Florence Nightingale founded Western nursing after her return from the Crimean War. Her conception of nursing was greatly shaped by both her education in philosophy and her experience of combat nursing. These influences led her to a concept of nursing that emphasized a heroic and devoted response to the public good.1, 2 After her success in the Crimea, she was given a charge to establish the first secular training school for nurses,3 and her legacy has continued to influence our understanding of modern nursing.
Before the Crimean War, soldiers and nurses were accorded very low status in Britain; both were seen as drunks, criminals, or incompetents.3, 4 Wartime journalists made the plight of the wounded British soldier apparent, and for the first time the populace could also appreciate the value of trained nurses. Practically overnight, the status of the ordinary soldier and the nurses who tended to them were raised to heroic stature. Not only was the profession of nursing born from the Crimean conflict, but Donahue5 has also contended that nursing has made its greatest advances and achievements during wars. The need to care for wounded soldiers dramatizes the work that nurses do and thus nurses are highly valued, recognized, and respected at these times.5
Recruitment and training of nurses has typically intensified during wartime, and any civilian shortages of nurses also has become more acute. Notably, the scope of practice has expanded and changed as a result of military nursing. Nurses exposed to these increased responsibilities return to civilian practice with new skills and ideas, just as Nightingale did, and this has shaped the professional practice of nursing.
Methods
This study examines the effect that combat nursing in Vietnam had on individuals, whose experiences were collected in oral histories and previously published.6, 7 These oral histories were collected by several journalist researchers but were not analyzed for themes. In their work a tape recorder was used to collect the nurses' stories, and the transcripts were edited for clarity and focus. In the case of Marshall's7 work, the participants were able to edit their own transcripts before signing a release form for the material to be included in the collection. These oral histories represent secondary source material since they have been edited and arranged in 2 collections of published oral histories and the collection and editing process are largely not described. In particular, the oral histories could have been modified by variable interview techniques, altered context, or omissions that occurred in the editing process. Both collections were published before Norman's8 original historical research of 50 military nurses in Vietnam, and both are cited in her references. Since her landmark work has established a historical account of nursing in Vietnam, it seemed unlikely that these oral histories would contradict such painstaking work; however, I wondered whether any new interpretation or insights could be gained by working with these materials. I found the stories of nurses who served in Vietnam compelling, and as one who was not there, I wanted an opportunity to further reflect upon their experiences.
A highlighting approach to content analysis was used. Recurrent experiences were marked through several readings of the material and collected into thematic clusters. In particular, congruence or departure from Norman's research8 of 50 military nurses in Vietnam was sought. Both inductive and deductive reasoning were used. Deductive analysis was used to search for congruence with Norman's work. As in Norman's research, themes of disorientation on arrival, disruption, and moral conflict were prominent and detailed in the nurses' stories. Similarly, a surprising number of nurses commented on positive aspects of military nursing, such as teamwork, increasing skillfulness, and the notion of a peak professional experience. Inductive analysis was used to develop the idea of becoming professionally real. I believe that the experiences of wartime nursing conferred a heightened sense of professional authority and helped develop a feeling of being genuine. For some nurses, service in Vietnam resulted in an intensive formation of their professional identity in the challenging environment of combat nursing; their experience portrays one pathway to becoming real.
Disruption and disorientation
The issue of separation from familiar surroundings and habitual patterns is a recurrent theme for nurses who served during the Vietnam War, as described in 2 collections6, 7 of oral histories. The nurses' sense of disruption was most dramatic on arrival to Vietnam; several nurses mentioned the strangeness of the climate, the heat, and the sounds of artillery fire. Tracer bullets, rats, mildew, and the impoverished living quarters were among their first impressions.
As one nurse commented6:
“You lose a lot when you talk about Vietnam because you don't have the smell. It's the smell of fish, nuc mam, and shit burners. I don't know another nice word for it. That's the way you burn excrement with diesel fuel. That in addition to the damp and wet, and the mold and mildew. Your senses were going ‘holy smoke!’”
