The United States Army Nurse Corps 

Transforming for a new century of caring 

October – December 2011 

Perspectives 1

MG David A. Rubenstein; COL Mustapha Debboun; Richard Burton 

Army Nursing: Transforming for a New Century of Caring 4

MG (P) Patricia D. Horoho 

Building the Army Nursing Campaign Plan 10

COL Susanne Clark; SGM Richard Brewer 

Designing and Implementing the Army Nursing Leader Academy 18

COL (Ret) Kathleen Dunemn; COL Denise L. Hopkins-Chadwick; et al 

Leader Development Transformation in the Army Nurse Corps 24

MAJ Tamara S. Funari; COL Kathleen Ford; COL Bruce A. Schoneboom

Human Capital Strategy: Talent Management 31

MAJ Michael Nagra 

Transforming Army Nursing Support Services to 38 

Centers for Nursing Science and Clinical Inquiry 

Lori A. Loan, PhD, RNC 

Establishing a Methodology for Development and Dissemination of 41 

Nursing Evidence-Based Practice to Promote Quality Care 

COL Carol J. Pierce 

Nursing and En Route Care: History in Time of War 45

MAJ R. Scott Davis; COL Linda K. Connelly 

Optimizing Wartime En Route Nursing Care in Operation Iraqi Freedom 51

MAJ Michael Nagra 

Optimizing Performance in the Combat Casualty Continuum 59

Kathleen D. Martin, RN, MSN; Mary Ann Spott, MPA, MSIS; et al 

Optimizing Nursing Care Delivery Systems in the Army: 65 

Back-to-Basics with Care Teams and Peer Feedback 

COL Kathy Prue-Owens; LTC Miko Watkins; COL (Ret) Kelly A. Wolgast 

Measuring Nursing Essential Contributions to Quality Patient Care Outcomes 74 

COL (Ret) Kelly A. Wolgast; LTC Katherine Taylor; LTC Dawn Garcia; LTC Miko Watkins 

Using Force Structure Analysis to Drive Transformation 82

COL Carol J. Pierce; COL Janice F. Nickie-Green 

Precision Recruiting: Building the Optimal Army Nurse Corps 89 

LTC Anthony J. Bohlin 
October – December 2011 The Army Medical Department Center & School PB 8-11-10/11/12 

By Order of the Secretary of the Army: 

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1124401 

RAYMOND T. ODIERNO 

General, United States Army 

Chief of Staff

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JOYCE E. MORROW 

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LTG Eric B. Schoomaker 

The Surgeon General 

Commander, US Army Medical Command 

MG David A. Rubenstein 

Commanding General 

US Army Medical Department Center and 

School 
 October-December 2011 1

Nothing endures but change. 

When the Greek philosopher Heraclitus penned that 

contemplation some 2,500 years ago, he undoubtedly 

had no concept of its increasingly profound relevance 

across the centuries that followed. His world was simple, bounded by the limitations of travel and communication. However, even then he recognized the inevitability of change in all aspects of human endeavor. 

Today, the phenomenon of change is unavoidable and 

inescapable. We are bombarded by information about 

its pace, its direction, its benefits, and, most important, 

its dangers. Every day we hear stories about the 

success enjoyed by institutions that recognize and 

adapt to change, and the stories of the failure of those 

that did not. Those institutions represent every type of 

organization and enterprise—religions, businesses, 

sports, education, and entire societies and civilizations, 

including their governments and militaries. 

Of course the most absolute of adaptations involve 

those institutions that deal with life and death, of 

which there are no more important examples than the 

practice of medicine, and the military. It follows 

directly that military medicine must cope with the 

combined challenges posed by both environments, 

some related, some not. Additionally, military medical 

organizations must contend with outside challenges 

pertaining to their unique hybrid character; societal, 

political, and financial, just to name a few. 

