring of 2014, two (67%) have obtained RN licensure and are gainfully employed in Florida medical facilities.¹⁵ Fifteen additional students will graduate in December 2015 and will be eligible to take the National Council Licensure Examination-RN (NCLEX-RN).

The current VBSN nursing student body boasts former licensed practical nurses, laboratory specialists, preventative medicine technicians, health care specialists, and emergency medicine technicians who have served in the Army (59%), Navy (36%), and the Air Force (9%) as active duty personnel, reservists, and National Guardsmen. This diverse group has students who have relocated from California, New York, Texas, Georgia, Hawaii, and Germany. Nonetheless, its composition is a similar representation of the demographic of the South Florida region.¹⁶ Hispanic (41%), African American (36%), and White (23%) are the racial groups represented. Male students account for 64% of the student body, which exceeds the national average for men in nursing.⁶ Through an accelerated curriculum, veteran students are provided with an opportunity to earn a BSN degree and be eligible to take the NCLEX-RN upon graduation. Reintegration into the nursing workforce allows veterans to rise above the poverty level, and avoid the predicaments of unemployment and homelessness that plague many veterans.

The VBSN program of study

Applicants to the VBSN program must meet distinct admission criteria for acceptance. In order to be considered for the program, applicants must be veterans of any branch of uniformed service, a drilling reservist, or a National Guardsmen. Applicants who were previous Army and Air Force medics or Navy corpsmen are preferred, however, the program also admits veterans who are civilian paramedics. In addition to the clinical experience requirements, applicants must have a minimum cumulative grade point average of 2.5 or higher in all lower college division coursework, complete the Test of Essential Academic Skills with 70%, 62% or higher in science, and earn a grade of “C” or better for all nursing prerequisite courses. Completion of an associate degree in any arts or science discipline is preferred, but is not a requirement.

The VBSN program of study is specifically targeted to the unique needs of veterans through use of a career ladder specifically structured to process, translate, and streamline a plethora of military credit earned by our veterans. Designed to build upon prior clinical education, experience, skills, and training, VBSN students receive credit for prior military didactic courses on a case-by-case basis. In addition, the VBSN students have the opportunity to demonstrate competencies in a Boot Camp course specifically designed for the VBSN program. Its purpose is to assess the baseline knowledge, skill, and ability of all students at the onset of the program. Each student possesses a unique military experience and perspective based on his or her branch of service. Through use of lecture, simulation, self-study modules, and adaptive testing, the fundamentals of nursing are reviewed while streamlining variability in students’ experiences and competencies. Upon completion, students are awarded credit for Fundamentals in Nursing, Health Assessment, and for clinical hours associated with each. Thereafter, students complete nursing pathophysiology and nursing pharmacology and may begin the VBSN course curriculum. The VBSN students follow an accelerated, unique curriculum track that is rigorous and reflective of the spectrum of nursing care including health promotion, acute and long-term care, and end-of-life care. Upon graduation, students are prepared for licensure.

Transitional resources

The resources available to the VBSN students to assist in their transition from military life to student body are not only offered through the continuous access to faculty and staff, an academic advisor, and a success coach, but through the various resources available on FIU’s campus. First, NWCNHS has the nationally renowned Simulation, Teaching, And Research Center (STAR Center),^17,18 where students can practice their nursing skills and proficiency under the watchful and helpful eyes of their well-trained staff. The STAR Center maintains its national status as a research center and is supported by the National Council of State Boards of Nursing through their multisite simulation study.¹⁹ Additionally, the college has fully equipped testing and study rooms available to the students to prepare for class and/or exams.

On campus, the students have unlimited access to the Green Library for studying and research, as well as to designated staff to assist with the nursing and health sciences students and conducting research via online courses: the Centers for Academic Success; University Learning Center for tutorial services and the University Testing Center; FIU Online for courses that are either fully online or through fully online programs; the Reading and Writing Center; the Math Lab; and Counseling and Psychological Services for those students who need assistance with the management of stress and anxiety. For students with learning or medical disabilities, the Disability Resource Center is available to the students to aid in needed academic accommodations.²⁰

Finally, the Veteran and Military Affairs Office is the hub of resources for the unique population for which we serve. The Veteran and Military Affairs Office aids the veteran student with accessing military benefits toward education like the GI Bill; financial resources for textbooks, technology, and child care services; and multiple other academic resources to guide them toward a successful career.²⁰

