Mister Chairman and distinguished members of the committee, I am Brigadier General Barbara Brannon, Assistant Surgeon General, Air Force Nursing Services and Commander of Malcolm Grow Medical Center at Andrews Air Force Base. This is my fourth testimony before this esteemed committee and, once again, I am very proud to represent Air Force Nursing and delighted to share our accomplishments and challenges with you. First and foremost, as the Air Force aggressively executes its mission in support of our great nation, Air Force medics are keeping our people fit and providing outstanding healthcare wherever it is needed. Air Force nurses and enlisted nursing personnel are meeting increasing commitments and challenges with great professionalism and distinction. Today I’d like to review the following: deployments, training, force management, optimization and research, as examples of these commitments and challenges. Over the past year, hundreds of Nursing Service personnel have been deployed to every corner of the globe to support the ongoing war on terrorism and to provide humanitarian relief. There are more than 400 nurses and technicians currently deployed in Expeditionary Medical Systems (EMEDS) facilities, and hundreds more prepared and awaiting orders to deploy. The Air Force continues to rely on an ambitious Air Expeditionary Force (AEF) rotation cycle to accomplish deployment missions and maintain home station health care services. In addition to supporting ongoing commitments to Operation ENDURING FREEDOM, IRAQI FREEDOM and other deployments, Air Force medical personnel have been called frequently to support humanitarian operations throughout the world. Four months ago, twelve nurses and technicians from Yokota AB Japan deployed to Guam to assist in federal medical support in the aftermath of the devastating Super Typhoon Pongsona. Arriving in the middle of the night, they established initial medical capability to triage and treat casualties within 24 hours. Nurses and technicians also provide humanitarian support through their active engagement in the International Health Specialist program. They are successfully forging and fostering positive relationships around the world. A great example is Major Doreen Smith, recognized as the Air Force International Health Specialist of the Year in Europe 2002 for her outstanding work in Africa. She was instrumental in establishing the first Republic of Sierre Leone Armed Forces (RSLAF) HIV/AIDS Prevention Committee that developed treatment protocols used by field medical technicians to prevent transmission of HIV/AIDS. She later implemented training programs in both Ghana and Nigeria. Aeromedical evacuation remains a unique Air Force competency and our ability to respond to urgent transport requirements is second to none. Nurses and technicians were integral members of teams providing care during the evacuation of over 2,548 patients from forward areas in Operation ENDURING FREEDOM and IRAQI FREEDOM. Aeromedical evacuation is the critical link between casualties on the front lines and progressive levels of restorative healthcare abroad and in the continental United States. Captain Michael McCarthy was on a Critical Care Air Transport Team mission over hostile territory to rescue two CIA operatives critically injured during the prison uprising in Kandahar, Afghanistan. This was not a typical mission for our critical care team -- the mission was flown in blackout conditions due to Special Operations requirements. Captain McCarthy’s expert critical care saved the life of a casualty whose condition deteriorated in-flight. He received the prestigious Dolly Vinsant Flight Nurse Award from the Commemorative Air Force for his heroic actions on this mission. The tremendous accomplishments of our Air Force Flight Nurses have also been heralded by civilian flight nurse organizations. The Air and Surface Transport Nurses Association (ASTNA) presented the 2002 Matz-Mason Award to Captain Greg Rupert, Critical Care Air Transport Team Program Coordinator, Lackland AFB, Texas, for exceptional leadership and positive impact on flight nursing on a global scale. Three years ago the Air Force identified that many medical personnel’s peacetime healthcare responsibilities did not adequately sustain their proficiency in critical wartime skills. Medical career field managers and specialty consultants developed the specific readiness skills required for each specialty and established training intervals to ensure our people were prepared to meet deployment requirements. This year, we refined the program based on lessons learned in the deployed environment. As I briefed last year, the Air Force has entered into partnerships with civilian academic medical centers to provide intense training for nurses and technicians prior to deployment. The first “Center for Sustainment of Trauma and Readiness Skills” (CSTARS) was initiated in January 2002 at the Shock Trauma Center in Baltimore. This program provides our health care