The Army Medical Department (AMEDD) charts a 

path between its incarnations. The AMEDD must 

respond to the ebb and flow of Army requirements, 

priorities, reorganizations, structural shifts, etc, as the 

military continually adjusts to the ever-changing 

nature of troubling trends and obvious threats to the 

nation. While this is occurring, the AMEDD must keep 

the highest level of medical competency, capability, 

sophistication, and skills within its ranks to ensure that 

the Army’s Soldiers receive healthcare second to none. 

This is not only the nation’s obligation to them as 

individuals, but healthy Warriors are absolutely 

essential to combat effectiveness. 

Each component of the AMEDD constantly faces 

those twin challenges, and must analyze, project, plan, 

and execute to have the correct combination of skills 

in sufficient numbers in the right places to maintain 

that healthcare support. This issue of the AMEDD 

Journal is dedicated to the recent work of the Army 

Nurse Corps as it undertook just such a transformation 

in response to the rapidly evolving, significant changes 

in both the military and medical responsibilities of 

their profession. 

I welcome MG (P) Patricia Horoho, the Chief of the 

Army Nurse Corps, to the pages of the AMEDD 

Journal to present her vision and guidance in the 

retooling of the Nurse Corps from top to bottom, not 

just structurally, but philosophically as well. Under her 

leadership, the Army Nurse Corps established the 

goals necessary to ensure it could achieve and 

maintain the highest standards of nursing care, not 

only for the military environment, but as professional 

nurses in any healthcare situation. The Nurse Corps 

then created a campaign plan to move it from here to 

there, a single, defined route to guide all the efforts 

required for such a transformation. The articles 

assembled in this issue cover the gamut of that work, 

including design of the campaign plan; the changes in 

professional training content and delivery; the 

methodologies to evaluate effectiveness and adapt 

accordingly; projecting the skills necessary to reach 

and maintain the standards of care, then getting the 

individuals with those skills to join the ranks as Army 

Nursing professionals. 

As shown in the pages of this AMEDD Journal, the 

transformation of the Army Nurse Corps has been an 

enormous effort, the complexity of which demanded 

strong, focused central leadership and a dedicated, 

closely coordinated team effort among the senior 

leaders across Army Nursing. The Corps Chief and 

those leaders are to be congratulated for their significant accomplishment. Further, the AMEDD looks 

forward to the continued leadership of MG (P) Patty 

Horoho as she assumes the mantle and duties as The 

Surgeon General of the Army, and Commanding 

General of the Army Medical Command. 

Perspectives Perspectives

COMMANDER’S INTRODUCTION

MG David A. Rubenstein 
2 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

EDITORS’ PERSPECTIVE

As mentioned by MG Rubenstein in his introduction, 

MG (P) Patricia Horoho opens this issue of the 

AMEDD Journal with a detailed description of the 

vision, concepts, planning, and execution of the 

transformation of the Army Nurse Corps under her 

leadership as Corps Chief. Her article provides 

excellent insight into the complexities involved in such 

an enterprise: the myriad of considerations, the level of 

detail, the challenges of inspiring and encouraging 

those who bring the necessary skills to the mission, 

and, most important, the establishment of priorities 

and adherence to the plan. The reader finishes this 

article with a solid understanding of the profession of 

Army Nursing, and what is required to sustain it. 

The next 4 articles deal with different aspects of 

implementing the transformation. First, COL Susanne 

Clark and SGM Richard Brewer describe the process 

of developing the Campaign Plan to guide the process 

along a focused, carefully specified route to achieve 

the desired final outcome. Their article expands on the 

interrelationships of multiple factors, the detail, and 

the wide range of considerations that went into the 

planning before the process could even begin. 

The Campaign Plan directed a thorough review of 

training programs for Army Nursing personnel. The 

article by COL (Ret) Kathleen Dunemn and her 

coauthors detail the process of review and revamp of 

the courses available, the means of delivery, and the 

expansion of resources attendant to the training 

process. The newly structured curricula and delivery 

methodology, now called the Army Nursing Leader 

Academy, is provided by the Department of Nursing 

Science at the AMEDD Center & School. The article 

is an excellent exploration of the details which must be 

considered in designing a training environment to 

support a professional throughout a military career. 

