- Email: [email protected]
Understanding deployment from the perspective of those who have served
Accepted Manuscript Understanding Deployment from the Perspective of Those Who Have Served Bonnie Mowinski Jennings, PhD, RN, FAAN, Colonel, US Army (retired), LTC. Kristal C. Melvin, PhD, NP-C, Donna L. Belew, MSN, RN PII:
S0029-6554(16)30408-0
DOI:
10.1016/j.outlook.2016.12.005
Reference:
YMNO 1202
To appear in:
Nursing Outlook
Received Date: 11 June 2016 Revised Date:
25 November 2016
Accepted Date: 5 December 2016
Please cite this article as: Jennings BM, Melvin LKC, Belew DL, Understanding Deployment from the Perspective of Those Who Have Served, Nursing Outlook (2017), doi: 10.1016/j.outlook.2016.12.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Understanding Deployment from the Perspective of Those Who Have Served Bonnie Mowinski Jennings, PhD, RN, FAANa,* Colonel, US Army (retired)
a
Nell Hodgson Woodruff School of Nursing Emory University 1520 Clifton Road NE, Room 226 Atlanta, GA USA 30322 Email: [email protected] b
c
d
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The Geneva Foundation 917 Pacific Avenue, #600 Tacoma, WA USA 98402 Email: [email protected]
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Center for Nursing Science and Clinical Inquiry Brooke Army Medical Center 3551 Roger Brooke Drive Joint Base San Antonio, TX USA 78234 Email: [email protected]
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Donna L. Belew, MSN, RNc,d
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LTC Kristal C. Melvin, PhD, NP-Cb
*
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Center for Nursing Science and Clinical Inquiry Madigan Army Medical Center 9040 Jackson Avenue Tacoma, WA USA 98431
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Corresponding Author: Bonnie Mowinski Jennings, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road NE, Room 226, Atlanta, GA USA 30322, [email protected]
Key Words: military personnel; veterans; deployment; Iraq; Afghanistan; qualitative research method
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Background: The term deployment is used by the military to describe sending troops to carry out a combat, peacekeeping, or humanitarian mission.
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Purpose: The purpose of this analysis was to illustrate the variations around combat deployment experiences.
Methods: Qualitative descriptive methodology was used to examine data from 17 members of
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the US military who deployed at least once to a combat zone following the September 11, 2001 attacks.
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Results: No two deployments were the same between individuals or within individuals if they deployed more than once. Variations were discovered in deployment experiences related to deployment demands, deployment resources, and coming back changed as individuals. Conclusions: Regarding deployment as a singular concept does not take into account the
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variations in the deployment experience. Individuals caring for those who have served in war
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would benefit from understanding that each deployment is unique and a life altering experience.
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Highlights •
Deployments are rarely, if ever, what a service member expects even if returning to the same place. The first deployment is not always the worst deployment.
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Paradoxical effects were found for deployment demands (both stress-filled and stress-
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less) and deployment resources, such as communication with family (both stressful and
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supportive).
Poor leadership may exacerbate the stress of being deployed.
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Veterans may be changed after deployments in ways that are not always visible.
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Health care providers may be able to better tailor care by (a) establishing rapport, (b)
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asking open-ended questions about deployment experiences, and (c) exploring combat
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exposures for lingering invisible effects.
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Understanding Deployment from the Perspective of Those Who Have Served Deployment, a term used commonly in the military, means “the rotation of forces into and out of . . . geographical areas in which military operations are conducted” (DoD Dictionary,
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2014, p. 72). Although the word deployment suggests sameness, not all deployments are the same. At a macro-level, there are two types of deployments: (a) combat deployments—moving into an area of conflict (i.e., a war zone), and (b) non-combat deployments (e.g., humanitarian or
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peace keeping missions; Department of Defense Dictionary, 2014). Physical and mental health concerns have been associated with a history of combat deployment (Cesur, Sabia, & Tekin,
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2013; Cifu et al., 2013).
When those who have served in the military seek health care, it is important for providers to understand the visible and invisible wounds that may exist after deploying. As noted by Morrison-Beedy (2016, p. 404), “over half of all [US] veterans do not receive health care
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through VA [Veterans Administration] facilities creating a demand . . .” for those caring for military veterans to “be knowledgeable about the needs of our nation’s veterans and military personnel.” The purpose of the analysis reported here is to illustrate variations in the deployment
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experience among those who have served in Operation Enduring Freedom (OEF) and Operation
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Iraq Freedom (OIF).
Background
Since the 1990s, important changes in the US military have altered deployment
experiences. First, the demographics of those serving shifted. The all-volunteer military force (AVMF) includes more service members who are (a) older (DoD, 2014), (b) women (DoD, 2014; Patten & Parker, 2011), and (c) dual military couples (i.e., both spouses serving in the military concurrently (DoD, 2014; IOM, 2010). Second, the military downsized. Today’s
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AVMF, at approximately 1.3 million service members (Kane, 2016) is 35% smaller than during the Cold War (Dorn et al., 2000), and less than half the size of the military at the height of the Vietnam war (Kane, 2016). Third, compared to deployments prior to the AVMF, the frequency
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of combat and noncombat deployments has increased five-fold (Eikenberry, 2013). Fourth, the reduced size of the active duty force and the frequency of deployments contribute to “an
unprecedented use of the reserves and National Guard” (IOM, 2010, p. 51) to supplement active
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duty numbers.
Following the September 11, 2001 attacks on the US, the demands on the US military
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escalated. These demands intensified during the “surges” in Iraq during 2006 (Kane, 2016) and again in 2010 in Afghanistan (Robinson et al., 2014). During each surge, an additional 30,000 service members were deployed to respond to increased insurgent risks (Kane, 2016; Robinson et al., 2014). At the peak of OEF and OIF in 2007, more than 300,000 service members (23% of
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the total US military force) were deployed to Iraq, Afghanistan, support regions such as North Africa, and ships in hostile waters such as the Persian Gulf. Overall, approximately 2.4 million combat deployments have occurred in support of OEF and OIF, with over 30 % of deployed
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service members having more than one deployment (Kane, 2016; Robinson et al., 2014). Typical metrics used to reflect deployment demands include deployment frequency,
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deployment length (Buckman et al., 2011), and time between deployments (i.e., dwell time) (IOM, 2010; MacGregor, Han, Dougherty, & Galarneau, 2012; MacGregor, Helmetes, Clouser, Han & Glarneau, 2014). The DoD goal for dwell time is to have active duty service members spend at least twice as much time at their home duty station as their most recent deployment length (Bonds, Baiocchi, & McDonald, 2010). A less common yet longstanding metric is the concept of deployment load, or the amount of time spent deployed in relation to the amount of
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time in the military (Castro & Adler, 1999). Interviews conducted for an on-going parent study contained detailed information about participants’ deployments, sensitizing investigators to the variations around combat deployment. It became evident that traditional deployment metrics fail
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to reflect the more meaningful features of the deployment experience. Methods The Parent Study
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The data used in this analysis were drawn from the parent study designed to explore military couples’ reintegration after combat deployment. The parent study, as well as the
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analysis reported here, was approved by appropriate institutional review boards. Recruitment for the parent study began in 2013; it is open and ongoing. As of November 2016, 151 military couples (302 individuals) have participated.
Participants were initially recruited from military installations in the Northwestern US,
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followed by social media and snowball recruitment to reach current and former military members across the US. Study participants were previously deployed military service members and their spouses who volunteered to complete several on-line questionnaires. Completion of the
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questionnaires served as evidence of consent to participate. In addition, parent study participants were asked to consider volunteering to be interviewed; both members of the couple had to
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volunteer for the interviews to take place. The interview data are being used in the parent study to construct a grounded theory of military couple reintegration following deployment. Recruitment is ongoing for the on-line surveys with recruitment for future interviews to be determined based on evolution of the grounded theory analysis. Of the 21 couples who agreed to be interviewed, 15 couples completed the interviews; the other 6 couples were lost to follow up. Although the preponderance of couples who
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volunteered for interviews were from the Army, all Navy, Air Force, and Marine couples who volunteered were approached about completing interviews. Each interview was about one hour long; all interviews were conducted by the second
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author (Principal Investigator of the parent study) between 2013 and 2016. The interviews were semi-structured with each member of the couple interviewed separately. The interviews were audio-recorded and transcribed professionally with pseudonyms assigned in lieu of actual
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participant names. Transcripts were reviewed for accuracy. Procedures
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Although the interview questions in the parent study were not designed to explore participant’s experiences during deployment, and the convenience sample of interviewees creates methodological limitations, abundant information about deployment was volunteered by the informants. The inclusion criteria for this secondary analysis were those individuals from the
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parent study who had deployed in support of OEF/OIF and completed both interviews and surveys. As this analysis proceeded and subsequent to the interviews, clarifying questions were developed by the research team and posed to the participants to ensure the understanding of their
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deployment experiences was as complete as possible. All but one participant readily responded to the request for further information, with many individuals providing detailed responses.
