A concept analysis of nurses in conflicts after World War II. — TEI-tagged view

Anne M. FinkpersName, Gwyneth R. MilbrathpersName (2022date). “A concept analysis of nurses in conflicts after World War II..” Journal of Advanced Nursingtitle·j.

Object of study — nursesterm·key' experiences during military conflicts since World Warterm·key II

Research question — what the antecedents, attributes and consequences of nursesterm·key' war-related experiences are

Contribution — a definition of nursesterm·key' war-related experiences to inform future research, interventions and policies

Full text — tagged

A concept analysisterm·key of nursesterm·key in conflicts after World Warterm·key II.

Abstract We analysed nursesterm·key' experiences during military conflicts since World Warterm·key II.

Nursesterm·key have successfully reduced morbidity and mortality in populations affected by warsterm·dom; despite centuries of nursesterm·key' global involvement in warsterm·dom, there is limited knowledge about their experiences.

We used Rodger's evolutionary concept analysisterm·key methodology to understand the antecedents, attributes, consequences, context and implications of nursesterm·key' warterm·key‐related experiences. We analysed data from quantitative and qualitative research, media reports, editorials, historical reviews and published accounts of nursesterm·key' experiences in many locations, including Afghanistan, Bosnia, Croatia, Korea, Kosovo, Iran, Iraq, Israel, Palestine, Russia, Somalia, Ukraine and Vietnam.

Two antecedent conditions preceded nursesterm·key' warterm·key involvement: actively responding to human suffering and having resources for readiness . Nursesterm·key were defined by five attributes: sacrifice , resourcefulnessterm·key , tunnel‐visionterm·dom , survival mindsetterm·key and comraderyterm·dom . We also found evidence for seven consequences; nursesterm·key saved lives ( reduced morbidity and mortality ), however, some nursesterm·key faced professional burnoutterm·dom/disillusionment , restricted practice authority , isolation and post‐traumatic stressterm·key after warterm·key. In addition, growth and pacifismterm·key were consequences for some nursesterm·key who were exposed to warterm·key.

The findings of our concept analysisterm·key illustrate how nursesterm·key have fulfilled critical life‐saving roles, but some nursesterm·key' post‐warterm·key experiences were debilitating, stigmatized and unsupported. We conclude that research about the resourcefulnessterm·key, innovations and resiliency nursesterm·key have developed during warsterm·dom is essential, and professional support mechanisms must be developed to prevent post‐traumatic stressterm·key, burnoutterm·dom and attrition from the profession. Governments can use utilize the knowledge nursesterm·key developed during warsterm·dom to expand emergency preparedness skillsets and promote nursesterm·key as the leaders of international efforts to promote peace.

Patients, service users, caregivers and members of the public were not involved in conducting this concept analysisterm·key or preparing the manuscript.

By understanding nursesterm·key' involvement with post‐WWII conflicts, we have demonstrated the significant public health contributions, challenges and personal and professional growth experienced by nursesterm·key.

Nursesterm·key' warterm·key‐related knowledge should be utilized to innovate healthcare practices during disasters and to advise policymakers in developing, implementing and evaluating peace‐promoting operations.

Keywords: concept analysisterm·key, deployment, emergency nursing, military, nursesterm·key' roles, peace, post‐traumatic stressterm·key, warterm·key INTRODUCTION Warsterm·dom—armed conflicts among governments or paramilitary groups—cause tremendous suffering, death and destruction. Warterm·key was defined by Griffiths and Jasper ( 2008 ) as the “antithesis of health,” physically, psychologically and economically. Nursesterm·key have cared for warterm·key‐afflicted populations by providing emergency care, supporting humanitarian missions and implementing measures to prevent infectious and food/water‐borne illnesses (Keeling & Wall, 2015 ). The boundaries of nursing knowledge, practice and authority have been pushed forward by the challenges that are inherent in warsterm·dom and disasters (MilbrathpersName, 2019 ). Warsterm·dom have also shaped the nursing profession's norms, achievements, and histories, over centuries, and around the world (MilbrathpersName, 2019 ). Despite nursesterm·key' impactful efforts in supporting the health of civilians and combatants, most research endeavours about warsterm·dom have overlooked nursesterm·key' experiences.

World Warterm·key II (WWII) represents a pivotal event in the history of nursing. The utilization of antibiotics, surgical asepsis and blood banking profoundly advanced nursing practice during this era (MilbrathpersName, 2019 ). Nursing degree programmes were established in universities around the world after WWII (Hazrati et al., 2011 ). Nursesterm·key' professional opportunities in the armed forces also expanded after WWII, particularly in the United States (U.S.) and United Kingdom (U.K.). Notably, a more diverse workforce was employed, and nursesterm·key could join the armed forces and receive military ranks, benefits, promotions and training (MilbrathpersName, 2019 ). Before WWII, for example, American nursesterm·key were contractors employed by the military to care for wounded and ill soldiers. When the U.S. Army and Navy Nurseterm·key Corps were established at the turn of the 20th century, the Nurseterm·key Corps remained siloed from the rest of the medical department, which withheld military training from nursesterm·key. The nurseterm·key was only provided with relative military ranks and limited opportunities for advancement. Significantly, only white women were permitted to join the Nurseterm·key Corps before and during WWII—men and women of colour were barred from serving, with rare exceptions (MilbrathpersName, 2019 ). Considering how the nursing workforce changed, and nursesterm·key became more autonomous and educated after WWII, the purpose of the present paper was to analyse nursesterm·key' warterm·key‐related experiences only during the post‐WWII era.

