Experiences of Swedish Military Medical Personnel in Combat Zones: Adapting to Competing Loyalties

MILITARY MEDICINE, 179, 8:821, 2014 Experiences of Swedish Military Medical Personnel in Combat Zones: Adapting to Competing Loyalties Kristina Lundberg, MDiv*; Sofia Kjellstro m, PhD ; MAJ Anders Jonsson, CF5* ; Lars Sandman, PhD* ABSTRACT Objectives: The aim of this qualitative study is to explore the Swedish military personnel s experience of what it means to perform a caring role in a combat zone. This study assesses the challenges faced by military medical personnel in the context of a combat zone. Methods: The design was descriptive with a qualitative inductive approach. Twenty military medical personnel (physicians, nurses, and combat lifesavers) were interviewed individually. They had been involved in international military operations between 2009 and 2012. This study was analyzed using qualitative content analysis. Results: The analysis produced four categories: being in a primarily noncaring organization, caring in emotionally charged relationships, lacking an open dialog about expectations of killing and having to prioritize scarce resources. Conclusions: This study shows that medical personnel easily adapt to a military setting. They care but also perform other tasks when they are in a combat zone. The medical personnel want to give care to host nation but use drugs they can spare. INTRODUCTION Sweden has a long tradition and history of participating in peacekeeping operations. 1,2 During these operations, Sweden contributes beyond a military contingent with medical personnel, i.e., physicians, nurses, and combat lifesavers. 3 According to International Humanitarian Law, 4,5 the medical personnel accompanying the armed forces are obliged to care for their own troops, both allied and civilian, as well as the enemy, injured in the event of war, without any adverse distinction based on gender, race, nationality, political opinions, religion, or any other similar criteria. Physicians and nurses are recruited from the civilian health care service. Physicians often have a surgery or anesthesia background, and nurses often have a prehospital background. Combat lifesavers are unlicensed medical personnel, 6 and their training is based on the NATO Stanag document. 7 DUALISM OF ARMED FORCES AND CARE PROVIDERS The armed forces and medical personnel appear to represent diametrically opposed value systems in the sense that one is prepared to take lives to achieve its objective, whereas the other focuses on saving lives. However, for the military leaders it has always been important to protect their forces, and for the armed forces, the medical personnel play an essential role. 8 Griffiths and Jasper 9 highlight the different value systems, focusing on the dualism of being both in a care organization and in an organization that, as an ultimate goal, can destroy health, and the way nurses cope with this. Being in the two roles, care provider and soldier, may result in an *School of Health Sciences, University of Borås, SE-50190 Borås, Sweden. School of Health Sciences, Jönköping University, PO Box 1026, SE-55111 Jönköping, Sweden. Centre for Defence Medicine, Swedish Armed Forces, PO Box 5155, SE-42605 Västra Frölunda, Sweden. doi: 10.7205/MILMED-D-14-00038 experience of dissonance and conflict and the study adds that further research is necessary in order to explore the essence of their caring role in the combat zone from both a military and a civilian perspective. 9 On the other hand, Kelly 10 explores the relationship between military and civilian nursing but concludes that the combat zone is very different from the emergency room and that the care situation can create a dual loyalty conflict, by being exposed to legal and ethical dilemmas. There is not much research on how military medical personnel experience their situation. There is one study of Swedish medical personnel in UNIFIL (United Nations Interim Forces in South Lebanon), from 1989, 11 where it was concluded that most interviewees adjusted well to the military context and wanted to go on another UN (united mission) operation. In their study of nurses lived experience of being in combat zones in Iraq and Afghanistan, Scannel-Desch and Doherty 12 focus on how nurses handle the initially unknown environment, how they stay in contact with their families at home, and how the combat zone both broadens and deepens their clinical skills. Given all the traumas the nurses in Scannel- Desch and Doherty s 12 study had to handle, they acquired unique experience that made them become more confident as nurses. When it comes to the joint experiences of physicians, nurses, and combat lifesavers, including places other than Afghanistan and Iraq, we did not find any earlier research. However, there is a large amount of research on the experiences of emotional wellbeing and post-traumatic stress disorders among soldiers in general. 13,14 Many feel stressed and mentally ill after an operation. 13 15 The military personnel do not utilize the opportunity to talk about their own emotions to its full extent when the operation is finished, even if they are encouraged to do so. 15 Support is generally offered to the individual soldier after each operation. 16 According to the values of the Swedish Armed Forces, it is important to be open-minded. 17 At the same time, among Swedish military personnel, confidence within the organization is sometimes MILITARY MEDICINE, Vol. 179, August 2014 821

