Context

Diversity, equity, and inclusion training in academic programming has evolved in recent years to address racial minority and lesbian, gay, bisexual, transgender, and queer populations; an additional special population that merits inclusion in this type of programming is the military-affiliated population.

Objective

Introduce the Campus Green Zone training workshop as an option to incorporate cultural competency for the military-affiliated patient or client population in athletic training programs.

Background

Commission on Accreditation of Athletic Training Education standards identify the need for students to engage with clients or patients who participate in nonsport activities such as those in the military. The Campus Green Zone training program focuses on educating individuals about military-affiliated culture. One athletic training program requested a tailored version of the training for graduate students to prepare them for interacting with military-affiliated patients.

Description

Staff from the institution's Office of Military Affairs presented the training to 2 classes of athletic training graduate students, working in collaboration with the athletic training program's clinical education coordinator, to develop a version of the Campus Green Zone training that would help students reflect on the potential for interaction with clients representing the military-affiliated communities.

Clinical Advantage(s)

By importing a training workshop that is already in use on campus, the instructor saved time researching and deploying cultural sensitivity materials related to the military-affiliated population. By collaborating closely with the staff of the Office of Military Affairs, the training was improved and expanded upon to better serve the needs of the athletic training students.

Conclusion(s)

Athletic training instructors may meet the standard of cultural awareness in part by incorporating Campus Green Zone workshops and materials into their curriculum for graduate-level preservice students.

  • Cultural awareness for the athletic training profession requires an understanding of the military-affiliated population.

  • Campus Green Zone training, like safe zone training, provides an accessible teaching vehicle for athletic training instructors.

  • Incorporation of Campus Green Zone training can instill skills in athletic training students, allowing them to feel more comfortable engaging with military-affiliated patients.

Nationwide, about 200 000 service members exit the military each year,1  and about 669 000 veterans use Veterans Affairs educational benefits to study at institutions of higher learning.2  They, along with their spouses and children, form a unique military-affiliated population. Often considered nontraditional, these learners may enter their institution of higher learning as transfer students, bearing credit translated directly from their military service and from one or more colleges or universities.2  While in pursuit of a 4-year degree, they earn a higher grade point average and have a higher graduation rate, on average, than their nonmilitary counterparts in the adult or nontraditional learner population.3  Due to the increase in military-affiliated individuals entering the realms of higher education, Green Zone training, based on the concept of safe zone training, was created to educate faculty, staff, and students about the unique attributes of these students.4,5  The term Green Zone refers to an area of central Baghdad, Iraq, formally known as the International Zone, which was the government center of the Coalition Provisional Authority.6  This area is considered a safe space due to being extremely protected.5 

With the increasing opportunities for athletic training within military installations as well as with military-affiliated individuals, it is imperative to educate athletic training students on military culture.7,8  Students in a Master of Science in Athletic Training program participated in a customized version of their institution's Campus Green Zone training, a cultural sensitivity workshop that aims to help practitioners understand the characteristics of the military-affiliated population. Multiple standards within the Commission on Accreditation of Athletic Training Education highlight the importance of educating students on the diverse patient or client populations that future athletic trainers could interact with and the importance of understanding their specific needs.9  Standard 17 explicitly mentions that, within clinical education, students need exposure to nonsport populations such as those who are military affiliated. Through competencies focused on patient-centered care (standards 56 and 57), it would benefit students to be knowledgeable regarding military-affiliated individuals to appropriately advocate for their health care needs.9  Additionally, keeping these needs in mind, students also must be able to effectively identify health care delivery strategies that account for health literacy. To facilitate compliance with the Commission on Accreditation of Athletic Training Education standards, we should take active measures to inform our athletic training students to be competent regarding military-affiliated individuals and military culture.8 