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In addition to the interview data, four questions from one of the surveys, the Traumatic
Events Questionnaire (TEQ; Vrana & Lauderbach, 1994), were useful in providing insights about combat-related traumatic events experienced by the informants. The TEQ is a self-report of previous trauma exposure (e.g., accidents, witnessing serious injury), and the severity or intensity of the trauma, at the time the event occurred and the time the survey was completed.
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Because this was a secondary data analysis, qualitative description (Neergaard, Olesen, Andersen, & Sondergaard, 2009; Sandelowski, 2000, 2010; Willis, Sullivan-Bolyai, Knafl, & Cohen, 2016) was the most suitable methodology for examining the deployment experiences.
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Unlike other qualitative methodologies, data are less transformed in qualitative description, yielding an interpretive rendering that is less complex than the highly interpretive results from a phenomenological approach or the construction of a grounded theory (Sandelowski, 2000, 2010).
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Data Analysis
Statements about deployment experiences were extracted from the interview data by the
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first author and verified by the second and third authors. The data were analyzed using conventional content analysis (Hsieh & Shannon, 2005). The first author devised an inductively derived coding structure from the data. The coding structure was then used independently by the other authors to open-code the extracted data as a preliminary step to organize the data according
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to major concepts. Differences of opinion were reconciled by discussing the various interpretations until agreement was reached. The concepts were arranged into matrices to examine patterns within and across cases based on consideration of branch of service and
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deployment characteristics. As the analysis proceeded, it was evident that models of military occupational stress (Adler & Castro, 2013; Harmon, Hoyt, Jones, Etherage, & Okiishi, 2012)
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offered an organizing structure for the themes. Because numbers are useful to “generate meaning from qualitative studies”
(Sandelowski, 2001, p. 231), the four TEQ questions were used in this analysis to count how many respondents reported the stated event and how many times the respondents reported the stated event. Lingering effects of combat-related trauma were also assessed by examining the severity reported for each of the four questions (scale of 1, low to 7, high) “then” (at the time
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they occurred) and “now” (how the same events were scored at the time the survey was completed). The focus was less on the actual score and more on the extent to which the event was still regarded as traumatic.
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Rigor was maintained by writing analytic and reflexive memos, documenting decisions to create an audit trail, achieving a thorough understanding of the data, and returning to the data to verify interpretations and seek contrary cases (Maxwell, 2013). Although respondent validation
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has limitations, another step toward maintaining rigor involved sending a summary of the
findings both to the 17 study participants and to 3 military members who had deployed but who
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did not participate in the study (i.e., non-participants). The 3 non-participants were asked (a) whether the summary resonated with their deployment experiences and (b) to send the summary to other individuals who had deployed for their review. This yielded feedback from a total of 13 non-participants representing all branches of the military (Army n = 3, Navy n = 2, Air Force n =
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3, Marines n = 5). Of the 17 study participants, 7 responded to the summary. Four of the seven fully endorsed the summary. All non-participants responded to the summary. Ten of the 13 nonparticipants fully endorsed the summary, indicating the deployment experience was portrayed
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accurately. Only findings about leadership were not validated by six individuals (three participants and three non-participants). These six individuals indicated that although their
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personal experiences with leadership were not reflected in the findings, they acknowledged the findings could apply to others. Findings
Participant Characteristics Demographic characteristics are portrayed in Table 1. None of the participants had visible wounds such as amputations or disfigurement. Twelve of the 17 participants had served
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in the Army although perspectives were offered from individuals in all four branches of the US military. The age range of participants was 24-52 years. There were two dual military couples in the sample; one couple was in the Army and the other couple was in the Air Force. Data from
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these couples supported contrasts between the two military services, as well as between deployments for those who were dual military and non-dual military. Deployment Characteristics
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Deployments varied in length ranging from 1 to 17 months. Shorter and more frequent deployments were more common for Army personnel in Special Forces and Navy personnel
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assigned to submarines. Other characteristics of combat deployments are shown in Table 2. Deployment load (total months deployed/total months in the military) was highest among Army Soldiers (2 enlisted and 2 officers), with 11 participants (65% of sample) reporting a deployment load of more than 10%. Other patterns were not readily apparent in the deployment data
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indicating the lack of sameness and typicality among deployments. For instance, there was no discernible pattern in the number of combat deployments by the branch of service—four Army Soldiers had deployed once just like the two Air Force service members. Dwell time (the length
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of time between deployments) for those with more than one deployment (n = 11) ranged from 1 month to 101 months. Although all participants deployed between the years 2002 and 2014 in
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support of OEF/OIF, three participants also had prior deployment experiences (1991-1997). Their perspectives offered useful contrasts as did the perspectives of the five individuals who had non-combat deployment experiences between1991 and 2015. Thematic Discoveries Reflecting Military Occupational Stress Each deployment was filled with uncertainty yielding circumstances that could be better or worse than expected. Some individuals deployed to combat zones where there “wasn’t any
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combat.” Some individuals deployed to combat zones where “the actual fight is.” Even when service members returned to the same deployment location and did work similar to previous deployments, “you’re with a different group of people . . . you’ll have different commanders who
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want things done differently.” A participant who deployed twice to Iraq expressed these
differences by noting that although the first tour was “tough” due to uncertainty about what the war would be like, the second tour was “much worse” and “more traumatic.” The overarching
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idea from this study was expressed by a participant with the experience of 5 deployments who noted, “none of them [deployments] are the same.” Variations in deployment experiences were
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further informed by the three themes discovered in the interview data: deployment demands, deployment resources, and coming back changed.
Deployment demands. Combat deployments were regarded as more stressful than noncombat deployments. Non-combat deployments involved 8 hour work days on bases with more
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options for recreation, shopping, and exploring the country without people “shooting at you.” By contrast, combat deployments involved 12-18 hour work days, often 7 days/week on bases located in austere surroundings where individual movement on and off base was restricted.
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Not all combat deployments, however, were the same. Differences were evident based on service affiliation as well as within the same service. Army and Marine participants were on
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the ground outside the wire (off the military base and into enemy territory), affording them a different experience than Navy personnel who were nearby yet at sea, and Air Force personnel who were in Afghanistan yet not directly involved with counter-insurgency operations. Within the same service, deployments differed over time, often based on the location of the deployment, or the amount of combat exposure. A Soldier who deployed twice to Iraq and then to Afghanistan noted that Afghanistan “brought the war home to me”; it brought the “ugly” and
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“twisted” aspects of war to life. Alternately, a Soldier who deployed to Afghanistan at a different point in time was located in an area with little fighting and action. In this case though, bad news penetrated the Soldier’s reasonably stable and safe place when “A [prior] Soldier of
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mine who was in a completely different region [in Afghanistan] . . . ended up getting killed. . . . That was a rough experience.”
For the five individuals who deployed to both Iraq and Afghanistan, movement on and
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off base was more restricted in Afghanistan compared with Iraq. Navy personnel also
experienced restricted movement, yet it was related to the type of vessel on which they served—
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submarines or aircraft carriers. Submarine deployments involved the monotony of “being underwater.” Day and night were the same. The days of the week were blurred. Telling time was based on “what they’re serving for chow.” Navy deployments on aircraft carriers, by contrast, were less stressful and movement was less restricted than deployments on submarines.
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Although the Air Force participants also deployed to Afghanistan, their experiences were inside the wire (within the confines of a US military base). They represent a contrary case because they were a dual military couple who (a) volunteered to deploy, and (b) deployed almost
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simultaneously to the same place. According to the male member of the couple, they experienced a “busy battle rhythm,” yet their accounts did not reveal the same kinds of stressors
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and demands expressed by other participants. Moreover, the synchronous deployment of the Air Force dual military couple contrasted sharply with the asynchronous deployments of the Army dual military couple whose relationship was like a revolving door with one deploying as the other one returned, yielding considerable time apart. There was infrequent mention of deployment length as a stressor, although an Army respondent indicated that 9-month deployments were “definitely doable;” and longer
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deployments were harder. What mattered more than the deployment length was what one participant described as getting “shanghaied” mid-tour with an extension, turning a 12-month deployment into 15 months.
