STATEMENT OF REAR ADMIRAL NANCY J. LESCAVAGE, NURSE CORPS UNITED STATES NAVY DIRECTOR, NAVY NURSE CORPS
April 28, 2004
SENATE APPROPRIATIONS COMMITTEE SUBCOMMITTEE ON DEFENSE ON THE NAVY NURSE CORPS Good morning Chairman Stevens, Senator Inouye and distinguished members of the Committee. I am Rear Admiral Nancy Lescavage, the 20th Director of the Navy Nurse Corps and Commander of the Naval Medical Education and Training Command. It is an honor and a privilege to speak before you during my third year in this position and to highlight the achievements and issues of our 5,000 Navy nurses.
Our performance during Operations Enduring Freedom and Iraqi Freedom clearly demonstrated operational readiness as we continue to meet our primary mission. I would now like to address Navy Nurse Corps impact in the areas of readiness and homeland security; nursing initiatives; education and training; jointness and research.
Readiness and Homeland Security
In support of Operation Iraqi Freedom, we had 500 nurses deployed from over eighteen facilities to the Hospital Ship COMFORT, Fleet Hospitals, Casualty Receiving Treatment Ships, Shock Trauma Platoons, and with the Marines. To maintain the continuum of care back at our Military Treatment Facilities, there were over 400 filled Reserve mobilization requests, the second largest recall since Desert Storm. In addition, there were over 400 Active and Reserve Navy Nurses involved in training exercises, such as Fleet Hospital Field Training, Operational Readiness Evaluations, Hospital Ship MERCY Exercises, Cobra Gold, West African Outreach Program, Operation Arctic Circle and Combined Armed Exercises. Throughout all operations and exercises, our military and civilian nurses readily adapted; remarkably delivered outstanding care; and achieved mission accomplishment at our facilities and while deployed.
In addition to meeting the medical needs of our Navy and Marine Corps team “in theater,” readiness also includes preparing health care personnel at Navy hospitals and clinics around the world to respond to a natural disaster or terrorist attack. Nurses are at the forefront of emergency preparedness across Naval Medicine in a variety of roles. Within Naval Medicine’s Homeland Security Office at the Bureau of Medicine and Surgery, there are two Navy nurses executing a comprehensive “Disaster Preparedness, Vulnerability, Analysis, Training and Exercise Program” to identify vulnerabilities in training and to test each military treatment facility’s emergency response plan. Their effectiveness was recently put to an immediate test during the third training day at Naval Hospital Charleston, when a real disaster occurred. Forty-four participants, two local hospitals and the Charleston County Emergency Medical System provided topnotch care for the casualties involved in a bus accident. In addition, we have several Navy nurses collaborating with local community disaster planning programs, promoting well-coordinated response plans, such as at Naval Hospital Pensacola and Naval Hospital Charleston.
Training Optimizing available training opportunities across the Federal and civilian sectors is essential in maintaining critical nursing specialty skills that are required in all operational environments. Great success is attributed to the Navy Trauma Training Program in conjunction with the Los Angeles County/University of Southern California Medical Center, one of the nation’s finest Level I Trauma Centers. Since its inception in the fall of 2002, over fifty Navy nurses have successfully rotated through this program to enhance their combat trauma skills and to further increase medical readiness with their respective platform teams. Due to intense follow-up with health care team graduates in the field, many operational lessons have been incorporated into their curriculum. The program has received positive national press coverage through television, nursing magazines and newspapers, praising the Navy faculty as experts in the most current trauma standards.
Trauma training is further enhanced through established agreements between six military treatment facilities with local trauma centers and critical care settings for over 50 nurses at San Diego, Bethesda, Jacksonville, Camp Pendleton, Bremerton, and Charleston. Other training opportunities include web-based critical care courses, such as the “American Association of Critical Care Nurses Essentials of Critical Care Orientation” and other instructor presentations, which provide continuing education credit. To support dual critical specialty skills in the operational environment, the Association of Perioperative Registered Nurses nursing curriculum for Perioperative Nurses Training has been adapted for critical care nurses. As an adjunct to traditional platform training, the nursing staff at Naval Medical Center San Diego conducted “Operational Skills Days” to enhance their clinical skills and didactic foundation. When operational needs required immediate training, Navy nurses were sent to Naval Hospital Okinawa to assist with Forward Resuscitative Surgical System training.
