Wednesday, February 14, 2007

Wars, the Military, and Nursing

In the American Military, nurses have played a crucial role in any conflict. From the Molly Pitchers of the American Revolution to the Army and Navy Nurse Corps of today, the care provided by nurses has always played an integral role during wartime. With the priceless caring attention given by the nurses tending to the wounded and dying, the military is able to focus on other issues. The role of the nurse in the military is simple: To provide care and aid to those who have become casualties of war. Throughout history, the popular view of the military nurse has changed from that of a simple recyclable resource used in times of need to a military necessity that can be called upon during any time of crisis.

The Crimean War

Florence Nightingale

The origin of the combat nurse began at the Crimean war (1854-1856), though official military recognition did not occur until after the war. The growth of nursing as a profession developed because of Florence Nightingale’s revolutionizing ideas. At this time, society’s view of nurses was extremely low and unrespectable. The stereotypical view of a nurse was as a whore or a drunk; this view was influenced by Charles Dickens Martin Chuzzlewit, where the nurse Sairy Gimp, was a horrible, drunken nurse who neglected her patients. Nursing was an undesirable position (Nurses in Crimea, n.d.).

Nurse attending wounded soldiers

The military was taking heavy losses in the war, most soldiers were not dying not from battle wounds; a staggering amount died from disease and poor sanitary conditions (The Crimean War, 2000) At first, the military rejected women’s involvement in healthcare for soldiers. However, the military was forced to change their mind on the subject because of the British public’s outcry for better care due to newspaper reports' criticisms. (Crimean War, n.d.). Florence Nightingale and her team of 38 nurses then sailed to Turkey and upon arriving they were appalled by the soldiers' neglect and poor sanitation. Military officers and doctors however refused attempts by Florence to reform the military hospitals. By using the power of the press, Florence’s ideas were permitted. These ideas were revolutionary, changing hospital standards and greatly improving the soldier’s quality of care as well as drastically reducing the death rate from sanitary issues (Nurses in Crimea, n.d.). Florence’s success in the Crimean war created high standards for a nurse; Queen Victoria’s approval helped these women get recognition of the British public. Because society’s view of nurses had improved, funding was available for the formal training of nurses after the Crimean war. The Royal Army Medical School was established in Britain in 1860 (Focus on Women in Nursing, n.d.) and three years before that, in 1857, the draft regulation for inspection of general hospitals had a section pertaining to women nurses. The growth and development of nursing schools impacted military nurses, allowing nurses to be officially recognized. Nursing had progressed greatly in just this one war, but now nurses were striving not to be seen as the stereotype of a whore, mother or angel, rather, they sought to be seen as a professional (Nurses in Crimea, n.d.). The development of the title "nurse" would improve as they participated in future wars.

The American Civil War
"...But one of them would make war rather than let the nation survive, and the other would accept war rather than let it perish, and the war came."
-Abraham Lincoln, 2nd Inaugural Address, March 4,1865

Civil War Nurse

The American Civil War, lasting from 1861 to 1865, cost the lives of over 620,000 Americans. Mortality was an increasing factor because of the inferior medical services that were available during that age. Simply put, decent medical care did not exist during the duration of the Civil War. Both the Union and Confederate governments did their best to provide proper medical care for their soldiers, but even the best could be considered less than ordinary and insufficient by today’s standards. Hospitalization was often considered equivalent to a death sentence; antiseptics were unknown, the relation of dirt to infection was generally not understood, anesthesia was just coming into general use and drugs were inadequate (“Hospitals, surgeons, and nurses,” 2002). Another controversial aspect of the Civil War was women’s insistence to aid in the medical department as nurses. The 2,000 women who volunteered as nurses were eager for direct involvement in the national struggle and refused to take the domestic support roles that society had put upon them. Society in the mid-1800s frowned upon women nurses mainly because it was unfeminine for women to tend and care for naked men. In addition, men were opposed to having female eyes witness the horrible sights that occurred within the hospital wards. In strong opposition, women continued to perform nursing duties such as cleaning wounds, feeding meals, administering medications, searching for injured soldiers on the battlefields, building up soldier morale by making simple conversation, assisting doctors during operations and overseeing sanitary conditions at various facilities (“Women nurses in the Civil War,” n.d.).