The VBSN program evaluation

The VBSN program not only provides a gateway for veteran personnel to transition from military life to a professional career in nursing, but the program also offers a multitude of resources to aid in this transition. The program’s objective is to elicit the strategies and resources that have been successful throughout the development and implementation of this program. Therefore, with the assistance of our Program Coordinator, we have collected data from the students on how to improve our program. All VBSN students receive an end-of-course evaluation, as well as an alumni exit survey. All data are collected and analyzed by the department of student services within the NWCNHS. According to the alumni exit survey administered through Qualtrics (Provo, UT, USA), there was 100% satisfaction with the VBSN nursing support personnel and availability of faculty throughout the program, as well as the course presentation, subject matter expertise, and the overall level of program difficulty. Additionally, students receive a monthly survey to garner which student resources have been utilized, which ones have been successful, and which ones have not. According to these data, resources such as the STAR Center, the Department of Veteran and Military Affairs, the NWCNHS computer labs, the Center for Academic Success, the Center for Excellence in Writing, and student services have been the most utilized and the most successful. The direct relation between these resources and class activities, as well as students’ overall navigation through the program might explain this situation. However, the program encourages veteran students to take advantage of all the other resources available to them such as the Green Library and the University Technology Services. These valuable data will continue to guide the program and determine the students’ success, as well as impart a respect toward the veterans for their contribution in sustaining this most needed and outstanding program.

Health care and psychological issues

VBSN students, as veterans themselves, have unique knowledge and exposure to the specific health and psychological issues of the veteran population overall. Health issues specific to veterans include but are not limited to tobacco use, drug use and abuse, general substance use disorder, rehabilitation care after injury, amputation, and traumatic brain injury. Psychological issues include posttraumatic stress disorder, depression and anxiety disorders, behavioral conditions (ie, aggression, fear, and hypervigilance), grief, loneliness, suicide, and military sexual trauma. In addition, veterans are plagued with social and legal issues such as homelessness, unemployment, social reintegration, divorce, and complex deployment issues (ie, financial difficulties).

VBSN students possess firsthand knowledge and exposure to military culture. Moreover, they are aware and more accustomed to military hierarchy, rank, war eras and specific health issues related to war eras, military traditions and code of conduct, values, communication styles, command, ceremony, loyalty, duty, and discipline. Therefore, VBSN students are uniquely poised and best prepared to most effectively care for the US population, particularly the current 22 million and 1.6 million US and Florida veterans, respectively.^9,21 The need for the VBSN program is clear, given the projected shortages of nurses and low proportions of BSN-prepared nurses (41%) for the entire country in 2011,²² and (26%) for the State of Florida, with ~18% coming from culturally diverse groups who can provide care for a population of nearly 44% minorities.^16,23

Benefits of the VBSN program

Value-added of VBSN graduates to the nursing workforce

Health care delivery is largely dependent on the RN workforce. The US Bureau of Labor Statistics²⁴ projects that employment of RNs will grow 19% by 2022 compared with only 11% for occupations overall. Growth of the nursing workforce lags behind the increasing demand for BSN-prepared RNs, which is largely attributed to an aging population, increased focus on preventative health care, and an increase in access to care as a result of health care reform.

In 2014, 21 million US residents were veterans who previously served in the US Armed Forces.²⁵ Veteran reintegration into civilian life can potentially be facilitated through building upon existing military education and training. Army and Air Force medics and Navy corpsmen possess the necessary education and training upon which to capitalize and further progress to become BSN graduates.

Nurses in the USA provide technologically advanced care in stressful and often chaotic environments. Medics and corpsmen are accustomed, and well suited to also provide care in similar settings. Navy corpsmen perform duties as assistants to physicians, dentists, and nurses in the prevention and treatment of disease and injury. Their scope of practice is diverse. Corpsmen can render emergency medical treatment on the battlefield, serve as surgical technicians in the operating room, fill prescriptions in the pharmacy, or independently perform patient care at remotely located duty stations where no other health care professionals exist. Similarly, Army and Air Force medics provide emergency medical care and evacuation in theater, and provide paraprofessional care in medical treatment facilities. Collectively, this group of clinically trained military personnel endure rigorous didactic and simulation training throughout their military careers. This suggests preparedness for progression through an accelerated BSN program in four semesters or less, as the American Council on Education recommends that prior military clinical experience and training be transferrable into college credits.²⁶

Producing nurses from a pool of highly trained veterans meets the growing demand for RNs in Florida. FIU’s VBSN program generates the supply to meet the demand for nurses statewide while simultaneously augmenting diversity. Approximately 85% of NWCNHS graduates are non-White, which is roughly a similar representation of the South Florida patient population.¹⁶ Moreover, the VBSN program has a 60/40 male-to-female sex mix exceeding the 9.6% national average of men in nursing as reported by the US Census Bureau.²⁷ Furthermore, the program has a very diverse student body with multiple backgrounds, given that a diverse nursing workforce is most befitting to render culturally competent care to the increasingly diverse US patient population, thereby minimizing the profound health care disparity in the USA.²⁸