personnel with valuable hands-on clinical experience that covers the full spectrum of acute trauma management, from first response to the scene, during transport, to trauma unit care, to operating room intervention and finally to management in the intensive care unit. The three-week session also incorporates the Advanced Trauma Care Course for nurses and the Pre-Hospital Trauma Life Support Course for our medical technicians. To date, over 200 personnel have been trained in Baltimore. Building on the success of this first site, the Air Force has developed and opened two new CSTARS programs, one at St. Louis University primarily for the Air National Guard (ANG) team training, and the other at the University Hospital of Cincinnati for Reserve teams. The St. Louis program started in January 2003, and we expect to train over 270 personnel during their two-week annual tour. Early feedback is impressive as reflected by an end-of-course survey comment, “this is far and away the greatest training program I have been able to attend in the Air Force/ANG”. The CSTARS partnership between the University of Maryland Medical Center (UMMC) and the Air Force was key to the great success of the exercise “Free State Response 2002” conducted in Baltimore Maryland in July of last year. The purpose of the exercise was to train as many people as possible in community disaster response and to foster effective coordination and collaboration between agencies involved in disaster management. The exercise received wide media coverage in the national capital area and was judged a huge success. Expeditionary Medical Systems (EMEDS) is a five-day course that provides hands-on field training for personnel assigned to EMEDS deployment packages to prepare them to work in the operational environment. There are currently three sites for EMEDS training: Brooks City Base Texas primarily for active duty, Sheppard AFB Texas for Reserves, and at Alpena Michigan for ANG personnel. So far, 3608 personnel have been trained in this critical operational requirement. Overall trends in healthcare delivery and the National Defense Authorization Act of 2001, allowing care for beneficiaries over age 65, have resulted in an increase in the acuity and complexity of the patients we serve. This has increased the need for experienced nurse clinicians. Facility chief nurses have expressed growing concerns over the challenge of providing the most effective care with a relatively junior staff. In our military system, rank reflects the relative experience of the individual. When we look at our current Nurse Corps force structure, we note that more than 72 percent of our authorizations are for second lieutenants, first lieutenants and captains. These nurses range from “novice to proficient” in their nursing skills. Nurses at the major and lieutenant colonel level are “expert to master” in their practice. The ratio of company grade to field grade nurses is significantly higher than for other medical career fields or the line of the Air Force. To correct the imbalance in our mix of novice and expert nurses, authorizations for field grade nurses would need to be increased. The Air Force Nurse Corps has initiated a Top Down Grade Review (TDGR) to identify, justify, and recommended needed adjustments. We are nearing the end of our data collection and research phase of the study and anticipate draft recommendations for our surgeon general in the next couple of months. If approved, and if additional field grade billets are indicated, the process to adjust authorizations among career fields can be initiated with the Chief of Staff of the Air Force’s approval. In a separate but related issue, the Nurse Corps has the poorest promotion opportunity among Air Force officers. With only 28% of our authorizations in field grade ranks compared to 46% in the line of the Air Force, it is easy to understand why so many excellent officers are not getting selected for promotion. This lack of promotion opportunity is a major source of dissatisfaction in our Nurse Corps. The inequity in promotion opportunity has caught the eye of many line and medical commanders and garnered some support for our TDGR initiative. It is anticipated that a TDGR would validate increases in field grade Nurse Corps requirements. An increase in field authorizations would improve Nurse Corps promotion opportunity and bring it closer to that of other Air Force Officers. Although the programs instituted on a national level to address the nursing crisis are encouraging, recruiting enough nurses to fill positions is still a huge challenge across the United States and in many other nations. Last year was the fourth consecutive year the Air Force Nurse Corps has failed to meet our recruiting goal. We have recruited approximately 30% less than the goal each year since FY 99. At the end of FY 02, we had 104 fewer nurses than our authorized end strength of 3974. Early personnel projections forecasted we would end the year 400 nurses under end