METHODS Design and data collection Concept analysesterm, according to Rodgers ( 2000 ), are inductive knowledge‐building exercises that must be performed before researchers can develop hypotheses, measures or interventions for future studies. Rodger's concept analysisterm·key methodology provides a systematic approach for defining a concept and its contextual factors. Rodgers encouraged investigators to analyse data from many different types of source material (e.g., research, news, literature or art), and she recommended obtaining at least 30 records to conduct a valid assessment. Consistent with these instructions, we designed a search strategy that would provide us with a combination of scientific literature, personal accounts and media reports. We conducted the literature search in April 2022. We used a purposive sampling method, similar to Ames et al. ( 2019 ), to collect a variety of articles about nursesterm·key' warterm·key‐related experiences that would reflect data from different perspectives, locations, nationalities and post‐WWII time periods. As shown in Figure 1 , we used the terms “nursesterm·key and warterm·key” to search multiple databases: the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE (via PubMed) and PsycINFO. We also entered “nursesterm·key and warterm·key” into Google where we selected eight news articles, two letters, one newsletter and one research paper. Using these databases, we selected 50 articles that reflected nursesterm·key' experiences with warsterm·dom and conflicts, globally. To be included in the analysis, papers were required to report the experiences of nursesterm·key who were deployed or living in areas impacted by warterm·key. We included papers about Military Operations Other Than Warterm·dom (MOOTWterm·dom), defined as humanitarian missions and military activities designed to deter impending warsterm·dom, as long as the nursesterm·key were engaged with frequent mass casualty events in regions experiencing sustained violence (e.g., Operation Restore Hope in Somalia). We excluded depictions of nursesterm·key from fictional literature or from sources designed for entertainment (e.g., M*A*S*H , China Beach ) because fictional characters may not reflect nursesterm·key' factual experiences and characteristics. In the present paper, we use the terms “warterm·key” and “conflict” interchangeably.

Literature search strategy.

Data analysis To analyse the articles, we read each paper twice while compiling a list of the common themes. After this reading phase, the themes were categorized as antecedents (pre‐existing conditions), attributes (clusters of conceptual definitions), or consequences (outcomes), which collectively described nursesterm·key' experiences with warterm·key (Table 2 ). We adhered to Rodgers' ( 2000 ) definition of concepts—she argued that concepts “are formed by the identification of characteristics common to a phenomenon” (p. 78).

Concept analysisterm·key results by article Rodgers also emphasized the importance of considering a concept's “contextual basisterm.” The contextual basisterm refers to the “temporal” and “sociocultural variations” of concepts (p. 85). Temporal variations consider the impact of time (referring to the conceptual antecedents and consequences) but also illustrate Rodgers' view that conceptual definitions often evolve over time (p. 85). Sociocultural variations explain how cultures, religions and nationalities may influence the definitions of a concept in different situations. To address these aspects of Rodgers' methodology, we reported the characteristics of nursesterm·key in each study (Table 1 ), such as their locations, nationalities, religions, genders, employment and education (when these data were available); this information was evaluated to determine whether the times, locations or nursesterm·key' characteristics altered any conceptual attributes.

Summary of articles used for the concept analysisterm·key RESULTS Our analysis included information about conflicts in the following locations and times: Korea (1950–1953), Vietnam (1955–1975), Somalia (1992–1993), the Balkan Peninsula (conflicts in Bosnia, Croatia and Kosovo; 1992–1999), the Middle East (conflicts in Afghanistan, Iran, Iraq, Israel, Kuwait and Palestine; since 1990) and Ukraine (2022). Our sources included journalists' reports/interviews (Crawford, 2022 ; DiFilippo, 2017 ; Johnson, 2022 ; Rosenwald, 2021 ; Si‐young, 2020 ; van Ingen, 2009 ; Weedall, 2017 ), nursesterm·key' personal perspectives (Bille, 1993 ; Collins, 2008 ; White, 2009 ), newsletters (Lancaster & Williams, 2010 ), commentaries (Moore, 2005 ), and review papers (Blaz et al., 2013 ; Ma et al., 2021 ; Wild, 2003 ; Yoder & Brunken, 2003 ). Most of the papers presented the results of original research studies (Agazio, 2010 ; Ben‐Ezra et al., 2013 ; Berger & Gelkopf, 2011 ; Conlon et al., 2019 ; Doherty et al., 2020 ; Doherty & Scannell‐Desch, 2015 ; Elliott, 2015 ; Firouzkouhi et al., 2013 ; Griffiths & Jasper, 2008 ; Lev‐Wiesel et al., 2009 ; Rahimaghaee et al., 2016 ; Ravella, 1995 ; Scannell‐Desch, 1996 ; Scannell‐Desch, 2000 ; Scannell‐Desch & Doherty, 2013 ; Shamia et al., 2015 ). Several papers focused on the training for military nursesterm·key (Agazio, 2010 ; Blaz et al., 2013 ; Byers, 2010 ; Lewis et al., 2016 ; Peterson et al., 2008 ; Rivers et al., 2006 ; Yoder & Brunken, 2003 ). Not all of the nursesterm·key who authored papers were affiliated with militaries or chose to support warterm·key, which gave our analysis a range of perspectives—several nursesterm·key published anti‐warterm·key arguments (Boyle & Bunting, 1998 ; Crowe & Hardill, 1991 ; Ford, 2022 ; Gorman, 2004 ; Livingston & Rankin, 1986 ; Tschudin & Schmitz, 2003 ).

