Warrior nurse: duality and complementarity of role in the operational
 environment
 Lauren Griffiths & Melanie Jasper
 Accepted for publication 15 August 2007
 Correspondence to L. Griffiths:
 e-mail: lgriff02@bcuc.ac.uk
 Lauren Griffiths BSc MA PhD CertEd ARRC
 Portfolio Leader for Practice Learning
 Faculty of Health, School of Pre-Registration,
 Buckinghamshire Chilterns University
 College, Buckinghamshire, UK
 Melanie Jasper BNurs MSc PhD RN RHV
 RM PGCEA
 Head of School of Health Science
 Faculty of Health Science, University of
 Wales, Swansea, Wales, UK
 GRIFFITHS L. & JASPER M. (2008) Warrior nurse: duality and complementarity
 of role in the operational environment. Journal of Advanced Nursing 61(1), 92?99
 doi: 10.1111/j.1365-2648.2007.04469.x
 Abstract
 Title. Warrior nurse: duality and complementarity of role in the operational envi-
 ronment
 Aim. This paper is a report of a study to explore the nature of military nursing in an
 environment of war, in particular the union of personal, professional and organi-
 zational tenets and to identify the actual or potential effect this had on the nursing
 role in this unique environment.
 Background. The history of nursing is intrinsically linked with war. There is an
 irony to this relationship. Active involvement with military activities has provided a
 vehicle in which nursing has developed, albeit through fostering war, which itself
 destroys health and contravenes the ethos of nursing. Military nurses, one would
 assume, are able to reconcile the dichotomy existing between their caring role and
 being a member of an organization associated with conflict.
 Methods. A grounded theory design was adopted and the data were collected from
 1999 to 2002 using a series of in-depth interviews and focus group with of 24
 military nurses.
 Findings. Three categories were identified: ?It?s Just Different Levels?, ?That Double
 Hat? and ?It?s Who We Are!? The first illustrates the reality of conflict. ?That Double
 Hat? outlines the military nurses dual role: those of caring and the military. ?It?s
 Who We Are!? demonstrates the transition from nurse-to-warrior. These integrate to
 create the core category: ?Caring for War: Transition to Warrior?.
 Conclusion. The symbiotic relationship of carer and warrior arises as a conse-
 quence of strategies used by military nurses to embrace their dual role. Further
 research is needed to explore the essence of the caring role within a conflict zone
 from military and civilian perspectives.
 Keywords: dual roles, grounded theory, military nursing, nursing roles, operational
 duty
 Introduction
 For those not involved in military activities, the concept
 of nursing in an organization involved in peacekeeping
 and war fighting is viewed as contrary to the beliefs and
 values that underpin health care. Furthermore, war is an
 antithesis of health on all levels; spiritual, physical,
 psychological and economical (Crowe & Hardill 1991).
 ORIGINAL RESEARCHJAN
 92  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
However, from the origins of the human race, war has
 been an integral part of history (Keegan 1997), with a
 close liaison between medicine and war dating back to
 antiquity (Lim 1997).
 Until the era of Florence Nightingale nursing, on or near
 a battlefield, was officially confined to men or those in holy
 orders (Edwards-Rees 1965). The catalyst for the employ-
 ment of appropriately-trained women to nurse casualties
 arising from the Crimean war of 1854?1856 was the
 graphic portrayal of the plight of the soldiers at the
 battlefront by war correspondents (Hudson & Stanier
 1997). Thus, Florence Nightingale was approached to lead
 nurses to Scutari to care for the sick and injured (Edwards-
 Rees 1965). As groups of nurses moved into other avenues
 of care during wartime, their worth became apparent
 (Taylor 2001). Ultimately, this led in the United Kingdom
 (UK) to the formation of the Royal Navy, Army and Royal
 Air Force Nursing Services.