strength. Our final end strength reflects an abnormally low number of separations last year, 136 compared to our historical average of 330. Our FY03 recruiting goal is 363 nurses, and, as of February 2003, 100 have been selected for direct commission. This year recruiting service is able to offer an accession loan repayment of up to $26K as an incentive. With $6.2M available to fund this initiative, we are hopeful that it will be as successful as last years retention loan repayment program and boost our accession numbers closer to the goal. Last year we revived an earlier policy that allowed Associate Degree (ADN) nurses who had a Baccalaureate degree in a health-related field to join the Nurse Corps. This was in response to Recruiting Service’s belief that this would give access to a robust pool of recruits. But, in reality, only 13 ADN nurses were commissioned under this carefully monitored program. I rescinded the policy in October 2002 since it did not produce the desired effect. We continue to recruit nurses up to the age of 47 because it proved very successful in FY 02. Thirty-four nurses over age 40 were commissioned into the Air Force last year. Many of them have the critical care skills and leadership we need to meet our readiness mission and most have the years of experience to make them valuable mentors for our novice nurses. “We are all recruiters” is our battle cry as we tackle the daunting task of recruiting the nurses we need, and I continue to partner closely with recruiting groups to energize our recruiting strategies. Among other activities, I have written personal letters to nurses inviting them to consider Air Force Nursing careers and have manned recruiting booths at professional conferences. I look for opportunities to highlight and advertise the exciting opportunities Air Force Nurses enjoy, and have had nurses featured in print media coverage. I encourage each nurse wearing “Air Force” blue to visit their alma mater and nursing schools near their base of assignment to make presentations to prospective recruits. I have also assigned four nurses to work directly in recruiting groups to focus exclusively on nurse recruiting. Recruiters are using innovative marketing materials that my staff helped develop to champion Air Force Nursing at conferences, in their website, and in other publicity campaigns. Retention is another key factor in our end strength. In an effort to identify factors impacting separations, I directed the Chief Nurse of every facility to interview nurses who voluntarily separate. Exit interviews were standardized to facilitate identification of the factors that most influenced nurses to separate. Nurses indicated they might have elected to remain on active duty if staffing improved, if moves were less frequent, if they had an option to work part time, or if they could better balance work and family responsibilities. Most of these are requirements of military life that cannot be changed by the Nurse Corps. With regards to staffing, our nurse-patient ratios are fairly generous compared to civilian staffing models. The Air Force Medical Service has launched an aggressive initiative to develop standardized staffing models for functions across all medical facilities to optimize staffing effectiveness. We are developing a new survey for all nurses to identify workplace/environmental impediments so we can target opportunities to increase satisfaction. We continue to recommend Reserve, National Guard, and Public Health Service transfers for those who desire a more stable home environment but enjoy military service and can meet deployment requirements. We appreciate the continued support for the critical skills retention bonus authorized in the FY 01 NDAA. The Health Professional Loan Repayment Program, implemented in FY 02, was embraced by 241 active duty nurses saddled with educational debt. These nurses had between six months and eight years of total service and were willing to accept an additional 2-year active duty obligation in exchange for loan repayment of up to $25K. This program improved our immediate retention of nurses and has great potential to boost long-term retention in critical year groups. The TriService Health Professions Special Pay Working Group identified Certified Registered Nurse Anesthesiologists (CRNAs) and Perioperative Nurses as critically manned and therefore eligible for a retention bonus. This program was enthusiastically welcomed with 66% of eligible CRNAs and 98% of Perioperative Nurses applying for a critical skills retention bonus in exchange for a one-year service commitment. We are looking at the benefits of increasing the number of civilian nurses in our workforce. We are grateful for the support of Congress in implementing US Code Title 10 Direct Hire Authority to streamline the civilian nurse hiring process. During the period from August to December 2002, the Air Force was able to use direct hire to bring 14 new civilian registered nurses on duty. With use of Direct Hire