Such vivid descriptions help make clear the immediate reality of the landscape. The fact that most nurses recalled concrete details of their arrival underscores the disruption in leaving the familiar world of family and friends and arriving in strange, new surroundings. Army nurses frequently mentioned the steep, aerial descents to elude enemy fire that marked their arrival by plane in Vietnam. When they stepped off the plane, often at night, the atmosphere frequently seemed surreal, and more than one nurse7 commented on the absurdity of being urged to run for cover in heels across the tarmac:
“We landed at Bien Hoa. Bien Hoa had been rocketed the day before, so there was this mad dash to get us off and get us going here I am in my little skirt and heels—I couldn't get my feet into them after 24 hours of sitting, so I was carrying my heels. Right away we were into fatigues. And I was in this place—it was a barracks for women with a guard out front and barbed wire all around it.”
Vietnam was a tropical climate in a combat zone; it was different from anything in the nurses' previous experience. Even nurses who were accustomed to hot, humid weather were impressed by the severe conditions in Vietnam. One nurse from North Carolina said the humidity at home was “nothing compared to what it was over there.”7 She, too, recalled the strangeness of her first night, when soaked by perspiration, she heard weapons fire and saw geckos running up and down the walls.
Many nurses related incidents in which they didn't fit in or in which they acted out of ignorance in the days immediately after arrival. Sometimes it was unfamiliar military jargon or routines that discomfited them; other times it was a difficulty in functioning competently in the clinical arena. Only after arriving in Vietnam did some nurses fully comprehend that they were in a war zone and could not return home at will. One nurse recalled that she wished she could go home so fervently that her experience was like a dream; she thought that one day she would “wake up and I wouldn't be there.”6 Many nurses used words such as “disorientation,” “trance,” “nightmare,” and “dream state” to describe their impressions upon arrival in Vietnam.
Arrival in Vietnam marked the first time most nurses had traveled to a foreign country or experienced a different culture. At the same time, they were adjusting to life in the military under combat conditions and adapting to unique and often improvised hospitals and staging centers. This represented a profound change in cultural environment, living conditions, and professional routine. One nurse3 described her first experience of treating wounded patients in Vietnam:
“I had never seen shrapnel wounds, just like I had never seen a traumatic amputation. I didn't know what to do, so I just quit functioning. But I knew I had eleven months to go. I couldn't just sit there folded up in a chair not functioning.”
Not only was the weather, impoverished housing, and military routines different from what new arrivals were accustomed to in America, but also the intense working conditions and level of traumatic injury surpassed everything in their prior experience. Most nurses recalled patients who had lost 3 or 4 extremities and lived. They remembered patients who were blinded, lost their genitals, or suffered traumatic brain injuries. As one7 recounted:
“Some days you felt like you'd lived a lifetime in a week. Because Vietnam was not John Wayne on the beach at Iwo Jima. It was not ketchup on make believe wounds. It was more like a grotesque form of ‘can you top this,’ because each time you thought you'd seen the ultimate, something else would come along.”
If the new graduates felt unprepared for the challenges confronting them in Vietnam, seasoned nurses were continually surprised that nothing in their past experience had prepared them for the level of traumatic injury and exotic illness they faced in Vietnam.
“Being older than them was some help. They (other nurses) were just kids of twenty-one or twenty-two. Still, there was no way to prepare yourself for what went on in Vietnam. Because in Vietnam, everyday was disaster day.”7
Not only did nurses confront massive airlifts of soldiers with combat-related injuries, but many encountered tropical illnesses with which they were completely unfamiliar. Unusual fevers, typhus, leprosy, and rabies were encountered in treating both military and civilian patients. Nurses could find themselves caring for civilians, orphans, and prisoners of war as well as injured Vietnamese and American soldiers. As one nurse7 commented, “they had things we'd never heard about in school. Dengue fever. Malaria. Hepatitis. Bubonic plague.”
Loss of idealism
Nurses reflecting on their experiences in Vietnam often described themselves as politically naive before their arrival in a war zone. This is not surprising, given the youthful age of most nurses joining the armed services. At the height of the conflict, young women and men were recruited directly from nursing school, since recruiters could offer tuition reimbursements and stipends. Some recruiters, due to either dishonesty or confusion, told nurses they would not have to serve in Vietnam unless they volunteered to go there. Shortly after joining the Army, one nurse reported her astonishment that she had received orders for Vietnam. Her supervisor explained that her recruiter “must have misunderstood”: “Sure—her and a lot of other recruiters! Because I went around and asked all these women, ‘What did your recruiter say?’ They had been lied to by the Army, too.”7
Such instances contributed to a sense of vulnerability and loss of faith in authority. Some of the nurses wondered, “Can the same government that lies to you also protect you?” Once nurses arrived in Vietnam, they learned to cope with chaotic and unanticipated situations and to rely on collective resources to protect themselves and their patients.