Next, MAJ Tamara Funari and her coauthors have 

contributed an article explaining the Nurse Corps 

restructure of its approach to developing nurse leaders. 

As part of the Campaign Plan, the Nurse Corps had to 

implement the means by which it could “grow” a 

reservoir of adaptive, innovative, capable leaders to fill 

positions of responsibility across all operations and 

environments. The analysis and planning was 

extensive, and implementation involved significant 

initiatives in training and career options available to 

Army Nursing professionals. 

The efficient management and use of the skills and 

talents of the people in an organization is essential to 

success. MAJ Michael Nagra has contributed an article 

describing the human capital management strategy 

within the Army Nurse Corps to identify, develop, and 

implement strategies to support the Corps’ human 

capital goals. His article details the difficulties and 

complexities inherent in implementing a system which 

will provide skills and leadership at the right place, at 

the right time. 

Dr Lori Loan’s article describes the Nurse Corps’ shift 

in the basic philosophy of care delivery from the 

expert-based practice approach, to a system-based care 

paradigm. In essence, the caregiver in the systembased care structure works within a system of 

interdependent healthcare resources to deliver the most 

advantageous and efficient patient care. This is the 

environment of military medicine, so the shift in Army 

Nursing’s approach is timely and will be beneficial to 

both the patients and caregivers. 

Among other things, system-based care depends on 

standardization of clinical practices such that all 

caregivers share the same guidelines for their approach 

to care. COL Carol Pierce’s article discusses the 

foundation for such guidelines, the evidence-based 

practice model. In order to be effective, caregivers at 

all levels must be on board with this approach, and 

nursing schools and training institutions must teach the 

tenets of evidence-based care. Also, institutions must 

have the infrastructure to identify and evaluate care 

delivery practices, and develop (and advocate) those 

that are judged to be beneficial in improving patient 

outcomes. COL Pierce describes how the Army Nurse 

Corps has adjusted its organization, structures, and 

training to support implementation and growth of 

evidence-based nursing care practice guidelines 

throughout the Army healthcare system. 

In their article, MAJ Scott Davis and COL Linda 

Connelly look at Army Nursing involvement with 

airborne en route care, developing their discussion 

from an historical perspective. Army nurses have been 

accompanying wounded Warriors in aircraft since 

World War II, but the bulk of that activity involved 

extended flights out of the combat theater, such as 

those flown by the Air Force evacuation flights today. 

It is surprising that, although helicopters have been 

flying battlefield wounded to medical care since the 

Korean War, and especially in Vietnam, the de facto 

Perspectives 
 October-December 2011 3

THE ARMY MEDICAL DEPARTMENT JOURNAL

requirement for critical care trained nursing capability 

en route did not manifest itself until the current 

conflicts began in 2003, a topic which is further 

developed in the following article. MAJ Davis and 

COL Connelly have provided an interesting and 

illuminating article which further emphasizes the need 

for flexibility and adaptability in the provision of 

healthcare in the ever-changing world in which Army 

medicine must operate. 

Transformation must be reactive to things happening 

in the dirty-boots world of combat theaters. MAJ 

Michael Nagra’s article expands that new role for 

Army nurses discussed in the previous article—en 

route care—which resulted from the changes that 

Army medicine has made in the delivery of trauma 

care in the battlefield environment. Earlier surgical 

intervention (resuscitation and stabilization) in the 

chain of evacuation of the wounded has markedly 

improved survivability, but has also introduced an 

increased level of complexity in the onward 

transportation of these wounded. The seriously 

wounded patients are often critical, and must be 

transported with equipment and medication to 

maintain resuscitation and allow intervention if 

necessary. The combat medic or aeromedical crewman 

is not trained in such sophisticated practices, so 

increasingly, Army nurses have been pressed into 

service in en route care. MAJ Nagra discusses the 

disruptions in resource management this unavoidable 

requirement has caused, the steps taken in the field to 

minimize the impact and predict the requirement, as 

well as the capture of data to address the needed 

structural and staffing changes. 