 World War I saw the recruitment of many military
 nurses (Summers 2000) and the portrayal of nursing
 endeavours in this war greatly assisted the recruitment of
 nurses in World War II (Summers 2000). However, unlike
 their predecessors, who were civilian nurses either called to
 serve or who chose to serve their country during wartime,
 contemporary military nurses are career nurses (Bassett
 1997), and for many the military is their chosen career
 pathway, either full- or part-time as a member of the
 Territorial Army. The adoption of rank, uniform, weapons
 and taking part in general military and annual weapons
 training, coupled with prior experience of the military
 environment in peacetime and conflict situations, makes
 them ?of the military? (Bassett 1997). Henceforth, military
 nurses belong to two professions, those of caring and the
 military, and embrace the ethos of both. Inherent within
 the dual demands of military nursing is the tension
 between professional responsibilities and military obliga-
 tions (Hawley 1997). No specific research exploring the
 duality of the military nursing role came to light during the
 study.
 The study
 Aims
 The aims of this study were to explore the nature of military
 nursing in an environment of war, in particular the union of
 personal, professional and organizational tenets and to
 identify the actual or potential effect this had on the nursing
 role in this unique environment.
 Methodology
 Strauss and Corbin?s (1998) model of grounded theory was
 chosen. This approach aided the discovery of a conceptual
 framework that goes some way to explain and capture the
 complex world of the modern military nurse through and
 from their world view.
 Participants
 Participants were recruited from the UK Royal Navy, Army
 and Royal Air Force. The inclusion criteria required partic-
 ipants to be regular serving members of the military who had
 worked in a conflict zone within the last 10 years. Participant
 demographics are detailed in Table 1.
 Data collection
 The use of in-depth interviews provided a forum where face-
 to-face exploration of the participant?s world could be
 undertaken. Interviews were scheduled through negotiation
 with the participants. Phase 1, open sampling, involved
 purposive sampling where participants were targeted on the
 basis of their military/nursing role, their operational experi-
 ence and therefore what they might contribute to the study.
 Open sampling started in October 1999 with five military
 nurses interviewed. Phase 2 involved selective sampling,
 where ?information rich? participants were approached to
 enable comparative analysis to take place. This resulted in a
 further 10 military nurses being interviewed. The interviews
 lasted between 45 and 90 minutes. Phase 3 involved theo-
 retical sampling to form a focus group of eight military nurses
 Table 1 Participant demographics
 Demographics Range
 Queen Alexandra?s Royal Naval Nursing Service 2 participants
 Age (years) 26?40
 Years of nursing experience 11?14
 Years of military nursing experience 11?14
 Operational experience 1?3 tours
 Queen Alexandra?s Royal Army Nursing Corps 16 participants
 Age (years) 25?45+
 Years of nursing experience 4?5?25
 Years of military nursing experience 5?26
 Operational experience 1?4 tours
 Princess Mary?s Royal Air Force Nursing Service 6
 Age (years) 26?40
 Years of nursing experience 5?15
 Years of military nursing experience 1?16
 Operational experience 1?2 tours
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and lasted for over 2 hours. All interviews were audio-taped
 and transcribed verbatim.
 Ethical considerations
 This study was approved by the appropriate military and
 university ethics committees. A research contract was drawn
 up to provide potential participants with information on the
 study aim, how the principle of confidentiality would be
 upheld and how the concept of anonymity would be applied
 to all study data. More information was given to the
 participants prior to the interviews and on signing the
 consent form, which included consent to audio-tape the
 interview. Participants were reassured that they had the right
 to withdraw from the study at anytime without prejudice.
 Data analysis
 In keeping with the grounded theory approach, constant
 comparative analysis was used (Strauss & Corbin 1998). This
 allowed the analysis of all sources of data simultaneously as
 well as a cross-interview analysis to shape future interviews
 (Strauss & Corbin 1998). Although the process appears as
 discrete stages in Figure 1, in reality the stages were
 undertaken simultaneously and in no particular order.
 Data analysis was undertaken by hand in three phases:
 open, axial and selective coding. Open coding started with a
 surface analysis and the formulation of notes identifying key
 areas (Wainwright 1994) and occurred on completion of an
 interview and prior to the next, with line-by-line examination
 of the data to identify patterns and themes (Strauss & Corbin
 1998). Descriptive notes relating to the open codes were
 made (Huberman & Miles 1994), highlighting how they were
 defined and allowing the development of open codes (Wain-
 wright 1994).