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Deployment demands were also reflected in the combat-related trauma exposure as
reported from the TEQ questions (Table 3). Of the 17 participants, 4 service members reported no combat-related trauma exposure (2 Army and 2 Air Force). The remaining 13 participants
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reported at least one combat-related trauma exposure. Lower deployment load did not always yield protection from combat-related trauma exposure. Two individuals who reported being
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deployed less than 10% of their military careers reported 5 or more incidents of combat-related trauma exposure.
A paradox was noted in deployment demands: Combat deployments were both stressfilled and stress-less. Although “you’re never safe in a war zone,” there were no “everyday”
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stressors during deployment (e.g., child care, home and automobile repairs, laundry, cooking), allowing service members to immerse themselves in their jobs and remain “focused on the mission.” The potentially opposite effect of deployment stress was further illustrated by the
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counterintuitive differences experienced by an individual who deployed twice to Afghanistan. The first deployment, 12 months in length, involved time outside the wire and witnessing an
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attack that killed 10 Soldiers; the participant helped remove the bodies for helicopter evacuation. Nonetheless, “I came back from the first one okay.” The second deployment was shorter, 4 months in length, and involved a job inside the wire doing “desk work.” Although seemingly safer, the second deployment was “tougher” because of feeling out of touch “with my Soldiers,” indicating the weight of responsibility felt by some individuals in leadership roles.
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Deployment resources. Both personal and occupational resources were mentioned in the interviews. Personal resources, such as coping strategies, were used to make sense of war. One participant reported finding himself in a “weird head space” because “the bad guys are also
emotions at bay: “you’re not murdering them, it’s combat.”
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people.” Comments were offered by an Army enlisted Soldier about reframing actions to keep
All but one individual mentioned the importance of communicating with family as a
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personal resource. Communication technology supported staying in touch via telephone calls, Skype, emails, text messages, blogs, pictures, and videos; letters and care packages remained
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important mainstays.
When someone in a unit was killed or seriously injured, however, communication went on “black out” pending notification of the deceased’s family. Life for submariners was always somewhat blacked out because, as one participant noted, time and relationships “freeze [in the]
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underwater world.” Communication from outside the submarine was either delayed (e.g., emails arriving 3 days later) or severed (e.g., no media or email access). A Sailor with experience on both submarines and aircraft carriers confirmed how much easier it was to communicate on an
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aircraft carrier.
A unique source of personal support was reflected for both Navy and Air Force
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participants. When serving in a combat zone on an aircraft carrier, Navy spouses were allowed to visit at a friendly port part way through the deployment, helping to reduce stress and making deployments easier. Although the Air Force couple was not allowed to cohabit during deployment, they could see each other every day, meet for meals, and share special events. Unlike all other participants, their personal resources were present for them in theatre throughout their deployment.
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Least often mentioned were occupational resources for mitigating stress. Chaplains were identified as an occupational resource, whereas formal leaders (i.e., commanders) were discussed in the positive by only one participant. An enlisted participant who deployed once for 15 months
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noted it was an “awful experience, not because of what I saw” but because of “toxic” leadership; the “chaplain saved me.” An officer participant also vocalized concerns related to poor
leadership and the “good ole boys club,” indicating there was “some very bad behavior on the
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part of some of the more senior folks.” Although one participant was complimentary regarding leadership, “I liked working for the boss that I was working for. . . . That was very rewarding for
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me,” leaders were more often mentioned as a stressor by Army and Marine participants, both officers and enlisted. Leaders were referred to as “negligent,” “ineffective,” and allowing an “abusive culture,” with abuse in both verbal and physical forms. At least three individuals claimed poor leadership was a greater source of trauma than combat. Just as combat-related
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trauma left individuals with lingering memories, the effects of poor leadership also were enduring as individuals who last deployed years ago verbalized vivid recollections of ineffective leaders. Although unexpected, leadership as a stressor during deployment came through in these
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findings.
Like deployment demands, a paradoxical effect also was noted related to deployment
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resources. Both personal and occupational resources could increase rather than mitigate stress. Respondents noted that communication with family could exacerbate stress for the service member who might become upset because of things shared by the non-deployed spouse. Service members also were stressed because they had to filter their communication home, figuring out what not to say, to protect the non-deployed spouse from worrying. A set routine for communication created expectations that could yield stress for the service member and the
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spouse when mission requirements interfered with established times for exchanges. Time zone issues were at play, and the onus for synchronous communication was on the person in theatre because they had to initiate this exchange. Although deployed individuals were supported by
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communication with family, deployed individuals also were supporting their families—and that was sometimes a source of stress. An Army respondent noted that the least stressful of eight deployments was the one when communication to the US was absent. A shared refrain was that
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less communication with home diminished stress because it allowed people to focus fully on the mission. By contrast, an Army participant who had deployed prior to the wars in Iraq and
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Afghanistan noted less stress related to communication in OEF/OIF because new technology made it easier to communicate than in the past.
Coming back changed. A recurrent outcome expressed by officers and enlisted personnel across all services was that people came back changed from deployment. Thirteen of
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the 17 respondents explicitly acknowledged coming back changed with 7 participants indicating that although they were different, they were “ok.” The other six participants were being treated with medications and outpatient counseling; two had received inpatient care. Of the six
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individuals who were not “ok,” three were still on active duty. Symptoms, negative emotions, and aggression were changes explicitly noted by nine
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participants. These included hypervigilance, being “jumpy” in response to noises such as cars backfiring, being in a “dark place,” and struggling with “mood swings.” Five participants compared their mild-manneredness before deploying with their predilection to be “hot temper[ed]” after deploying. Words about anger were common and offered with forceful intonation; less common but related were statements about feeling “rage.” Contradictions were
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found in statements by two Army enlisted Soldiers who expressed a great deal of anger and also said they were “numb” and “emotionally dead.” Lingering effects of combat-related trauma were determined by comparing TEQ self-
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reports of the severity of the traumatic event at the time it occurred with the severity of the event when the survey was completed. Three of the 17 participants reported events that were not at all severe at the time of the occurrences; these had no lingering effects. By contrast, 7 of the 17
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participants reflected at least one event remained traumatic for them to some degree even now. One of these 7 individuals rated two events at the highest level of severity despite 52 months
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elapsing between the events and completing the questionnaire.
Participants also reflected changes in their perspectives about ordinary things. These included their desire to socialize. Following deployment, individuals sought quiet time alone or avoided crowds such as movies, large parties, and sometimes being in public in any form.
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Participants also noted their gratitude for previously taken for granted and simple things. “Clean bathrooms,” for instance, were now regarded as “living in luxury.” Discussion
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Most investigators who study military deployments use large data sets and large cohorts with a focus on statistical analyses. Such work is important, yet it does not reveal some critical
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issues that are discoverable in interview data and a more in-depth analysis. By exploring variations in deployment experiences as described by those who have deployed in support of OEF/OIF, this analysis advances knowledge in an understudied area. Compared to existing literature, these findings begin to show that variations in deployments are less about the branch of the military, the frequency, length, or whether it is a service member’s first deployment. Rather, each deployment experience is unique; no two deployments are the same. Unanticipated
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findings included the paradoxical effects of deployment demands (both stress-filled and stressless) and deployment resources (personal and occupational as both reducing and exacerbating stress). To our knowledge, issues about the potentially opposite effects of demands and
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resources have not been reported except by Durham (2015) who found communication between deployed service members and their families as being both supportive and stressful.
This analysis offers support for the recommendation that unexpected extensions in
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deployments are best avoided (Buckman et al., 2011) and that while deployed, time may be frozen or at least lagging in regard to the media, entertainment, and even keeping up with family
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and friends (Wands, 2013). These findings differ from some of the existing reports concerning deployment length (Adler, Huffman, Bliese, & Castro, 2005; Buckman et al., 2011), the stressful nature of the first deployment compared to subsequent deployments (Hoge, Auchterlonie, & Milliken, 2006), and that deployments to OIF locations were more stressful than deployments to
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OEF locations (Hoge et al., 2006). Based on the analysis reported here: (a) shorter deployments were sometimes more stressful than longer deployments, (b) subsequent deployments were often more stressful than first deployments, and (c) deploying to Afghanistan was more stressful than
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deploying to Iraq, although the dates of the deployment and the nature of the work increased or decreased the stress. These findings also offer new perspectives about “no one get[ting] through
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it ok” (Wands, 2013, p. 197). Studying individuals who return from war changed but ok could offer important insights that might help those who return with problems. Models of military occupation stress (Adler & Castro, 2013; Harmon et al., 2012) include
demands, resources (personal and occupations), and outcomes, all of which apply to the work required of military service members. Deployment creates a context in which occupational demands are heightened. Combat-related exposure to traumatic events is a demand that was
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confirmed in these findings. Heightened demands on deployed individuals make resources that might moderate the stress all the more important. Yet the paradoxical effects found in this analysis call into question the strength of these moderating effects. A personal resource,
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communication with family, was sometimes stressful as well as supportive. Likewise an
occupational resource, leadership, often was perceived as ineffective and rarely mentioned as supportive. Leadership ineffectiveness was identified in prior research as well (Harmon et al.,
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2013) and thus lends credibility to these findings despite the lack of endorsement from some individuals who reviewed the summary of the findings. Findings about resources that help to
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mitigate stress during deployment may assist military leaders and planners to capitalize on available resources for service members. Future research is needed that focuses on the specific leadership behaviors that help to mitigate, rather than elevate, stress during deployment. Providers who are aware of the military occupational stressors of deployment, and that
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each deployment has the potential to be completely different, will be better able to help service members and their families adapt following deployment. For instance, sharing knowledge about challenges and stressors during deployment from unexpected sources, such as leadership could
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help manage expectations after deployment.
