Maj. Gen. Patricia D. Horoho, RN, the new chief of the Army Nurse Corps, has ambitious plans to transform Army nursing using lessons learned from the wars in Iraq and Afghanistan, the best of military nursing research, and the latest advances in the nursing profession.

Her 15-year blueprint to revamp the ANC includes molding leaders who can adapt to the unpredictability of modern warfare, training new nurses who are ready to face the trauma of war, and educating RNs who can incorporate evidence-based practice at the bedside from Iraq to Walter Reed Army Medical Center in Washington, D.C.

"The plan will be driven by courage to do the right thing, innovation to meet the rapidly evolving war, fighting, and medical demands of the 21st century, and constant compassion for those we serve and those with whom we serve," Horoho said in her acceptance speech in July 2008 in Fort Lewis, Wash. "We will critically assess ourselves and the care we provide in every location along the continuum of care from the forward surgical teams in the thick of battle to the [combat support] hospitals under mortar fire and back home to our hospitals and clinics, where we care for warriors of all generations and their families."

Strategize First

Horoho was appointed as chief of the ANC last summer and received a rare two-rank promotion from colonel to major general. She was previously the commander of the Walter Reed Health Care System. In addition to being chief of the ANC, she also is the commander of the Madigan Army Medical Center and Western Regional Medical Command in Tacoma, Wash.

Horoho was working at the Pentagon on 9/11 when a jet hijacked by terrorists slammed into the building. She was praised for her efforts in organizing triage and caring for the wounded. Horoho was Nursing Spectrum's and the American Red Cross' Nurse Hero in 2002.

Interviewed in the Army's Falls Church, Va., office in November 2008, Horoho said she wants the ANC to have a more prominent voice in the development of the Army Medical Department's overall strategy for providing care to soldiers and their families during peacetime and war.

"What we need to do is to make sure we are developing and training nurse leaders … for success in future years," she said. "We are doing 100% assessment of every single position across the Army Nurse Corps to ensure we have a voice where we need to, so we can help AMEDD [U.S. Army Medical Department] team to affect the policies and services that are going to be provided to soldiers."

Horoho, with her deputy chief Col. Susanne Clark, designed the 15-year blueprint for the ANC based on four criteria: leader development, warrior care, evidence-based management, and human capital.

Horoho and Clark want a standardized professional practice model to be used across the ANC. Currently, practice models vary among military institutions depending on a hospital's or clinic's mission and its resources, Clark says. For example, some facilities use primary nursing and others use team nursing. They are evaluating several different patient care models, which are patient driven.

They already have implemented a new year-long residency preceptorship program to ensure new graduate nurses are trained to be clinical leaders at all levels of care. The program includes assigning new nurses to small and large military hospitals in the U.S. for a broader clinical and educational experience.

The preceptorship concludes with specific training to prepare new nurses for what they may experience when deployed to a war zone.

New nurses are no longer immediately deployed to Iraq or Afghanistan, as many of them have been since the wars started. "We think we really owe them that first year to prepare," says Horoho.

Evidence-Based Practice at Home and Abroad

Horoho and Clark are planning to weave evidence-based practice and nursing research into Army nursing at the bedside, whether the bedside is a stretcher in a field hospital or an ICU bed at Brooke Army Medical Center in San Antonio. Military nurses now conduct research in every major military hospital in the U.S. and in Iraq. But Horoho wants the research to reach young lieutenants caring for patients by partnering them with senior nurse researchers.

Much of the ANC blueprint was shaped by the lessons that have come out of Iraq and Afghanistan during the last seven years, say Horoho and Clark.

In October 2008, Clark returned from Iraq, where for more than a year she was the chief nurse overseeing all Army nurses deployed to the Middle Eastern country. About 3,000 Army nurses, including National Guard and Reserve have served in Iraq and Afghanistan and about 400 currently are deployed.

The ANC is made up of active duty nurses, RNs from the Army Reserve and National Guard, and civilian nurses, who comprise 60% of the workforce, says Horoho.

Many medical and nursing lessons from the war were quickly analyzed and incorporated back into the battlefield, says Clark. For example, new protocols for preventing ventilator-acquired pneumonia for wounded soldiers were implemented. The protocols were then evaluated to see if they were effective or if there was a breakdown in care as soldiers were evacuated from one point of care to the next out of Iraq and Afghanistan.

The ANC also is redefining the role of head nurses in combat support hospitals and hospitals at home.

"We have gotten some good lessons from Iraq on how to develop adaptive leaders," says Clark. "You have to learn to think quickly on your feet in any situation."

The ANC also learned it needs to ensure its nurses are prepared for the psychological strain of war and that they are given appropriate emotional support when they return to their families and work in the U.S and abroad.

"Nobody deploys [to war] and comes back as the same person," Horoho says.

The ANC takes advantage of the mental health programs offered to all servicemembers by the Army and the Department of Defense. Horoho and Clark are looking at what additional strategies are needed to make nurses more mentally resilient before, during, and after deployment so they are less likely to leave the Army.

Horoho and Clark admit their plan is ambitious but are confident that in four years they will accomplish their goals. "We have four years to make a difference across the corps," says Horoho.