One common problem concerned the need for ingenuity to procure equipment and supplies. As one nurse6 noted, “half of our equipment was being pilfered on the dock, so we never got it.” Nurses and corpsmen found equipment wherever they could, relying on their contacts and friends in other units to help them overcome shortfalls of military supplies. Some of the nurses became skilled negotiators and enjoyed proving their abilities in “scrounging” missions. But for all of the nurses, distribution problems were a concrete demonstration that the military, and by extension, the government could not meet their needs. Idealism and faith in the government were tested under such conditions.
A greater threat to idealism came as nurses confronted the horrifying casualties and loss of life in their daily work. Some nurses came to the conclusion early in their tours of duty that the war was a mistake.
“It took me only about a week to realize that the war was wrong. That we didn't belong there. That it was gross, war was gross.”7 Other nurses professed a sense of patriotism and purpose while they were in Vietnam but reversed their opinions on returning home.
“At the time, I never questioned the war. My country said go, and I went. I was really patriotic. I guess it was in the next couple of years that we really began to say, “What's going on over here? How much longer?”6
Nurses working in military hospitals in the United States saw some of the aftermath of soldiers' war injuries. Taking care of men who were blind, brain damaged, or missing multiple extremities underscored the high cost of war. One nurse who worked on an orthopedic floor of a military hospital upon returning to the United States noted: “That's when it really hit you, because it's not like you are saving their life. Now you had time to think about what the hell you'd saved them for.”6
In the end, nurses had to find a way to reconcile their political beliefs with what they had experienced during the war. It was difficult to remain uncritical of the war when they confronted such suffering in their nursing practice. Although nurses supported the individual soldiers in Vietnam, many were conflicted about the necessity of the war. In some cases, their reappraisal of political belief occurred during their tour of duty, although many stated they were too busy to examine their beliefs during the war.
The war posed a direct challenge to idealism by disrupting ordinary assumptions and beliefs, juxtaposing horrible suffering with high-minded purpose. The nurses who thought critically about the war often found their political orientation changing. As one Army nurse7 put it:
“When I was over in Vietnam, I thought we were right to do what we could do to keep them from becoming a communist country. Now I think it was inevitable that Vietnam would go communist. And if we hadn't interfered, Vietnam would be in a lot better shape than it is.”
Nurses also suffered a more general loss of idealism when they faced the horrific injuries of their patients. Sometime this occurred dramatically, as in the following nurse's example: “I looked down and saw this guy who was about 17 years old. He had both eyes out, and he was clutching a Purple Heart. I remember standing there and thinking, ‘My God, that Purple Heart means nothing.’”7
The political purposes of the war appeared meaningless when contrasted with such severe individual loss.
Another occurrence that undermined morale in Vietnam was the practice of “fragging,” which began to occur in the later years of the war. One nurse6 explained:
“By 1969, for instance, fragging was becoming something that I won't say it was routine, but it did happen a number of times. Fragging basically is our guys shooting at our guys.”
Sometimes the violence was impersonal and pointless, such as a soldier shooting into a group of buddies at a canteen. At other times the pressure and fear soldiers felt in the field resulted in the intentional injury of their platoon leader. Commanders worried that their own men would shoot them. A nurse7 told the following story:
I learned about the rules, all kinds of rules. Like, there were some units that weren't issued weapons because maybe the second lieutenants didn't have the respect of the men, were afraid their own men would kill them. So they wouldn't let their guys have weapons and their units would be overrun. They'd get slaughtered. It was terrible.”
A nurse might be idealistic on his or her arrival in Vietnam but could not escape the insults to morale among the troops. Sometimes stories that were gruesome, even by the standard of everyday combat nursing, were circulated. One nurse6 recalled a story related to her by an ambushed soldier:
“The Viet Cong had captured two medics from the unit. And they had skinned them alive, cut off their testicles, put them in their mouths and hung the two medics in the trail.”