Military culture is different from the civilian culture. These differences are intense enough that service members who transition out of the military experience elements of culture shock as they leave the support of the military environment for the free-range atmosphere of a college campus.10  The way student veterans interact with their institution of higher learning can present challenges for faculty and administrators who are not familiar with the military culture.11  College administrations can choose to support military-affiliated students in a myriad of ways, including by offering the Campus Green Zone training program, which is considered a best practice by the American Council on Education.12  Although the Campus Green Zone concept is not standardized nationally, typically, the Campus Green Zone training workshop is geared toward faculty and frontline administrators who work directly with students in all areas of campus and academic life. It is based on safe zone or ally training programs on college campuses and is guided by principles based on a willingness to support military-affiliated students.5  Often the completion of the Green Zone training results in receiving a sticker that can be placed on an office door indicating a military-friendly environment. Veterans have indicated that the simple display of this sticker makes them feel better even if they did not need any assistance.5 

Our organization is a midsized, public institution in a region heavily populated by military members and veterans from several branches of the US Armed Forces. While every state has National Guard components, our state is unique with every military service represented minus the newly created Space Force. Our university supports upwards of 2100 military-affiliated students per year; about 30% of those are veterans or are currently serving, with about 10% who are military or veteran spouses and about 60% who are military dependents.13  The students may be found in a broad variety of academic programs at all levels of the institution, from traditional first-year students on campus to online doctoral students. With access to the largest Marine Corps installation on the East Coast of the United States, Camp Lejeune (Jacksonville, North Carolina), as well as an active local Coast Guard, Army, and Navy reserve units and an Army National Guard unit, the community benefits from the inclusion of the military community.

Because the training is not standardized, it may be flexed to support individual program needs. At our institution, the workshop is offered to faculty and staff several times per year, both in-person and in virtual formats, although it is also offered as a self-paced, asynchronous course in the online learning management system. All employees are welcome to self-enroll in any version of the workshop, and individual departments may request a workshop geared toward their unit's interactions with students or military community members. Registered student organizations may request tailored training workshops for their organization. Additionally, preservice students—students in programs such as social work, teacher education, and nursing, among others—may enroll in the online version of the course.

The training is cofacilitated by 2 staff members from the Office of Military Affairs at our institution. One staff member is the Military Student Services Specialist; she is a military veteran who was raised in a military family. The second, the Military Liaison and Program Coordinator, is a military spouse who also served on a Marine General Officer's staff as a Family Readiness Officer overseas. During the Campus Green Zone training, broad generalizations are illustrated with specific anecdotes from the instructors' own experiences and observations of life in the military and veteran community. As cofacilitators, they create a relaxed atmosphere for the training, recognizing that sometimes people are apprehensive about learning more about the culture of the military. They work to break down stereotypes and assumptions about what it means to belong to this population. Their anecdotes humanize military-affiliated individuals, in some instances highlighting what about military-affiliated individuals necessitates their status as a “special” population while, in others, drawing parallels between military affiliates and nonmilitary college students.

The Green Zone workshop covers 3 main topics: military culture, the transition to veteran life, and support on campus. Organizing the training in this way allows participants to approach the broad concepts of diversity, equity, and inclusion through the highly specific lens of the military-affiliated population. First, the training examines the background of veterans by considering the principles that guided their professional development in the military. Through interactive exercises, training participants identify the branches of the military and what service members of each branch are called. For health care practitioners, understanding basic military terminology can help establish rapport with military-affiliated clients or patients and facilitate building trust, thus improving patient compliance.14  They are presented with an opportunity to classify hallmarks of military culture, including the concepts of the warrior ethos, the total institution, and task and social cohesion.15,16  The military working environment is contrasted with nonmilitary working environments. Noting those differences underscores the ways military-affiliated students can contribute to the overall diversity of a student body.

Next, the training identifies the challenges service members experience as they transition away from the supportive structure of the military to the college campus structure. This phase of the workshop encourages the learners to consider equity for student veterans—to identify policies, procedures, and programming that allow student veterans to enter college on a level playing field. The training follows a hierarchy of needs for student veterans that was developed by the University of Massachusetts-Lowell.17  Like Maslow's hierarchy of needs,18  which identifies categories of needs that must be met to achieve self-actualization, the transition model acknowledges that veterans have certain needs that must be met in a certain order to allow the veteran to succeed as a student. Establishing personal resilience, financial stability, medical and mental health, social support, and academic success leads to the crowning achievement of career success for student veterans (see the Figure). This hierarchy also provides a framework for the experience of military spouses and military dependents on campus.