In short, our Senior Nurse Executives are very resourceful in seeking educational resources and skills enhancement training to meet platform and specialty requirements, particularly when located in smaller, remote facilities or overseas. These clinical training opportunities have also expanded to other required nursing specialties, such as labor and delivery, nursery and mother infant nursing for our Naval Hospitals at Guam and Keflavik through clinical programs in facilities stateside and overseas. In addition, we continue to place strong emphasis in developing a solid clinical foundation for our graduate nurses through Nurse Intern Programs at several of our facilities, providing a good mix of clinical rotations tailored to varied patient acuity and specialties resulting in better prepared nurses.
Related to operational training while supporting community needs, I would like to highlight three unique military training exercises. The Civil-Military Innovative Readiness Training Program with our reserve nurses helps to rebuild America in underserved areas through Operation Arctic Care in Alaska. Partnership efforts include regional, state and local communities with Guard and Reserve units in providing exceptional medical care. Through our nurses’ sound leadership and detailed coordination in the deployment and movement of these units, operational and combat readiness skills of the military units are enhanced. While on the exercise, the health care team on the Hospital Ship MERCY provided medical care to eighty-three Seattle veteran-eligible patients last summer, lauded by the Seattle Post for their community support. While in the Pacific Northwest, our health care professionals met with Canadian health care counterparts to discuss response plans for a major earthquake scenario. In addition, during the recent Southern California fire, our hospital ship provided housing and hot meals for over 100 military families.
At the Deckplate The expanding direct Fleet support by our Navy nurses has been well received by the Navy and Marine Corps communities. Our two nurse practitioners assigned to the Norfolk Naval Base see 300 Fleet sailors a month onboard ship or while underway for wellness and readiness efforts alone. They also function as trainers and consultants and have developed a CD-ROM for Fleet implementation of the Preventive Health Assessment Program. Women’s Health Nurse Practitioners have provided clinical exams for females onboard the USS Kennedy and also serve as instructors for the gynecological portion of the Independent Duty Hospital Corpsman curriculum. Through the newly-established Force Nurse Initiative with Commander, Naval Air Force US Atlantic Fleet and Commander, Naval Air Force US Pacific Fleet, two Navy nurses are now integral to Fleet level oversight, guidance and assistance to aircraft carrier medical departments and aviation squadrons. Professional nursing and technical recommendations are also provided on Force Health Protection, Shipboard Medical Training, Medical Department Quality Assurance, Infection Control, the acquisition of new medical equipment and other programs.
Preventive Health Assessment Nurse-Run Clinics, such as in our Naval Hospitals at Pensacola and Corpus Christi, have been praised by the Navy Line Community for promoting healthy, physically fit Naval Forces as program compliance dramatically increased. With the addition of a mental health clinical nurse specialist, the Outreach Program at Corpus Christi has further expanded suicide awareness briefs and other services.
Within the operational nursing division at our Naval Health Research Centers, our nurse researchers are leading funded research projects focused on women’s health issues and casualty care. In addition, they collaboratively developed research-based methods for providing surgical support during special operations at sea and in caring for the Medical and Security forces at Camp Delta in Guantanamo Bay, Cuba. These are just a few examples of how Navy nurses at the deckplate are involved in diverse activities ranging from direct care to the conduct of research in support of our operational forces.
Nursing Initiatives Across Naval Medicine, Navy nurses are involved in the planning and implementation of a variety of programs as leaders, clinical experts and researchers from population health to specific disease management. Military and civilian nurses are valued catalysts across our facilities directing patient safety initiatives and leading collaborative teams to evaluate patient outcomes that reduce error, variability, and cost. Several nursing initiatives include implementation of the JCAHO National Patient Safety goals, skin care studies, staffing effectiveness project, the management of diabetic patients, inpatient bed utilization, and medication/non-medication related near misses and actual events. Navy nurses at our three Healthcare Support Offices have been primary movers in linking the clinical aspects of Naval Medicine with strategic and annual business planning efforts to create more efficient practices and improve outcomes. Their most significant impact is in relating the clinical processes to business rules and interpreting the data relative to true clinical practices. In addition, nurse leaders and researchers are very involved with Navy Advisory Boards, Joint Readiness Clinical Advisory Boards and nationwide studies to collaborate on clinical advances and identify specific metrics to demonstrate efficient business practices.
