Nurses in War: Roles, Responsibilities, and Ethical Considerations

Posted on by Soumya Ranjan Parida
Nurses in War: Roles, Responsibilities, and Ethical Considerations

Nurses in War: Roles, Responsibilities, and Ethical Considerations

Comprehensive guide to military nursing in war zones with historical context, international law, and clinical protocols

Table of Contents

Introduction to Military Nursing

Military nursing represents a specialized field of practice where registered nurses provide care in conflict zones, battlefields, and military medical facilities. These healthcare professionals serve a crucial dual role: providing medical care while operating within challenging and often dangerous environments.

Definition of Military Nursing in War Zones

Military nursing in war zones involves providing nursing care to wounded military personnel and civilian casualties in combat areas, field hospitals, or evacuation facilities, often with limited resources and under hazardous conditions.

Nurses in war zones operate in a unique healthcare environment characterized by:

  • High acuity of trauma and mass casualty situations
  • Resource limitations and improvisation requirements
  • Ethical challenges specific to conflict settings
  • Need for adaptation to changing battlefield conditions
  • Legal protections under international humanitarian law

Historical Context of Military Nursing

The evolution of nursing in war zones traces a path from informal caregivers to highly trained military professionals with specialized skills and qualifications.

Revolutionary War (1775-1783)

Women volunteers cared for wounded soldiers with little formal training or military recognition.

Civil War (1861-1865)

Female nurses provided physical and mental care, wrote letters for soldiers, offered comfort, and established more formal nursing roles.

World War I (1914-1918)

US Army Nurse Corps established formal nursing positions. Nurses worked in field and base hospitals, though initially not intended to face dangerous conditions near the battlefield.

World War II (1939-1945)

Military nursing expanded significantly. For the first time, nurses administered anesthesia, gave intravenous medications, and had increased authority in combat zones. Flight nurses became responsible for in-flight patient care.

Modern Era (Post-1950)

Military nurses gained full officer status, specialized training, and expanded scopes of practice across all branches of military service. Combat medical care advanced with integrated trauma systems.

Evolution of Military Nursing Authority

The necessities of combat have historically expanded nursing responsibilities and authority. During World War II, nurses began administering anesthesia and intravenous medications, while flight nurses gained complete authority over medical care during air evacuations—representing significant advancements in nursing autonomy.

Roles and Responsibilities of Nurses in War Zones

Military nurses perform diverse roles that extend beyond traditional nursing practice, adapting to the unique demands of conflict environments.

Clinical Care Responsibilities

Trauma Management

  • Performing triage in mass casualty situations
  • Assessing and stabilizing life-threatening injuries
  • Managing complex trauma wounds
  • Monitoring for and responding to shock
  • Administering blood replacement therapy

Surgical Support

  • Preparing patients for emergency surgeries
  • Assisting in surgical procedures
  • Administering anesthesia (expanded role)
  • Monitoring post-operative recovery
  • Managing surgical complications in resource-limited settings

Patient Monitoring and Care

  • Taking vital signs (TPRs) at regular intervals
  • Assessing for signs of infection or complications
  • Managing pain in austere environments
  • Providing nutrition and hydration support
  • Preventing complications like pressure injuries

Medical Evacuation (MEDEVAC) Duties

  • Preparing patients for transport
  • Providing care during evacuation
  • Adapting care to transport conditions
  • Making independent clinical decisions during transit
  • Coordinating with receiving facilities

Administrative and Support Functions

Ward Management

  • Supervising medics and support staff
  • Maintaining appropriate ward environment
  • Ensuring cleanliness and infection control
  • Managing medical supplies and equipment
  • Coordinating patient care with physicians

Documentation and Reporting

  • Maintaining accurate patient records
  • Documenting injuries and treatments
  • Reporting health trends and concerns
  • Tracking supply usage and needs
  • Recording casualty statistics

Extended Responsibilities in War Zones

Public Health Functions

  • Preventing disease outbreaks
  • Implementing sanitation measures
  • Conducting vaccination campaigns
  • Monitoring environmental health risks
  • Educating troops on health protection

Psychosocial Support

  • Providing psychological first aid
  • Supporting patients with combat stress reactions
  • Facilitating communication with families
  • Offering comfort to seriously wounded
  • Addressing moral injury in patients

Resource Adaptation

Military nurses in war zones must develop exceptional skills in improvisation and resource management. During World War II, nurses reused glass syringes after sterilization, washed and patched rubber gloves, and repurposed available materials to create medical supplies—skills that remain relevant in modern combat nursing.

International Humanitarian Law and Protection of Nurses

Nurses working in conflict zones are protected under international humanitarian law (IHL), specifically the Geneva Conventions and their Additional Protocols, which establish legal protections for medical personnel.