For her, this incident legitimated any sort of retaliation by American troops:
“I thought how could anything we do be wrong.”
Moral conflict
If nurses suffered threats to their idealism, they also discovered unexpected ethical challenges. The practice of separating patients expected to die from others disturbed many nurses. Most described having to use screens to separate these patients from the other men and yet trying attend to them, when time permitted, so they wouldn't die alone. Often it was hard to know when to forego and when to sustain heroic measures. As one nurse6 recalled:
That fellow I was talking about who lost all those limbs and his eyes we should have put him aside probably. You say to yourself, ‘God, what am I doing sending this boy home?’I thought of his mother. What is she going to embrace?
At the same time, nurses spoke of learning to distance themselves psychologically from their patients. During mass casualty situations nurses often didn't notice the faces of their patients. They spoke of “building a wall” around themselves to remain emotionally stable. Sometimes they deliberately avoided any personal knowledge that might make their patients more individual. Most never learned the names of their patients. The debate over connection versus objectivity has a long history in nursing, and the problem of trying to maintain emotional distance to remain effective has been in the professional literature since the beginning of the century.9
Less often discussed were the ethical challenges posed by caring for Vietnamese civilians. Because it was difficult to know whether a civilian might not be an enemy fighter, nearly all Vietnamese people were suspect. A nurse recalled her emotions when she had to care for a Vietnamese infant. Her first reaction was reluctance. After all, this orphan could have been a baby of “the enemy.” At first, she only propped the bottle for the baby, but after a while, she held the baby during the feeding. “How, I wondered, had I ever come to believe I hated a baby? I had lost all perspective and I knew it.”7
Some nurses didn't want to treat Vietnamese casualties at all. One nurse has never forgotten her sense of outrage at another nurse who ignored dying Vietnamese patients caked with mud who had been buried alive by Viet Cong. She was shocked that her subordinate, who was not busy at the time, did not offer them any care or comfort.
“I really believe that nurse should have been court marshaled [sic].”6
Many nurses remembered feeling angry and confused when caring for Vietnamese patients. As one6 explained:
“We'd shoot them up, burn them up, and then we take care of them. It wasn't that I was disillusioned. I'd say I felt more confused.”
A nurse7 commented about being at the Third Field Hospital in Saigon where she was caring mostly for Vietnamese civilians: “It was very confusing. I hadn't gone there to minister to them.”
Others remembered overcoming their initial responses to caring for Vietnamese: “I sat down and really looked at this Vietnamese as a human being. And what I saw was a fourteen year old kid.”7
If caring for Vietnamese civilians sometimes seemed pointless for American nurses, caring for Vietnamese prisoners of war caused even more turmoil and conflict. One nurse recalled rationalizing that a high-ranking prisoner of war was someone with a great deal of useful information and that once he was interrogated, this information might save American lives. She remembered thinking: “Do I want to keep this guy alive to save one hundred GIs? Or do I want him to die because he's killed one hundred GIs?”7
Adding to the confusion was the American soldiers' reaction to hospitalized prisoners of war. After one nurse remarked while on duty about the irony of having military police guard prisoners of war without legs, she was told that the military police were there to keep the wounded American soldiers from fighting with the prisoners of war. But the behavior she actually witnessed in American soldiers was almost invariably solicitous toward the wounded prisoners of war. She commented7: “I never once saw a GI try to harm a POW. What I saw was ‘Hey lieutenant, come quick—the gook over there is in a lot of pain; would you give him a shot’. Times like that you couldn't help but wonder what we were in the war for. I mean what was it all about?”
Responsibility and powerlessness
American nurses in Vietnam experienced great disruptions in their personal and professional lives as well as threats to their sense of idealism and unexpected ethical challenges. Many times they were morally outraged at what was happening to young soldiers. Because there was no defined front and thus no safe zone, nurses were exposed to combat conditions more than nurses in previous wars. Although only 1 nurse was killed by direct enemy fire in Vietnam, others were killed in helicopter crashes and many nurses described being under attack, donning helmets and flack jackets, and running for bunkers. Nurses found themselves in the very midst of war, tending to a flood of wounded young men whose injuries were appalling. They felt a great sense of responsibility for their patients coupled with a sense of powerlessness to prevent the injuries that were all around them.