A limitation of this analysis is the use of data from a parent study that was designed for
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another purpose. Seventy-one percent of the sample was Army personnel thereby confining the perspectives and reducing informational redundancy across all services. Moreover, the interviews were not designed for the purpose of exploring deployments per se. Despite these shortcomings, the existing interviews afforded the investigators access to information-rich data that fostered a beginning understanding of the variability across deployments. The veracity of the findings from this secondary analysis is enhanced, however, because of the 13 non-
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participant respondents who represented all branches of the military and largely endorsed a summary of the findings. Some comments, such as those about the opposite effects of deployment and thoughts about leaders, would have benefitted from additional questions and
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probes. Future studies also could be designed with the explicit purpose of interviewing people about their deployment experience using a purposeful sampling strategy guided by findings from this analysis.
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Despite the limitations, these findings have implications for helping health care personnel who care for veterans with combat experience. They also offer insights that are useful to the
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American Academy of Nursing’s “Have You Ever Served in the Military?” campaign (Collins, Wilmoth, & Schwartz, 2013). An affirmative response to “have you ever served in the military?” requires follow up questions about whether individuals have deployed and if yes, further inquiry to understand their deployment experience, and the potential for hidden or
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invisible combat-related injuries. Although the visible wounds of war gain attention (e.g., amputations, disfigurement), they affect fewer than 1,700 service members (.06% of those deployed to combat; Fischer, 2015). By contrast, hidden or invisible injuries (e.g., post-
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traumatic stress disorder, chronic pain, binge drinking, sleep problems) have affected over 100,000 service members (Crum-Cianflone, Powell, LeardMann, Russell, & Boyko, 2016;
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Fischer, 2015; Lew et al., 2009; Pugh et al., 2014). The prevalence of invisible injury diagnoses after combat deployment is estimated to be 12-29% (Cesur, Sabia & Tekin, 2013; Cifu et al., 2013; Hoge et al., 2006).
Wartime experience, however, is often a private experience that people safeguard.
Health care providers must therefore realize the importance of establishing rapport with veterans who have served in combat, showing an interest in them and being attentive to all verbal and
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nonverbal responses. A solid rapport may lay the foundation for combat veterans to disclose answers to open-ended questions about their deployment experiences, and uncovering previously unmentioned sources of deployment stress. A starting point to identify some of the invisible
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effects of war could be to explore the nature of combat-related trauma using questions similar to those in the TEQ, including the service member’s sense of the severity of the event (e.g., very severe, not very severe). Asking about symptoms or behavioral changes also may help health
treatment plans.
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Conclusions
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care providers understand the nature of the effects of deployment and assist them in tailoring
Understanding the variations around deployment experiences is important when caring for individuals who have served in the military. Regarding deployment as a singular concept does not take into account the level of danger at the deployment location, the trauma exposure
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during deployment, or other factors that could alter deployment experiences. The findings from this analysis show that the experience known as deployment varies vastly among those who have served. More person-centered care may be rendered through seeking to understand an
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individual’s military deployment experience. Knowing that deployment experiences are deeply
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personal, gaining insights about that experience requires finesse and skill.
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Acknowledgements The authors express gratitude to five doctorally prepared colleagues, two who have military experience, for commenting on earlier drafts of this manuscript. Dr. Judith Baggs was
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particularly supportive and helpful in offering guidance throughout the preparation of this manuscript
Funding: The parent study is supported by the TriService Nursing Research Program in
N12-P07, Grant number HT9404-12-1-TS10).
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sponsorship with the Uniformed Services University of the Health Sciences (Project number
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Disclaimer: The information, content or conclusions in this article do not necessarily represent the official position or policy of, nor should any official endorsement be inferred by the TriService Nursing Research Program, the Uniformed Services University of the Health
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Sciences, the Department of the Army, or the Department of Defense or the US Government.
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23 References
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Table 1 Participant Demographic Characteristics
Gender Male
15 (88%) 2 (12%)
Military Status Active Duty
13 (76%)
2 (12%)
Separated from Militarya
2 (12%)
Navy
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Air Force
12 (71%)
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Army
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Retired
Branch of Service
Marines Age
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Female
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(N = 17)
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Characteristics
2 (12%)
2 (12%) 1 (5%)
24-34
11 (65%)
35-45
3 (17.5%)
46-52
3 (17.5%)
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Enlisted
8 (47%)
Officerb
9 (53%)
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Note. aSeparated from Military: Left military before retirement eligible bOfficer: Includes both warrant officers (n = 1) and commissioned officers (n = 8)
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Rank
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Table 2
Total Number of
Combat
Non-Combat
Deployment
Deployments2
Deployments3
Deployments4
Load5
1
Beth
3
2
Chris
2
2
Dale
10
8
Eli
1
1
Frank
3
3
Gary
2
Harold
3
Ian
2
Jessie
10
Kevin
1
Total Months Total Months Combat
Non-Combat
Deployed
Deployed
0
5%
6
0
1
11%
16
0.25
0
7%
23
0
2
24%
42
3.75
0
5%
6
0
0
17%
17
0
0
29%
21
0
3
0
25%
32
0
2
0
17%
15
0
7
3
23%
24
43
1
0
7%
10
0
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1
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Amber
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Pseudonyms1
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Deployment Characteristics (N = 17)
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2
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Total Number of
Combat
Non-Combat
Deployment
Deployments2
Deployments3
Deployments4
Load5
Total Months Total Months Non-Combat
Deployed
Deployed
21%
48
18
11%
30
0
6
5
1
Mason
3
3
0
Nolan
3
3
Oscar
1
1
Paul
2
1
Quinton
1
1
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Lee
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Combat
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Pseudonyms1
6%
6
0
0
13%
15
0
1
31%
12
9
0
11%
8
0
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0
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Note. 1Pseudonyms=Assigned fictitious names used to protect participant identity 2 Total Number of Deployments = Combined total of both Combat and Non-combat Deployments 3 Combat Deployments = Number of deployments to an area of conflict (i.e., war zone) 4 Non-Combat Deployments = Number of deployments to location(s) not deemed a war zone or area of support 5 Deployment Load = total number of months deployed/total months in the military
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Table 3 Combat-Related Trauma Exposure Based on the Traumatic Events Questionnaire (TEQ) N = 13*
Witnessed rocket attack or IED
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Combat-Related Traumatic Event
n = 9 (all Army)
Event occurred three or more times
n = 7 (all Army)
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Witnessed mutilation/serious injury/violent death
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Event reported as having occurred at least once
Event reported as having occurred at least once
n = 10 (Army and Navy)
Event occurred three or more times
n = 5 (all Army)
Experienced a life threatening event
n = 10 (Army, Navy, and Marine)
Event occurred three or more times
n = 6 (Army and Marine)
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Event reported as having occurred at least once
Close friend seriously injured or killed
n = 9 (Army and Marine)
Event occurred three or more times
n = 3 (all Army)
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Event reported as having occurred at least once
Note. *13 of the 17 participants reported experiencing at least one combat-related traumatic event. Four individuals (2 Army and 2 Air Force) did not report experiencing any combat-related traumatic events.
ACCEPTED MANUSCRIPT UNDERSTANDING DEPLOYMENT Highlights •
Deployments are rarely, if ever, what a service member expects even if returning to the same place. The first deployment is not always the worst deployment.
•
Paradoxical effects were found for deployment demands (both stress-filled and stress-
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•
less) and deployment resources such as communication with family (both stressful and
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supportive).
Poor leadership may exacerbate the stress of being deployed.
•
Veterans may be changed after deployments in ways that are not always visible.