missing and they suspect that their experiences are documented and reported to military chiefs. This phenomenon, or stigmatization, 18 is found in a number of different countries armed forces. 19 If they suffer from emotional shortcomings, they talk about it within the unit. In essence, even if there are some studies showing a certain dissonance between the caring and military role, there is a lack of recent in-depth research on the experiences of military medical personnel acting in combat zones that could create a basis for deepening the understanding of their situation and provide background for the further development of training and preparation. However, the general lack of studies motivate an open approach to the experiences of medical personnel, and the results of earlier studies are therefore only seen as a background and not fully as working assumptions to this study. The aim of this research is to explore the Swedish military medical personnel s subjective experience of what it means to perform a caring role in a combat zone. METHOD A descriptive qualitative design and individual interviews provided the method for this study. The theoretical framework is based on military medical personnel s own lifeworld perspective. 20 Participants It was estimated that 20 participants were sufficient to bring variety and still provide manageable, representative data material to analyze. The inclusion criteria required participants to be Swedish citizens to have been on an international military operation within the last 3 years (2009 2012) and to have a caring position as physicians, nurses, or combat lifesavers, but participants fulfilling these criteria were selected using a sample of convenience. 21 The Swedish combat lifesavers training consists of 5 weeks basic combat lifesaver training, 3 weeks prehospital training, and Tactical Combat Casualty Care. 7 In total, we recruited 20 participants with the characteristics shown in Table I. Data Collection Several measures were taken to inform the participants about the project. First, information was given at medical staff meetings in Afghanistan in the fall of 2011 by the first author. Later, in the spring of 2012, information was sent to the Swedish Centre for Defence Medicine where medical personnel are trained before going on international operations. Information was also put on Facebook and Twitter, and it was spread from person to person during the spring of 2012. No personal outreach took place. The participants actively volunteered to participate. 21 When they contacted the first author, they were given further oral and written information about the project. A time was set for the interviews. Four of them took place in Afghanistan. The rest of the interviews took place in Sweden in different places according to the participants wishes. The medical personnel answered an open question on how they experienced being in a combat zone and the starting question was followed by more in-depth open questions, i.e., questions dealing with their experiences of being medical personnel in the context of a combat zone. The first author conducted and recorded the interviews on a dictaphone. The interviews lasted for 40 to 120 minutes and were then transcribed verbatim. Data Analysis The data were analyzed using qualitative, inductive manifest content analysis, given the aim of exploring subjective experiences and remain close to the utterances of participants. 21 23 The analysis process comprised distinctive stages. First, the research team read through each interview several times and identified meaning units, i.e., phrases or sentences that described or expressed different aspects of the interviewees experiences and feelings. The research team then read the meaning units again to ensure that they corresponded to the purpose of the issue and performed open coding. The first and fourth authors then picked out the codes, after which the research team read the codes again until everyone agreed and collapsed the codes to represent four categories and eight subcategories about the medical personnel s lived experiences in the combat zone. 21 23 Ethical Considerations The research was approved by the Regional Ethics Review Board in Gothenburg (Dnr 1029-11; 2011-12-12). All the informants signed up voluntarily, and all the requirements for informed consent and confidentiality were met. RESULTS Four categories were identified according to the matrix in Table II. TABLE I. Participants Participants Sex Age Places of Assignment Male Female 21 30 31 40 41 50 51 60 Afghanistan Africa (Chad and Central African Republic) Balkan (Bosnia and Kosovo) Physicians 3 2 3 2 5 1 Nurses 2 6 2 6 8 3 4 Combat Lifesavers 7 5 2 7 3 5 822 MILITARY MEDICINE, Vol. 179, August 2014