With the initiation of combat operations in 

Afghanistan in 2003, and later at an even larger scale 

in Iraq, the Army’s Landstuhl Regional Medical 

Center in Germany found itself facing a significant 

increase in patients requiring sophisticated trauma care 

which had not been experienced in decades. As 

described by Kathleen Martin and her author team, it 

was immediately apparent that Landstuhl needed to 

initiate development of a trauma center in order to 

provide the resources and capabilities necessary to 

contend with the steady stream of critical trauma 

patients moving into and out of that facility. Their 

article is an excellent explanation of the process, the 

timelines, the resource commitments and management, 

and the continuous coordination and communication 

involved in driving a vitally needed capability from 

concept to reality. 

Among the elements of nursing care receiving special 

emphasis as part of the transformation is the quality of 

the delivery of bedside care, and the integration of a 

formal, professional peer feedback process to enhance 

individual performance. COL Kathy Prue-Owens and 

her coauthors detail the implementation of the guidelines, procedures, and organization to, essentially, take 

a back-to-basics approach to patient care with the use 

of care teams and structured scheduling throughout the 

shifts. The article also describes the philosophy behind 

peer feedback, its value, and the approaches that are 

being implemented as part of the transformation of the 

Army Nurse Corps. 

Inherent in the provision of quality nursing care is the 

ability to consistently match personnel resources to the 

needs of the patients. As described by COL Karen 

Gausman and her team, an element of information 

necessary to this ability is a standard classification of 

the patient’s needs, the acuity and complexity of care. 

The article explains patient classification systems, how 

they are designed, how they are used, and how their 

utility is viewed by the users. 

The Army Nurse Corps transformation is essentially 

an extremely complex personnel management task. As 

explained by COL Carol Pierce and COL Janice 

Nickie-Green, the personnel force structure is the 

foundation to turn all visions, concepts, and plans into 

capabilities and reality. Their excellent article is a 

primer on the Army’s manpower planning and 

execution process, and how to organize to make 

optimum use of its requirements and functions. Indeed, 

force structure models and adjustments are a 

continuous process in reaction to the demands of 

changing military requirements. 

LTC Anthony Bohlin closes this important issue of the 

AMEDD Journal with an informative article about the 

essential first step in any human resource management 

process—recruiting those people with the skills, 

intelligence, commitment, and personalities to provide 

the required capabilities. The AMEDD identifies 

specific skill requirements projected for the future, 

based on many factors, and sends those needs to the 

Medical Recruiting Brigade. These skill sets now 

become precision recruiting targets, the goal of which 

is to obtain trained, qualified personnel who will 

require minimal additional medical training. This is 

especially important to the Army Nurse Corps, where 

optimization of resources is an important goal of the 

transformation effort. 
4 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Army Nursing: Transforming for a New 

 Century of Caring 

 MG (P) Patricia D. Horoho 

INTRODUCTION

On October 28, 2008, Army Nursing senior leaders 

from around the world convened in San Antonio, TX, 

to finalize the premier Army Nursing Campaign Plan 

and begin the transformation of Army Nursing. The 

group of individuals included retired Army nurses, 

Army nurse clinical experts, Department of the Army 

civilian nurses, and noncommissioned officers, each 

selected for the experience and knowledgeable skill 

sets they could bring to bear on the campaign planning 

process. During the conference, Army Nursing’s (AN) 

new motto was launched, as conceived by MAJ 

Jeremie Siegfried: “Embrace the Past, Engage the 

Present, Envision the Future.” I selected this motto 

from the many that were submitted because it articulated my commitment to leveraging lessons learned 

from the past and from those who came before us, and 

harnessing innovation and technology from the present 

in order to shape the future of professional nursing. 