•
Health care providers may be able to better tailor care by (a) establishing rapport, (b)
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•
asking open-ended questions about deployment experiences, and (c) exploring combat
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EP
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exposures for lingering invisible effects.
S0029-6554(16)30408-0
DOI:
10.1016/j.outlook.2016.12.005
Reference:
YMNO 1202
To appear in:
Nursing Outlook
Received Date: 11 June 2016 Revised Date:
25 November 2016
Accepted Date: 5 December 2016
Please cite this article as: Jennings BM, Melvin LKC, Belew DL, Understanding Deployment from the Perspective of Those Who Have Served, Nursing Outlook (2017), doi: 10.1016/j.outlook.2016.12.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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1
Understanding Deployment from the Perspective of Those Who Have Served Bonnie Mowinski Jennings, PhD, RN, FAANa,* Colonel, US Army (retired)
a
Nell Hodgson Woodruff School of Nursing Emory University 1520 Clifton Road NE, Room 226 Atlanta, GA USA 30322 Email: [email protected] b
c
d
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The Geneva Foundation 917 Pacific Avenue, #600 Tacoma, WA USA 98402 Email: [email protected]
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Center for Nursing Science and Clinical Inquiry Brooke Army Medical Center 3551 Roger Brooke Drive Joint Base San Antonio, TX USA 78234 Email: [email protected]
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Donna L. Belew, MSN, RNc,d
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LTC Kristal C. Melvin, PhD, NP-Cb
*
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Center for Nursing Science and Clinical Inquiry Madigan Army Medical Center 9040 Jackson Avenue Tacoma, WA USA 98431
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Corresponding Author: Bonnie Mowinski Jennings, Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Road NE, Room 226, Atlanta, GA USA 30322, [email protected]
Key Words: military personnel; veterans; deployment; Iraq; Afghanistan; qualitative research method
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2 Abstract
Background: The term deployment is used by the military to describe sending troops to carry out a combat, peacekeeping, or humanitarian mission.
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Purpose: The purpose of this analysis was to illustrate the variations around combat deployment experiences.
Methods: Qualitative descriptive methodology was used to examine data from 17 members of
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the US military who deployed at least once to a combat zone following the September 11, 2001 attacks.
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Results: No two deployments were the same between individuals or within individuals if they deployed more than once. Variations were discovered in deployment experiences related to deployment demands, deployment resources, and coming back changed as individuals. Conclusions: Regarding deployment as a singular concept does not take into account the
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variations in the deployment experience. Individuals caring for those who have served in war
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would benefit from understanding that each deployment is unique and a life altering experience.
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3
Highlights •
Deployments are rarely, if ever, what a service member expects even if returning to the same place. The first deployment is not always the worst deployment.
•
Paradoxical effects were found for deployment demands (both stress-filled and stress-
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•
less) and deployment resources, such as communication with family (both stressful and
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supportive).
Poor leadership may exacerbate the stress of being deployed.
•
Veterans may be changed after deployments in ways that are not always visible.
•
Health care providers may be able to better tailor care by (a) establishing rapport, (b)
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•
asking open-ended questions about deployment experiences, and (c) exploring combat
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EP
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exposures for lingering invisible effects.
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4
Understanding Deployment from the Perspective of Those Who Have Served Deployment, a term used commonly in the military, means “the rotation of forces into and out of . . . geographical areas in which military operations are conducted” (DoD Dictionary,
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2014, p. 72). Although the word deployment suggests sameness, not all deployments are the same. At a macro-level, there are two types of deployments: (a) combat deployments—moving into an area of conflict (i.e., a war zone), and (b) non-combat deployments (e.g., humanitarian or
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peace keeping missions; Department of Defense Dictionary, 2014). Physical and mental health concerns have been associated with a history of combat deployment (Cesur, Sabia, & Tekin,
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2013; Cifu et al., 2013).
When those who have served in the military seek health care, it is important for providers to understand the visible and invisible wounds that may exist after deploying. As noted by Morrison-Beedy (2016, p. 404), “over half of all [US] veterans do not receive health care
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through VA [Veterans Administration] facilities creating a demand . . .” for those caring for military veterans to “be knowledgeable about the needs of our nation’s veterans and military personnel.” The purpose of the analysis reported here is to illustrate variations in the deployment
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experience among those who have served in Operation Enduring Freedom (OEF) and Operation
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Iraq Freedom (OIF).
Background
Since the 1990s, important changes in the US military have altered deployment
experiences. First, the demographics of those serving shifted. The all-volunteer military force (AVMF) includes more service members who are (a) older (DoD, 2014), (b) women (DoD, 2014; Patten & Parker, 2011), and (c) dual military couples (i.e., both spouses serving in the military concurrently (DoD, 2014; IOM, 2010). Second, the military downsized. Today’s
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AVMF, at approximately 1.3 million service members (Kane, 2016) is 35% smaller than during the Cold War (Dorn et al., 2000), and less than half the size of the military at the height of the Vietnam war (Kane, 2016). Third, compared to deployments prior to the AVMF, the frequency
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of combat and noncombat deployments has increased five-fold (Eikenberry, 2013). Fourth, the reduced size of the active duty force and the frequency of deployments contribute to “an
unprecedented use of the reserves and National Guard” (IOM, 2010, p. 51) to supplement active
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duty numbers.
Following the September 11, 2001 attacks on the US, the demands on the US military
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escalated. These demands intensified during the “surges” in Iraq during 2006 (Kane, 2016) and again in 2010 in Afghanistan (Robinson et al., 2014). During each surge, an additional 30,000 service members were deployed to respond to increased insurgent risks (Kane, 2016; Robinson et al., 2014). At the peak of OEF and OIF in 2007, more than 300,000 service members (23% of
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the total US military force) were deployed to Iraq, Afghanistan, support regions such as North Africa, and ships in hostile waters such as the Persian Gulf. Overall, approximately 2.4 million combat deployments have occurred in support of OEF and OIF, with over 30 % of deployed
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service members having more than one deployment (Kane, 2016; Robinson et al., 2014). Typical metrics used to reflect deployment demands include deployment frequency,
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deployment length (Buckman et al., 2011), and time between deployments (i.e., dwell time) (IOM, 2010; MacGregor, Han, Dougherty, & Galarneau, 2012; MacGregor, Helmetes, Clouser, Han & Glarneau, 2014). The DoD goal for dwell time is to have active duty service members spend at least twice as much time at their home duty station as their most recent deployment length (Bonds, Baiocchi, & McDonald, 2010). A less common yet longstanding metric is the concept of deployment load, or the amount of time spent deployed in relation to the amount of
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time in the military (Castro & Adler, 1999). Interviews conducted for an on-going parent study contained detailed information about participants’ deployments, sensitizing investigators to the variations around combat deployment. It became evident that traditional deployment metrics fail
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to reflect the more meaningful features of the deployment experience. Methods The Parent Study
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The data used in this analysis were drawn from the parent study designed to explore military couples’ reintegration after combat deployment. The parent study, as well as the
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analysis reported here, was approved by appropriate institutional review boards. Recruitment for the parent study began in 2013; it is open and ongoing. As of November 2016, 151 military couples (302 individuals) have participated.
Participants were initially recruited from military installations in the Northwestern US,
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followed by social media and snowball recruitment to reach current and former military members across the US. Study participants were previously deployed military service members and their spouses who volunteered to complete several on-line questionnaires. Completion of the
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questionnaires served as evidence of consent to participate. In addition, parent study participants were asked to consider volunteering to be interviewed; both members of the couple had to
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volunteer for the interviews to take place. The interview data are being used in the parent study to construct a grounded theory of military couple reintegration following deployment. Recruitment is ongoing for the on-line surveys with recruitment for future interviews to be determined based on evolution of the grounded theory analysis. Of the 21 couples who agreed to be interviewed, 15 couples completed the interviews; the other 6 couples were lost to follow up. Although the preponderance of couples who
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volunteered for interviews were from the Army, all Navy, Air Force, and Marine couples who volunteered were approached about completing interviews. Each interview was about one hour long; all interviews were conducted by the second
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author (Principal Investigator of the parent study) between 2013 and 2016. The interviews were semi-structured with each member of the couple interviewed separately. The interviews were audio-recorded and transcribed professionally with pseudonyms assigned in lieu of actual
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participant names. Transcripts were reviewed for accuracy. Procedures
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Although the interview questions in the parent study were not designed to explore participant’s experiences during deployment, and the convenience sample of interviewees creates methodological limitations, abundant information about deployment was volunteered by the informants. The inclusion criteria for this secondary analysis were those individuals from the
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parent study who had deployed in support of OEF/OIF and completed both interviews and surveys. As this analysis proceeded and subsequent to the interviews, clarifying questions were developed by the research team and posed to the participants to ensure the understanding of their
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deployment experiences was as complete as possible. All but one participant readily responded to the request for further information, with many individuals providing detailed responses.