Antecedents Actively responding to human suffering Unlike natural disasters, humans create and perpetuate warsterm·dom, causing profound human suffering. Warsterm·dom forced people into austere environments with limited access to clean water, food, electricity, medicine, safety and shelter. Nursesterm·key responded by caring for civilians and combatants who suffered from traumatic injuries, illnesses, dehydration, starvation, psychological distress and the chronic effects of extreme poverty (Agazio, 2010 ; Boyle & Bunting, 1998 ; DiFilippo, 2017 ; Kenward & Kenward, 2015 ; West & Clark, 1995 ; Yoder & Brunken, 2003 ). In some cases, nursesterm·key volunteered to travel to countries experiencing invasions and warterm·key, such as Ukraine, Vietnam and Korea (Johnson, 2022 ; Scannell‐Desch, 1996 ; Si‐young, 2020 ). Nursesterm·key deployed from Europe (Finnegan et al., 2016 ; Griffiths & Jasper, 2008 ; Kenward & Kenward, 2015 ; Ma et al., 2021 ; Si‐young, 2020 ; Wild, 2003 ), Australia (Conlon et al., 2019 ) and North America (Table 1 ), and nursesterm·key also described the suffering caused by attacks on their own hometowns in Iran (Firouzkouhi et al., 2013 ; Ma et al., 2021 ; Rahimaghaee et al., 2016 ), Israel (Ben‐Ezra et al., 2013 ; Berger & Gelkopf, 2011 ; Lev‐Wiesel et al., 2009 ), and Palestine (Shamia et al., 2015 ).

An Iranian nurseterm·key said “I was always present on the front, and voluntarily so, because I felt the urge to help. The only reason for my presence there and for tolerating the extreme warterm·key conditions was love… there were people who didn't have to be there, who could have simply stayed in their own cities, but they were there serving anyways” (Rahimaghaee et al., 2016 ). Another nurseterm·key who joined the U.S. military described being inspired by a compassionate surgeon's character on the popular American television show M*A*S*H , which led him to value “talented healthcare providers” who could “save” people (Collins, 2008 ).

Resources/Readiness There were no reported cases of nursesterm·key working alone; they were always a part of teams supported by existing institutions (e.g., hospitals and military units). Nursesterm·key who were educated, trained and licensed to work in nursing were available and ready to support healthcare/humanitarian missions. Nursesterm·key who were military officers often had advanced practice degrees (Table 1 ), and they could lead interdisciplinary teams, practice autonomously and accept a high degree of responsibility (Blaz et al., 2013 ; Collins, 2008 ; Griffiths & Jasper, 2008 ; Lewis et al., 2016 ).

Attributes Sacrifice Nursesterm·key made sacrifices in their roles to protect patients. They expected themselves to be prepared for “self‐sacrifice and selfless service” (Yoder & Brunken, 2003 ), and they described being proud of their commitment and patriotism (Agazio, 2010 ; Firouzkouhi et al., 2013 ; Kenward & Kenward, 2015 ; Scannell‐Desch, 1996 ; West & Clark, 1995 ). An Iranian nurseterm·key explained “under the influence of the soldiers' self‐sacrifice, I was also sacrificing myself. This spirit seemed to dominate everyone everywhere at that time” (Rahimaghaee et al., 2016 ).

Nursesterm·key faced uncertainty and danger as they worked long, unpredictable schedules. One described ‘living in a twilight zone” because they were “permanently on‐call” (Kenward & Kenward, 2015 ). When patients required urgent surgeries and transfusions, nursesterm·key who had the same blood types quickly donated their blood (Agazio, 2010 ; Kenward & Kenward, 2015 ; Weedall, 2017 ). White ( 2009 ) described how nursesterm·key used their bodies to shield patients when mortars exploded in the emergency department of Ibn Sina Hospital in Baghdad. They continued working while facing risks within medical facilities, such as frequent bombings (Crawford, 2022 ;Kenward & Kenward, 2015 ; Rahimaghaee et al., 2016 ) or when they were attacked by patients (Agazio, 2010 ). A nurseterm·key in Iran said “we were giving our own lives for the job. Amid the fire of the mortars, we carried the wounded to be treated; you could say the atmosphere itself was encouraging us” (Rahimaghaee et al., 2016 ). You might be “making the ultimate sacrifice, your life,” explained an American nurseterm·key who had worked in Vietnam (Scannell‐Desch, 1996 ). American and U.K. nursesterm·key also described sacrificing time with their families when they deployed because they left their spouses and young children at home (Finnegan et al., 2016 ; Scannell‐Desch & Doherty, 2013 ).

Resourcefulnessterm·key Supplies were limited, and nursesterm·key relied on their abilities to devise creative approaches to fulfil their caregiving roles (Conlon et al., 2019 ; Lancaster & Williams, 2010 ; Scannell‐Desch, 1996 ; West & Clark, 1995 ). The “harsh conditions encouraged innovations” (Rahimaghaee et al., 2016 ). Nursesterm·key described “improvising” (Kenward & Kenward, 2015 ; Si‐young, 2020 ), having to “figure out how to fix stuff” (Agazio, 2010 ), being “extremely adaptable” to “think out of the box” (Yoder & Brunken, 2003 ), and becoming “multi‐skilled” (Griffiths & Jasper, 2008 ) and “self‐reliant” (Kenward & Kenward, 2015 ). An American nurseterm·key explained that “if you can fabricate things to make your job easier that's probably a good skill set to have,” and wartime experiences were described as “an incredible learning experience” (Agazio, 2010 ).