 Axial coding allowed data to be sorted and emerging
 patterns identified. Data were merged to form categories,
 which were revised and combined or re-ranked as further data
 were collected. Examples of axial coding included: ?having a
 gun? (related with the dual role of nurse and military
 personnel), ?achieve a balance? (moral stance adopted), ?new
 ways of working? (role definition) ?spiritual need? (safety
 blanket), and ?credibility? (badge of office). These were then
 grouped to formulate sub-categories, ?The Interface of
 Professions? and ?Value Laden Image? and integrated to
 illustrate the nature of the category ?That Double Hat?.
 The final phase, selective coding, resulted in three catego-
 ries: ?It?s Just Different Levels?, ?That Double Hat? and ?It?s
 Who We Are!? These categories came together to form the
 core category of ?Caring for War: Transition to Warrior?,
 capturing the nature and essence of the study. Saturation was
 achieved after interviewing 16 military nurses, when no new
 themes arose. The data were validated and enhanced by a
 further eight military nurses through the focus group. The
 overall analysis led to the development of a substantive
 grounded theory.
 Findings
 The grounded theory
 The symbiotic relationship of carer and warrior appears to
 arise as a consequence of the strategies used by military
 nurses. These strategies create a psychological comfort zone,
 allowing the individual to adopt the persona of warrior nurse
 when needed and thereby allowing them to respond in an
 appropriate way to the unique challenges of nursing in a
 conflict zone. Key rites of passage mark the transition from
 nurse-to-warrior, resulting in what is considered to be a
 seamless change to act out the core category of ?Caring for
 War: Transition to Warrior?.
 Three categories are presented, using pseudonyms and
 direct quotations from participants to illustrate their key
 components.
 Category 1: It?s Just Different Levels
 ?It?s Just Different Levels? summarizes the nature of the
 operational environment from a social and working
 Interview transcript 
Overview (theoretical sensitivity) 
Open coding 
Theoretical notes formed 
Axial coding 
Compilation of memos   
Emergence of the theoretical framework 
Identification of categories 
Development of the grounded theory 
Figure 1 Grounded theory analysis process.
 L. Griffiths and M. Jasper
 94  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
perspective and, in particular, highlights the positive and
 negative impact this has on the nurses? role. The traditional
 image typified by two World Wars gives way to peacekeeping
 and humanitarian aid initiatives at one end of the spectrum
 and high intensity conflicts, such as the First Gulf War, at the
 other (McCorquodale 1997).
 Sub-category: A Changing World
 For each participant, the experience of war is different. The
 level of psychological distancing employed by personnel in
 this situation allows a cocooning society to be established,
 with defined physical and psychological barriers:
 You were almost detached from the whole situation, because we were
 100ks back off the frontline, so apart from the alarms going off for
 the scud attacks that was about the only thing that really made you
 think ?Oh, maybe I could be in danger? (Jayne ? First Gulf War:
 Army)
 The sense of threat is therefore cushioned by distance and
 they are able to detach themselves from what is happening as
 they are removed from the reality of war (McManners 1994).
 Therefore, those to the rear of the battlefront have different
 perceptions and experiences of the conflict from those
 positioned at the front.
 The involvement of British forces in complex political
 conflicts has given rise to a range of diverse operational roles.
 Role in this context is not ring-fenced or tethered to or
 constrained by the physical environment:
 The time I went operational it was a fairly new concept putting the
 Aeromed Liaison Officers with field units. So, nobody knew what we
 were going to do. (Patrick ? Bosnia Peacekeeping Mission: RAF)
 The developmental aspect of Patrick?s role signalled new
 ways of working and the re-defining of role boundaries, as it
 was considered to be a ?new concept?. For some, this took
 them into new roles that required military rather than nursing
 skills.