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In addition to the interview data, four questions from one of the surveys, the Traumatic
Events Questionnaire (TEQ; Vrana & Lauderbach, 1994), were useful in providing insights about combat-related traumatic events experienced by the informants. The TEQ is a self-report of previous trauma exposure (e.g., accidents, witnessing serious injury), and the severity or intensity of the trauma, at the time the event occurred and the time the survey was completed.
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Because this was a secondary data analysis, qualitative description (Neergaard, Olesen, Andersen, & Sondergaard, 2009; Sandelowski, 2000, 2010; Willis, Sullivan-Bolyai, Knafl, & Cohen, 2016) was the most suitable methodology for examining the deployment experiences.
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Unlike other qualitative methodologies, data are less transformed in qualitative description, yielding an interpretive rendering that is less complex than the highly interpretive results from a phenomenological approach or the construction of a grounded theory (Sandelowski, 2000, 2010).
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Data Analysis
Statements about deployment experiences were extracted from the interview data by the
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first author and verified by the second and third authors. The data were analyzed using conventional content analysis (Hsieh & Shannon, 2005). The first author devised an inductively derived coding structure from the data. The coding structure was then used independently by the other authors to open-code the extracted data as a preliminary step to organize the data according
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to major concepts. Differences of opinion were reconciled by discussing the various interpretations until agreement was reached. The concepts were arranged into matrices to examine patterns within and across cases based on consideration of branch of service and
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deployment characteristics. As the analysis proceeded, it was evident that models of military occupational stress (Adler & Castro, 2013; Harmon, Hoyt, Jones, Etherage, & Okiishi, 2012)
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offered an organizing structure for the themes. Because numbers are useful to “generate meaning from qualitative studies”
(Sandelowski, 2001, p. 231), the four TEQ questions were used in this analysis to count how many respondents reported the stated event and how many times the respondents reported the stated event. Lingering effects of combat-related trauma were also assessed by examining the severity reported for each of the four questions (scale of 1, low to 7, high) “then” (at the time
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they occurred) and “now” (how the same events were scored at the time the survey was completed). The focus was less on the actual score and more on the extent to which the event was still regarded as traumatic.
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Rigor was maintained by writing analytic and reflexive memos, documenting decisions to create an audit trail, achieving a thorough understanding of the data, and returning to the data to verify interpretations and seek contrary cases (Maxwell, 2013). Although respondent validation
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has limitations, another step toward maintaining rigor involved sending a summary of the
findings both to the 17 study participants and to 3 military members who had deployed but who
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did not participate in the study (i.e., non-participants). The 3 non-participants were asked (a) whether the summary resonated with their deployment experiences and (b) to send the summary to other individuals who had deployed for their review. This yielded feedback from a total of 13 non-participants representing all branches of the military (Army n = 3, Navy n = 2, Air Force n =
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3, Marines n = 5). Of the 17 study participants, 7 responded to the summary. Four of the seven fully endorsed the summary. All non-participants responded to the summary. Ten of the 13 nonparticipants fully endorsed the summary, indicating the deployment experience was portrayed
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accurately. Only findings about leadership were not validated by six individuals (three participants and three non-participants). These six individuals indicated that although their
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personal experiences with leadership were not reflected in the findings, they acknowledged the findings could apply to others. Findings
Participant Characteristics Demographic characteristics are portrayed in Table 1. None of the participants had visible wounds such as amputations or disfigurement. Twelve of the 17 participants had served
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in the Army although perspectives were offered from individuals in all four branches of the US military. The age range of participants was 24-52 years. There were two dual military couples in the sample; one couple was in the Army and the other couple was in the Air Force. Data from
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these couples supported contrasts between the two military services, as well as between deployments for those who were dual military and non-dual military. Deployment Characteristics
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Deployments varied in length ranging from 1 to 17 months. Shorter and more frequent deployments were more common for Army personnel in Special Forces and Navy personnel
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assigned to submarines. Other characteristics of combat deployments are shown in Table 2. Deployment load (total months deployed/total months in the military) was highest among Army Soldiers (2 enlisted and 2 officers), with 11 participants (65% of sample) reporting a deployment load of more than 10%. Other patterns were not readily apparent in the deployment data
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indicating the lack of sameness and typicality among deployments. For instance, there was no discernible pattern in the number of combat deployments by the branch of service—four Army Soldiers had deployed once just like the two Air Force service members. Dwell time (the length
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of time between deployments) for those with more than one deployment (n = 11) ranged from 1 month to 101 months. Although all participants deployed between the years 2002 and 2014 in
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support of OEF/OIF, three participants also had prior deployment experiences (1991-1997). Their perspectives offered useful contrasts as did the perspectives of the five individuals who had non-combat deployment experiences between1991 and 2015. Thematic Discoveries Reflecting Military Occupational Stress Each deployment was filled with uncertainty yielding circumstances that could be better or worse than expected. Some individuals deployed to combat zones where there “wasn’t any
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combat.” Some individuals deployed to combat zones where “the actual fight is.” Even when service members returned to the same deployment location and did work similar to previous deployments, “you’re with a different group of people . . . you’ll have different commanders who
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want things done differently.” A participant who deployed twice to Iraq expressed these
differences by noting that although the first tour was “tough” due to uncertainty about what the war would be like, the second tour was “much worse” and “more traumatic.” The overarching
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idea from this study was expressed by a participant with the experience of 5 deployments who noted, “none of them [deployments] are the same.” Variations in deployment experiences were
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further informed by the three themes discovered in the interview data: deployment demands, deployment resources, and coming back changed.
Deployment demands. Combat deployments were regarded as more stressful than noncombat deployments. Non-combat deployments involved 8 hour work days on bases with more
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options for recreation, shopping, and exploring the country without people “shooting at you.” By contrast, combat deployments involved 12-18 hour work days, often 7 days/week on bases located in austere surroundings where individual movement on and off base was restricted.
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Not all combat deployments, however, were the same. Differences were evident based on service affiliation as well as within the same service. Army and Marine participants were on
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the ground outside the wire (off the military base and into enemy territory), affording them a different experience than Navy personnel who were nearby yet at sea, and Air Force personnel who were in Afghanistan yet not directly involved with counter-insurgency operations. Within the same service, deployments differed over time, often based on the location of the deployment, or the amount of combat exposure. A Soldier who deployed twice to Iraq and then to Afghanistan noted that Afghanistan “brought the war home to me”; it brought the “ugly” and
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“twisted” aspects of war to life. Alternately, a Soldier who deployed to Afghanistan at a different point in time was located in an area with little fighting and action. In this case though, bad news penetrated the Soldier’s reasonably stable and safe place when “A [prior] Soldier of
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mine who was in a completely different region [in Afghanistan] . . . ended up getting killed. . . . That was a rough experience.”
For the five individuals who deployed to both Iraq and Afghanistan, movement on and
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off base was more restricted in Afghanistan compared with Iraq. Navy personnel also
experienced restricted movement, yet it was related to the type of vessel on which they served—
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submarines or aircraft carriers. Submarine deployments involved the monotony of “being underwater.” Day and night were the same. The days of the week were blurred. Telling time was based on “what they’re serving for chow.” Navy deployments on aircraft carriers, by contrast, were less stressful and movement was less restricted than deployments on submarines.
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Although the Air Force participants also deployed to Afghanistan, their experiences were inside the wire (within the confines of a US military base). They represent a contrary case because they were a dual military couple who (a) volunteered to deploy, and (b) deployed almost
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simultaneously to the same place. According to the male member of the couple, they experienced a “busy battle rhythm,” yet their accounts did not reveal the same kinds of stressors
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and demands expressed by other participants. Moreover, the synchronous deployment of the Air Force dual military couple contrasted sharply with the asynchronous deployments of the Army dual military couple whose relationship was like a revolving door with one deploying as the other one returned, yielding considerable time apart. There was infrequent mention of deployment length as a stressor, although an Army respondent indicated that 9-month deployments were “definitely doable;” and longer
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deployments were harder. What mattered more than the deployment length was what one participant described as getting “shanghaied” mid-tour with an extension, turning a 12-month deployment into 15 months.
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Deployment demands were also reflected in the combat-related trauma exposure as
reported from the TEQ questions (Table 3). Of the 17 participants, 4 service members reported no combat-related trauma exposure (2 Army and 2 Air Force). The remaining 13 participants
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reported at least one combat-related trauma exposure. Lower deployment load did not always yield protection from combat-related trauma exposure. Two individuals who reported being
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deployed less than 10% of their military careers reported 5 or more incidents of combat-related trauma exposure.
