Esprit de Nurse Corps
Monday June 26, 2000
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Over the Wild Blue Yonder
Military nursing is a peaceful resolution to the internal battle between the thirst for change and the comfort of security. "You get a taste of everything before you decide what you want to specialize in," says Lieutenant George Zangaro, NC, USN (Nurse Corps, United States Navy), "There is an opportunity for diversity and learning a little bit about everything in nursing." Zangaro was originally a nuclear medicine technologist when he enlisted 18 years ago, and is currently a clinical nurse specialist acting as assistant division officer on a surgical floor at the National Naval Medical Center in Bethesda, MD.
"We rotate constantly through different areas," adds Lieutenant Commander Josephine Brumit, NC, USN, who rotated through pediatrics, med/surg, obstetrics, OR, and the ED before landing in her current role as a consultant for writing policies related to women's health issues. "I always felt prepared when I went into a new assignment," says Brumit, who was energized by the rotation.
Lieutenant George R. Gentile, AN (Army Nurse), an ED charge nurse at Walter Reed Army Medical Center in Washington, DC, is also familiar with these constant rotations. He spent 16 weeks preparing for his role in the ED. This included an extensive didactic program and clinical rotation through the ED, as well as other areas including a burn unit, critical care, and being out in the community with the emergency medical system.
Nursing Overseas
When it comes to nursing aboard a navy ship, the challenges nurses face can be twofold. "The environment is very demanding in terms of space and heat," says Brumit, who also explains that, unlike a typical hospital, the patient population onboard are usually active duty, young, and healthy. Zangaro notes, "Resources are very limited. You don't have everything you need right at your fingertips. You have to adapt to your environment quickly."
Captain Meryia Moran, AN, of Walter Reed, recalls her experience with Kurdish refugees during Operation Pacific Haven in Guam as an eye-opener in terms of nursing in other cultures. She had been teaching the refugees about everything from tuberculosis to breastfeeding only to watch them return to the physicians and ask the same questions. She learned from her translator that her patients were not accustomed to having a nurse with a high school education, let alone a college degree.
Keeping Military Nurses Afloat
One thing that remains a constant in the military is the presence of top-notch support staff. The scope of the navy corpsman goes far beyond that of their civilian nursing assistant counterparts. The corpsmen perform a variety of tasks depending on their training including medication administration, IV therapy, phlebotomy, wound care, assessments, and even suturing.
According to Moran, the army uses LPNs as support staff and is gradually phasing in EMTs. In the air force, the support staff are called medical technicians. Although not trained by nurses, "they go through a rigorous training program," says Captain Michele M. Leadbeter, USAF, NC, from Malcolm Grow Hospital on Andrews Air Force Base, MD.
"One of the main jobs of the navy nurse is to train the corpsmen," says Lieutenant Commander Margo Villanova, NC, USNR (Nurse Corps, United States Naval Reserve). This perhaps explains the level of comfort and confidence the military nurse has in terms of delegation of duties.
Villanova's role at the Department of the Navy Bureau of Medicine and Surgery (BUMED) is focused on Reserve Force Integration. "I provide guidelines and coordination to assure that the support provided by Naval Reserve doctors, nurses, ancillary providers and corpsmen meets priority needs," says Villanova.
The goal is for "seamless integration" where reservists and active duty staff are virtually indistinguishable in terms of functioning. Lieutenant Commander Steven Wyrsch, NC, USN, CHE, has seen the concept of seamless integration in action and cites its effectiveness as a "measure of the training that the reservists go through."
As a business and health policy analyst, Wyrsch is like the rudder for the navy healthcare ship. "I look at how the business correlates with the clinical practice," Wyrsch explains, "We've come up with a process to look at not only the business sense of a project, but also to make sure that it makes sound clinical sense." Wyrsch's extensive background includes pediatrics, intensive care, quality management, and a rotation with the commander-in-chief. As part of the inauguration committee for President Bush, Wyrsch had the opportunity to be on the platform during the inaugural ceremony and part of the medical support during the inaugural ball.
Nurse-Physician Roles and Relationship
A positive feature in the military is the nurse-physician relationship. Multidisciplinary collaboration is a reality and an expectation. Lieutenant Colonel Marjorie Graziano, USAF, NC (United States Air Force, Nurse Corps) describes the relationship as one of "mutual respect," and says, "We work together very well because we're a team. We all bring different qualities and different skills to the healthcare arena."
The rank structure is also beneficial for the nurse-physician relationship. Graziano notes that nurses often outrank physicians, so they provide "military mentoring" in return for "medical mentoring." Moran notes that the rank structure is also useful in that it reflects level of experience.
Captain Tracy Malone, NC, USN, who also rubbed elbows with the executive branch during her Triservice medical unit assignment in the White House in the mid 1980s, notes that some roles open up serendipitously for military nurses. "I became involved in debriefing members of Congress on issues related to Desert Storm," she explains. "I designed a survey to find out about the reservist experience." This survey, which Malone initially thought was a simple project, turned out to be a benchmark.