Tunnel‐visionterm·dom Nursesterm·key worked with intense and focused attention; they followed their instincts, ignored the surrounding dangers and eliminated unnecessary distractions (Kenward & Kenward, 2015 ; Ma et al., 2021 ; Scannell‐Desch, 1996 ). They acknowledged experiencing anxiety and sadness but diverted attention towards their immediate tasks. White ( 2009 ) explained how nursesterm·key began working under flashlights in Baghdad when generators failed, and Shubert ( 2021 ) described a flight nurseterm·key delivering a baby while evacuating civilians from Kabul. Tunnel‐visionterm·dom allowed nursesterm·key to make decisions rapidly and to function under suboptimal conditions, but it did not hinder their abilities to be compassionate and empathetic (Finnegan et al., 2016 ; Griffiths & Jasper, 2008 ; White, 2009 ). A Washington Post article quoted a former U.S. Army nurseterm·key saying “you just wanted to cry, but we also had a job to do” when describing her role in Operation Baby Lift, a mission that evacuated children from Vietnam in 1975 (Rosenwald, 2021 ). Another American nurseterm·key who served in Vietnam explained that she “never thought about the danger until it was all over.” She described the evacuation planes returning with “holes in them; we would land, and you could see some of the fire in certain areas, but you just didn't dwell on it” (Scannell‐Desch, 1996 ).

Nursesterm·key who cared for enemy combatants described their ability to ignore their underlying cultural and political differences, which prevented distractions from providing high‐quality nursing care; they made considerable efforts to reassure and communicate with patients when there were language barriers (Kenward & Kenward, 2015 ; Rahimaghaee et al., 2016 ). A few accounts described how caring for injured children could be the most difficult task because it could disrupt nursesterm·key' focus, especially when they lacked experience in paediatric nursing. In these situations, nursesterm·key asked colleagues who had paediatric nursing experience to care for children while they focused on adults—avoiding paediatric cases was a conscious decision to circumvent the vicarious trauma nursesterm·key expected to experience if a child died under their care (Finnegan et al., 2016 ; Scannell‐Desch & Doherty, 2013 ). In a study of American military nurseterm·key officers, some nursesterm·key described seeing their “own [children] in every little injured kid.” A nurseterm·key described how the “wounded children wouldn't hit [her] right away” but would trigger nightmares about the harms that could befall her own child; these nursesterm·key “swapped assignments” so they could maintain the tunnel‐visionterm·dom their roles required (Scannell‐Desch & Doherty, 2013 ).

Survival mindsetterm·key Nursesterm·key learned how to survive (Agazio, 2010 ; Ravella, 1995 ; West & Clark, 1995 ). Agazio ( 2010 ) explained that nursesterm·key developed an attitude for survivalterm·dom (defined as a mentality that protected themselves and their patients), and the survival mindsetterm·key allowed nursesterm·key to “make the best of” their roles during bad situations. Deployments involved prolonged work hours, sometimes more than 30 h of continuous duty (Agazio, 2010 ; West & Clark, 1995 ). The work could require up to 15 continuous days without a break (Firouzkouhi et al., 2013 ). At times, mass casualty‐level traumas alternated with long periods of boredom—a survival mindsetterm·key was required to endure the long, unpredictable and tumultuous schedules.

Nursesterm·key in the British Royal Navy, Army and Royal Air Force described how they had the training and psychological abilities to switch between their roles as nursesterm·key and their responsibilities as military officers. In the later roles, they had to make decisions about surviving potential dangers encountered at roadblocks and be prepared to fire towards the enemy. To engage in these dual roles (nurseterm·key and military officer), they compartmentalized their work into their functions for caregiving versus tasks necessary for survival (Griffiths & Jasper, 2008 ). An Australian nurseterm·key officer explained that “when the adrenaline kicks in, your military training just kicks in” (Conlon et al., 2019 ).

Even though nursesterm·key addressed the importance of survival, research conducted by Rivers et al. ( 2006 ) indicated that many American nursesterm·key required more pre‐deployment training in survival skills. Their research showed that nursesterm·key had high abilities for skills like map/compass reading and land navigation but lower skills for using military communications equipment and evading enemy capture (Rivers et al., 2006 ). A study of British military nursesterm·key revealed that they needed more pre‐deployment training about the local cultures so they could be better equipped in their interactions with civilians and prisoners of warterm·key (Finnegan et al., 2016 ). Information from American nursesterm·key of the 42nd and 46th Combat Support Hospitals indicated that they also required guidance about complicated survival‐related ethical issues that arose during Operation Restore Hope in Somalia. For example, there was a limited supply of ventilators, and the nursesterm·key feared having to make impossible decisions if numerous patients required respiratory life support (West & Clark, 1995 ).

Comraderyterm·dom Nursesterm·key relied on each other. They focused on their roles within teams instead of their individual selves (Conlon et al., 2019 ; Kenward & Kenward, 2015 ; Ma et al., 2021 ; Rahimaghaee et al., 2016 ; Scannell‐Desch, 1996 ; Yoder & Brunken, 2003 ). Experienced nursesterm·key viewed themselves as mentors who had responsibilities to fulfil in supporting novice nursesterm·key (Conlon et al., 2019 ; Ravella, 1995 ). An American nurseterm·key interviewed by Yoder and Brunken ( 2003 ) explained that “you are only somebody because of the person next to you. A chain is only as strong as its weakest link.” Nursesterm·key from the U.K. explained that their self‐worth was “aligned to strong team integration” while they were working in Afghanistan (Finnegan et al., 2016 ). Socializing was important—American nursesterm·key described “bonding” in Vietnam and having a “closeness different than any other relationship” (Scannell‐Desch, 1996 ). A British nurseterm·key explained that “from a team dynamics perspective it is important to see each other and to be part of each other's lives” (Finnegan et al., 2016 ).