Figure

Hierarchy of needs for student veterans.17 

Figure

Hierarchy of needs for student veterans.17 

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Finally, the training outlines the measures our institution has taken to help student veterans and their family members feel included on campus, like supporting the annual Veterans Week celebration activities, offering scholarships and financial incentives, and providing the services of the Office of Military Affairs. This phase of the training invites participants to consider their role as campus representatives. They are asked to reflect on how they can contribute to a welcoming and inclusive environment for military affiliates. They are also encouraged to consider that their campus colleagues may be military affiliated.

The Green Zone training, offered to the professional athletic training students, is tailored to the program's needs to increase military culture awareness. Specific focus was placed on the types of interactions that athletic trainers may have with military-affiliated individuals in their careers from patients or clients to colleagues.8  The version of the Green Zone training offered to the athletic training students hones in on the medical and mental health layer of support identified in the Transition Success Model for Student Veterans.17  The 2-hour-long training is offered by the Office of Military Affairs and includes the presentation of materials as well as group discussion.

Like the presentation given to the campus community, this training reviews basic military information including military branches and slogans. While the missions and values of the armed forces branches are alike, separately, they have their own subcultures that are important to discuss.19  The athletic training students play an interactive game to assist with information recall. The background and origin of the Green Zone training are explained to the students as a concept of creating a safe space or a space of belonging for military-connected students as well as why it is necessary on a college campus. Students are then asked, if comfortable, to share if they are military affiliated. In the last 2 years, approximately 30% of our athletic training students have indicated having military affiliation, including a Marine Veteran and a military spouse currently living on base.

Total institution and warrior ethos concepts are introduced as well as all the different reasons people join and leave the military. The Green Zone training then expands to discuss the hierarchy of needs for veterans, military spouses, as well as military children. The students are then taught icebreaker questions to ask about military affiliation (eg, “In which branch of the armed forces did you serve?”, “What was your specialty while in service?”), why those questions are important, as well as what questions to never ask a veteran.19 

Challenges related to the military experience and the transition out of military service may, in turn, create challenges for health care providers as they engage with patients or clients who are military affiliated. During the Green Zone training, athletic training students are encouraged to consider this when asked to imagine their future careers and workplaces. They should evaluate how they would create an inclusive environment for military-affiliated individuals whom they might encounter throughout their clinical practice.

During the training, students are invited to answer the following questions:

  1. Who will your potential patients or clients be?

  2. How will you identify that someone has a military affiliation?

    • Which type(s) of affiliation will you encounter most often?

      • Military children

      • Military parents

      • Veterans

      • Active service members

      • Military or veteran spouses

  3. How will you observe military affiliation and its potential effect on interactions between you and your patient?

  4. What will you do with this information?

Students use Think-Pair-Share to discuss their responses to these questions with a partner and then share their responses with the whole group. Facilitators guide them to link what they have heard about military culture with what they know or think they know about their future practice settings. Ultimately, they are reminded that, while they may not know everything about the military, they can always find out more about someone's military experience simply by asking them about it. They are encouraged to find ways to go beyond saying, “Thank you for your service,” to create a deeper connection with their patients or clients when possible and to reflect on their practice often to ensure they are creating an inclusive, culturally sensitive environment for everyone.

To the authors' knowledge, no other synchronous trainings are currently being offered to athletic training students that comprehensively discuss military-affiliated individuals to improve their cultural awareness. One other training module by PsychArmor is for currently practicing health care professionals.20  It is also free, but it is entirely online and lacks interactive discussion. The asynchronous training by PsychArmor is more general in nature, and the module on “15 things veterans want health care providers to know” only takes 30 minutes to complete. However, this training is a good option for currently practicing athletic trainers and can be completed at their convenience.

Knowing that athletic trainers work in a variety of health care and health-care-adjacent settings, practitioners need to recognize the ways military and veteran families tend to interact with the health care system. Two areas that often surprise practitioners are the overall health of veterans and military families and the overall health care literacy of these patients or clients. Educating athletic training students on how the military health care system works can facilitate understanding of veterans' health care literacy barriers.

