Caring for Minority Veterans

Link to MinorityNurse.com

The Changing Face of Minority Veterans

When you hear the term "minority veteran," what image comes to mind? First of all, it would probably be a person of color. The person you visualize is also likely to be male, and perhaps even an older man who fought for his country in a historic conflict like World War II or the Vietnam War. But in recent years, the traditional profile of minority veterans has begun to expand and evolve. Patients from other types of underrepresented populations are becoming a growing presence in the VA health care system, bringing with them a whole new set of unique health challenges and needs.

While women may not be a group that comes to mind under the "minority" heading, female veterans are definitely a minority within the VA system, says Jacinda Beug, BSN, RN, who works in the Women's Health Program at the Southern Arizona VA Health Care System in Tucson. The program, along with its outlying clinics, treats about 5,500 women annually, providing primary care, prenatal care, gynecological and obstetrician services.

Many of these patients are veterans of Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF). In 2003, says Beug, 6% of America's 23.5 million veterans were women. Today that figure is 7.4% and is expected to climb to 8.7% by 2013.

"We were noticing that [within the overall population of veterans coming back from Iraq and Afghanistan], women had their own specific concerns and needs," says Norma Hernandez, RN, manager of the medical center's OEF/OIF Transition Program. These special concerns include mental health issues, post traumatic stress disorder (PTSD) and sexual trauma. The Women's Health Program focuses on providing gender-specific care, and it has an all-female staff-including doctors, nurses, receptionists, clerks and dietitians-to make the patients feel more comfortable, says Beug.

Another new "minority" group to surface within the VA is the young veteran. "[Because of OEF/OIF], many younger veterans are coming into the system. We're treating age groups ranging from 17 and 18 up to 90," Beug says.

Hernandez agrees that the younger patient population within the VA medical system has become a minority group with its own set of specialized needs. The VA is used to serving older veterans, she explains, and is now having to adapt to these younger vets' needs and develop different treatment modalities to meet them.

This is an example of how the VA is constantly evolving, creating new programs and services as specific needs arise, Hernandez adds. For awhile, the special needs of Vietnam veterans were the catalyst for new programs. But now OEF/OIF is bringing in a new special-needs population of combat veterans. The percentage of OEF/OIF veterans in the VA system right now is less than 5%, says Hernandez, but that figure is misleading. Military personnel serving in OEF/OIF are predominantly reservists and National Guard troops who bounce between two different roles. They are activated, come home, are discharged into the VA system, but then can be reactivated back to active duty.

"That creates a variety of issues and concerns we need to keep abreast of," she says. "Their situation keeps fluctuating. It used to be you did active duty, were discharged and then became a veteran."

The unique combat injuries suffered by OEF/OIF veterans, such as those caused by improvised explosive devices (IEDs), are also creating a whole new set of challenges for VA nurses, says Dianne Lethaby, RN, CRRN, Polytrauma Nurse Case Manager at Southern Arizona VA's Polytrauma Network Site. The site is one of 21 facilities in the nation designed to provide long-term rehabilitative care to veterans who experience severe injuries, including traumatic brain injury, hearing loss, amputations, fractures, burns and visual impairment.

The Tucson Polytrauma Network Site, which treats about 320 veterans from Arizona, Texas and Colorado, operates clinics that give patients access to a medical provider, social worker, speech/language pathologist and psychologist, all in one visit. If time permits, the clinics will try to fit in sessions with physical and occupational therapists.

"Essentially, [the younger veterans] want to get back and get on with their lives. They're young and have families to support," Lethaby says. "It's been a challenge getting them into the system."

Who Are Today's Veterans?

Estimated U.S. Veterans Population: 23,532,000
Number of Total Enrollees in VA Health Care System (FY 2006): 7,900,000

Veteran Population by Race:

White Non-Hispanic.....80%

Black Non-Hispanic.....11%

Hispanic.....6%

Other.....3%

Veteran Population by Gender:

Male.....93%

Female.....7%

Percentage of Veteran Population Age 65 or Older: 39%

Source: Department of Veterans Affairs, October 25, 2007

What are their unique health care needs and how are VA nurses creating culturally competent strategies to meet them?

By Kimberly Bonvissuto

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Acording to the U.S. Department of Veterans Affairs (VA), approximately 20% of our nation's 23.5 million veterans are people of color. Like other racial and ethnic minority populations, minority veterans face a variety of unique health care challenges, ranging from chronic disease disparities and high levels of post-traumatic stress disorder (PTSD) to difficulties in accessing medical treatment.

Bruce Kafer, MSN, RN
Testifying before the House Committee on Veterans Affairs in July 2007, Lucretia McClenney, MSN, RN, director of the VA's Center for Minority Veterans (CMV), noted that "in many instances, any challenges that minority veterans encounter as they seek services from VA are magnified by the adverse conditions in their local communities. These challenges may include [lack of] access to VA medical facilities (especially for American Indians, Alaska Natives, Pacific Islanders and other veterans residing in rural, remote or urban areas), disparities in health care centered on diseases and illnesses that disproportionately affect minorities, homelessness, unemployment, lack of clear understanding of VA claims processing and benefit programs, limited medical research and limited statistical data relating to minority veterans."