Joint Population Health Programs Through the Joint Population Health Program across three California-based Naval Hospitals at San Diego, Camp Pendleton, and Twenty-Nine Palms, masters and doctorally-prepared nurses demonstrate savvy in program implementation, policy, practice and research to shape the health status of Naval forces and all eligible beneficiaries, while focusing on quality, cost and access. The Joint Population Health Office at Naval Medical Clinic Pearl Harbor, Hawaii has been labeled as a benchmark for population health in the Navy. Based on a comprehensive screening and assessment process, the program addresses Preventive Health Assessments (Active Duty); adult and children immunization and health maintenance status; and health education literature and classes based on individual needs. Statistically proven results support the benefits of both of these programs.
Case Management In today’s rapidly changing health care environment, nurse case managers play a crucial role in helping patients and providers select the most appropriate level of care in the most cost-effective setting. Optimal outcome is best exemplified through the Case Management Program across Navy Medicine based on the collaborative efforts of 93 civilian nurse case managers. Their focus on Active Duty, Exceptional Family Member Program families, patients with multi-system medical problems, targeted disease management entities and frequent emergency room users resulted in recaptured workload, decreased lost training days, enhanced patient/provider satisfaction and better managed care. The Active Duty Trauma Nursing Case Management Program at Naval Medical Center, San Diego coordinated the health care needs of 87 Operation Iraqi Freedom wounded and 233 non-operational trauma patients. Among other programs, such as at Naval Hospital Guam, nurse case managers have been responsible for reducing emergency room visits and inpatient admissions for chronically ill patients by responding to hundreds of consults and processing catastrophic, complex, high risk, high-cost health care requests.
Nurse-managed Clinics The rise in nurse-managed or nurse-run clinics has demonstrated the art and science of nursing in facilitating wellness, prevention and health maintenance towards self-management for patients. The nature of registered nurse practice in collaboration with physician champions meets the standards of the American Academy of Ambulatory Nurses through the use of research-based clinical practice guidelines, spanning across the spectrum from neonates to geriatric patients. Using the latest technological advances in wound care, nurses at Naval Hospitals Pensacola and Portsmouth enhance the care of complex battlefield injuries. Within Family-Centered Care, nurses plan, coordinate, and provide direct care and case management through a variety of programs, such as Postpartum Care Clinics. Home Action Plans for Pediatric Pulmonary patients at three of our facilities reduced admission rates by 50%. Other innovative nursing initiatives include: a nurse call center supporting 24/7 accessibility; post-deployment stress briefings; and disease management (diabetes, hyperlipidemia, and hypertension), to name a few.
Successful open access initiatives as a result of the innovative leadership of nurses at Naval Hospitals Pensacola and San Diego have increased patient satisfaction; decreased emergency room visits and unscheduled walk-in appointments; and improved patient/provider matching. With the assistance of the Institute for Healthcare Improvement at Naval Hospital Great Lakes, demand and patient flow processes were reviewed; inefficiencies were identified; new business plans were developed; and appointments were adjusted to maximize access. Success has migrated these processes to other clinics and clinical support areas as well.
Research We value research as an essential component to quality nursing care, from utilizing evidence-based practice to conducting research. For example, at Naval Medical Center Portsmouth, adult patients with bladder problems are now scanned for urinary retention resulting in an 87% reduction in catheterizations. Upper respiratory infection, urinary tract infection, diabetes and asthma clinical practice guidelines have improved clinical parameters and therefore decreased the number of appointments. In support of patient safety, an evidenced-based practice initiative for a more comprehensive risk assessment and protocol for “falls” was implemented at National Naval Medical Center Bethesda and has become a model for civilian and military facilities. The Sports Medicine and Reconditioning Team at Naval Medical Center San Diego includes a nurse researcher to evaluate “return to duty” time and re-injury rates of our Sailors and Marines to identify areas for improvement. Through a multidisciplinary research study, MedTeams strive to eliminate errors in the obstetrical area, increase patient satisfaction, and enhance collegiality and collaboration among health care professionals.