Interactions With Military-Affiliated Patients or Clients and Colleagues

Notable characteristics of veterans are important to remember when interacting with them during clinical practice.8,19  First is the idea of never accepting defeat and always placing the mission first through the development of the warrior ethos.21  This mentality creates a sense of responsibility within military personnel and veterans. They may have a desire to continue serving the community in their civilian life after their military service ends, and they may feel gratitude for skills learned during military service, such as personal discipline and commitment to their work.22  Understanding some of the characteristics that veterans may possess can assist in creating valuable relationships with patients or clients or colleagues.

Veterans often experience both medical and mental health issues as they exit the military service. This sometimes astounds workshop participants because military members are often depicted in our society as strong, physically competent heroes. Regardless of how physically fit and healthy they were while in the military, the effects of prolonged stress and burnout can take a toll on service members and veterans. During the Green Zone workshop, the effects of relentless transitions, recurrent deployments, and high-pressure working environments, plus the pressure to achieve professional milestones for promotion are offered as causes of burnout.14 

Athletic training students are invited to consider times when they have experienced burnout and how it felt for them. If they have ever experienced a feeling of overwhelming at the beginning and end of each term, they have a way to empathize with military members who also experience routine transitions. Active service members may deploy for several weeks for training, then deploy for several months for an operational mission, then return to dismantle their deployment team and transition to a new cycle of training and deployment. A recurrent theme throughout the Green Zone training is reminding participants that military members are more like other people than they are different14 ; even if college students have not deployed for a military mission, they have gone through the ups and downs of their classes and transitions from one term to the next throughout their college career. A specific example in athletic training education is the required clinical immersive experiences when students transition to full-time practice which can be a prodigious experience for some.

Veterans may experience symptoms of burnout, but they may also experience other health challenges throughout the process of leaving the military and becoming established in a new life, whether on a college campus or in a new civilian career. They may drop healthy habits instilled in them by the military service, such as a physical fitness routine, and acquire unhealthy habits, such as eating convenience foods, during their transition.23  Here again, they are not unlike nonmilitary college students, who may struggle with developing a new routine on campus or have difficulties adjusting to a new course schedule and new instructors each semester. Once more, athletic training students may be invited to consider times when they have found it hard to get comfortable and maintain health and wellness habits.

Health Care Literacy

In terms of health care literacy, the Green Zone training customized for the athletic training students outlines the challenges veterans may encounter such as tracking their routine medical and dental appointments once they exit the military.24  They may not have a primary care health provider identified or have a health insurance provider identified for themselves, and they may not be comfortable with calling providers to arrange appointments. These concerns were handled for them by the military, up to and including scheduling appointments and arranging transportation to those appointments. Health care is of the utmost importance to military readiness, so the military invests time, money, and effort in ensuring that its members' health care is maintained. Many veterans have difficulty adjusting to the idea that they now need to learn to maintain their health care by seeking medical experts and making appointments for routine checkups or to follow up on referral appointments on their own. Athletic trainers who engage with veterans in clinical practice may have to assist these patients in navigating the health care system through patient education.

Another concern with military veterans and health care is the quality of care they may have received within the military health care system itself. Trauma related to negative experiences with military health care providers may lead some veterans to avoid seeking health care services and to seek them out only with reluctance when necessary.25  Meanwhile, current service members may seek to avoid notice as an injury develops because they are fearful of losing their promotion status. They may also be wary of letting down the team—the foundational concept of social cohesion in the military means that weakness on the part of an individual is damaging to the rest of the unit, so military members do their best to stay away from sick call, and they may choose not to follow guidance from health care providers.16  Regardless of a service member or veteran's claims of physical and mental wellbeing, practitioners must recognize that these clients are not necessarily comfortable presenting a holistic picture of their wellness, even if withholding information about injuries and mental health may be detrimental to their care. Athletic trainers, who are hopeful of providing preventative health care services, may find that they spend most of their time with active military clients and with veterans on the opposite end of the health care spectrum, seeking to address injuries once they have already happened rather than to prevent them.26 

While military members and veterans may experience the same mental health conditions as the rest of the population (for example, anxiety and depression), they may also experience conditions related to their time in military service.23,26  The signature issues of the Global War on Terror—posttraumatic stress and traumatic brain injury27  and the effects of military sexual trauma engender unique considerations for practitioners.26  Athletic trainers need to be able to recognize these psychological conditions, regardless of the clinical setting, and refer to mental health practitioners as necessary. The Green Zone training mentions these potential psychological issues and sets the framework for deeper discussion within the psychosocial aspects of the athletic training course offered later in the program's course sequence.