The nurses were assigned to give care. Older than the soldiers, they often felt they stood in for the soldiers' mothers and sisters. Their hearts were torn by the injuries they witnessed, and they questioned the purpose of war and the responsibility of those who sent such young men into battle. However, there were also confounding reports in the nurses' accounts of their experience in Vietnam as a peak professional experience, with many describing a formative experience of nursing at its very best.
Professional peak
Although nurses in Vietnam experienced a simultaneous sense of responsibility and powerlessness, they also discovered themselves in a situation of intensified professional challenge, a situation in which they might prove themselves. It is paradoxical, perhaps, that many nurses would subsequently describe their time in Vietnam as a high point in their careers. One nurse7 put it this way:
“We did wonderful, wonderful work. I can't even imagine anything else I could have done where it would have felt more satisfying. In Vietnam I worked harder than I ever have, and I did more good. Thinking back, it just amazes me.”
Many nurses recalled the hard work, the challenges, and the rewards of nursing in Vietnam. On reflection, it surprised them that this experience was one of the most significant and satisfying of their careers. One nurse6 called it a “moment of greatness” that occurred in such a way that “you didn't even know what happened.”
Many nurses mentioned the element of teamwork in their experience of professional effectiveness. Nurses felt crucially important to the effort of saving soldiers' lives. The usual professional hierarchy of their hometown hospitals was noticeably absent and was replaced by collegial relationships with physicians and others.
It may be worth noting that many nurses held the same military rank as physicians, and this may have leveled the usual sense of professional hierarchy. But beyond this, nurses felt respected and appreciated by both physician colleagues and patients. Soldiers appreciated the fact that most nurses volunteered for duty in Vietnam. Nurses were admired for their courage to work under hazardous conditions and for enduring the privations of military life in Vietnam.
Norman8 commented that the absence of family and old friends heightened the nurses' dependence on colleagues in Vietnam. In her study of 50 Vietnam nurse veterans, Norman8 found that 55% reported that their friendships in Vietnam were among the most intimate of their lives. This intimacy and spirit of camaraderie were corroborated in her later work10 with nurses taken prisoner on Bataan during World War II. Most nurses mentioned having strong feelings of camaraderie with other nurses, physicians, and medics while in Vietnam.
“I think most of us got by sharing with one another. Friendships, talking—I met the most beautiful people of my life in Vietnam. Yeah, if there was ever an example of brotherhood and helping and doing and love, that was it. I really feel I was very fortunate and very blessed to go to Vietnam.”7
In addition to the strong sense of camaraderie, nurses believed that serving in Vietnam enhanced their sense of professional competence. Although they felt inadequate on arrival and occasionally helpless in the face of overwhelming injuries, most nurses eventually reported feeling effective and competent. Holm1 reported that 98% of the wounded patients who entered American military hospitals in Vietnam survived. Although this figure does not account for the death toll before patients reached the hospital or the great disability and loss soldiers faced later, it nonetheless justifies the feelings of success nurses felt in the immediate work of saving lives.
Nurses found themselves performing duties beyond their expected roles—putting in chest tubes, performing surgery and closing wounds—all this at a time when nursing was much more limited in scope and more closely regulated at home. Recalling the role of nurses during this period, a nurse11 reflected on civilian practice:
“Comical though it must sound today, in the 70s nurses did not routinely carry stethoscopes, much less use them for anything except blood pressures. We were neither educated nor expected to listen to breath, heart, or bowel sounds. Physicians started and managed IVs; central lines did not exist, nurses did not draw blood. Only the head nurse spoke to the doctors.”
The break with traditional roles in Vietnam enhanced the sense of a medical team dedicated to a common cause and doing what was necessary to save lives. Nurses who exceeded previous role boundaries were rewarded by success and a sense of effectiveness. Because of the exigencies that existed in military mass casualty situations, nurses were called on to perform procedures they were not permitted to do in US hospitals. Performing beyond role expectations often contributed to confidence and professional growth. Within the supportive camaraderie of a highly functional team saving lives, nurses could be expected to feel confirmed in their professional performance.