We continue to focus on advancing the practice of military specific nursing and its response to requirements of military readiness and deployment. The TriService Nursing Research Program has conducted Grant Management Workshops, which provided invaluable mentorship and training, resulting in an increased number of higher quality grant submissions. Research results are collaboratively shared across the services and are further disseminated to other facilities. Many of our research grant findings have been presented worldwide in numerous nursing conferences and in at least ten professional publications. Joint Initiatives There are several examples of joint programs across our Federal agencies, which combine the talent of our health care teams to provide quality care. Nurses at Naval Hospital Great Lakes are involved in coordinating a partnership program for active duty treatment and inpatient care with the North Chicago Veterans Affairs Medical Center. Nurses at Naval Hospital Corpus Christi are involved in the business planning and management of specialty care with their local Department of Veterans Affairs Hospital. Combined training initiatives and the mutual sharing of clinical expertise are beneficial, particularly for our overseas duty stations. Noteworthy coordinated efforts include a mental health nursing program with Walter Reed Army Medical Center in Washington, DC; an Obstetrics Course at Langley Air Force Hospital; Labor and Delivery training at Landstuhl Army Medical Center; assisting Madigan Army Medical Center with their medic (Licensed Practice Nurse) clinical training; and providing Advanced Cardiac Life Support and Pediatric Advanced Life Support classes for the Air Force at our Naval Medical Clinic in London. Professional Nursing in Naval Medicine Our goals are to shape the force with the right number of people in the right specialties, to meet the mission in all care environments, and to become the premiere employer of choice. Accomplishing this requires close attention to the national nursing issues; the pursuit of available recruitment and retention initiatives; and the alignment of our military and civilian nurses to meet Naval Medicine needs. The Department of Health and Human Services and other independent studies project that the current national nursing shortage of several hundred thousand registered nurses may add up to 750,000 by 2020. Despite recent increases in the number of nursing school entrants, the nation could have a long way to go in making a dent in the overall shortfall. We carefully monitor civilian compensation packages to maintain the strength of our military and civilian nursing work force by offering a variety of incentives.
Recruitment and Retention Through our diversified accession sources, pipeline scholarship programs, pay incentives, graduate education programs, specialized training opportunities and varied retention initiatives, Naval Medicine has historically been able to meet military and civilian recruiting goals and specialty nursing requirements to this point. We presently have 96.4% of our authorized active duty billets filled and 100% fill for our Reserve component. We continue to focus on our operationally-related nursing specialties, such as medical-surgical, critical care, perioperative and anesthesia, as well as women’s health nurse practitioner and certified midwives. Although we had a slow start in recruiting this year when compared to the past 10 years, we expect to meet our active and reserve recruiting goals this fiscal year.
Our civil service workforce challenges have been identified in remote locations stateside and overseas, as well in certain specialties, such as labor and delivery. Recruiting and retention incentives are utilized and career ladders initiated where possible.
Graduate Education Graduate education program and specialized training have been extremely successful in meeting our nursing specialty mission requirements and promoting retention. This year, we are sending two nurses to the recently established Doctoral Program at the Uniformed Services University of Health Sciences (USUHS). In addition, we continue to send several of our students to the USUHS anesthesia, family nurse practitioner and perioperative nursing programs.
Nurse Leadership Navy nurses continue to function in pivotal executive roles to impact legislation, health care policy and medical delivery systems. Executive nurse leaders in the Active and Reserve component are in key command positions as Commanding Officers and Executive Officers; at the Bureau of Medicine and Surgery Headquarters as Deputy Surgeon General and Deputy Directors; and other staff positions at Tricare Management Activity, Health Affairs.
As leaders, we value mentorship, which is accomplished via many innovative formal programs and informal forums with our enlisted personnel, Naval Reserve Officer Training Corps students, Medical Enlisted Commissioning Program students, junior nurses, and novice researchers.
Recognition Our nurses are recognized for their exceptional talent, outstanding leadership and professional nursing community involvement and have received clinical practice awards through the American Association of Critical Care Nurses, the Sigma Theta Tau Nursing Honor Society; the Association of Women’s Health, Obstetric and Neonatal Nurses; and the American Academy of Ambulatory Care Nurses. Our integral presence has also been documented through an extensive list of journal publications. For example, the June 2003 Critical Care Nursing Clinics of North America was specifically dedicated to military and disaster nursing. In addition, our professional achievements have been highlighted in many forums at the Academy of Medical-Surgical Nurses Conference, the Association of Perioperative Nurses Workshop, the California Nurse Leader Workshop, and at the Institute for Health Care Improvement Conference.
Conclusion In closing, I appreciate the opportunity to share the accomplishments and issues that face the Navy Nurse Corps. I see our nurses as dynamic leaders and innovative change agents in all settings. I remain truly proud of our Navy military and civilian nurses as they stand ready to promote, protect, and restore the health of all entrusted to our care anytime and anywhere. I look forward to continuing to work with you during my tenure as the Director of the Navy Nurse Corps. Thank you for this honor and privilege.