 Sub-category: The Human Impact of War
 Involvement in peacekeeping and humanitarian aid opera-
 tions potentially exposes members of the military to an
 environment where moral dilemmas not previously encoun-
 tered may be prevalent. Respect for humanity and the value
 of life become lost amid the blatant hatred displayed by
 hostile parties:
 The worse thing was seeing all the ruined houses and kids on the side
 of the street begging for food. Seeing the way the Serb militia had
 daubed the walls with some of the atrocities they had committed in
 the houses. (Tom ? Peacekeeping Enforcement Mission Bosnia: RAF)
 The human impact on an individual?s needs, whereby
 children are ?begging for food?, housing is ?ruined? and safety
 no longer assured, is evident. Individuals resort to creating an
 environment of fear and violence, where atrocities are a
 common event and human trophies are used to heighten and
 maintain that fear culture (Glover 1999). Fran highlights the
 problems associated with maintenance of a neutral position:
 When you saw what was happening to the Kosovo Albanians and
 you heard about the rapes, the murders, the slaughtering and the
 separation of families and just the complete brutality of it all, it was
 very difficult to try and keep that centre ground. (Fran ? Peace
 Enforcement Mission Macedonia: RAF)
 Their moral discomfort is exacerbated further by the confines
 of the role specification, defined by the overall military
 operational mission, and their inability to move from that
 ?centre ground?. The participants? narratives illustrate an
 altered reality arising from the operational environment, and
 in particular the human impact of conflict.
 Category 2: That Double Hat
 ?That Double Hat? illustrates the nature of simultaneously
 being a member of two professions. Participants acknowl-
 edged their duality, in terms of their roles, authority,
 responsibility and accountability. Challenges inherent with
 the dual professional status were highlighted, the nature of
 which is outlined within two sub-categories: ?The Interface of
 Professions? and ?Value Laden Image?.
 Sub-category: The Interface of Professions
 The conflict zone places unique demands on healthcare
 practitioners in terms of balancing their caring and military
 roles to ensure that they remain within the codes of practice
 of those professions:
 It?s job role at the end of the day. I?m not just answerable to the
 military, I?m answerable to the civilian side also and at the end of the
 day the c**p stops at my door! (Sandra ? Peace Enforcement Mission
 Bosnia: Army)
 The obligation to the military is apparent but there is also
 acute awareness of professional/statutory requirements. The
 use of ?job role? by Sandra implies that there are specific
 identifiable skills related to her practice that are well-defined
 in terms of rights and duties and are clearly expressed in the
 term ?answerable?.
 Unlike their civilian counterparts, military nurses may find
 themselves having to adopt a ?Jack-of-all-trades? position;
 general clinical skills are more desirable and serve to assist
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  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd 95
nurses to adapt to clinical demands in a conflict situation.
 Equally, military nurses can assume a number of sub-roles,
 sometimes extending far beyond the traditional boundaries of
 caring:
 I was, at the time, the most far north RAF Officer in the Bosnia
 operation and the only RAF person in the whole Brigade (Army)
 area?. So I ended up almost running a mini air desk. I was also the
 local Met(eorology) man. So that double hat was sometimes a
 quadruple hat: collating the weather, doing the taskings and the aero-
 med and clinical role as well. (Patrick ? Bosnia Peacekeeping Mission:
 RAF)
 In this situation, Patrick has assumed roles which are
 associated with a general duties RAF officer, organizing a
 helicopter booking system and collecting and collating the
 weather forecast for aircrew. His multiple roles demanded
 competency in a number of roles.
 Sub-category: Value Laden Image
 Although there has been a gradual shift towards the milita-
 rization of nurses over the last century (Bassett 1997; Taylor
 2001), the role expectations associated with nursing remain.