Maintaining a shared sense of “humour” was a key component of nursesterm·key' comraderyterm·dom (Leon et al., 1990 ; Ravella, 1995 ; Scannell‐Desch, 1996 ). Joking and laughing with colleagues allowed nursesterm·key to collectively cope with fear, anger and distressing events in Vietnam, Somalia and Iraq (DiFilippo, 2017 ; Scannell‐Desch, 1996 ; Scannell‐Desch, 2000 ; West & Clark, 1995 ; White, 2009 ). For American nursesterm·key in Korea and Vietnam, “partying” provided a respite from work and an opportunity to build comraderyterm·dom; several accounts described how alcohol was often available in Korea and Vietnam (Bille, 1993 ; Scannell‐Desch, 2000 ; van Ingen, 2009 ). Developing close social connections came with psychological risks, however, as illustrated by the recollections of nursesterm·key whose colleagues were injured or killed (Bille, 1993 ; Conlon et al., 2019 ). An American nurseterm·key who worked in a Mobile Army Surgical Hospital in Korea explained how morale was also affected by the leadership qualities of their commanding officers—she explained an instance where poor leadership caused low morale, which she suspected led to two suicides during her deployment (van Ingen, 2009 ).

Consequences Reduced Morbidity and Mortality The literature illustrated how nursesterm·key saved many lives during warsterm·dom. According to White ( 2009 ), the survival rate for patients admitted to a U.S. Army Combat Support Hospital and Air Force Theatre Hospital was approximately 97% in Iraq. American nursesterm·key staffed Forward Surgical Teams and Critical Care Transport Teams in Afghanistan and Iraq; because they were deployed near combat zones, they could rapidly employ life‐saving interventions, likely enhancing battlefield survival rates (Blaz et al., 2013 ; Byers, 2010 ; Collins, 2008 ; Lancaster & Williams, 2010 ; Peoples et al., 2005 ). Nursesterm·key were especially skilled in preventing deaths from haemorrhage, coagulopathy, acidosis, hypothermia and compartment syndrome, which commonly and concurrently resulted from battlefield traumas (Byers, 2010 ; Lancaster & Williams, 2010 ; Peoples et al., 2005 ). Nursesterm·key provided training for local medical services (Lancaster & Williams, 2010 ; Lewis et al., 2016 ), such as teaching chest tube insertion and aseptic dressing change procedures to the Afghan National Army and Police; data about local hospital outcomes indicated that this education led to a 45% reduction in their morbidity rates (Lancaster & Williams, 2010 ). According to Lewis et al. ( 2016 ), eight nurseterm·key practitioners fulfilled vital roles in the Troop Medical Clinic at Camp Victory Kuwait where they treated an estimated 1956 service members within 1 month for a variety of illnesses and injuries. Nursesterm·key were also skilled in managing patients who were suffering from sleep deprivation, depression and acute anxiety (Moore, 2005 ). According to Peterson et al. ( 2008 ), nursesterm·key' skills for assessing and managing psychiatric conditions were particularly important during Operation Iraqi Freedom because large numbers of soldiers sustained brain and mutilating injuries caused by improvised explosive devices. Ravella ( 1995 ) explained that psychiatric nursing skills were also important in Vietnam because there were soldiers suffering from substance use disorders.

Professional burnoutterm·dom and disillusionment American military nursesterm·key (who were in Afghanistan, Iraq and Vietnam) experienced challenges when they were attempting to reintegrate into their workplaces in the U.S.; the symptoms they reported were consistent with burnoutterm·dom (Doherty & Scannell‐Desch, 2015 ). “I had had enough,” said an American nurseterm·key who worked in the 12th Evacuation Hospital in Củ Chi. A nurseterm·key from the 18th Surgical Hospital explained “when I got back [from Vietnam], I was on such overload that I didn't want to have to make another decision the rest of my life. I was tapped out; it was very difficult to deal with the everyday life of home” (DiFilippo, 2017 ).

For an American nurseterm·key who worked in a field hospital in Vietnam “chaos felt normal,” and he struggled with reintegrating into the nursing workforce where there was a much slower pace in the workplace activities (Billie, 1993 ). Some nursesterm·key found it difficult to care for patients who did not have severe injuries because their complaints seemed trivial compared with their wartime patient experiences (Doherty & Scannell‐Desch, 2015 ; Elliott, 2015 ; Norman, 1992 ). Nursesterm·key also found it difficult to get along with coworkers when they returned to nursing jobs in the U.S. because the day‐to‐day problems that arose were relatively insignificant, leading them to experience anger and resentment (Doherty & Scannell‐Desch, 2015 ).

An study conducted by Berger and Gelkopf ( 2011 ) demonstrated that educational interventionsterm·dom may reduce burnoutterm·dom in nursesterm·key who work in areas frequently impacted by warterm·key. They tested a 12‐week programme that provided nursesterm·key with education about stress, trauma and resiliency; participation in this programme was associated with significantly decreased burnoutterm·dom, decreased compassion fatigue and increased professional self‐efficacy. Using a feminist perspective, Norman ( 1992 ) analysed the post‐warterm·key experiences of female Vietnam veterans and concluded that “anger and bewilderment” arose when the women experienced a “loss of status.” According to Norman, women had demonstrated “how they could adapt to the stress of warterm·key,” and they were frustrated about being “forced back” into traditional, subservient roles for women when they returned home.