Malone is the first nurse corps officer to serve as military assistant to the Navy Surgeon General and now finds herself active in legislative affairs and health policy. She describes her experiences in such broad scale decision-making as a "blending of clinical, administrative, and health policy aspects," and strives "to make sure policies are addressing needs."
Is It Worth It?
For the civilian nurse, time and money can be major obstacles for academic pursuits. For the military nurse, time and money for educational development are the perks. In many instances, the military pays for tuition, books, moving expenses, and even salary for nurses obtaining graduate degrees. "That was my full-time job," Wyrsch says of his work toward a master's degree in health administration. He cautions that paid education is not a given, and says, "It's basically up to you, your performance, your undergraduate record, and the needs of the navy." Wyrsch has also obtained a number of professional certifications including healthcare quality, utilization management, and managed care, all on the navy's tab. Zangaro will be starting a PhD program in the summer and notes that he will be attending part-time. He further notes that the Navy will be providing some financial assistance in this endeavor. The GI Bill is also a potential source of educational funding for the military.
Because most military nurses have multiple roles, this additional training is essential. Gentile, for example, is also the assistant officer in charge for the North Atlantic Regional Medical Command of the Special Medical Augmentation Response Team. This team is responsible for biological and chemical medical management for acts of terrorism or hazmat situations. This specialized information is not readily available in nursing journals and the role isn't conducive to on-the-job training. Gentile puts his certifications to work keeping not only his team, but civilians in community hospitals, up to speed.
The military makes time not only for collegiate education, but for continuing in-house education as well. Captain Rosemary Mackey, AN, an instructor in the nursing education and staff development section at Walter Reed, notes a high level of support for offerings at the hospital. "Some classes have waiting lists," says Mackey, who offers a variety of programs, including professional advancement, clinical skills, and the usual mandatory classes like restraints. Mackey reports that for the proactive, motivated individual, "that [the class] is their place of duty for that eight-hour class."
Intensive training is not restricted to the experienced staff. Leadbeter, in addition to acting as the assistant nurse manager and staff development monitor for the surgical unit, coordinates the Nurse Transition Program for nurses with less than one year of experience. This 12-week program includes skills practice and additional training to promote a smooth adjustment to the real world of nursing. Recruits attend the program at Malcolm Grow, one of five hospitals in the country that offers the program to nurses before they move on to their assignments. This wise use of resources by consolidating the programs serves as a good model for community hospitals struggling to fill slots in similar programs for new nurses.
The Beat Goes Marching On
Travel and change are a fact of life in the military, about every three years or so, but there is also a certain degree of choice and safety. "You can move around the world and still have security," explains Villanova, who is a reservist serving on a three year voluntary recall to carry out her duties.
Coming from a civilian managed care setting, Villanova jokes, "Three years is job security for me." Malone, who went back to active duty after being in the reserve describes the need for a commitment to readiness, "You need to be ready to go at a moment's notice." Graziano points out that seniority is maintained with each move rather than starting from scratch with each assignment. On the downside, choice of shift is generally not an option. For married couples, there is the potential to be separated, although the military tries to make accommodations for the spouses to be colocated.
Sometimes, a choice assignment is sacrificed for the benefit of family. "You have to find a balance between your career and your home life," says Leadbeter, who recently spent two months in Texas for management training and 12 months in Korea to be able to stay in the Maryland/DC area.
Brumit sums up the military nurse experience as a "chance to combine clinical excellence with military leadership responsibilities." Continual career progression can often lead the nurse away from the bedside. "I would like to see senior nurses providing patient care, to take their knowledge and experience and be there for the junior nurses and the patient," says Villanova of the navy structure. In the air force, "The main mission [of the air force nurse] is to provide bedside care," says Graziano. Although she is on faculty at the Uniformed Services University of Health Care Sciences in Bethesda, MD, she also maintains her clinical practice as a family nurse practitioner.
Through Thick and Thin
There is a special association among military nurses that is not often seen with the rapid turnover in civilian hospitals. "We work and play well," says Moran. Graziano describes it as a feeling of "being in the club." She adds, "Ethnic diversity is embraced and there is a mutual acceptance of everybody."
Just as there is comaraderie among nurses, there is also a kinship among the branches of the service. Graziano, for example, is affiliated with the air force, but works at a navy installation for an army commander. Gentile describes a healthy relationship with leadership and sees his commanders as a strong source of support. Drawbacks are age limitations and the notion of progressing according to a predetermined timetable.
These nurses, although from different branches of the service, come together to form a tree strong enough to weather any storm. During the mild seasons, it remains unassuming while continuing to grow and thrive. Malone might be working on a policy that will affect the masses, but she still looks at her homemade afghan and remembers the surgical patient who made it for her. It is these universal moments that bridge the gap between the military and civilian worlds and reminds us that we are all compatriots in caring.
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