Categories Being in a Primarily Noncaring Organization Caring in Emotionally Charged Relationships Lacking an Open Dialog About Expectations of Killing Having to Prioritize Scarce Resources TABLE II. Categories and Subcategories Subcategories Adapting to Military Objectives Before Following Caring Norms Suffering Consequences When Prioritizing Caring Norms Finding That Care Has a Low Position in the Military Hierarchy Caring for One of Us Forced to Care for the Enemy Saving Essential Material for Their Own Unit Wishing to Give Even Limited Help to the Host Nation Having to Act in Isolation Being in a Primarily Noncaring Organization The reason the medical personnel are in the combat zone is that they have chosen to enlist with an organization whose main purpose is a military objective in terms of peacemaking efforts using military force. As a result, they perform a supportive caring function in a primarily noncaring organization with an objective that would appear to conflict with the caring objective. The care provider appears to adapt to this situation by taking on tasks that are not primarily caring. At times, their caring instinct gets the upper hand, but at the expense of being disciplined by the organization. Their role in the organization is emphasized by the low status they have as care providers. Adapting to Military Objectives Before Following Caring Norms The threat is not always obvious. Before caring for people from other units or from the host nation, the medical personnel have to perform a body search. Many people from the host nation mix civilian and military attire, and it is then uncertain whether an individual is a friend or an enemy among the medical personnel. The care providers think primarily in terms of military tasks and secondarily about care. As one put it: It s a civilian with a gun on his back and what complicates things even more is that the police forces and the Afghan army are also dressed a bit so-so with an RPG (Rocket Propelled Grenade) on their backs...it s so very difficult to distinguish the enemy. The medical personnel offer health care to the host nation in order to acquire information, What we did was to bond a bit with these CIP (Critical Infrastructure Protection program) guards, 24 we met and talked to them and asked if they also had some care needs. The main purpose is information, so off from a care provider to become a liaison officer with the agendas he or she has, you are supposed to gather information. Receiving information is a kind of force protection in itself, You know how, when and where to avoid meeting the enemy. As a result, the medical personnel primarily refer to the needs of the military and secondarily to the patient s needs, with the explanation, You do things in order to adapt, it s a question of your own survival. The medical personnel know it is against International Humanitarian Law to be on guard duty, So then we were on guard duty, even if we were wearing the Red Cross armlet, but they feel they have to adjust to the military demands, and say that, Interruption as the threat in the environment has become more unstable and you have to increase the number of times you are on guard duty, well, there is no military chief in that state who would say Well, then we are going to interrupt the operation, so they have to try to find solutions...so we meet a little bit, me a little bit, they a little bit but it is a conflict, it is difficult, it becomes awkward at some point, yes... Suffering Consequences When Prioritizing Caring Norms The caring instinct can sometimes disregard the threat when there is a conflict between threat and care. The medical personnel stated in interviews how they ignored the chief s decision not to care for a severely injured colleague lying in the field, even if the military chief determined that it was too risky for them to leave the safe place. However, the caring instinct took the upper hand and they ignored the military chief and provided care anyway. As a result, the medical personnel were given a lower grade, no medal, and were transferred to another unit. Finding That Caring Has a Low Position in the Military Hierarchy In the armed forces, the soldiers have the status and the medical personnel feel they are not real soldiers because the soldiers remind them continuously and give hints like the medical personnel do not do anything. As long as people stay healthy, their work is to be on standby. They must, then, prove their skills when they enter the military arena and show that they are equally good at being soldiers. They feel that as there is some... what could you call it... mistrust of medical care from some soldiers who think it is...it s a little girly perhaps and you need to be pretty much a man to be accepted as a man if you are interested in health care. I think this can still be found in these macho cultures. The consequences when they do this is that they try to be more active on the shooting range and they voluntarily expose themselves to the more dangerous operations in the unit because they feel that others say They bring health care, but they are not real warriors...they are not as sharp as the others (soldiers). MILITARY MEDICINE, Vol. 179, August 2014 823

Caring in Emotionally Charged Relationships Care providers always care in emotionally charged relationships. There are variations, but everyone they care for belongs to a side their own or the enemy s. Then there are different spheres, those who belong to us and are more or less close, and those who belong to the enemy. In the us, they also include people from host nation who are on our side. Caring for One of Us It is difficult to maintain neutral emotions towards the people they care for. They care for different people who are regarded as being on their side. This we are in different spheres: those they live closest to, work with, those in other units, and some they only met in the dining hall or laundry. At the end of this chain, there are the unknown individuals from the host nation who are still on their side. It makes it more difficult to be professional when you more or less know everyone or at least view them as being on your