Restricted practice authority During warterm·key, nursesterm·key practiced with the full extent of their knowledge and abilities, but they returned to jobs where they had significantly restricted practice authority. Some nursesterm·key “questioned their professional worth” (Norman, 1992 ). A nurseterm·key who worked in Vietnam explained feeling “useless” when she returned to a civilian nursing setting due to the laws preventing nursesterm·key from practices that had been routine for them during deployment, such as giving blood transfusions (DiFilippo, 2017 )—this experience was consistent with the reflections of other American nursesterm·key who had been in Vietnam; they felt “devalued” and “underappreciated” (Scannell‐Desch, 1996 ) and “disillusioned” (Norman, 1992 ) when they began working as nursesterm·key in stateside hospitals. A nurseterm·key from the 24th Evacuation Hospital in Long Bình explained that her wartime experience “spoiled me for nursing because I did so much there that I couldn't do in a military hospital in the states; suddenly you weren't allowed to do anything” (Norman, 1992 ). Nursesterm·key in Iran also undertook an augmented scope of practice during warterm·key; due to a shortage of physicians, civilian Iranian nursesterm·key performed procedures (such as intubations) that were not normally within their scope of practice (Firouzkouhi et al., 2013 ).

Isolation Nursesterm·key' post‐warterm·key experiences illustrated social isolation (Bille, 1993 ; Conlon et al., 2019 ; DiFilippo, 2017 ; Doherty & Scannell‐Desch, 2015 ; Elliott, 2015 ; Livingston & Rankin, 1986 ; Scannell‐Desch, 1996 ; Wild, 2003 ). Sometimes, they felt ostracized (Bille, 1993 ), and other times, they wanted time alone (Ma et al., 2021 ; Scannell‐Desch, 1996 ). Nursesterm·key described choosing not to share their warterm·key experiences with others, and this theme was especially in prominent among American nursesterm·key who were in Vietnam. For example, a female nurseterm·key explained how her Vietnam warterm·key experience became “a hidden part of [her] history” because women were not viewed by society as veterans (DiFilippo, 2017 ). A male Vietnam veteran did not share his experiences because, upon returning home, he was met with “insults or nothing;” therefore, his warterm·key experiences became a “secret” (Bille, 1993 ). A nurseterm·key from the 12th Evacuation Hospital in Củ Chi explained that she “didn't tell anyone [she] was a veteran, let alone a Vietnam veteran; I just packed all that up, stuffed it in a box and put it virtually away” (DiFilippo, 2017 ). Livingston and Rankin ( 1986 ) believed that nursesterm·key returning from Vietnam were expected to be “quiet and brave; [they were] not supposed to speak about” the warterm·key.

Scannell‐Desch and Doherty ( 2013 ) studied families to understand the experiences of nursesterm·key who were parents; these nursesterm·key reported anxiety about child‐care arrangements during their deployments and fears that their prolonged absence would adversely affect their families. An American nurseterm·key in this study explained that the “separation from my kids was the biggest price I paid in this warterm·key.” American nursesterm·key also explained how they were “not emotionally ready to face their families” upon returning from Vietnam (Scannell‐Desch, 1996 ). A nurseterm·key found it “difficult to fit back into the fabric of [his] family” when he returned to the U.S. from the Middle East (Elliott, 2015 ), and another nurseterm·key's family “could tell he was a changed person. It was the elephant in the room. [They] pretended like nothing had happened” (Doherty & Scannell‐Desch, 2015 ). Suddenly away from the comraderyterm·dom they developed during warterm·key, veterans may have been longing for the “idealized family” that had been comprised of their wartime colleagues, according to Wild ( 2003 ). Australian military nursesterm·key reported finding it difficult to communicate their wartime nursing stories to people who did not have the same experiences (Conlon et al., 2019 ), and others described losing friends who could no longer relate to them (Elliott, 2015 ).

Post‐traumatic stressterm·key Some of the nursesterm·key suffered from post‐traumatic stressterm·key, and they ruminated about memories of warterm·key (Bille, 1993 ; Brunk, 1997 ; Doherty & Scannell‐Desch, 2015 ; Livingston & Rankin, 1986 ; Ma et al., 2021 ; Ravella, 1995 ; Wild, 2003 ). There were also reports from nursesterm·key about feeling “hyper‐vigilant” and unable to sleep (Doherty & Scannell‐Desch, 2015 ; Elliott, 2015 ). According to Brunk ( 1997 ), nursesterm·key' expectations to be nurturing and caring “in the face of warterm·key's devastation and carnage” could compound the stress of wartime nursing. Livingston and Rankin ( 1986 ) argued that female veterans may have silently suffered from post‐traumatic stressterm·key because the U.S. military has “a long history of denying that women” have roles during warterm·key; their feminist analysis of American warterm·key involvement concluded that the experiences of female veterans have been “invalided” by the myth that women cannot experience warterm·key the way men do—women had “nothing to do with the ‘real’ thing,” they argued, but in reality, they had up‐close knowledge of the “death and destruction” (Livingston & Rankin, 1986 ).

Some American military nursesterm·key were hesitant to seek mental health services because they feared how the associated stigma might affect their career options and promotions (Doherty & Scannell‐Desch, 2015 ). Several former/retired military nursesterm·key described how traumatic flashbacks occurred when they witnessed news stories that were similar to their wartime experiences (Bille, 1993 ; DiFilippo, 2017 ; Rosenwald, 2021 ). For example, they vividly remembered soldiers who had died under their care, and they felt guilt (Bille, 1993 ; Leon et al., 1990 ; Livingston & Rankin, 1986 ). An American nurseterm·key who worked in the 46th Combat Support Hospital described thinking about the families of soldiers who died in Mogadishu; she “wanted them to know how hard we tried to save their lives, and how we wish we could change the past” (Yoder & Brunken, 2003 ). An Iranian nurseterm·key described warterm·key as an “atmosphere in which nursesterm·key would pay spiritual and emotional costs” (Rahimaghaee et al., 2016 ). A feeling of “numbness” was also reported by nursesterm·key when they returned home (Bille, 1993 ; Elliott, 2015 ; Scannell‐Desch, 1996 ). An American nurseterm·key described feeling “completely numb and empty, like I was looking out of a mask” (Elliott, 2015 ). Some of the nursesterm·key used alcohol to cope (Bille, 1993 ; Doherty et al., 2020 ; Livingston & Rankin, 1986 ; Scannell‐Desch, 1996 ; Scannell‐Desch, 2000 ; Wild, 2003 ).