Healing the Wounded

The introduction of female staff into responsible roles in a traditionally male military environment was a significant step in the progress of women toward a fuller involvement in American society (“Civil War Nurses: The Angels of the Battlefield,” N.D.). Dorothea Dix and Clara Barton were two extraordinarily powerful women in the Civil War. Seperately, they led a national effort to organize a nursing corps to care for the wars wounded and sick. Carrying the official and prestigious title of Superintendent of Women Nurses, “Dragon Dix” was noteworthy for her recruitment of middle-aged and plain looking women to serve as nurses in the Army Medical Bureau. She wore this nickname as a badge of honor as she succeeded in creating the army’s first professional nursing corps. After the Civil War, Clara Barton became a key influence in the creation of an American branch of the International Red Cross. Originally a schoolteacher from Massachusetts, Barton traveled to Washington determined to care for the injured soldiers who had returned home from war. Along with the combined powers of healthcare nationwide, nurses worked to aid the Civil War disaster and, furthermore, used the experience as a forefront to overcome similar dilemmas of future wars and crises.

World War I

Group of Red Cross Trainees

Nurses have always made a large contribution to the American Military. In 1898, during the Spanish-American War, the large contributions made by the female nurses encouraged the US government to create a permanent nursing corps out of military necessity. Finally in 1901, legislation was passed creating the Army Nurse Corps (ANC), which made the nursing profession an official part of the United States Military (Cox, 2001). In 1908, the Navy Nurse Corps (NNC) was created to bring nurses to each service included in the military spectrum at the time. Even though the ANC and NNC were official entities for sixteen and nine years respectively, it was not until the entrance of the United States into World War I in 1917 that the government, military, and the public saw the invaluable benefits of having nurses as a resource during conflict. When the United States entered the War in May 1917, the numbers of nurses in the ANC and NNC were quite low. With only 4,093 active duty nurses in the Army and 160 in the Navy, there was a great need for wartime aid (“Nurses and the U.S. Navy, 1917-1919”, 2005). The growth of active duty nurses was a continuously steady process. There was no immediate influx of the number of nurses serving in the military, but by the wars end in November 1918, there were more than 21,000 active nurses in the ANC, and 1,400 nurses in the NNC (Cox, 2001).

Operating Room Scene with Specialty Nurses

With constant tragedy and bloodshed, during World War I, the need for well-trained nurses was in high demand. With the help of the American Red Cross, which functioned as a nursing reserve for the Army and Navy, numerous professionally trained nurses were chosen to serve as part of the wartime Nurse Corps (“World War I accomplishments of the American Red Cross," n.d.). The services the nurses provided for the military varied during the war. The ANC served primarily in the surgical hospitals on bases, evacuation zones, or as part of mobile units traveling and caring for the wounded. Nurses also worked in hospital trains throughout Europe during the war, and on transport ships tending to soldiers crossing the Atlantic back to the United States (Cox, 2001). The NNC developed the nursing profession greatly during this period. The Navy created the idea of Base Hospital units in France, Scotland, and Ireland and sent nurses to serve in small mobile units close to the battlefronts. Even though the on site care of the soldiers during the War was crucial to saving lives, the greatest military accomplishment of the Nurse Corps was their service back home in the United States. This is where the bulk of the nurses served; training new corps members and soldiers about basic care. The nurses of World War I were busy training and guiding new recruits regarding disease and tending to the never-ending casualties that were caused by the devastation of the war. In this pre-antibiotic era, nurses understood the need to keep a clean environment for better heath-care (“Nurses and the U.S. Navy, 1917-1919," 2005). When the armistice was signed on November 11, 1918, the growth of the Army and Navy Nurse corps continued to grow, as they served on base back in the United States and aboard ships carrying the wounded back home. However, over the course of the next year, the numbers of active duty corps nurses decreased rapidly since there was no longer a need for constant care. Even though the number of nurses in the military diminished after the war, it showed society and the US government that no war could be won, or fought, without healthcare providers. World War I changed the face of the nursing profession forever. The Great War planted the seed for the importance of nurses in crisis (Cox, 2001).