A number of nurses mentioned the greater sense of authority and appreciation they had in Vietnam. In Vietnam, nurses had the chance to do what they felt professionally accountable for. The practical expansion of their role and the loosening of traditional hierarchy allowed them to feel a greater sense of their own effect, and this translated to a greater sense of professional authority. Being responsible for things one has no real control over is a difficult and unrewarding position. Even though nurses had no control over the conditions of war, they did have increasingly appropriate authority in practice, and this may be what made nursing in Vietnam ultimately a satisfying professional experience for many.
The occurrence of a satisfying professional experience under conditions of such disruption and challenge is somewhat paradoxical. The disparate elements of experience resulted in disorientation and moral conflict but also in a sense of confidence on the basis of the ability to respond effectively. Nurses did save lives. They also offered comfort and care. By doing so, they ultimately became professionally real.
Becoming real
Given the challenging environmental and clinical conditions, one of the more remarkable themes in these oral histories was the development of a strong sense of professional confidence. This is particularly striking because most of the nurses arriving in Vietnam were young and inexperienced.
According to the Random House Dictionary of the English Language, “real” means something genuine and true, not artificial, fraudulent, or illusory. It also means having an objective, independent existence. Caregiving professionals become authentic not just by formal education but through the practical experience that grounds education and becomes the matrix for professional change and growth. Practical situations that support the performance of professional duty are an effective catalyst for authenticity.
Much of the experience in the caregiving professions is acquired gradually in ordinary practice. However, situations occasionally arise in which professional experience is intensified and accelerated. For a number of nurses, Vietnam supplied this sort of situation. It was not the only situation in which nurses could become professionally real but it was an intense, critical situation. The experience of nursing in Vietnam was a crucible for those who withstood its harshness and who thereby came into a genuine sense of professional authority (Box 1). This notion of becoming professionally real may have contributed to the nurses' frequent mention of Vietnam as the ultimate nursing experience. For it is the situation and one's effectiveness in the situation that define how professionally genuine one feels.
Professional authenticity
“Vietnam was the ultimate in nursing experiences. It taught me that I was a good nurse, that I could function with minimum equipment under maximum stress.”2 “But Vietnam showed me what you can do what can be done as a nurse. It was the best nursing experience I'll ever have.”2 “Vietnam taught me that I was capable, pretty much of handling anything.”2 “I would never have given up the experience of going over, because when I got back I was a far better nurse than I could have hoped to be had I stayed in the states.”3 “I have lived all of my life situations here I had no power. Vietnam was about the only exception.”2 “It was a wonderful, horrible experience. I felt that everything that I had ever learned in my career, I put to use in Vietnam. I felt that I was in control. I wasn't a subservient individual. Vietnam gave me a feeling of accomplishment. I actually had the power to do what I wanted to do.”2
Nursing in Vietnam was a formative professional experience because it provided a challenging, professionally intense situation in which nurses were permitted the power and authority to meet their responsibilities in an effective and dramatic way. Teamwork and a spirit of camaraderie helped them meet the challenges of adjusting to personal and professional change. Nurses witnessed great hardship and suffering, but they were also instrumental in bringing order and comfort to American and Vietnamese soldiers. Even though they often felt dispirited by the tide of suffering, they had daily proof of their effectiveness. For many, whose stories are told here, meeting these challenges allowed them to become genuine nurses and achieve a marked sense of professional identity early in their careers.
This research corroborates previous work by Norman8 of nurses during combat nursing in Vietnam and pulls together common elements from 2 collections of individual oral histories.6, 7 It also serves to open a dialog on how nurses become authentic professionals.
The nursing profession has been profoundly influenced by Nightingale's notion of a heroic and noble dedication to the public good, so it is perhaps not surprising that the crucible of war should confer a particular sense of professional authenticity. Although this is not the only pathway by which nurses become professionally genuine, it would be useful to further examine elements mentioned in these accounts, such as camaraderie, hardship, and heroism as potential contributors to professional authenticity. Future research might pose the question of how professional authenticity is first achieved. Such work could have an impact on the recruitment and retention of nurses and prove valuable in the current nursing shortage.
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