The CMV's mission is to identify barriers to service and health care access, increase local awareness of minority veteran-related issues and improve minority participation in existing VA benefit programs. As a result, VA medical facilities throughout the country are implementing strategies to provide veterans of color with more accessible, culturally sensitive care. Each VA health care facility has a Minority Veterans Program Coordinator (MVPC) who serves as a liaison and advocate for minority patients. And VA health care professionals are taking the lead in developing innovative solutions for closing the gap of health disparities, from outreach programs designed to increase minority veterans' use of services to diversity training programs aimed at increasing staff members' understanding of patients' cultural needs.

Not surprisingly, nurses are playing key roles in these efforts. Here's a look at how individual nurses are working to improve health outcomes for minority veterans, one program at a time.

Native American Outreach

Bruce Kafer, MSN, RN, is a member of the Oglala Sioux (Lakota) Tribe that resides on the Pine Ridge Indian Reservation in South Dakota. Adopted as an infant by white parents, he grew up with virtually no knowledge of his tribal culture. After tracking down his birth mother in 2000, he began to learn about his lost Indian heritage from his Tiospaye (Lakota extended family) and tribal elders. Now, as American Indian/Latino Outreach Coordinator at the Louis Stokes Cleveland (Ohio) Department of Veterans Affairs Medical Center, Kafer is drawing on his rediscovered heritage to provide culturally sensitive healing to Indian vets.

Yvonne Garcia,BSN, RN
Kafer, who works with Native veterans both in Cleveland and in Arizona, is also a PhD student at Case Western Reserve University in Cleveland, where he is conducting research with Indian vets to add to the limited body of knowledge available about this population. Through his research, he has discovered some compelling statistics about Native Americans who have fought for their country. During World War II, for example, 40% of the Cheyenne Nation volunteered service to the U.S. military. During the Vietnam War, 90% of eligible Cheyenne volunteered for duty, with the overwhelming majority serving in combat areas. Yet despite this long-standing history of service, Native Americans have historically underutilized VA services, Kafer says.

Part of my role," he adds, "is to help bridge that gap and make services more accessible." To accomplish this, Kafer does outreach to the American Indian community, participating in powwows and other cultural events, visiting reservations in remote locations and working with Native veterans and elders from a variety of tribes to develop culturally appropriate programs.

There are about 562 federally recognized Indian tribes in this country and 365 state-recognized tribes, each with their own unique cultural traditions and, in many cases, their own indigenous languages. Therefore, VA nurses who work with Native veterans often find themselves treating a patient population that is not homogeneous but highly diverse—a concept Kafer calls "diversity within diversity." Still, he says, while culture and language may differ from tribe to tribe, there are some basic beliefs about health, illness, healing and spirituality that are common to all Native people.

"In traditional Native American culture, health and healing begin first in the spirit, then the mind, then in the body," he explains. "In the Western model of health care, it's an opposite paradigm—health and disease begin first in the body, then in the mind, last in the spirit."

Kafer won an award from the Society of American Indian Government Employees (SAIGE) for a VA diversity training video he helped produce, called "Native America: Diversity Within Diversity." Created as part of the VA's R.E.A.C.H. for Diversity program, the video has been distributed to all VA medical centers nationwide to increase employees' understanding of the unique challenges Indian veterans face.

"Native America resonates with me and my history," Kafer says. "I'm in a unique position to contribute to improving health care for Native American veterans because I understand about bureaucracy, government and the various phenomena that can impact tribal access to health care."

Kafer is also involved in another innovative diversity training project, the Gathering of Healers program at the Southern Arizona VA Health Care System in Tucson. The program brings the facility's staff together with Native veterans and elders to learn more about American Indian culture and how to provide culturally competent care.

"Staff come back from the Gathering of Healers and are more aware of the special needs of this [population]," says Yvonne Garcia, BSN, RN, the facility's American Indian Nursing Case Manager. "They learn to treat people with cultural humility. They want to know more about them instead of making assumptions."

Garcia, who is part Mandan Indian, also works with the Indian Health Service to complement services delivered to Native veterans.

Researching Health Disparities

Carol Baldwin, PhD, RN, CHTP, CT, AHN-BC, associate professor and director of the Office of International Health, Scientific and Educational Affairs at Arizona State University College of Nursing and Healthcare Innovation in Phoenix, is a nurse researcher who has focused some of her recent work on studying chronic disease disparities in Mexican American veterans, a population about whom very little health information is available. She led one study which found that, compared to non-Hispanic white veterans, Mexican American veterans were significantly more likely to have diagnosed type 2 diabetes and that having a high body mass index (BMI) put them at greater risk of developing the disease.

More recently, Baldwin published a study in the September 2007 issue of the Journal of Nursing Scholarship that compared homocysteine levels and other stroke risk factors between Mexican American and Caucasian male veterans. High homocysteine levels in the blood have been associated with increased risk of cardiovascular diseases, such as coronary heart disease and stroke.