Protection Under Geneva Conventions

Protection Category Legal Provisions
Status of Medical Personnel Medical personnel must be respected and protected in all circumstances. They cannot be targeted or prevented from performing their duties.
Capture and Detention Medical personnel cannot be considered prisoners of war if captured. They can be retained only to provide medical care to prisoners.
Distinctive Emblems The Red Cross, Red Crescent, and Red Crystal symbols identify and protect medical personnel, units, and transports.
Medical Ethics Nurses cannot be compelled to act contrary to medical ethics or provide information about patients that could be harmful to them or their families.
Loss of Protection Protection is lost only if medical personnel commit acts harmful to the enemy outside their humanitarian duties.

Rights and Obligations of Nurses in Conflict Zones

Rights Under IHL

  • Right to be respected and protected
  • Right to carry out medical duties without interference
  • Right to refuse orders contradicting medical ethics
  • Right to maintain medical confidentiality
  • Right to identify themselves using protective emblems

Obligations Under IHL

  • Obligation to provide impartial care
  • Obligation to treat patients without discrimination
  • Obligation to uphold medical ethics
  • Obligation not to carry out harmful acts outside humanitarian function
  • Obligation to wear identification (armband with emblem)

Important Warning: Misuse of Protective Emblems

Using Red Cross, Red Crescent, or Red Crystal emblems to shield combatants or for any purpose other than identifying medical personnel/facilities constitutes perfidy and is considered a war crime when resulting in death or injury.

Clinical Protocols in Combat Settings

Military nurses follow specialized clinical protocols designed for battlefield medicine and austere environments where resources may be limited and standard hospital procedures impractical.

Battlefield Triage Protocols

Combat Triage Categories

  • Immediate: Life-threatening injuries that require immediate intervention
  • Delayed: Serious injuries that can wait hours for treatment
  • Minimal: Walking wounded who can assist or wait
  • Expectant: Unlikely to survive given available resources

Triage Decision Process

  • Assess: Airway, Breathing, Circulation, Disability (ABCD)
  • Categorize: Assign triage category based on injury severity
  • Tag: Apply color-coded identification
  • Track: Document triage decisions and reassess regularly
  • Transport: Move patients according to priority

Trauma Care Protocols

MARCH Algorithm for Combat Casualty Care

Military nurses often follow the MARCH protocol for initial trauma assessment:

  • Massive hemorrhage control
  • Airway management
  • Respiratory support
  • Circulation assessment and management
  • Hypothermia prevention/Head injury assessment

Medication Administration in Field Settings

Medication administration protocols in war zones reflect the unique challenges of the environment:

Challenge Field Protocol Adaptation
Limited medication availability Use of standardized field formularies with essential medications
Storage constraints Heat-stable medication selection; use of alternative routes when refrigeration unavailable
Emergency situations Standing orders for critical interventions; push-dose protocols for resuscitation
Documentation challenges Simplified field documentation systems; use of casualty cards
Resource conservation Multi-dose vials when appropriate; extended use protocols

Infection Control in Austere Environments

Field Sterilization

  • Chemical sterilization using available agents
  • Boiling instruments when autoclave unavailable
  • UV light exposure when applicable
  • Prioritization of critical items
  • Reprocessing of single-use items when necessary

Wound Management

  • Delayed primary closure for contaminated wounds
  • Regular wound irrigation with available solutions
  • Aggressive debridement of necrotic tissue
  • Early antibiotic therapy for high-risk wounds
  • Improvised negative pressure wound therapy

Field Documentation Adaptations

During World War II, nurses maintained bedside notes to monitor patient health. Modern military nursing continues this practice with field medical cards that track vital signs, procedures, medications, and clinical observations. These records travel with patients through evacuation chains to ensure continuity of care.

Ethical Considerations for Nurses in War Zones

Military nurses face unique ethical challenges that require balancing professional nursing ethics with military obligations and the realities of conflict situations.

Ethical Dilemmas in Combat Nursing

Resource Allocation

Dilemma: How to allocate limited medical resources when faced with mass casualties

Ethical Framework: Utilitarian approach focused on maximizing lives saved while respecting dignity of all patients

Impartial Care

Dilemma: Providing equal care to enemy combatants and friendly forces

Ethical Framework: Humanitarian principle of impartiality; professional duty to treat based on medical need, not political affiliation

Dual Loyalty

Dilemma: Balancing military orders against professional nursing judgment

Ethical Framework: Professional autonomy and patient advocacy while respecting military chain of command

Informed Consent

Dilemma: Obtaining informed consent in emergency situations or language barriers

Ethical Framework: Presumed consent for lifesaving measures; use of interpreters when available; documentation of decision-making process

Medical Neutrality and Confidentiality

The principle of medical neutrality is central to nursing practice in war zones:

  • Nurses must maintain confidentiality of patient information
  • Under the Geneva Conventions, nurses cannot be compelled to provide information about patients that could be harmful
  • Medical records should be protected from military intelligence uses
  • Treatment decisions must be based on medical need, not military value
  • Medical neutrality requires refraining from participating in interrogations or military operations

Protection of Medical Confidentiality

The Geneva Conventions explicitly state that persons engaged in medical activities may not be compelled to give information concerning the wounded and sick under their care if this information would prove harmful to patients or their families.

