Introduction
Operation Iraqi Freedom (GIF) has resulted in a paradigm shift from the concept of traditional war and peacekeeping operations to that of combating terrorism and urban warfare. The U.S. Army is transforming itself into a Future Force of combined armed forces that can be configured and modified to deploy rapidly and to merge with support units as force packages capable of responding to the changing requirements of diverse contingency operations.1 The Army Medical Department (AMEDD) is also undergoing transformation by redesigning theater hospital assets into modular medical elements capable of 24-hour operations with reduced administrative overhead, a smaller footprint in the area of operations, and greater mobility to perform specific battlefield functions as required for the mission.1 In light of the future AMEDD transformation, careful deliberation must be given to expanding the primary care role of deployed advanced practice nurses (APNs). Their advanced educational training, clinical expertise, and ability to offer primary health care make APNs invaluable resources for deployed military health care teams.2
Nurse practitioners (NPs), who are APNs, are educated to make independent decisions and to synthesize theoretical, scientific, and contemporary clinical knowledge for the assessment, management, and diagnosis of illness, health states, and health promotion.2-4 A master's degree is required for entry-level practice. The professional role of a NP is as a primary care provider who practices in ambulatory, acute, and long-term care settings.4-6 NPs are able to order and to interpret diagnostic and laboratory tests and to prescribe pharmacological agents when offering medical care to diverse populations across the life span. The American Nurses Association5 supports the role of NPs as advocates of health promotion and disease prevention, with an established record of providing excellent primary care in diverse settings. It is the ability of NPs to provide primary care to a diverse population that enables them to work in a variety of practice settings. One such practice setting is the military health care system. Army Regulation 40-68(6) authorizes NPs to provide medical health care for diverse populations in primary, acute, and long-term care settings. The role of NPs as primary care providers in peacetime health care has been well established; however, the role of NPs in wartime medical care has yet to be delineated. Notably absent from Army Regulation 40-686 is any mention of NPs as primary care providers in deployed settings. The roles and experiences of five NPs deployed to 0IF are described, to provide a better understanding of the contributions NPs can make in providing primary care in an austere wartime environment.
NP Roles and Experiences
All of the authors deployed to 0IF with the 28th Combat Support Hospital (CSH), a 296-bed, corps-level asset staffed by an interdisciplinary health care team of 500 soldier-medics. The 28th CSH had the capability to provide level III combat care and offered the following services: emergency/trauma, physical therapy, outpatient/sick call, radiology, laboratory, pharmacy, intensive care nursing, medical/surgical nursing, operating room and recovery room, medical maintenance, chaplain, combat stress, and patient administration. NPs traditionally are assigned to work as medical/surgical nurses in a CSH; however, the changing operational requirements of 0IF necessitated the use of these primary care specialists in a variety of positions. Changing operational requirements and phase of deployment were primary determinants of role assignments for NPs.
The warning order to deploy the 28th CSH was issued in February 2003. The predeployment phase of operations readied personnel physically and militarily for the impending mission. A NP, assigned as the primary care provider for the 28th CSH, served as the commander's advisor on medical issues and was responsible for the physical readiness of all personnel assigned to the unit. The NP prepared personnel for deployment by reviewing medical records, facilitated medical care for individuals with outstanding medical problems by coordinating health care with the local military medical treatment facility, and served as the immunization coordinator. To serve as the immunization coordinator, the NP completed an Internet-based didactic module and a real-time, hands-on, certification program supervised by an immunologist. More than 500 soldiers in the 28th CSH were screened for the immunizations necessary to protect them against biological warfare agents, as a direct result of having an immunization coordinator available within the organization. Furthermore, the ability to field an immunization coordinator enhanced the flexibility of the 28th CSH in accepting similar missions in the deployment phase of operations. The 28th CSH arrived at Camp Doha, Kuwait, in increments on March 8 to 10, 2003, and was billeted in warehouses while awaiting mission orders. A tasking from higher medical headquarters directed the 28th CSH to send mobile immunization treatment teams to staging areas on the Iraqi border, to inoculate troops against smallpox and anthrax. The NP, as immunization coordinator, educated and assembled four mobile immunization treatment teams, composed of physicians, nurses, and medics, that inoculated >2,000 troops. The immunization mission continued as the 28th CSH moved to its staging area at Camp Victory, Kuwait, on March 24, 2003, and assumed an outpatient troop medical clinic (TMC) mission.