World War II

The Cadet Nurse Corps

World War II started for the United States on December 7, 1941, when the Japanese bombed Pearl Harbor. In order to be prepared for the likelihood of entering the war, President Roosevelt signed the Labor-Federal Security Appropriation Act on July 1, 1941, which allotted 1.8 million dollars for nursing education (Kalisch&Kalisch, 2004). As a result, the ANC and the NNC would recruit 69,000 nurses to take care of the millions of wounded and dying soldiers (Donahue, 1985). The nurses worked in field and evacuation hospitals, hospital trains and ships, and medical transport planes as part of a new development called “flight nursing.” At the beginning of the war, nurses received “relative rank,” meaning that nurses held an officer’s title and uniform; however, they did not receive officer’s commission, retirement privileges, or the same pay as the men who served. Finally, on June 22, 1944, Congress granted temporary officer’s rank to the ANC and NNC, giving them the same pay, rights, and benefits as commissioned officers (Kalisch&Kalisch, 2004). In 1945, Roosevelt announced his request for a nursing draft, but it never went through. Army and navy nurses provided first-aid, surgery, blood transfusions, chemotherapy, and evacuation from the battle field to the soldiers. The health care and compassion from the nurses would greatly reduce the number of casualties and increase the praise from society (Kalisch&Kalisch, 2004).

World War II Poster: Recruiting Nurses

As a result of proper nursing care during WWII, 96 out of every 100 soldiers were saved, meaning that less than four percent died from injuries and disease (Bellafaire, 1993). After the war, society as a whole looked at women and the nursing profession differently. The status of women in general went up in society because they contributed so much to the war effort. The government recognized the importance of educating people to become nurses and gave free education for nursing students until 1948. Nurses returning from military service learned to deal with wounds and death on a whole new level. They learned practical skills by serving in the war that they could not learn anywhere else (Bellafaire, 1993). After World War II, society saw the important role played by nurses and that role would continue to become more significant as the United States continued to engage itself in war.

The Vietnam War

The era of the war in Vietnam was a very unstable time for America, lasting from about 1959 until 1975. The war did not evoke widespread support from the nation or the nursing profession. In need of nurses to aid the injured, the military began recruiting nurses throughout the 50’s and 60’s. According to Kalisch and Kalisch (2004), nursing was already battling a major shortage in the civilian world. However, military services were obliged to recruit in direct competition with civilian nurse employers. Military personnel knew that they would need to enact some sort of incentives in order to get nurses to enlist. The Army Student Nurse Program was one such incentive. Through the Army Student Nurse Program student nurses received financial aid in return for service in the army. Student nurses had to go to school for a minimum of two years to earn a diploma or three years for a degree. This incentive accounted for 52% of the total Nurse Corp’s growth in 1962. On May 1, 1964, the Walter Reed Army Institute of Nursing (WRAIN) was established. Like the Army Student Nurse Program, the main goal of the WRAIN was to increase the army’s number of degree holding nurses and increase the re-enlistment rate of army nurses. Clearly, without such incentives, the nurse corps would have remained relatively weak. With civilian hospitals paying higher salaries and improving working conditions for the nurses, the military was having great difficulty recruiting nurses (Kalisch & Kalisch, 2004).

On June 11, 1970, Anna Mae Hays, the 13th Chief of the ANC made history when she became the first female ever promoted to the rank of general officer in the U.S. Armed Forces. Army Nurse Corps History:Vietnam

From an ethical standpoint, going to Vietnam to serve in the war effort was a rather daunting task for nurses. Support was lacking in the United States. Protesting rather than patriotism was heard throughout America. According to Kalisch & Kalisch(2004), “There was widespread resistance to fighting…profound guilt…and a deeply embedded antiestablishment anger was common” (p. 258). However, those serving in the war had to set their moral opinions aside and perform the duty that they promised to their country. Moral dilemmas could not hinder nurses. It was a battle in itself trying to face these dilemmas, but nurses had to keep in mind the bigger picture, and that was the war.