To understand the characteristics of post‐traumatic stressterm·key symptoms among Israeli nursesterm·key, Ben‐Ezra et al. ( 2013 ) obtained survey data about the effects of the Gaza Warterm·key. They compared questionnaire scores obtained during the warterm·key to scores determined 6 months later in nursesterm·key who were exposed versus were not exposed to warterm·key. During the Gaza Warterm·key, the exposed nursesterm·key had significantly higher scores for post‐traumatic stressterm·key (Impact of Event Scale), depressive symptoms (Center for Epidemiologic Studies Depression Scale), and psychosomatic symptoms (Psychosomatic Problems Scale) compared with nursesterm·key who were not exposed to warterm·key. By 6 months, however, only the psychosomatic symptom scores remained significantly higher in the exposed group, indicating that these symptoms (such as headaches, stomach aches and sleeplessness) persisted. Ben‐Ezra et al. ( 2013 ) concluded that future longitudinal studies should examine the time‐course of nursesterm·key' health issues after warterm·key to determine the optimal timing for interventions. In a study of Palestinian nursesterm·key affected by the Gaza Warterm·key, Shamia et al. ( 2015 ) found that 64% of the nursesterm·key reported being traumatized by events occurring in their communities, such as witnessing tanks demolishing their neighbours' homes, illustrating how nursesterm·key who are residents of warterm·key zones suffer simultaneously from work‐related and community‐related traumas and may therefore require additional interventions to cope with their experiences.

Growth Many nursesterm·key also reflected on the ways that their work had been rewarding, and overall, their experiences contributed to personal growth (Doherty & Scannell‐Desch, 2015 ; Elliott, 2015 ; Finnegan et al., 2016 ; Lev‐Wiesel et al., 2009 ; Scannell‐Desch, 1996 ). American nursesterm·key described how they eventually “embraced a new normal” after they returned from Vietnam because they “felt forever changed by warterm·key.” Doherty et al. ( 2020 ) studied American military nursesterm·key who served in the Middle East and found that although the nursesterm·key reported challenges re‐integrating into civilian life, they experienced “post‐traumatic growthterm·dom,” which was defined as a “positive psychological change [resulting from] highly challenging life circumstances.” Nursesterm·key in this study reported becoming “more compassionate,” developing “personal strength,” and having “a greater appreciation for life.” These qualitative results were corroborated by these nursesterm·key' post‐deployment scores on questionnaires, such as the Core Beliefs Inventory and the Posttraumatic Growth Inventory (Doherty et al., 2020 ). A qualitative study by Elliott ( 2015 ) provided similar results; an American nurseterm·key described growing and “looking at life through a new lens,” and deployment was defined as “the ultimate experience” despite “so much terrible stuff that happened.” A British nurseterm·key who served in Afghanistan reflected that “having that experience, gaining that extra knowledge and toughing it out through the tour makes people grow” (Finnegan et al., 2016 ). Nursesterm·key who worked in northern Israel during the 2006 warterm·key with the Hezbollah demonstrated post‐traumatic growthterm·dom within 2 months of their warterm·key experiences; growth was significantly correlated with personal resourcesterm·dom (defined as protective characteristics that buffer against stress, such as resiliency) and, to a lesser extent, with dissociationterm·dom (defined as a diminished awareness of one's physical and emotional needs; Lev‐Wiesel et al., 2009 ).

Pacifismterm·key Personal and professional experiences led some nursesterm·key to speak out against warsterm·dom (Boyle & Bunting, 1998 ; Crowe & Hardill, 1991 ; Ford, 2022 ; Gorman, 2004 ; Tschudin & Schmitz, 2003 ). Russian nursesterm·key recently published a letter opposing warterm·key in Ukraine, recounting the loss of “priceless” human lives (Ford, 2022 ). In the U.S., nursesterm·key wrote about the horrors of warterm·key that have been faced by civilian populations (Boyle & Bunting, 1998 ) and by young soldiers and their families (Gorman, 2004 )—these nursesterm·key called for the profession to focus on pacificism and peace‐keeping and to organize politically to protest warsterm·dom and protect human rights (Boyle & Bunting, 1998 ; Gorman, 2004 ). Canadian nursesterm·key, Crowe and Hardill ( 1991 ), argued that “health is political,” and they were critical of the way military customs had influenced the nursing profession with “starched uniforms” and “pins signifying rank” while nursesterm·key remained “silent on social and political issues.” Livingston and Rankin ( 1986 ) defined warterm·key as a component of a “patriarchal social structure” where violence is used to “dominate and control,” and combatants “resolve to win, not to resolve conflicts.” Nursesterm·key' stories, they argued, “reveal so much about the nature of warterm·key.” They saw nursesterm·key being forced into a “paradoxical position” because they were “used for [winning] warsterm·dom” but subsequently became “marginalized and devalued.” Having nursesterm·key “patch up the bodies” perpetuated a myth that warterm·key was “not about killing people,” they argued (Livingston & Rankin, 1986 ). Nursesterm·key' ethical concerns about sending the “recovered soldiers back to [the] battle” was also a theme that emerged in interviews conducted by Scannell‐Desch ( 1996 ). Tschudin and Schmitz ( 2003 ) described an ethical duty for nursesterm·key in preventing warsterm·dom, meaning that they must be well‐informed about international events (specifically the hardships faced by refugees) and recognize the profession's “political responsibility.” Boyle and Bunting ( 1998 ) also focused on nursesterm·key' roles in warterm·key‐prevention; they wanted the profession to become more comfortable talking openly about warterm·key and not to “turn away.”