Camp Victory was a "holding camp" for troops awaiting movement orders into Iraq and, when the 28th CSH arrived, was in a state of brisk construction. Medical support was exceedingly limited, consisting of an ambulance squad with four medics and two field ambulances. The medics provided triage and treatment for minor illnesses from their sleeping tent. Patients with acute/ urgent medical needs were transported to a nearby Air Force hospital for advanced care. It soon became apparent that the rapid influx of troops required definitive, on-site, medical care that could be ably provided by the health care professionals of the 28th CSH and the newly arrived 21st CSH (The 21st CSH, with a full medical complement, was also awaiting movement orders into Iraq.)
Two senior NPs assigned to the 28th CSH were selected to lead the mission of organizing, equipping, and staffing a TMC, as officer in charge (OIC) and assistant 0IC. Permission to establish an interim TMC was obtained by these NPs through close coordination with the leaderships of Camp Victory, the 28th CSH, and the 21st CSH. An eight-section temper tent with lights and air conditioning was rapidly assembled; it contained a waiting area, a screening section (with a pharmaceutical distribution point), and a treatment area with six cots/beds. The TMC was open 7 days per week, 24 hours per day, with sick call each morning and an immunization mission each afternoon. The 0IC and assistant 0IC made staffing decisions for the TMC, with responsibility for coordinating the work schedules of physicians (family practice, internal medicine, and general surgery), NPs, registered nurses, medics, a physical therapist, a psychiatric nurse, a pharmacist, and administrative personnel. Qualified staff members were able to suture lacerations, to drain simple infections, to dress wounds, to tape ankle sprains, to provide intravenous rehydration, and to diagnose simple acute problems, such as upper respiratory infections, gastroenteritis, and conjunctivitis. Eight NPs who deployed with the 28th CSH were an integral part of the interdisciplinary health care team that provided world-class primary care services at the Camp Victory TMC. Tables I and Il illustrate the variety of patient care and workload data documented during a 9-day period at the TMC. Many of the diagnoses/illnesses found in Table II are common to both peacetime and wartime primary health care settings. The ability of NPs to treat these common illnesses in peacetime supports the continued employment of NPs as primary care providers during deployment.
The two NPs who led the Camp Victory mission were experienced professionals who used their expert abilities and experiences as primary care providers and leaders to establish the TMC. The NPs not only supervised clinic operations but also treated patients daily, coordinated with higher command and the medical regulating officer regarding evacuation issues, and procured medical and administrative supplies for the TMC. Advanced knowledge of pathophysiology and pharmacology enabled the NPs to teach critical thinking skills and a systems approach to assessing, managing, and diagnosing common illnesses to medics and registered nurses working in the primary care setting. The success of the Camp Victory TMC is a telling example of the benefits inherent in having experienced senior NPs in the deployed environment.
Flexibility in accepting role assignments enabled all of the NPs in the 28th CSH to make valuable contributions in each phase of operations. For example, the NP assigned as the immunization coordinator in the predeployment phase of operations was reassigned as a primary care provider at Camp Victory. Upon deployment into Iraq, this NP was then employed as an evening/ night supervisor and worked in the emergency medical treatment section of the hospital, providing primary care.