The VBSN program has sparked a surge in veteran student enrollment in the NWCNHS and provided the impetus for infusing veteran-centered content into its nursing curriculum. Exposing veteran and civilian nursing students to the health care issues of all veterans will produce baccalaureate prepared nurses equipped to contribute to improving outcomes for this growing population, which stands at 22 million US residents.²⁵ Furthermore, the NWCNHS provides faculty development regarding veteran culture and veteran characteristics to enhance teaching strategies that address the unique veterans student needs such as building upon leadership experience, and addressing the needs of veterans with physical or emotional disabilities that may impact learning. These veteran-centric efforts to enhance curriculum and teaching strategies are intended to recruit, retain, and graduate transitioning veterans as RNs and reintegrate them into the civilian nursing workforce. Additionally, the VBSN program will alleviate challenges, such as unemployment, substandard income, and homelessness that many former service members face after separation from the military.

Reduced unemployment

Many veterans, including military medics, face employment challenges in the civilian workforce after leaving the military. The Iraq and Afghanistan Veterans of America, in its 2009 report, attributed these challenges to the difficulty former service members have explaining and translating military skills, networking and negotiating comparable salaries, and separating themselves from the wrongful stigma of mental illness.¹⁰ These associated obstacles to securing decent employment in the civilian workforce have translated into a high rate of unemployment among veterans. In 2014, the US Bureau of Labor Statistics reported an unemployment rate of 5.3% among all veterans and 7.2% among post-9/11 veterans.²⁹ Yet, economic pundits identified Florida as a state more apt to hire veterans than any other.³⁰ However, despite a large military presence, the unemployment rate among veterans in the State of Florida stands at 5.0%³¹ compared with a rate of 5.3% in the civilian world.³² Given the expected shortage in the nursing profession and the increasing demand for RN jobs, it is an opportune time for VBSN students graduating with a BSN to secure full-time employment as licensed RNs.

Improved income

Graduation from the VBSN program, and the opportunity for veterans to earn a BSN and become RNs, translates into a significant boost in salary for veterans and an improved lifestyle for this group and their families. The median salary for a new BSN-prepared nurse is ~US$57,759 per year,³³ while the average yearly earnings from wages and salary for veterans is $US43,370.³⁴ This boost in salary, and the associated lifestyle improvement, has the potential to lift many veterans out of financially overwhelming situations and poverty. According to a 2012 study, the poverty rate among recent veterans was estimated to be 5.1%.³⁴

Reduced homelessness

Nearly 535,000 adults in the USA are homeless and of those, 49,933 have proudly served this country.³⁵ Meanwhile, 1.4 million additional veterans are considered at risk because they face circumstances of poverty, substandard housing, overcrowding, and dismal living conditions.³⁶ In 2013, the National Coalition for Homeless Veterans estimated the number of homeless veterans to be around 5,500 in the State of Florida. In fact, the same organization reported that 44% of all homeless veterans in the country lived in Florida, California, and New York.³⁷ A myriad of factors contribute to homelessness, such as the shortage of affordable housing, insufficient livable income, and unemployment. For many veterans, the complexities of homelessness are further compounded by posttraumatic stress disorder, substance abuse, and unemployability because military training is commonly unacknowledged in the civilian sector.³⁸ The underlying premise of public and private coordinated efforts that support veterans is sustainable employment. Through the VBSN program, veteran medics and corpsmen are able to transition from military service to collegiate life and ultimately reintegrate into the workforce as registered professional nurses, thereby circumventing becoming a homeless statistic.

Conclusion

Army and Air Force medics, and Navy Corpsmen possess exceptional clinical skills and receive excellent training in care delivery, which could be utilized to add value to the nursing workforce and has the potential to substantially reduce the nursing shortage in the USA, particularly in the State of Florida. Unfortunately, the civilian sector is unaware of these skills and training. Service members including military clinical personnel face barriers in transitioning into the civilian workforce, which has been supported by the published literature. FIU’s NWCNHS, through its flagship VBSN program, is eluding these barriers in recruiting, retaining, and graduating transitioning veteran medics and corpsmen as BSN-prepared RNs who reintegrate into the civilian workforce. Of the three VBSN graduates, two (67%) have taken and passed NCLEX-RN licensure and secured full-time employment as RNs in Florida health facilities. Through this program, 15 additional students will graduate who will be eligible to sit for the NCLEX-RN in December 2015. Graduating BSN-prepared nurses addresses the profound nursing shortage, eliminates barriers that plagued transitioning veterans, and circumvents unemployment and homelessness. Current and future graduates of the NWCNHS are poised to contribute to improving outcomes for the growing veteran population and the South Florida community.

Acknowledgments

This project is supported by funds from the Division of Nursing and Public Health, Bureau of Health Workforce, Health Resources and Services Administration, Department of Health and Human Services Grants (UF1HP26491; UF1HP26980), Veteran Bachelor of Science in Nursing Program.

Disclosure

The authors report no conflicts of interest in this work.

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