ARMY NURSING’S OPERATIONAL LANDSCAPE

Today the nation remains engaged in an era of 

persistent conflict, a period of protracted confrontation 

against adversaries willing to use any and all means at 

their disposal to achieve their political and ideological 

ends. The wars that we are fighting in this new era are 

unlike any other in American history, wars in which 

military forces operating among the people will decide 

the outcome. In addition to meeting the demands of 

persistent conflict, the Army is undergoing its largest, 

most comprehensive transformation since World War 

II. It is midway through its transition to a modular 

force, capable of deploying and fighting and winning 

anywhere in the world. Meanwhile, throughout these 

seismic shifts, our Soldiers and their Families have 

displayed phenomenal personal courage and sacrificed 

heroically for the good of our nation. We are 

constantly striving to ensure Soldiers and their 

Families have everything they need to overcome the 

risks and challenges they will continue to face during 

this turbulent period. 

Change is always difficult. It requires courage, often 

an illusive virtue, but a fundamental, essential component of nursing. Our transformation journey began at a 

time when the nursing shortage was a looming public 

health crisis that had the potential to erode access to 

and quality of military healthcare. This aspect of the 

operational environment has not changed. Specialty 

nurses, such as psychiatric and family nurse practitioners, are critical to meeting the increasing healthcare needs of our most vulnerable populations. We 

need competitive-edge strategies to attract and retain 

qualified nurses and nurse candidates from an increasingly diverse population. Also needed are healthcare delivery systems utilizing predictive models that 

can delineate required nursing capabilities and capacities. Current and future changes in nursing workload 

processes and requirements demand measurement 

systems that capture workload quality and quantity; 

promote nurse staffing models, and, by balancing 

standardization with innovative best practices, allow 

for measurement of nurse-sensitive patient outcomes. 

During the mission analysis performed from 2008 to 

2009, we noted differences in nursing care delivery 

models across care environments, for example, 

inpatient, outpatient, deployed care, and Warrior 

Transition Units. This practice variance limited our 

capability to reliably measure nurse-sensitive patient 

outcomes and codify best practices across Army 

Nursing, and had caused imbalances in nursing 

workload and workforce ratios across the Army 
 October-December 2011 5

Medical Department (AMEDD). Further, an 

optimized, steady-state workforce was threatened by 

an inability to offer innovative, flexible career 

programs to promote nurse retention. Compounding 

the challenges was the lack of a leader succession plan 

and talent management strategy congruent with a force 

structure analysis that optimized clinical leader 

knowledge and skills necessary for a credible, 

sustainable Army Nursing organization. No corporate, 

cohesive nurse training blueprint existed that leveraged 

human capital asymmetric advantages such as a novice 

nurse’s capability to innovate in complex, dynamic 

environments that could potentially mitigate gaps in 

technology and nursing capacity. 

TDA-focused* Army Nurse Corps areas of 

concentration and additional skill identifiers were 

developed for a hospital-based environment in an era 

when the Army was downsizing and currently do not 

address new capability gaps exposed as a result of 9 

years of war. In the fall of 2008, the sustained 

increased demand for Army nurses was beginning to 

exceed the sustainable supply. 

The challenges enumerated above—war and 

deployments, patient and family care needs, demand 

and supply, workload quality and quantity, and leader 

development—warranted a full review of the Army 

Nursing operational environment. The time to 

transform was now! I knew we could not accomplish 

everything at once. We needed to make deliberate, 

resource-informed decisions to ensure that we met the 

challenges of today while preparing for those of 

tomorrow. As the Army and AMEDD had developed 

strategic plans that provided clear glide paths for the 

future, Army Nursing had to strengthen its place as a 

relevant, agile, and outcomes-driven leader and 

collaborator in AMEDD healthcare. 