side. Here we mostly help people who are very close to us and this is clearly different from working at home, many of our patients here are close friends. Forced to Care for the Enemy Caring for the enemy is not easy. It is difficult for the care providers to put their own emotions to one side. As they put it, Caring for the enemy who we ve just been in combat with. After that, you may end up in a combat situation and shoot at each other and then you go and you win the fight and you have to care for the enemy, that s difficult. Lacking an Open Dialog About Expectations of Killing The duty of the medical personnel is to care for injured people and save lives and, at the same time, they make themselves battle ready. They go from a caring, life-saving role to the killing role, saying, Somehow, you are going to kill people - that is just tucked away and We are, after all, lifesavers first and now we turn life on and off in the same function... and We should talk about this - how you feel when you ve killed someone. Having to Prioritize Scarce Resources The medical personnel care in a situation where the resources are scarce. Medical equipment is usually limited to what they can carry; they are in the combat zone for a limited amount of time and there is a staff limitation, i.e., they often work alone. Saving Essential Material for Their Own Unit There is a tendency not to provide necessary medication to the host nation if there is a risk that someone in their own unit may need it later on. The caring instinct is tested and they prioritize their own colleagues before the host nation. They hesitate about whether to give the host nation the care they really need. As they say, You wonder...shall we give them (Afghans) oxygen when we are so limited as well or...well, what shall we do? Wishing to Give Even Limited Help to the Host Nation Before each international operation, the medical personnel discuss whether or not to provide health care to the host nation. They often hear that they should not do this because You can t follow up the treatment properly as you are required to do at home..., but the medical personnel keep helping people with the argument that it is better to give a little help than no help at all. The wish to help the host nation is very strong among medical personnel in the Swedish battalions, once they get to the combat zone and see the host nation s lack of resources. When the medical personnel care, they use material their own unit does not need, We have patches and bandages and infusions that we are going to throw away because the date has expired and, if we give it to the locals,...we support them. Having to Act in Isolation The medical personnel can be in a totally isolated location, far from secure camps. They do not always know this in advance; once they get to the combat zone, they wonder where everybody is, saying You have a special position, you are alone...there are so few of each...totally convinced that far from everyone is prepared mentally for it... maybe you are all... The answer to this question is perhaps that you alone are everybody. As one medic said, At home, I always have people (colleagues) around me... Now I might have to work alone in the dark with stress that is perhaps caused by an ongoing battle around me. Being alone creates fear and the responsibility rests on only 1 person. This makes the medical personnel feel insufficient. DISCUSSION The study resulted in three main findings. First, the medical personnel adapt to a military role when they are in the military context and allow that role to override their caring role to some extent. Second, they lack discussions on how they cope with killing. Third, the impact limited resources have for the medical personnel in the military context. Our results show that when medical personnel are deployed in the armed forces and arrive in a combat zone, they allow themselves to perform tasks that are not purely caring. They care, but they care in order to obtain information, which they refer to as force protection. Furthermore, they are on guard duty. The physicians and nurses are provided with a Red Cross ID and are instructed to wear Red Cross armlets in international military operations, according to International Humanitarian Law 4,5 as they are noncombatants. 5 However, the combat lifesavers do not have Red Cross ID, nor do they wear Red Cross armlets; they are primarily combatants. It is a recurring theme that the medical personnel are not always aware of the imperative to carry the Red Cross ID and the armlet, and the implication of wearing Red Cross ID. 824 MILITARY MEDICINE, Vol. 179, August 2014

The medical personnel have low status and, in combination with adapting to the military setting, this so easily makes them want to show that they can handle more duties than health care alone. The point is that it is a flagrant violation of International Humanitarian Law when licensed medical personnel are on guard duty and care to obtain information. 4,5 Our study shows that the medical personnel broaden their military skills once they arrive in the combat zone. It appears to be important for them to fit in with the military forces, so in order to elevate their status, they take on more of a warrior role. Scannel-Desch & Doherty, 12 on the other hand, report how the medical personnel s clinical skills are extended when they are in the combat zone. The Swedish medical personnel are reminded of their low status, even though the armed forces regard them as vital, as described by Enemark. 