Military Family Members and Dependents

Military family members may also present challenges for the athletic trainer. Military spouses and military dependents have access to health care benefits while their sponsor (the military member(s) in the family) is on active duty. However, they may not have access to those same benefits once the sponsor has left the service, and their level of health care literacy may mean that they are not easily able to arrange insurance or primary care support for their families. It is often challenging to be accepted as a new patient after a recent move to a new place. While associated with military health care, the availability of services varies greatly between branches of service and duty stations, and it varies for active military members and their spouses and dependents. For athletic trainers, this may mean that additional time needs to be spent with their patients or clients educating them on how to navigate the health care system.

Military family members often have reason to be mistrustful of the health care and mental health care services available to them.25  Military spouses may be wary of jeopardizing their sponsor's status by requesting specialized services for themselves or their children. In some cases, services for special needs may be difficult for family members to access without dedicated advocacy. Sometimes, the need to insist upon access to specialty care leads military spouses to become excellent advocates for themselves and their families in the civilian health care system, but all too often, it leads to frustrations and a lack of trust toward health care providers. Athletic trainers may approach these clients with a sense of curiosity and openness about previous experiences with the medical establishment coupled with intensive follow-up services and even making referral appointments for the client instead of expecting the client to make the appointment on their own.

Military parents are a subset of the military-affiliated population with whom athletic trainers may come into contact because of their professional setting. Perhaps they are working in secondary schools with students or with college athletes who have military parents. Being understanding of the challenges related to military family life will help athletic trainers provide good support to their students. Recognizing that military parents may come across as intensely goal oriented or as mistrustful of their services at the outset may serve as a reminder to take the time to build a working relationship with the parents as well as with the children as part of the holistic model of health care.

Campus Green Zone training is an entry-level workshop designed to introduce the basic tenets of military life. As such, the training only brushes the surface of health care and mental health care concerns for veterans and military family members. At our institution, the Campus Green Zone training program is robust and widely available to campus members, but this may not be the case at other universities. Schools with a small population of military-affiliated students and schools located in areas that do not support a large military population may not wish to devote as much time to military culture. However, athletic training programs whose institutional campuses do not offer this training but still desire to include this into their curriculum can access the one discussed here.

Safe zone training for sexual minorities and training on diversity, equity, and inclusion of ethnic and racial minorities are incorporated into athletic training programs to prepare students to be more comprehensive practitioners. However, diversity covers a much broader span than these 2 areas. While health care practitioners are not expected to become experts in every culture or subculture they come across, the more they learn about each special population, the more sensitive they will become to the needs of their patients or clients. Therefore, Campus Green Zone training or similar materials should be included in athletic training programs to improve competence regarding this equal-employment-opportunity-protected population.

By learning more about the special population of military-affiliated individuals, in and of itself a diverse population, future athletic trainers develop an understanding of how to approach people with a military background from a place of respect and curiosity. By being asked to empathize with what their fellow students experience on college campuses, future practitioners learn how to empathize with their patients or clients. Encouraging practitioners to understand the hallmarks of military service, military community life, and the transition from the military to the civilian environment encourages them to appreciate what these members of society have to offer. By combining what they have learned in the Green Zone training with information gleaned from safe zone training and other diversity, equity, and inclusion initiatives, athletic training students will become well-rounded, empathetic practitioners who are sensitive to the needs of the patients or clients they serve.

For schools that do not offer Campus Green Zone training, please contact militaryaffairs@uncw.edu to request a consultation and recommendations for appropriate training materials.

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Author notes

Dr Schroeder is currently an Associate Professor and Clinical Education Coordinator of the Athletic Training Program at the University of North Carolina Wilmington.