THE PATIENT CARINGTOUCH SYSTEM

My first priority was to build a system that 

encompassed all nursing care delivery environments; 

reduced delivery variance so that care outcomes could 

be analyzed for care improvement; ensured patients 

were receiving the best nursing care across the system 

based on the same standards of care and professional 

practice; established baseline standards for AN 

clinical, professional, and business practices; and, 

finally, reduced nurse turnover and improved nurse 

retention. The care system needed to exemplify Army 

Nursing’s core values—what we believe as nursing 

care providers—and guide, gauge, and ground the 

work in all nursing care environments. The Patient 

CaringTouch System came from this commitment and 

includes 5 elements: patient advocacy, enhanced 

communication, capability building, evidence-based 

practice and management, and healthy work 

environments as illustrated in the Figure. We believe 

that these 5 elements, when combined synergistically, 

produce the best patient outcomes. 

The Army Nursing Creed (presented on page 9), 

written by Army nurse LTC Leigh McGraw in 2009, 

begins with the statements: 

I am a member of the Army Nursing Team. My patients 

depend on me and trust me to provide compassionate 

and proficient care always. 

The Creed not only defines patient advocacy for Army 

Nursing by delineating how we want to morally and 

ethically deliver care, it further illuminates the bedrock 

beliefs upon which Army Nursing operates. This 

Creed, along with the American Nurses’ Association 

Standards of Practice and Professional Performance1

and Code of Ethics,

2

 the Army Values, Soldier’s Creed, 

and Army officer Oath of Office, comprise Army 

Nursing’s core values that define our vision for the care 

we provide. The Patient CaringTouch System is how we 

put that vision into practice. This system provides a 

sustainable framework for our transition from a diverse, 

location-dependent, single expert-based style of nursing 

practice and nursing care delivery to a standard, 

consistent system of caring across Army Medicine. It 

*TDA–Table of Distribution and Allowances. The TDA prescribes the organizational structure, personnel and equipment authorizations, and requirements of a military unit to perform a specific mission for which there is no appropriate table of organization 

and equipment. 
6 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

cultivates patient and staff trust by providing standard 

processes in which care is measured across Army 

Medicine as it allows us to look critically at what we do, 

how we do it, and how we can improve. 

The Patient CaringTouch System ensures our patients 

know that we have their best interests at the forefront of 

all care decisions and it promotes best practice 

standards, not standardization, for nursing care Armywide. When we piloted the Patient CaringTouch System 

at Fort Campbell, Kentucky, we found that we had a 

positive impact on patient outcomes, patient 

satisfaction, clinical communication, provider-nursing 

staff collaboration, and provider satisfaction. We 

believe these results will be reproducible across Army 

Medicine. We are using evidence-based metrics to 

benchmark nurse sensitive indicators against AMEDD 

and national standards to validate our firm belief that 

our patients are receiving world-class, high quality 

patient care. The Patient CaringTouch System 

transcends care environments and, although currently 

being implemented at 3 exemplar facilities based in the 

United States, it will soon be implemented in diverse 

care environments such as outpatient care areas, combat 

support hospitals, and mobile locations such as the back 

of a medical evacuation helicopter relative to Army 

Nursing’s en route critical care transport mission. 

EVIDENCE-BASED PRACTICE AND MANAGEMENT

Evidence-based practice is a key element in the Patient 

CaringTouch System and nursing researchers, embedded within newly formed Centers for Nursing science 

and Clinical Inquiry (CNSCI), are translating research 

into practice to optimize the quality of care provided to 

our patients. These Centers are promoting enhanced 

nursing decision support, evidence-based practice, and 

research. Nurse scientists, clinical nurse specialists, and 

our healthcare systems analysts comprise the CNSCI. 

These experts working together are affecting the 

transition from a “question-to-answer model” to the 

more valuable “question-to-translation-to-evaluation 

model.” Consolidating nursing support assets who are 

working on a common sense research priority agenda 

increases the capacity for evidence-based management 

and evidence-based practice Army Nursing-wide. 