The movement of the 28th CSH from Camp Victory into Iraq required NP role reassignment because operational orders dictated that the 28th CSH be reconfigured from a 296-bed CSH into two separate, autonomous, functional, hospital units. The first slice of the 28th CSH that entered Iraq was a 42-bed package designated the Rapid Mobile Surgical Hospital (RMS). The mission of the RMS was to provide emergency, surgical, and intensive care services wherever and whenever mission requirements dictated. The 28th RMS deployed into Iraq on March 29, 2003, traveled through the war-torn country, and arrived at its final destination of Forward Logistics Base Dogwood on April 6, 2003. Two NPs were selected to deploy forward with the RMS. One of the NPs had extensive experience as a critical care nurse and demonstrated leadership ability; therefore, she was selected as the head nurse of a busy intensive care unit (ICU) that cared for wounded U.S. soldiers, Allied personnel, Iraqi civilians (including woman and children), and enemy prisoners of war. A second NP, who had experience in emergency nursing, worked in the emergency medical treatment area, providing acute and primary care not only as a clinical staff nurse but also as a NP. The advantage of assigning a NP as an ICU head nurse is the ability of this primary care provider to serve as a collaborative link between nursing and physician staff members with respect to patient admission, discharge, clinical care, and evacuation issues. In this instance, the NP assisted physicians in writing admission and discharge orders during rapid influxes of casualties. An additional benefit of employing a NP in the ICU environment is the presence of a health care provider who can communicate advanced clinical knowledge and skills to others. The NP was the lead educator for ICU nurses and medics and taught critical topics, including advanced physical assessment and care of the pediatrie patient. The opportunity to learn advanced assessment skills was exceptionally important for a relatively inexperienced ICU staff that cared for a large number of critically Injured patients with a variety of injuries, including blast injuries, gunshot wounds, burns, fractures, blunt trauma, and psychiatric illnesses. The versatile clinical skills and leadership possessed by the NP were tremendous assets to a medical team that was challenged to identify and to overcome barriers to patient care In the midst of war.
Advanced education and the critical thinking skills of a primary care provider make NPs valuable resources that can be used in a variety of practice settings. For example, a NP from the 28th CSH was tasked to exchange positions with a pediatrician assigned to the 549th Area Support Medical Company (ASMC). The ASMC had a need for a primary care provider and the 28th CSH needed a specialist to care for critically ill and injured Iraqi children. Recognition of the NFs ability to provide primary care resulted in an equal exchange of qualified personnel to accomplish the mission of both organizations.
The NP quickly became an integral member of the 549th ASMC primary care team. The 549th ASMC was responsible for providing basic field medical care (outpatient services) and relied on the 28th CSH for specialty care. With limited diagnostic equipment, 549th ASMC clinicians were required to use astute physical examination and assessment skills to arrive at diagnoses and treatment options that would result in timely return of soldiers to duty. An outbreak of gastroenteritis in the early summer months of 2003 resulted in > 100 patients per day being treated at the 549th ASMC. It is estimated that 85% of the patients treated for gastroenteritis were returned to duty within 48 hours after presenting with symptoms. Expert primary care knowledge and assessment skills equipped the NP with the expertise necessary to diagnose and to treat patients with gastroenteritis and other illnesses encountered during assignment to the 549th ASMC.
In June 2003, the 28th CSH was tasked to deploy a 32-bed surgical hospital to Tikrit to support the 4th Infantry Division. NPs were once again selected to lead the primary care mission for the organization. The newly established hospital in Tikrit ventured into unfamiliar territory when an acute care clinic was created to meet an expanded mission of providing primary care sick call for active duty troops. The acute care clinic was situated adjacent to the emergency medical treatment area and contained orthopedic, physical therapy, and comprehensive medical/surgical sick call capabilities. Two senior NPs were assigned as the primary care providers for the clinic. One of the NPs served in the additional capacity as 0IC. The acute care clinic served as the "gateway" into the hospital system for patients with nonemergent illnesses and injuries. Redirecting an estimated 800 patients per month through the acute care clinic created the flexibility needed within the hospital to concentrate on true emergency cases in the emergency medical treatment area. The employment of NPs as primary care providers had a measurable effect on the organization's ability to provide expanded medical services, supporting the use of NPs in the roles for which they were educated.
Discussion
Military tactical and technical preparedness were essential elements in assisting NPs in transitioning from the predeployment phase of operations to the deployed environment. Soldiers of the 28th CSH were required to qualify with their assigned weapons, to practice wearing the protective (gas) mask and chemical protective overgarments, and to perform self-decontamination procedures. Participation in hospital equipment training, tent assembly, and orientation with respect to standard operating procedures assisted soldiers in becoming technically proficient in their assigned roles. Clinical preparedness was another important element in the deployment process. NPs listed Advanced Cardiac Life Support, Advanced Trauma Life Support, and Field Medical Chemical Biological Courses as important adjuncts in building a knowledge base suited to deployment. The simulated war environment created at the Joint Readiness Training Center in Fort Polk, Louisiana, presented an opportunity for two of the NPs to integrate their clinical, tactical, and technical skills. The NPs considered their Joint Readiness Training Center experience as a pivotal training event in preparing to go to war.