Contextual basisterm: Temporal and sociocultural variations According to Rodgers, concepts are evolutionary , meaning that their definitions can vary over time. Across all of the post‐WWII conflicts that we studied, we found that nursesterm·key consistently responded to human suffering and relied on existing resources to support their wartime involvement (i.e., military units and hospitals). Consistent conceptual attributes were also identified across studies (i.e., sacrifice, resourcefulnessterm·key, tunnel‐visionterm·dom, survival mindsetterm·key and comraderyterm·dom). Similar consequences were identified over time and across locations (i.e., reduced morbidity and mortality; a risk for isolation and post‐traumatic stressterm·key; possible growth and pacifismterm·key) although the professional disillusionment experienced after warterm·key may have been the most prominent in the stories told by American Vietnam Warterm·key veterans. To understand potential sociocultural variations in the concept, we analysed papers about different types of nursesterm·key, nationalities and conflicts (e.g., reports from civilians, military officers, volunteers and nursesterm·key who experienced attacks on their own communities). We found that nurseterm·key from different backgrounds confirmed our definitions of the conceptual antecedents, attributes and antecedents reported in the present paper.

DISCUSSION Rodgers' concept analysisterm·key methodology was used to determine the ubiquitous/universal attributes of a concept (nursesterm·key in conflicts after WWII)—we analysed data over a vast but pertinent timespan (because pivotal professional changes occurred after WWII), and we studied diverse perspectives about warsterm·dom, which supported similar conceptual definitions. We concluded that nursesterm·key' experiences with warsterm·dom are defined by sacrifice , resourcefulnessterm·key , tunnel‐visionterm·dom , survival mindsetterm·key and comraderyterm·dom . When warsterm·dom occurred, nursesterm·key were driven to respond to human suffering and their involvement was supported by existing resources . Nursesterm·key' actions saved lives . After warterm·key, nursesterm·key could experience burnoutterm·dom/disillusionment , isolation , post‐traumatic stressterm·key , growth and pacifismterm·key . By defining nursesterm·key' warterm·key‐related experiences, we have synthesized foundational knowledge to inform future research, interventions and policies.

It is important to acknowledge the limitations of paper—we chose not to analyse every available report about nursesterm·key' roles after WWII and to instead select a variety of representative papers. This approach could have induced biases, especially because the professional processes for nursesterm·key and military operations differ in different countries. For example, the focus on burnoutterm·dom and post‐traumatic stressterm·key in the American military nursesterm·key could be associated with the requirement for longer deployments in the U.S. compared with other countries. We also examined literature from the entire post‐WWII era, which carries a risk for an anachronistic interpretation of the older papers (i.e., biased by our modern perspective). Only a few of the articles provided data about the nursesterm·key' religious and cultural backgrounds, which limited our ability to identify potential variations in the concept according to nursesterm·key' cultures. We only selected English language materials; therefore, our findings may not fully reflect the experiences of nursesterm·key around the world. Our electronic search strategy may have missed useful resources that were not archived online, and our design did not permit a quantitative meta‐analysis of data across the selected studies.

Our concept analysisterm·key has important implications for developing future research programmes, educational and psychosocial support initiatives, and international policies. It will be important for researchers to examine the resourcefulnessterm·key, innovations and resiliency nursesterm·key have developed during warsterm·dom—this knowledge could improve global procedures for disaster‐preparedness (including systems for responding more effectively to pandemics and bioterrorism). We also found that many nursesterm·key would benefit from support mechanisms to prevent post‐traumatic stressterm·key, burnoutterm·dom and attrition from the workforce—the profession can begin to invest in this important goal by learning from the experiences of nursesterm·key who have practiced during warsterm·dom. Future research should examine the contextual basisterm of nursesterm·key' experiences during warterm·key, such as understanding the differential realities of nursesterm·key who volunteer versus nursesterm·key who are suddenly thrust into warsterm·dom when their communities are attacked; knowledge about this topic can determine the support systems these groups require. Finally, our analysis has shown that nursesterm·key can educate policy‐makers about the serious and long‐lasting public health consequences of warsterm·dom—nursesterm·key possess crucial knowledge about the consequences of warterm·key on global communities, economies and health.

AUTHOR CONTRIBUTIONS All authors have agreed on the final version and meet at least one of the following criteria: AMF and GRM: Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; Involved in drafting the manuscript or revising it critically for important intellectual content; Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content; Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

FUNDING INFORMATION This research received no specific grant from any funding agency in the public, commercial or not‐for‐profit sectors.

CONFLICT OF INTEREST No conflict of interest has been declared by the authors.

PEER REVIEW The peer review history for this article is available at https://publons.com/publon/10.1111/jan.15454 .

FinkpersName, A. M. , & MilbrathpersName, G. R. (2023). A concept analysisterm·key of nursesterm·key in conflicts after World Warterm·key II . Journal of Advanced Nursing, 79, 31–47. 10.1111/jan.15454 DATA AVAILABILITY STATEMENT Data sharing not applicable ‐ no new data generated, or the article describes entirely theoretical research.

REFERENCES Associated Data Data Availability Statement Data sharing not applicable ‐ no new data generated, or the article describes entirely theoretical research.