A paradox was noted in deployment demands: Combat deployments were both stressfilled and stress-less. Although “you’re never safe in a war zone,” there were no “everyday”
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stressors during deployment (e.g., child care, home and automobile repairs, laundry, cooking), allowing service members to immerse themselves in their jobs and remain “focused on the mission.” The potentially opposite effect of deployment stress was further illustrated by the
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counterintuitive differences experienced by an individual who deployed twice to Afghanistan. The first deployment, 12 months in length, involved time outside the wire and witnessing an
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attack that killed 10 Soldiers; the participant helped remove the bodies for helicopter evacuation. Nonetheless, “I came back from the first one okay.” The second deployment was shorter, 4 months in length, and involved a job inside the wire doing “desk work.” Although seemingly safer, the second deployment was “tougher” because of feeling out of touch “with my Soldiers,” indicating the weight of responsibility felt by some individuals in leadership roles.
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Deployment resources. Both personal and occupational resources were mentioned in the interviews. Personal resources, such as coping strategies, were used to make sense of war. One participant reported finding himself in a “weird head space” because “the bad guys are also
emotions at bay: “you’re not murdering them, it’s combat.”
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people.” Comments were offered by an Army enlisted Soldier about reframing actions to keep
All but one individual mentioned the importance of communicating with family as a
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personal resource. Communication technology supported staying in touch via telephone calls, Skype, emails, text messages, blogs, pictures, and videos; letters and care packages remained
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important mainstays.
When someone in a unit was killed or seriously injured, however, communication went on “black out” pending notification of the deceased’s family. Life for submariners was always somewhat blacked out because, as one participant noted, time and relationships “freeze [in the]
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underwater world.” Communication from outside the submarine was either delayed (e.g., emails arriving 3 days later) or severed (e.g., no media or email access). A Sailor with experience on both submarines and aircraft carriers confirmed how much easier it was to communicate on an
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aircraft carrier.
A unique source of personal support was reflected for both Navy and Air Force
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participants. When serving in a combat zone on an aircraft carrier, Navy spouses were allowed to visit at a friendly port part way through the deployment, helping to reduce stress and making deployments easier. Although the Air Force couple was not allowed to cohabit during deployment, they could see each other every day, meet for meals, and share special events. Unlike all other participants, their personal resources were present for them in theatre throughout their deployment.
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Least often mentioned were occupational resources for mitigating stress. Chaplains were identified as an occupational resource, whereas formal leaders (i.e., commanders) were discussed in the positive by only one participant. An enlisted participant who deployed once for 15 months
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noted it was an “awful experience, not because of what I saw” but because of “toxic” leadership; the “chaplain saved me.” An officer participant also vocalized concerns related to poor
leadership and the “good ole boys club,” indicating there was “some very bad behavior on the
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part of some of the more senior folks.” Although one participant was complimentary regarding leadership, “I liked working for the boss that I was working for. . . . That was very rewarding for
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me,” leaders were more often mentioned as a stressor by Army and Marine participants, both officers and enlisted. Leaders were referred to as “negligent,” “ineffective,” and allowing an “abusive culture,” with abuse in both verbal and physical forms. At least three individuals claimed poor leadership was a greater source of trauma than combat. Just as combat-related
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trauma left individuals with lingering memories, the effects of poor leadership also were enduring as individuals who last deployed years ago verbalized vivid recollections of ineffective leaders. Although unexpected, leadership as a stressor during deployment came through in these
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findings.
Like deployment demands, a paradoxical effect also was noted related to deployment
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resources. Both personal and occupational resources could increase rather than mitigate stress. Respondents noted that communication with family could exacerbate stress for the service member who might become upset because of things shared by the non-deployed spouse. Service members also were stressed because they had to filter their communication home, figuring out what not to say, to protect the non-deployed spouse from worrying. A set routine for communication created expectations that could yield stress for the service member and the
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spouse when mission requirements interfered with established times for exchanges. Time zone issues were at play, and the onus for synchronous communication was on the person in theatre because they had to initiate this exchange. Although deployed individuals were supported by
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communication with family, deployed individuals also were supporting their families—and that was sometimes a source of stress. An Army respondent noted that the least stressful of eight deployments was the one when communication to the US was absent. A shared refrain was that
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less communication with home diminished stress because it allowed people to focus fully on the mission. By contrast, an Army participant who had deployed prior to the wars in Iraq and
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Afghanistan noted less stress related to communication in OEF/OIF because new technology made it easier to communicate than in the past.
Coming back changed. A recurrent outcome expressed by officers and enlisted personnel across all services was that people came back changed from deployment. Thirteen of
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the 17 respondents explicitly acknowledged coming back changed with 7 participants indicating that although they were different, they were “ok.” The other six participants were being treated with medications and outpatient counseling; two had received inpatient care. Of the six
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individuals who were not “ok,” three were still on active duty. Symptoms, negative emotions, and aggression were changes explicitly noted by nine
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participants. These included hypervigilance, being “jumpy” in response to noises such as cars backfiring, being in a “dark place,” and struggling with “mood swings.” Five participants compared their mild-manneredness before deploying with their predilection to be “hot temper[ed]” after deploying. Words about anger were common and offered with forceful intonation; less common but related were statements about feeling “rage.” Contradictions were
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found in statements by two Army enlisted Soldiers who expressed a great deal of anger and also said they were “numb” and “emotionally dead.” Lingering effects of combat-related trauma were determined by comparing TEQ self-
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reports of the severity of the traumatic event at the time it occurred with the severity of the event when the survey was completed. Three of the 17 participants reported events that were not at all severe at the time of the occurrences; these had no lingering effects. By contrast, 7 of the 17
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participants reflected at least one event remained traumatic for them to some degree even now. One of these 7 individuals rated two events at the highest level of severity despite 52 months
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elapsing between the events and completing the questionnaire.
Participants also reflected changes in their perspectives about ordinary things. These included their desire to socialize. Following deployment, individuals sought quiet time alone or avoided crowds such as movies, large parties, and sometimes being in public in any form.
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Participants also noted their gratitude for previously taken for granted and simple things. “Clean bathrooms,” for instance, were now regarded as “living in luxury.” Discussion
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Most investigators who study military deployments use large data sets and large cohorts with a focus on statistical analyses. Such work is important, yet it does not reveal some critical
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issues that are discoverable in interview data and a more in-depth analysis. By exploring variations in deployment experiences as described by those who have deployed in support of OEF/OIF, this analysis advances knowledge in an understudied area. Compared to existing literature, these findings begin to show that variations in deployments are less about the branch of the military, the frequency, length, or whether it is a service member’s first deployment. Rather, each deployment experience is unique; no two deployments are the same. Unanticipated
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findings included the paradoxical effects of deployment demands (both stress-filled and stressless) and deployment resources (personal and occupational as both reducing and exacerbating stress). To our knowledge, issues about the potentially opposite effects of demands and
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resources have not been reported except by Durham (2015) who found communication between deployed service members and their families as being both supportive and stressful.
This analysis offers support for the recommendation that unexpected extensions in
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deployments are best avoided (Buckman et al., 2011) and that while deployed, time may be frozen or at least lagging in regard to the media, entertainment, and even keeping up with family
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and friends (Wands, 2013). These findings differ from some of the existing reports concerning deployment length (Adler, Huffman, Bliese, & Castro, 2005; Buckman et al., 2011), the stressful nature of the first deployment compared to subsequent deployments (Hoge, Auchterlonie, & Milliken, 2006), and that deployments to OIF locations were more stressful than deployments to
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OEF locations (Hoge et al., 2006). Based on the analysis reported here: (a) shorter deployments were sometimes more stressful than longer deployments, (b) subsequent deployments were often more stressful than first deployments, and (c) deploying to Afghanistan was more stressful than
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deploying to Iraq, although the dates of the deployment and the nature of the work increased or decreased the stress. These findings also offer new perspectives about “no one get[ting] through
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it ok” (Wands, 2013, p. 197). Studying individuals who return from war changed but ok could offer important insights that might help those who return with problems. Models of military occupation stress (Adler & Castro, 2013; Harmon et al., 2012) include
demands, resources (personal and occupations), and outcomes, all of which apply to the work required of military service members. Deployment creates a context in which occupational demands are heightened. Combat-related exposure to traumatic events is a demand that was
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confirmed in these findings. Heightened demands on deployed individuals make resources that might moderate the stress all the more important. Yet the paradoxical effects found in this analysis call into question the strength of these moderating effects. A personal resource,
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communication with family, was sometimes stressful as well as supportive. Likewise an
occupational resource, leadership, often was perceived as ineffective and rarely mentioned as supportive. Leadership ineffectiveness was identified in prior research as well (Harmon et al.,
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2013) and thus lends credibility to these findings despite the lack of endorsement from some individuals who reviewed the summary of the findings. Findings about resources that help to
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mitigate stress during deployment may assist military leaders and planners to capitalize on available resources for service members. Future research is needed that focuses on the specific leadership behaviors that help to mitigate, rather than elevate, stress during deployment. Providers who are aware of the military occupational stressors of deployment, and that
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each deployment has the potential to be completely different, will be better able to help service members and their families adapt following deployment. For instance, sharing knowledge about challenges and stressors during deployment from unexpected sources, such as leadership could
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help manage expectations after deployment.