Jawel Lemons, RN, MS, FNP-C
Baldwin conducted her research in Tucson at the Southern Arizona VA Health Care System's Minority Vascular Center. She found that Mexican Americans have higher homocysteine levels regardless of whether they scored a high or low risk for stroke. She also determined that the Framingham Stroke Profile, a commonly used stroke risk assessment tool, was derived for a predominantly Caucasian population and does not necessarily provide relevant stroke risk factors for people of other races and ethnicities.

Baldwin says her findings suggest that Mexican American veterans, like other minority populations, face barriers to stroke prevention and therapy, including lower income and education, as well as dietary, genetic and environmental factors.

There has also been very little research conducted on the health care needs of Puerto Rican veterans, says Constance Uphold, PhD, ARNP-BC, FAAN, a research health scientist with the Rehabilitation Outcomes Research Center at the North Florida/South Georgia Veterans Health System in Gainesville. Her current work focuses primarily on the health challenges experienced by Puerto Rican veterans returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF).

In one study, Uphold—who has a master's degree in transcultural nursing and a doctoral degree in family health nursing—examined mental health issues affecting Hispanic veterans and their care-givers and families. She documented stressors from each group's perspective, as well as successful coping models. Based on her findings, Uphold and her colleagues developed 12 culturally competent fact sheets for veterans, family members and clinicians. These educational materials are tailored to Puerto Rican veterans, complete with colors and symbols from the Puerto Rican flag. She's now working to secure funding to reproduce and disseminate the fact sheets.

This past February, Uphold became a co-investigator of a grant that will research stroke interventions and family caregiving for Hispanic veterans, as well as how to disseminate stroke prevention information to this population. The Spanish-language information will be posted on MyHealtheVet.com, an interactive Web site that encourages veterans to take charge of their own health.

Promoting Health Literacy

Teaching minority veterans with chronic diseases how to self-manage their conditions is also a priority for Jawel Lemons, RN, MS, FNP-C, associate director of Patient Nursing Services at the Charlie Norwood VA Medical Center in Augusta, Georgia. Lemons remembers watching her own father struggle with his health. The man who raised her had a third-grade education and couldn't read the directions printed on his medicine bottles.

"I thought, 'If he wasn't living with me, what would he do?'" she says. "That's when I came up with the idea for the labels."

Norma Hernandez, RN
The "labels" in question were part of a highly successful health literacy program Lemons created and implemented at the Dallas VA Medical Center in Texas before transferring to her current position in Augusta last year. As a cardiology nurse practitioner in the medical center's congestive heart failure clinic, she often received referrals from primary care providers for patients who appeared to be noncompliant with their medications. Assessing the situation, Lemons discovered that the real reason why the veterans weren't taking their medicine was that they had low literacy levels and couldn't understand the instructions printed on their prescription labels.

So she designed a protocol for teaching her low-literacy patients how to take their medications correctly, using pictures instead of words. She found colorful, easy-to-understand computer clip art symbols, copied them onto adhesive labels and stuck them on the patients' medicine bottles. For example, a rooster pictured with a sunrise symbolized a morning medication, while a bed indicated a nighttime medication. Lemons also transferred the same symbols to the patients' pill boxes. As a result, the patients' health improved dramatically.

Her current goal is to establish special needs clinics across the VA system, with physician consults on site and nurses who are trained to make sure medications are properly labeled. She also hopes the concept of using picture labels will catch on with pharmacies.

Another way Lemons is empowering minority veterans to take control of their health is by providing them with culturally relevant dietary guidelines. "A lot of our [patient education] information is geared toward the average [majority] American, but there's not much on the different cultures," she notes.

Suggested menus for a low-salt diet, for example, are usually designed with Caucasian patients in mind and don't always address the foods that African American or Hispanic patients may include in their regular diets. Lemons provides her patients with the general list of approved foods, but she also offers additional food lists that take into account a patient's particular culture.

This is another example of how minority patients can be labeled as "noncompliant" when the real problem is that they simply could not overcome cultural barriers to their care, Lemons emphasizes. "If they don't understand how to eat and take their medicine, they're not in control of their ailment," she says. "It really impacts the cost of health care when you have people who end up in the hospital over and over because they just don't understand what they're supposed to do."

VA Travel Nurse Corps

One of the Department of Veterans Affairs' newest initiatives for increasing minority veterans' access to culturally sensitive nursing care is the VA Travel Nurse Corps (TNC). Designed for RNs who prefer the flexibility and adventure of travel nursing, this program will establish an internal pool of nurses who can be available for temporary, short-term assignments at VA medical centers throughout the country. The TNC deployed its first nurse in December 2007.

Jacqueline E. Jackson, RN, MS, MBA, director of the TNC, says the new program is actively recruiting nurses from culturally diverse backgrounds. "[Minority] VA nurses bring not only cultural competence but respect and acceptance to the many culturally diverse patients under VA care," she explains. "Nurses in the VA Travel Nurse Corps have an opportunity to travel the country working with a diverse VA patient population and a diverse VA workforce."

For more information about the VA Travel Nurse Corps, visit www.travelnurse.va.gov.

Kimberly Bonvissuto is a freelance writer based in Cleveland, Ohio.