Authority, positions that had been vacant for as long as 18 months were filled within weeks. Our ability to hire civilian nurses would be greatly enhanced if we could hire at a competitive salary. We greatly appreciate your support and interest in Title 38-like pay authority for health professions. We are delighted to report that this year six Air Force Academy graduates selected the profession of nursing for their career field. This is the largest group to choose nursing since the option was instituted in 1997. Cadets selected for direct entry into the Nurse Corps attend Vanderbilt University School of Nursing via the Health Professions Scholarship Program. This accelerated degree program allows non-nurses with a bachelor’s degree to obtain a master’s degree in nursing after two years of study. To date, eight academy graduates have completed this program. Graduates of the Vanderbilt program have the leadership skills gained at the Academy coupled with a nursing degree from a prestigious university. They are prepared as advanced practice nurses and have the leadership base and potential to become top leaders in military healthcare. Air Force Nursing has been actively engaged in optimizing the contributions of our enlisted medical technicians by expanding their responsibilities and, in some cases, merging skill sets. In November 2002, the Air Force consolidated three career fields, the aeromedical technician, medical service technician and public health technician. We now have two key career fields, the aerospace medical service technician and public health technician. This consolidation provides more robustly trained enlisted medics and increases manpower to support force health protection and emergency response. In this transition, every health care facility stood up a Force Health Management element responsible for ensuring designated personnel are medically cleared, prepared and ready to deploy at a moment’s notice. Air Force Independent Duty Medical Technicians (IDMTs) have been tasked to support an expanding variety of missions and have become high demand, low-density assets. In Operation Enduring Freedom, they have been added to Special Forces teams for a variety of missions. IDMTs have provided medical care during prisoner transports, on an expedition into Tibet for recovery of remains, on drug interdiction operations, in austere, remote locations and on the front lines. This year, we are substituting IDMTs for the medical technicians assigned to our Squadron Medical Elements, teams deployed with flying squadrons to provide medical care in the operational environment. To support these additional taskings, we have increased our IDMT training program from 108 to 168 per year. We continue our efforts to expand the scope of enlisted nursing practice through licensed practical nurse (LPN) training programs. This past year, we continued to send personnel to St. Phillip’s College in San Antonio Texas for a six-month program that prepares graduates to take the state board LPN licensure exam. To date, 48 medical technicians have completed the LPN program at St. Phillips College. This year, we are partnering with the Army Licensed Vocational Nurse Program to provide a more structured and comprehensive training program and increase our numbers of graduates to 60 students per year. As of 1 November 2002, a special experience identifier was implemented to provide visibility in the personnel system for licensed practice nurses and enable appropriate assignment actions. We are successfully maintaining our medical enlisted end strength. The overall manning for technicians in the aerospace medical service career field remains above 90%, which can be construed as a positive reflection of satisfaction and the impact of quality of life initiatives. The neurology technician career field has been critically manned for some time, and I am pleased to report that the implementation of a selective reenlistment bonus has been very successful. The neurology career field manning has improved from 69.2% in May 2001 to 88.5% in November 2002 and is projected to grow to over 90% with the graduation of the next training course. Nursing services is actively engaged in optimizing health care. This maintains a healthy, fit and ready force, improves the health status of our enrolled population and to provides health care more efficiently and effectively. The Air Force has seen continuing growth in the success of Primary Care Optimization (PCO) and we are now beginning the optimization of specialty services throughout our system, moving towards Health Care Optimization (HCO). Nurses and medical technicians continue to be the backbone of successful optimization, and we are refining the roles of the ambulatory care nurse, medical service technician, and Health Care Integrator (HCI) to ensure the patient receives the right care, at the right time, by the right provider. The PCO team is the epicenter for preventive services, management of population health and