8 The results also show that there is a lack of discussion about the ultimate consequence of being in a military organization, which is that the medical personnel might have to kill another human being. The medical personnel have actively volunteered, whereas the combat lifesavers are deployed full time in the armed forces and they are all armed. Since there is confirmed research that reveals that many people do not feel good after military operations 13 and that discussions about killings are to a large extent tucked away, 25 it is important to lift this to the surface. The lack of discussions about how it feels to kill is also confirmed by other researchers. 25 In their study, Griffiths and Jasper 9 write that the two roles soldier and care provider may be in conflict. Furthermore, the results show that, even though the resources are scarce, the medical personnel want to care for people from the host nation. When the host nation may need medicine, the Swedish medical personnel give medicine they can spare but save essential drugs in case their own unit needs it. In theory and also in the concrete situation the medical personnel prioritize people in their own unit in favor of people from the host nation, regardless of injury. This is a contravention of International Humanitarian Law, 5 according to which they are expected to care for everybody in need, regardless of who they are. However, this is a topic for other nations as well. Reviewing Michael Gross, Selgelid 26 writes that, when in the military setting, medical personnel are expected to follow orders and obey military regulations. 26 The medical personnel are taught that they should not provide treatment as they are not able to follow up the treatment, according to Paix, 27 who says that performing triage is also necessary in the combat zone. However, Paix says that triage in the combat zone differs from civilian usage. 27 In war, triage is primarily for their own and coalition forces, and secondarily for the host nation and enemy, which is also confirmed by Enemark. 8 Medical personnel at home normally have colleagues, but in the armed forces they can, without being prepared for it, be sent to a distant place on their own. Fry et al 28 discuss the circumstances under which nurses work in the setting of the combat zone and conclude that they live under an immense risk of developing moral distress. It is striking that the medical personnel appear to adapt to the military context so easily and this has already been confirmed by Lundin and Otto, 11 although many of the medical personnel are civilians. There is tension between the military context, International Humanitarian Law, and health care guidelines. If the medical personnel are on guard duty and care is needed, what will then be prioritized by the medical personnel? This tension is foreign to the civilian context, as Selgelid 26 also points out. There is an immediate risk of a mission creep, 29 in relation to the caring role. METHODOLOGICAL REFLECTIONS Credibility of the research was supported by the whole research group being involved in the analysis of data by using quotations from the participants. Dependability and avoidance of risk for inconsistency during data collection was supported by using the same introductory question to the participants. Parts of the result that was considered more controversial were checked against a few of the respondents. However, a possible weakness is that the full result did not undergo respondent validation in that way. On the other hand, the multifaceted background of the researchers (caring science, theology, ethics, and military experience) vouched for the interdisciplinary triangulation. 30,31 Confidence in the interviewer (first author) was established before the interviews, and since she was acting as battalion chaplain in Afghanistan, it was emphasized that the interviews were not a pastoral confession and that the interview would be terminated if this took place; this did not happen. 23 The transferability is determined by the reader. 23 The first and third authors have been in the same context as some of the medical personnel, and it was important to maintain total reflexivity. 30 32 However, there are possible weaknesses with the research. First, we got the participants who actively volunteered and the ones that were interested in the research. Second, if we had made a strategic sample, the sample of combat lifesavers could have included women, which might have affected the result. CONCLUSION It is striking that the Swedish medical personnel adapt, to a large extent and very easily, to the military context. They perform tasks other than caring when they are in the combat zone, i.e., being on guard duty and caring in order to obtain information. It appears to be important for them to fit in, even if this means that they violate their own laws and guidelines. Before going to the combat zone, the medical personnel never talk about how it feels to kill another human being. They want to care for people in the host nation, but, when they do this, they give drugs they can spare. Their ways of performing triage differ from the way they have practiced at home. FURTHER RESEARCH Given the approach of the study, further research is necessary in order to explore and confirm the aspects found in the MILITARY MEDICINE, Vol. 179, August 2014 825

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