Military Nursing in the Present
The Vietnam Women's Memorial

The Vietnam conflict was the first war that America really “saw.” Video clips and pictures on the evening news showed, to average Americans, the true violence of war. When the GI’s returned from battle, they found support for US troops at an all time low. However, in contrast, a deeper respect for military nurses, who had selflessly worked in such horrific conditions, developed. The growth of support and respect for military nurses is truly reflected in the Vietnam Women’s Memorial. Diana Carlson Evans, a former Vietnam War nurse, initiated the drive to add a special women's memorial to the Vietnam War Memorial in Washington, D.C. Evans was successful in her efforts to recognize and honor the work of military nurses when, on November 11, 1993, the memorial was dedicated. The memorial shows society’s growth and recognition of the role of women and nurses in the American military ("Vietnam Women's Memorial," 2005).

Gulf War
Because of advances in the feminist movement in the 1980’s (in the US), many women no longer assumed the traditional role of housewife. Instead of choosing between being a mother or a business women, many women became both. Thus when military nurses began being deployed for the Gulf War in 1990 family situations became complicated. Raelene Hoogendorn (1991), a US Navy Nurse Corps who served in the Gulf war, recalls, “Mothers were deployed en masse for the first time in history, leaving a legion of ‘Mr. Moms’ and crying infants behinds, and retirement and educational plans …scattered for the four winds” (p. 27A). The Gulf war was the first time in American history when it became common for nurses to leave children behind with their fathers or extended family members.
Soldiers learn how the CP DEPMEDS low pressure alarm works. DEPMEDS was first used in the Gulf War.

Over 2200 nurses were deployed to the Middle East during the Gulf War, also known as “Operation Desert Shield” (Cox, 2001). Because of the heavy casualties experienced in Vietnam, nurses were prepared for the worst-case scenarios and received considerable training before being deployed. Judy Little (1991), of the Navy Nurse Corps recalls being told, “to prepare to receive 150 casualties…and 120 general trauma cases per day” (p. 807). She later states, “Although the casualties were not as heavy as anticipated, we felt that we were prepared to handle what had been expected of us”(p. 807). The Gulf War was the first major conflict in which DEPMEDS (deployable medical systems) were used. DEPMEDS were combat support hospitals in which critical modular units were housed in rigid aluminum tents. They included “laboratory, radiology, pharmacy, sterilization departments and operating rooms” ("US army DEPMEDS" 1998). With the help of the new facilities, military nurses achieved the lowest ever rate of disease and non-battle injury in a conflict (Cox, 2001).

Ethics in Military Nursing
Because the circumstances of any war demand exceptional medical treatment, in an environment of limited resources, the concept of “distributed justice” comes into play. Burkhardt and Nathaniel (2002) define justice as, “fair, equitable, and appropriate treatment in light of what is due or owed to a person, recognizing that giving to some will deny receipt to others who might otherwise have received these things” (p. 422). Military nurses, throughout history, found themselves in situations where they had to choose which soldiers would receive medical treatment and which had no chance of survival. Judy Little (1991) recalls, “If a patients had a chance at the outset, he or she would be placed on the surgical priority list. If a patient was too badly injured, according to the criteria in the standard operating procedure, he or she became an ‘expected’ statistic…transferred to a special ward where they would be cared for until they died.” (p. 801). While military nurses initial reaction may be to try everything possible to save every soldier, they must realize that they have to use the limited resources available to save as many as practical.

While each war brought about human tragedy and sorrow, it also brought about advances in medical and nursing care. Even though nursing was viewed differently by society during each war, nurses from the Crimean War to the Gulf War had one goal in mind: to medically and emotionally care for the wounded soldiers. As a result of the experiences nurses went through, the nursing profession changed and developed along the way. Today, America finds itself in the “war on terrorism.” Thus far, over 2,000 military nurses have been deployed, mainly to Iraq. Although this war will inevitably have positive and negative effects on the nursing profession, as did all the other wars, it is too early to understand their full magnitude.

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