 The military uniform is a powerful statement of authority
 that clearly signals the scope and boundaries of the role and
 the associated skills and behavioural expectation, as does the
 traditional uniform of nursing. Even when the traditional
 stereotypic image of a carer is not evident, the caring role
 remains present and is seen in isolation from the military role
 and its associated value system:
 ?the padre is fantastic at welfare. However, you see him as the
 padre, you don?t see him as a Captain, Major or whatever. That is
 probably why we still have this issue of credibility, where they don?t
 see us as Army people ? they see us as people who are going to patch
 them up when they are injured. (Geraldine ? Bosnia Peace Enforce-
 ment: Army)
 The caring role is aligned to ?welfare? and is seen in the
 context of someone who will ?patch them up?, rather than the
 warrior role or being ?Army people?. In other words, rank
 and the associated position in the military is considered to be
 subordinate to the overriding caring ethic. The issue of
 credibility, associated with being a member of two profes-
 sions, is also viewed as problematic in that nurses are not seen
 as ?Army people?.
 Category 3: It?s Who We Are!
 ?It?s Who We Are!? captures the notion that military nurses
 are comfortable with their dual authority, as well as the
 challenges to their role and professional position. The high
 contrast roles of nurse and warrior allow them to cross these
 boundaries with relative ease, as each is clearly defined in
 terms of responsibility and authority. The two sub-categories
 of ?Warrior Nurse? and ?Their Story? illuminate the social and
 psychological processes used by military nurses in a war zone.
 Sub-category: Warrior Nurse
 Under the auspices of North Atlantic Treaty Organisation
 (NATO), personnel were able to exercise their rights as a
 soldier, which allowed them to use their weapons for pro-
 tective purposes. External pressures are fundamental to the
 transformation from nurse to warrior. Integral to this change
 is the movement from one role to another, where the indi-
 vidual changes from the expected behaviour of their civilian
 profession (nursing) to that associated with another social
 system (Allen & van de Vliert 1984), in this case the role of
 warrior:
 We set up, with the Gurkhas, a disco for the under 10s in a local
 village. We were on the way back, we had broken curfew, but had
 permission to be out late. We were in an open top vehicle and we
 only had 10 live rounds amongst us. The armoured vehicle with the
 Gurkhas that was supposed to be protecting us seemed like it was at
 least a mile behind. Suddenly we came to this civilian roadblock.
 I leaned over, out of the vehicle, to see what was going on and it was
 an armed roadblock. At the time I just thought, ?Oh my God! Me or
 them!? I just went, ?Well make yourself ready?. I basically flipped my
 safety (catch) off and switched to automatic (fire). I thought, ?I?ve got
 10 rounds, I will spray?. As we were getting ready, the armoured
 vehicle came and ploughed them (the civilian roadblock) off the
 road?I never thought I would just flip my safety (catch) off and point
 my weapon and actually use it. I still don?t know if I would, to this
 day, but I was prepared to at that point. (Sandra ? Bosnia Peace
 Enforcement Mission: Army)
 The military ethos becomes dominant and the roles assumed
 by personnel are based on military rules, regulations and
 tenets to facilitate the adoption of a ?combatant? stance. In
 this instance, the transformation from nurse to warrior is
 triggered by the direct threat, allowing them to cross from
 one profession to another (Burr 1972) and disengaging from
 the role of nurse to engage with the role of warrior. The
 intention to fire is clearly stated, with acknowledgement that
 to fire the gun would take Sandra away from the philosoph-
 ical base of ?save a life, not take one?. The highly contrasting
 roles of nurse and warrior allow a degree of compartmen-
 talization of identities (Ashforth & Mael 1989, Nippert-Eng
 1996). To move from one professional base to another, there
 is a requirement for the ?mental fences? (Zerubavel 1991) that
 separate each role to be negotiated and overcome. Partici-
 pants achieve this by responding to the environmental
 L. Griffiths and M. Jasper
 96  2007 The Authors. Journal compilation  2007 Blackwell Publishing Ltd
challenge, which in this case is a direct threat to life, by
 mobilizing the innate instinct to survive.
 Sub-category: Their Story
 Military nurses are required to be multi-skilled to respond to
 the dynamic environment of a conflict zone. To become an
 integrated and effective member of the military family, a
 practitioner must be adaptable and flexible and able to rec-
 oncile the conflicting identities of nurse and warrior:
 I?m comfortable with who I am and what uniform I wear...it allows
 you to concentrate on what you are actually there to do. What we are
 interested in is ?Can you do your professional job in the environment
 of the field?? I think that is a key skill for the military nurse. (Philip ?