The role of the NP as a primary care provider has been well established in the literature4-6; however, Army Regulation 40-68(6) does not address the role of the NP in a deployed combat setting. It should be noted that combat medical units have positions designated for APNs working in the operating room but not for APNs working in primary care. The failure of regulation and doctrine to define the wartime role of the primary care NP influences role assignments in the combat medical unit. NPs deploy as medical/surgical registered nurses and are often assigned as a staff nurse, nurse administrator, or head nurse, depending on the needs within the organization. In comparing doctrine and the freshly experienced realities of war, several questions are posited with respect to the use of NPs in a traditional registered nurse role. (1) Do NPs1 primary care skills degrade over time during extended deployments? (2) If data show that skills do degrade over time, what impact does this have when NPs resume their peacetime primary care missions? (3) Are NPs able to transition from a primary care role to the registered nurse role in a seamless manner, or is reeducation needed? Seven of the NPs assigned to the 28th CSH were tasked as primary care providers in at least one phase of the deployment. Slotting NPs in a primary care provider role required subtle shifts in staffing to accommodate role reassignment. Perhaps fewer staffing shifts would have been necessary if several NP slots had been designated on the unit's staffing matrix before deployment. A careful analysis must be conducted to reevaluate the requirements of NPs on the battlefield, the staffing plan for deployable hospitals, and the requisite number of primary care slots for NPs in deployed medical organizations.
In analyses of future staffing plans for deployable medical organizations, it is important to consider the interchangeable nature of the physician assistant (PA) and NP roles in peace and war. Both PAs and NPs are intermediate or midlevel care providers. The differentiation between the two groups is that PAs are typically assigned to units located near the frontlines of battle, whereas NPs are typically placed in rear-echelon medical units such as a CSH.7 The unprecedented transformation of the Army into a Future Force necessitates that previously assigned roles for NPs in peacetime and wartime be examined for their validity and applicability in today's world. Army Regulation 601280 envisions the Future Force as an organization that is flexible, proactive, and responsive, with management and support processes to take care of the soldiers.8 Recent academic initiatives at the Uniformed Services University of the Heath Sciences are transforming the Future Force vision into a reality. The graduate nursing faculty has developed a comprehensive program of practica and specialty rotations in suturing, orthopedics, podiatry, dermatology, emergency care, and burn care, which provides family NP (FNP) students with the additional skill sets necessary for employment as midlevel providers in deployable medical organizations. The proactive and responsive addition of skill sets to the FNP program has given the AMEDD the flexibility to consider substituting FNPs for PAs in future deployments. Working together, NPs and PAs have a rare opportunity to shape the future of medical care for deployed soldiers. Validation of the interchangeable nature/roles of PAs and NPs must be analyzed in terms of clinical outcome criteria and warrants additional study.
The versatility of the NPs assigned to the 28th CSH was clearly demonstrated by their ability to function in such critical roles as head nurse, primary care provider, 0IC, and evening/night supervisor. NPs selected clinical acumen and experience level as important predictors of their ability to perform these critical roles. The lived experiences and proven performance of deployed NPs are true to the reputation of Army nurses for being able to "get the mission done."
Conclusions
The U.S. Army and AMEDD are being transformed into a Future Force capable of rapidly projecting scaleable and modular combined arms formations and medical elements. The mobilization of APNs in wartime and peacetime health care was critically examined. This article described the experiences and roles of APNs deployed to 0IF and supports expanded and legitimized roles for these health care professionals in future conflicts and peacekeeping operations.
Acknowledgment
We thank Linda Yoder, RN PhD AOCN (USA. Ret.), for her valuable assistance in the editing of this article.
© 2006 Association of Military Surgeons of the United States Provided by ProQuest LLC. All Rights Reserved.
Source: Military Medicine
