Veterans in Care Homes: An International Scoping Review to Inform UK Policy and Practice
Background
Social care in the UK has long been considered the poor relation of NHS-provided healthcare, comparatively neglected in terms of the attention, priority, and state funding it receives [1], [2]. The social care needs of UK Armed Forces Veterans are no different, holding a similarly marginal position in Veterans’ policy and research compared to the focus on their mental and physical health needs. The Veterans and Strategy Action Plan 2022–2024 [3], has scant mention of the social care needs of Veterans amongst its multiple commitments to advancing mental and physical health through funding, service improvement, and research.
The circumstances under which Veteran care home residents live, and are cared for, remain underexplored [4]. However, given that some Veteran residents of care homes may have Service-connected conditions and/or Service-informed care needs, it is important to better understand the experiences of Veterans in care homes.
As a starting point to gaining a better understanding, a scoping review of existing literature was conducted to address two questions:
- What is known about the social care needs of Veterans residing in care home settings in the international research literature?
- What military-connected health needs are present amongst Veterans in care homes, and do these affect how they are cared for?
Method
A scoping review was conducted to map the breadth of relevant evidence in order to address the two questions and to identify knowledge gaps about Veterans in care homes. The scoping review entailed searching relevant research paper and grey literature databases in May 2022 using key words, e.g., Veteran, ex-military, nursing home, care home. Once papers were identified they were screened for their eligibility based on an inclusion/exclusion criteria (see full paper).
Findings
Following the search and review of papers, 33 relevant papers were identified, of which 31 were peer-reviewed journal articles, one was a PhD thesis, and another a grey literature research report. The majority of studies were conducted in the US (n = 24). The remainder were conducted in Taiwan (n = 4), Canada (n = 2), New Zealand (n = 1), UK (n = 1), and Poland (n=1). Most of the studies were conducted with a sample of Veterans who resided in care homes (n = 31), with only two studies conducted with a sample of care home staff. Most studies (n = 17) used quantitative methods, eight had multiple or mixed-methods designs, seven used qualitative methods, and one was a clinical case study.
The review and analysis of the results of the papers led to three broad thematic areas within the existing evidence being identified: social connection, care preferences and autonomy, and military-related physical and mental health needs.
Social connection
Of the 33 studies retrieved, 15 related to the social connection needs of care home-situated Veterans. While Veterans had similar social connection concerns to those expected of a civilian care home population, e.g., social isolation and boredom, Veteran residents also had additional or differing social care needs due to their military backgrounds. A desire for military-connected social bonds was found amongst Veteran residents who chose to engage in military-connected social activities and friendships with other Veterans, in and outside of the home. Spontaneous and structured reminiscence activities were also found to be useful catalysts for Veterans in developing social connections and alleviating depressive symptoms [5],[6].
Despite the benefits that military-connected social bonds can bring to Veterans, proposals to increase military-connected offerings for all Veterans within care homes as a means of enhancing wellbeing should be carefully considered. While some Veterans may enjoy a continued connection to the military and their Veteran identity in the care home environment [7], others may feel ambivalent, disinterested, or find reminiscence about their military Service distressing [8], [6]. This distress may be especially problematic when other co-morbidities, such as dementia and challenging behaviour, are present. Given the decline in nursing home bed availability in the UK [9], military specialist care home providers need to consider that for some residents, their decision to select their care home may have been a pragmatic, conflicted, or reluctant decision rather than one grounded in a desire for a military-replicating care home environment. Therefore, the potential for variations in the degree to which military social connection is desired, or indeed rejected, by Veteran residents despite their residency in a military-connected environment should be considered as a possibility for each individual Veteran resident.
Care preferences and autonomy
Differing attitudes towards autonomy and routine were found amongst Veteran residents, with 15 papers relating to this theme. Although some Veterans may transition and acculturate well from one ‘total institution’ [10], i.e., the military, to a care home, some may not. Veteran residents were found to be more comfortable with features of institutional care settings, such as regular bedtimes and mealtimes, than civilian residents [11]. Yet other studies found Veterans who had difficulty with routines and perceived restrictions on their autonomy [7],[6]. Both attitudes were found to derive from within-Service experiences. As the scoping review did not identify qualitative research that explored the preferences and attitudes amongst institutionalised Veteran residents themselves, further research centred around this topic, using qualitative methodology, is necessary.
Military-related physical and mental health needs
Eleven of the 33 studies reported on military-related physical and mental health needs of Veteran residents. Although only a minority of British Veterans are thought to experience Post-Traumatic Stress Disorder (PTSD) (3.4%) or dementia (1.8%) [12], the scoping review findings revealed the complexity of how these conditions manifest and can be managed amongst care home-situated Veterans. Whilst the symptoms of PTSD and dementia may appear similar on the surface, there are nuances between them, with co-occurring PTSD being characterised by additional symptoms amongst those with dementia, such as increased fear intensity, nightmares, aggression, suspicion, and withdrawal [13]. Moreover, Veterans with co-occurring PTSD require more complex support than those with dementia alone, as usual care strategies for behavioural symptoms of dementia may be ineffective or even counterproductive for those who also have PTSD [13]. Given the possibility for under or misdiagnosis of PTSD and lesser recognised conditions such as Delayed Onset PTSD, especially when dementia is also present, there remains a need for increased awareness, research, assessment, and management of these conditions in older institutionalised Veterans.
Conclusion
Current evidence of the social care needs of Veterans who reside in care homes is limited, broad, and disparate, with only one of the 33 retrieved studies conducted in the UK. As such, the transferability of the studies to a UK context needs to be interpreted with these limitations in mind. That only one of the studies identified as part of this scoping review was conducted in the UK further highlights the neglect of the social care needs of this population in terms of research funding and priority in comparison to other areas of Veterans’ research in the UK, such as mental and physical health [3].
The scoping review found that Veterans in residential care homes experience challenges akin to those experienced by civilian care home residents, such as difficulties in forming and maintaining social connections and personal autonomy. However, Veteran residents may have their attitudes and experiences of social connection and autonomy shaped by their military background, which may also depend on how positively they connect and identify with their military Service. Veterans in care homes also have the potential to have military-connected physical and mental health care needs for which non-military-informed care may be ineffective or counterproductive. Within-group variations regarding the degree and direction of influence that military Service may have on Veteran residents’ social care needs, emphasises the need for personalised, military-informed care planning amongst both specialist and non-specialist care home providers. Specialist Veterans’ care homes are well-placed for concentrating and building expertise in the care of Veterans with Service-connected ageing needs, with some UK-based care homes already making inroads in the development of Service-connected specialist ageing care programmes [14]. Given that recent evidence has demonstrated that improving Veteran social care in the UK can alleviate pressure on the NHS [15], improving and investing in the development of Veteran-informed social care may have far greater implications beyond that of the individual Veteran.
Thank you to Dr Nicola Gillin for writing this research summary for the FiMT Research Centre.
Full text available at:
References
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