Research and evidence-based practice are overarching 

and core constructs in the Army Nursing Campaign 

Plan. Army Nursing is transforming from a single 

facility, “expert-based” practice model to a systemsbased care model to best leverage knowledge 

management and research translation across all nursing 

care environments. This is critical to improve patient 

outcomes, safety, healthcare value, and quality. Tenets 

of a systems-based care model include system resourcing, health care economics, teamwork, costbenefit considerations, and practice management. Key 

to success is gleaning the knowledge of diverse 

nursing support experts such as systems analysts, 

doctors of nursing practice, nurse informaticists, and 

clinical nurse specialists to better meet the needs of 

bedside nurses and the nurse leaders who provide and 

direct the delivery of patient care. 

Army Nurse scientists are collaborating in joint, multinational, and academic settings to infuse nursing practice with evidence-based science. The premier Army 

Nursing Practice Council (ANPC), established in the 

fall of 2010, is providing the critical connection between nursing science and nursing practice. The ANPC 

meets monthly to review evidence, data, and science to 

develop evidence-based Tactics, Techniques, and Procedures that then become the standards across Army 

Medicine. We are constantly refining our clinical 

capabilities to meet the ever-changing complexity of 

providing care in challenging care environments by data 

mining and application of lessons learned. For example, 

with this analysis, we determined a need for Army 

trauma nurses whose capability was connected to a 

mission (trauma care) rather than a location (emergency 

room, intensive care unit). This new area of 

concentration would produce economies of scale by 

producing mission-driven capability for the same cost, 

economies of effort by exploiting manpower, materiel, 

and time, and economy of scope by producing a nurse 

who could function in any critical care environment. 

As a result of increasing demands for trauma nurses 

and the complexity of care required in both theaters of 

operation, we made the decision to establish a separate 

area of concentration consolidating intensive care unit 

and emergency nursing with the educational and 

clinical focus on combat trauma care. This new area of 

concentration will provide us a flexible and agile 

economy of force, while providing an economy of 

effort for training. We are reshaping our intensive care 

unit and emergency nursing courses into a single 

curriculum focused on acquisition of trauma nursing 

and critical care competencies. The Army trauma 

nurse area of concentration will result in assignment 

flexibility in both our hospitals and deployed combat 

support hospitals, and provide an unprecedented level 

Army Nursing: Transforming for a New Century Of Caring 
 October-December 2011 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

of trauma nursing capability for military medicine. 

Every Army nurse must be a trauma nurse. 

The Perioperative Nurse Consultant, in collaboration 

with the national perioperative nursing organization, 

expanded perioperative nursing’s capabilities by 

adding complex additional sterilization procedures to 

the curriculum for both our perioperative nurse and 

operating room technician programs. This proactive 

initiative addresses a national health concern regarding 

potential infectious disease transmission resulting from 

improper sterilization processing of surgical scopes. 

Currently, we are developing a pilot program to 

leverage the capability of graduate prepared 

Perioperative Clinical Nurse Specialists into the new 

role of Perioperative Nurse Case Managers. These case 

managers will be responsible for the coordination of 

clinical care across the perioperative continuum from 

preoperative preparation to postanesthesia care. This 

role will concentrate on quality assurance with a focus 

on patient safety and perioperative arena efficiency to 

include the operating room and the centralized sterile 

processing department. The operating room can be one 

of the busiest patient touch points in a facility, and as a 

result, a high-risk area where we want maximum 

perioperative nurse oversight of all nursing processes 

throughout the perioperative care continuum. 

We implemented an initiative related to critical care 

skills for our enlisted licensed practical nurses (LPNs). 

My priority was to fully leverage their capabilities, 

along with that of our medics, as members of the 

AMEDD healthcare delivery team. In October 2010, 

we conducted our first predeployment critical care 

course for enlisted practical nurses from one of our 

deploying combat support hospitals. The Soldiers 

received didactic instruction and clinical rotations in 

critical care and burn care at Brooke Army Medical 

Center and the Institute of Surgical Research. Three 

enlisted practical nurses from the deploying 115th 

Combat Support Hospital attended a “critical care 

skills during deployment” pilot. On average, students 

demonstrated a 42% increase in self-reported skills 

related to chest tube drainage system setup, cardiac 

strip interpretations, and patient report/handoff. With 

the success of this pilot, we are currently developing a 

predeployment LPN course that will prepare deploying 

LPNs for the complex trauma missions they will 

support. Licensed practical nurses and medics stand 

shoulder to shoulder with Army nurses in deployed 

care environments and as such, must be able to deliver 

care to the fullest extent of their scopes of practice 

(LPNs) and scopes of competency (medics). 

