Caring with Honor: A Grounded Theory of Caring for Veterans within the Veterans Health Administration

Alvita K. Nathaniel, West Virginia University School of Nursing, USA, Lisa Hardman, Women’s Health Services Veterans Health Administration


Veterans comprise a unique culture. Through their military experience, Veterans become ingrained with shared values, beliefs and attitudes that characterize their everyday existence. Health care providers must take into consideration that culture impacts health care seeking behaviors.  The theory of Caring with Honor is emerging through the classic GT method.  A team of investigators within the VA health care system gathered data from 19 health care professionals via one-on-one interviews.  The emerging theory, Caring with Honor, represents an amplifying process whereby health care professionals engage with Veterans through a process of enculturating, witnessing, connecting, honoring, and caring with purpose.

Keywords: Veterans, military, grounded theory

The U.S. Department of Veterans Affairs (VA) provides eligible Veterans needed hospital and outpatient health care in one of its more than 1,700 sites (U.S. Department of Veterans Affairs, 2017).  This paper provides a glimpse at the emerging theory of Caring with Honor that focuses on those who care for patients within the VA system.  The theory provides a powerful look at the psychosocial and social cultural processes within the VA health care system.  Following is a background of Veterans’ health care and a snapshot of the theory and one of the categories that has emerged from interviews with a variety of Veteran and non-Veteran health care professionals who work within the VA health system.


In fiscal year 2015, 44% of all Veterans used at least one VA benefit or service (U.S. Department of Veterans Affairs & National Center for Veterans Analysis and Statistics, 2015a, 2015b). When caring for Veterans, VA employees must go beyond providing traditional health care required by non-Veteran patients.  Veterans’ health care must also address Veteran-specific health care issues such as post-traumatic stress disorder, traumatic brain injury, spinal cord injury, military sexual trauma, readjustment difficulties, and war-related illness and injury.

Veterans comprise a unique cultural group. Through their military experience, Veterans share values, beliefs and attitudes that characterize their everyday existence. Characteristics seen within the cultural group include positive qualities such as a strong sense of duty, honor, loyalty and commitment to fellow soldiers. Other less positive characteristics of Veterans include hesitance to seek health care (Malmin, 2013; Denneson, et al., 2015); debilitating feelings of guilt and shame (Denneson, 2015); feeling of loss of sense of self (Johnson et al.; Demers, 2011); reluctance to report physical and mental health concerns that may bring embarrassment and stigma (Malmin, 2013; Simmons & Yoder, 2013); and feelings of weakness for experiencing mental and physical needs (Malmin, 2013). Health care providers must take into consideration that culture influences health seeking behaviors and that understanding cultural aspects will allow care that effectively meets the unique needs of the Veteran population.

Even though Veterans have a high acuity of complex physical and mental health concerns that could make health care delivery challenging, many VA employees find satisfaction with their work. The Department of Veterans Affairs Federal Employee Viewpoint Survey Results (2015) indicates that 72% of VA employees responding to the survey feel their work gives them a sense of personal accomplishment; 92% are constantly looking for ways to do a better job; 84% identify their work is related to the VA’s goals and priorities, and 94% rated that the work they do is important.

The theory of caring with honor

The theory of Caring with Honor represents an amplifying process whereby health care professionals engage with the Veteran through a process of enculturating, witnessing, connecting, honoring, and caring with purpose.  After being employed by a VA health care system, professionals quickly begin to differentiate between non-Veteran and Veteran health care experiences, explicitly denoting these as “outside” or “inside.”  As they learn the complex social-structural processes within the VA, health care workers also observe and accumulate information about the Veterans.  Their perceptions evolve over time as they begin to understand and appreciate Veterans’ unique needs.  They begin to deeply appreciate Veterans and become more and more interested in connecting intimately with them in ways that are unlike patient/provider relationships on the “outside.” Recognizing that Veterans, especially combat Veterans, live with lingering wounds of their service—inflicted not only by physical injury, but also by the psychological cost of war and, at times, the violation of their own values—health care professionals begin to perceive Veterans’ actions with understanding and begin to feel honored to care for them.  Honoring of Veterans is an amplifying process that leads health care professionals to a deep commitment to caring for them with purpose.

Because it is not within the scope of this paper to examine each concept of the theory of Caring with Honor, the following discussion offers a glimpse of the category of witnessing.  After communicating with, reading about, and observing Veterans over time, health care providers who work in the VA system view Veterans with understanding and compassion. They witness words and behavior that lead them to perceive Veterans as unique, with multitudes of problems, many of which are hidden or repressed.  Although most providers deal with the myriad physical problems which plague Veterans, nearly all participant responses in this study focused their responses on moral, mental, and spiritual suffering of Veterans. Thus, providers describe many Veterans as “messed up” or “broken,” particularly those with combat experience.

Providers come to understand that many Veterans have experienced “awful things” such as seeing fellow soldiers killed or mutilated, children injured, or the suicide of a fellow soldier.  Providers begin to understand that many Veterans were required to commit acts in the line of duty that violated their own previous beliefs and values.  Combat Veterans may have killed others, perhaps even children.  One provider said, “Can you imagine being told right from wrong all of your life and then having to do what you know is wrong.  But, you have to do it or you die or your fellow soldiers die.  You lose either way.”  Having witnessed these outcomes, study participants sensed that the impact is so significant that, once deployed, a combat Veteran never comes home as the same person.  According to one provider, “They carry around so many stressors that they cannot get back to normal life.” Although Veterans may look strong, many problems are unseen and perhaps will never heal.  Witnessing Veterans’ behavior and hearing their stories changes providers’ views over time.  For example, one participation stated, “When I first started working here, I got p****d off at them at how they acted.  They were noncompliant.  Then I started to see in their charts why they are like they are.”  Another said, “… no wonder they can’t function. I don’t get angry now.  I don’t judge.  I am a better person now.”  Both statements give clues as to how VA providers develop an ethos of care with honor.


Over time, those who deliver care to Veterans become aware of the uniqueness of Veteran patients and their culture.  Health care providers gain appreciation and understanding and evolve a sense of honoring those to whom they give care.  The theory of Caring with Honor represents an amplifying process whereby health care professionals engage with Veterans through a process of enculturating, witnessing, connecting, honoring, and caring with purpose.  A recognition of this process can enhance VA health care employee orientation and speed the process of caring with honor.


This material is the result of work supported with resources and the use of facilities at the Louis A. Johnson VA Medical Center, Clarksburg, WV.

The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Authors would also like to acknowledge of the immeasurable contributions of other members of the research team:  Denise Boehm and Frank “Jay” Ketterman.


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