Clinical Applications: War Zone Nursing Scenarios

The following case scenarios illustrate practical applications of nursing knowledge in combat settings.

Case Study 1: Mass Casualty Triage

Scenario: A military nurse is the first medical responder after an explosion injures 15 soldiers with varying degrees of trauma.

Assessment:

  • Patient 1: Unconscious, significant head trauma, irregular breathing
  • Patient 2: Conscious, arterial bleeding from leg wound
  • Patient 3: Conscious, stable vital signs, shrapnel wounds to arm
  • Multiple additional patients with varying injuries

Nursing Actions:

  1. Apply MARCH assessment protocol to quickly evaluate each casualty
  2. Prioritize Patient 2 for immediate tourniquet application to control arterial bleeding
  3. Assign Patient 1 to immediate category for airway management
  4. Designate Patient 3 as delayed category
  5. Direct walking wounded to assist with buddy aid when possible
  6. Document triage decisions on casualty tags

Rationale: In mass casualty events, controlling immediate life-threatening hemorrhage takes precedence. The nurse applies combat triage principles to maximize survival across all casualties rather than focusing resources on the most severely injured.

Case Study 2: Resource Adaptation

Scenario: A field hospital nurse needs to maintain sterile technique for wound care but has limited supplies.

Assessment:

  • Multiple patients requiring wound care
  • Limited sterile dressings and gloves
  • No autoclave available for instrument sterilization
  • Clean water supply available

Nursing Actions:

  1. Establish priority system for sterile supply use based on wound contamination risk
  2. Implement chemical sterilization of instruments using available antiseptics
  3. Create sterile field using cleaned plastic sheeting
  4. Boil instruments for 20 minutes when chemical sterilization not possible
  5. Reprocess gloves through washing, disinfection, and integrity testing
  6. Create saline solution from clean water and salt packets

Rationale: The nurse applies resourcefulness and improvisational skills to maintain infection control principles despite resource limitations—a critical skill in military nursing that balances ideal practice with field realities.

Case Study 3: Ethical Decision-Making

Scenario: A military nurse must allocate limited pain medication between friendly soldiers, enemy combatants, and civilian casualties.

Assessment:

  • Ten patients requiring pain management
  • Limited supply of morphine
  • Mix of friendly forces, enemy soldiers, and civilians
  • Varying severity of pain and injuries

Nursing Actions:

  1. Assess pain levels using objective assessment tools
  2. Prioritize pain medication based on severity, not patient status
  3. Implement non-pharmacological pain management strategies
  4. Use lower doses at more frequent intervals when possible
  5. Document decision-making process and rationale
  6. Communicate plan transparently to medical team

Rationale: The nurse upholds the ethical principle of impartiality by basing pain management decisions on medical need rather than military affiliation. This aligns with both nursing ethics and Geneva Convention requirements while acknowledging resource constraints.

Summary: Military Nursing in War Zones

Military nursing in war zones represents a specialized practice area that combines clinical expertise with adaptability to challenging environments. Key points to remember include:

Historical Evolution: The role of military nurses has expanded from basic caregiving to autonomous clinical practice with specialized skills and increased authority in combat settings.

Role Expansion: Nurses in war zones perform beyond traditional scope, including trauma management, specialized evacuation care, and increased clinical decision-making authority.

Legal Protection: The Geneva Conventions provide specific protections for military nurses, including respect for their role, protection from attack, and the right to uphold medical ethics.

Clinical Protocols: Battlefield nursing requires specialized protocols for triage, trauma care, medication administration, and infection control—all adapted to resource-limited environments.

Ethical Challenges: Military nurses navigate complex ethical dilemmas around resource allocation, impartial care, dual loyalty, and medical confidentiality.

Adaptability: Success in military nursing requires resourcefulness, improvisation, and the ability to maintain nursing standards even in challenging conditions.

Clinical Significance

The experiences and innovations of military nursing have historically driven advancements in civilian healthcare, particularly in trauma care, disaster response, and resource management. Understanding the roles and responsibilities of nurses in war zones provides valuable insights for all nursing practice in high-stress, resource-limited settings.

References

© 2025 Nursing Education Resources. All rights reserved.

Created for educational purposes only.

Leave a Reply

Your email address will not be published. Required fields are marked *

Related Posts