 First Gulf War: Army)
 Military nurses are considered to be ?professional warriors? in
 that they hold a dual professional position and consider the
 codes and values of the professions to be in harmony. This
 allows an individual to ?concentrate? on their operational
 role. Doing a ?professional job? in the difficult conditions
 associated with the ?field? is considered to be of great
 importance. Socialization, training and identification with
 the professional standing of military nursing are therefore
 central to reconciliation of the two roles, in that the processes
 enable the individual to be socialized into the wider military
 organization.
 Core category: Caring for War: Transition to Warrior
 The categories, ?It?s Just Different Levels?, ?That Double Hat?
 and ?It?s Who We Are? and their associated sub-categories,
 combine to formulate the core category ?Caring for War:
 Transition to Warrior?, diagrammatically represented in
 Figure 2. The core category summarizes the processes within
 the categories to illustrate their world and illuminate the
 strategies used by military nurses to embrace the transition to
 warrior. The socially-structured processes and strategies used
 by military nurses are illustrated by the enactment of the core
 category.
 Study limitations
 The study limitations are primarily associated with the study
 cohort and the timeframe between the last data collection
 phase and publication. At the start of the study, few Royal
 Navy nurses had been involved in front-line operational
 duties. Latterly, they have played an active role in a broad
 spectrum of conflicts, including undertaking roles that were
 The spectrum of conflict
 The changing
 world
 The human
 impact of war The interface
 of professions
 Value-laden
 image
 The profession of arms
 Category & profession of caring 
It?s just different levels
 That double hat
 CORE CATEGORY 
?Caring for war: transition to warrior?
 Caring warriors
 Category
 It?s who we are!
 Warrior nurse Their story
 Category
 Figure 2 Mapping the concepts.
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traditionally ring-fenced for a particular service, e.g Army
 nurses. This study is therefore time-bound, a snapshot of their
 lived experience. It would be reasonable to expect any
 replication of this study to include a higher number of Royal
 Navy nurses.
 The data collection phase of the study was completed in
 2002. However, the findings remain current and continue to
 be validated through the lived experiences of military nurses
 serving in Iraq and Afghanistan. Despite the change of
 location, the nature of modern conflict remains extant, as
 does the evolving role of the military nurse.
 Conclusion
 As the involvement of military nurses in conflicts continues,
 the importance of adequate preparation for the range of roles
 they are required to adopt should not be under-estimated.
 They require adequate and appropriate military and profes-
 sional training to enable them to function at an optimal level,
 and flexibility and transferability of skills are central features.
 A multi-skilled workforce allows the military to respond to
 the competing and changing demands prevailing within a
 conflict environment so they can reasonably meet these.
 It is vital that military nurses are able to work alongside
 mainstream military personnel, including United Nations and
 NATO personnel, Non-governmental Organisations (NGOs)
 and local civilian organizations, to ensure that optimum care
 is given to injured military personnel and the local civilian
 population. The experiences of military nurses will be
 relevant not only to military nurses, but also to NGOs and
 other civilian organizations working in conflict zones.
 Although members of these other organizations do not carry
 arms, the challenges prevalent within that environment pose
 similar challenges to their roles. Specific preparation and
 opportunities for shared learning with all parties, military
 and civilian, would be beneficial prior to entering that
 environment.
 Further research is required to capture the essence of the
 caring role within a conflict zone to prepare military, NGO
 and civilian personnel for their work. Undertaking further
 research in this unique and under-researched field will
 contribute to the development of the substantive and/or
 grand theory: further research should include support and
 military personnel and make comparisons with NGOs, such
 as the Red Cross or Me`dicins sans Frontie`res.
 Author contributions
 LG was responsible for the study conception and design and
 LG and MJ were responsible for the drafting of the
 manuscript. LG performed the data collection and data
 analysis. LG made critical revisions to the paper. MJ
 supervised the study.
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 ? The world of the contemporary military nurse is com-
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 ? The roles of soldier and carer may be in conflict at
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 ? Further research is needed to explore the essence of the
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