A limitation of this analysis is the use of data from a parent study that was designed for
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another purpose. Seventy-one percent of the sample was Army personnel thereby confining the perspectives and reducing informational redundancy across all services. Moreover, the interviews were not designed for the purpose of exploring deployments per se. Despite these shortcomings, the existing interviews afforded the investigators access to information-rich data that fostered a beginning understanding of the variability across deployments. The veracity of the findings from this secondary analysis is enhanced, however, because of the 13 non-
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participant respondents who represented all branches of the military and largely endorsed a summary of the findings. Some comments, such as those about the opposite effects of deployment and thoughts about leaders, would have benefitted from additional questions and
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probes. Future studies also could be designed with the explicit purpose of interviewing people about their deployment experience using a purposeful sampling strategy guided by findings from this analysis.
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Despite the limitations, these findings have implications for helping health care personnel who care for veterans with combat experience. They also offer insights that are useful to the
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American Academy of Nursing’s “Have You Ever Served in the Military?” campaign (Collins, Wilmoth, & Schwartz, 2013). An affirmative response to “have you ever served in the military?” requires follow up questions about whether individuals have deployed and if yes, further inquiry to understand their deployment experience, and the potential for hidden or
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invisible combat-related injuries. Although the visible wounds of war gain attention (e.g., amputations, disfigurement), they affect fewer than 1,700 service members (.06% of those deployed to combat; Fischer, 2015). By contrast, hidden or invisible injuries (e.g., post-
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traumatic stress disorder, chronic pain, binge drinking, sleep problems) have affected over 100,000 service members (Crum-Cianflone, Powell, LeardMann, Russell, & Boyko, 2016;
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Fischer, 2015; Lew et al., 2009; Pugh et al., 2014). The prevalence of invisible injury diagnoses after combat deployment is estimated to be 12-29% (Cesur, Sabia & Tekin, 2013; Cifu et al., 2013; Hoge et al., 2006).
Wartime experience, however, is often a private experience that people safeguard.
Health care providers must therefore realize the importance of establishing rapport with veterans who have served in combat, showing an interest in them and being attentive to all verbal and
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nonverbal responses. A solid rapport may lay the foundation for combat veterans to disclose answers to open-ended questions about their deployment experiences, and uncovering previously unmentioned sources of deployment stress. A starting point to identify some of the invisible
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effects of war could be to explore the nature of combat-related trauma using questions similar to those in the TEQ, including the service member’s sense of the severity of the event (e.g., very severe, not very severe). Asking about symptoms or behavioral changes also may help health
treatment plans.
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Conclusions
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care providers understand the nature of the effects of deployment and assist them in tailoring
Understanding the variations around deployment experiences is important when caring for individuals who have served in the military. Regarding deployment as a singular concept does not take into account the level of danger at the deployment location, the trauma exposure
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during deployment, or other factors that could alter deployment experiences. The findings from this analysis show that the experience known as deployment varies vastly among those who have served. More person-centered care may be rendered through seeking to understand an
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individual’s military deployment experience. Knowing that deployment experiences are deeply
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personal, gaining insights about that experience requires finesse and skill.
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Acknowledgements The authors express gratitude to five doctorally prepared colleagues, two who have military experience, for commenting on earlier drafts of this manuscript. Dr. Judith Baggs was
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particularly supportive and helpful in offering guidance throughout the preparation of this manuscript
Funding: The parent study is supported by the TriService Nursing Research Program in
N12-P07, Grant number HT9404-12-1-TS10).
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sponsorship with the Uniformed Services University of the Health Sciences (Project number
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Disclaimer: The information, content or conclusions in this article do not necessarily represent the official position or policy of, nor should any official endorsement be inferred by the TriService Nursing Research Program, the Uniformed Services University of the Health
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Sciences, the Department of the Army, or the Department of Defense or the US Government.
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Table 1 Participant Demographic Characteristics
Gender Male
15 (88%) 2 (12%)
Military Status Active Duty
13 (76%)
2 (12%)
Separated from Militarya
2 (12%)
Navy
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Air Force
12 (71%)
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Army
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Retired
Branch of Service
Marines Age
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Female
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(N = 17)
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Characteristics
2 (12%)
2 (12%) 1 (5%)
24-34
11 (65%)
35-45
3 (17.5%)
46-52
3 (17.5%)
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Enlisted
8 (47%)
Officerb
9 (53%)
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Note. aSeparated from Military: Left military before retirement eligible bOfficer: Includes both warrant officers (n = 1) and commissioned officers (n = 8)
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Rank
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Table 2
Total Number of
Combat
Non-Combat
Deployment
Deployments2
Deployments3
Deployments4
Load5
1
Beth
3
2
Chris
2
2
Dale
10
8
Eli
1
1
Frank
3
3
Gary
2
Harold
3
Ian
2
Jessie
10
Kevin
1
Total Months Total Months Combat
Non-Combat
Deployed
Deployed
0
5%
6
0
1
11%
16
0.25
0
7%
23
0
2
24%
42
3.75
0
5%
6
0
0
17%
17
0
0
29%
21
0
3
0
25%
32
0
2
0
17%
15
0
7
3
23%
24
43
1
0
7%
10
0
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1
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Amber
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Pseudonyms1
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Deployment Characteristics (N = 17)
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Total Number of
Combat
Non-Combat
Deployment
Deployments2
Deployments3
Deployments4
Load5
Total Months Total Months Non-Combat
Deployed
Deployed
21%
48
18
11%
30
0
6
5
1
Mason
3
3
0
Nolan
3
3
Oscar
1
1
Paul
2
1
Quinton
1
1
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Lee
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Combat
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Pseudonyms1
6%
6
0
0
13%
15
0
1
31%
12
9
0
11%
8
0
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0
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Note. 1Pseudonyms=Assigned fictitious names used to protect participant identity 2 Total Number of Deployments = Combined total of both Combat and Non-combat Deployments 3 Combat Deployments = Number of deployments to an area of conflict (i.e., war zone) 4 Non-Combat Deployments = Number of deployments to location(s) not deemed a war zone or area of support 5 Deployment Load = total number of months deployed/total months in the military
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Table 3 Combat-Related Trauma Exposure Based on the Traumatic Events Questionnaire (TEQ) N = 13*
Witnessed rocket attack or IED
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Combat-Related Traumatic Event
n = 9 (all Army)
Event occurred three or more times
n = 7 (all Army)
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Witnessed mutilation/serious injury/violent death
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Event reported as having occurred at least once
Event reported as having occurred at least once
n = 10 (Army and Navy)
Event occurred three or more times
n = 5 (all Army)
Experienced a life threatening event
n = 10 (Army, Navy, and Marine)
Event occurred three or more times
n = 6 (Army and Marine)
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Event reported as having occurred at least once
Close friend seriously injured or killed
n = 9 (Army and Marine)
Event occurred three or more times
n = 3 (all Army)
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Event reported as having occurred at least once
Note. *13 of the 17 participants reported experiencing at least one combat-related traumatic event. Four individuals (2 Army and 2 Air Force) did not report experiencing any combat-related traumatic events.
ACCEPTED MANUSCRIPT UNDERSTANDING DEPLOYMENT Highlights •
Deployments are rarely, if ever, what a service member expects even if returning to the same place. The first deployment is not always the worst deployment.
•
Paradoxical effects were found for deployment demands (both stress-filled and stress-
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•
less) and deployment resources such as communication with family (both stressful and
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supportive).
Poor leadership may exacerbate the stress of being deployed.
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Veterans may be changed after deployments in ways that are not always visible.
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Health care providers may be able to better tailor care by (a) establishing rapport, (b)
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asking open-ended questions about deployment experiences, and (c) exploring combat
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exposures for lingering invisible effects.