treatment of disease. We use civilian benchmarking to assess our healthcare outcomes and progress. The Health Plan Employer Data and Information Set (HEDIS) measures the health of our population and compares our outcomes to those of comparable civilian health plans. Using ideas generated from “Best Practices”, we have seen impressive increases in the indicators of good diabetic management. In fact, 91% of Air Force facilities exceed the quality indicators for diabetic control measured through blood screening. Air Force facilities have been highlighted for other outstanding achievements in healthcare. Nurses and technicians at VA/DoD Joint Venture, 3rd Medical Group (MDG), Elmendorf AFB, AK were part of a project to increase the involvement of family and friends in patient care. This initiative’s tremendous success led to the facility’s selection by the Picker Institute as the #1 Benchmark Hospital in the United States for patient-centered surgical dimensions of care. In the 3rd MDG's ICU and multi-service unit (MSU), Air Force and Veteran Affairs (VA) nursing personnel are working side-by-side to deliver the highest quality care to DoD and VA beneficiaries. Air Force nurses train VA nurses in the MSU and VA nurses train Air Force nurses in the ICU. The robust and successful professional collaboration is the bedrock of this joint venture. Another great success in ambulatory care is the implementation of a population–based approach to case management. This program proactively targets at-risk populations and individuals along the health care continuum. One of our leading case managers, Lt Col Beth Register at Eglin AFB, FL has built an integrated approach that allows her six team members to each manage 50 cases, 200% above civilian industry caseload standards. Lt Col Register is preparing a TriService Nursing Research grant proposal to look at “Efficacy of Case Management at an Air Force Facility” and to test and validate the success of this case management program. Air Force nurse researchers continue to provide the answers to clinical questions that improve the science and the practice of nursing. Twenty-three Air Force nurses are actively engaged in TriService Nursing Research Program (TNSRP) funded research. The TNSRP-funded Nurse Triage Demonstration Project is in its second and final year of looking at the effective and efficient delivery of TeleHealth Nursing Practice. There have been some demonstrated positive outcomes. Clinical practice has been standardized through the use of medically approved telephone practice protocols; documentation has been improved through computer-based technologies and training programs have been developed and implemented. Another study conducted on in-flight invasive hemodynamic monitoring identified inaccuracies due to procedural variance. The recommendations resulted in significant process changes – and for the first time change was driven by scientific research. These process changes will be incorporated into the training programs for Critical Care Air Transport Teams (CCATT) and Aeromedical Evacuation (AE) nurses.
The nurse researchers at Wilford Hall Medical Center in Texas are studying the care of critical patients in unique military environments. One of these studies looked at physiological responses to in-flight thermal stress in cargo aircraft used for aeromedical evacuation. The study identified areas in the aircraft where thermal stress was at a level that could be detrimental to critically ill patients. They also identified previously unrecognized limitations in accurate measurement of patient oxygenation during flight. These findings led to a study of warming devices to protect trauma victims from the deleterious effects of thermal stress following exposure in cold field environments or on cargo aircraft. It has been an exciting year for the Graduate School of Nursing at the Uniformed Services University and it is wonderful to be part of the planning for the development of a PhD nursing program. This program is crucial for Air Force Nursing to help us build leaders who are strategically prepared to lead in our unique military nursing environment. Closing Remarks Mister Chairman and distinguished members of the Committee, I have had the opportunity to lead the men and women of Air Force Nursing Services for three years and each has been full of new challenges, great opportunities and many rewards. Our nurses and aerospace medical technicians remain ready to support our Air Force by delivering best-quality healthcare in peace, in humanitarian endeavors and in war. The escalation of world tensions in the last year has afforded a showcase for their enormous talent, stalwart patriotism and devotion to duty. On behalf of Air Force Nursing, I thank this committee for your tremendous support of military men and women, and in particular, for the special recognition and regard you have shown for our nurses. We are forever grateful for your advocacy and leadership. Thank you and may GOD BLESS AMERICA!