LEADERSHIP

In the fall of 2009, a leadership study was undertaken 

by MAJ Tamara Funari, an Army nurse student at the 

Command and General Staff College, to examine 

Army Nursing to determine how best to develop fullspectrum Army Nursing leadership at every level. We 

needed to replace the business practice of assigning 

leaders based on seniority and an outdated lifecycle 

model with one of capability-based assignments 

wherein talent, performance, and an officer’s 

capabilities were carefully matched with job capability 

requirements. Furthermore, I knew that any Army 

Nursing transformation would not be sustainable 

simply because of our core competencies or technology, but because we continuously regenerated 

leadership at all levels of Army Nursing. This was the 

strategy that would allow leaders at every level to 

innovatively reinvent competencies, cultures, and 

technology. Field Manual 1 states, 

...the ambiguous nature of the operational environment 

requires Army leaders to know themselves and deal 

with circumstances as they are....3

 

I knew that our nurse clinical leaders were making 

nanosecond clinical decisions in disparate, highoptempo care environments that relentlessly presented 

complex challenges that had no prescribed solution 

sets. We needed a concept of Army Nursing leadership 

tethered to the Patient CaringTouch System but 

comprehensive enough to mount a full-scale 

transformation of Army Nursing leader development. I 

asked MAJ Funari to define full-spectrum leaders for 

Army Nursing within the context of leaders who could 

adapt to any conditions-based mission. Her definition 

was the blueprint we used to begin construction of the 

virtual Nursing Leader Academy at Fort Sam Houston, 

Texas. The purpose of the Leader Academy concept 

was to develop a process that continuously developed 

leadership and promoted the acquisition of leader 

capabilities required for and aligned with the changing 

demands of our care environments. 

FORCE STRUCTURE

My third priority was to optimize Army Nursing’s 

footprint by leveraging inventive, groundbreaking 

recruiting, retention, and incentive strategies, then 

adjusting and enhancing Army Nursing force structure 
8 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

to better align it with missions and requirements in 

support of The Surgeon General’s vision. The mission 

analysis evaluating Army Nursing force structure 

looked at past growth and development of new 

capabilities (areas of concentration (AOCs), additional 

skill identifiers), internal strengths and weaknesses, the 

macroenvironment (external to the AMEDD), AMEDD 

corporate level strategy and business strategy, as well 

as functional strategies the AMEDD was pursuing to 

build competitive advantage through superior efficiency, quality, innovation, and customer responsiveness in order to achieve the business strategy. We 

also evaluated Army Nursing’s structure and control 

systems—did we have the right level of vertical 

differentiation? For example, were there the right 

numbers and levels of senior nursing hierarchy in 

place or was control decentralized? We evaluated 

horizontal differentiation to analyze if we were 

organized functionally or around a “product,” such as 

nursing care delivery. And finally we evaluated 

whether we had the right integration or control systems 

in place to not only manage day-to-day Army Nursing 

operations, but to continuously evaluate and improve 

our product, nursing care across care environments. To 

evaluate the macroenvironment, we used a modified 

version of Porter’s 5 forces.4

 First, we considered 

external “industry competitors” to evaluate if anyone 

was delivering nursing care better than us, and if so, 

how? For this, we collaboratively partnered with 

Kaiser Permanente Nursing who became our “thought 

partners” as we were both on a similar journey of 

transformation. Second, we wanted to know where our 

pressure points from “substitutable products (nurses)” 

were, that is, who were our competitors for our 

Department of Defense civilian nurses, and what was 

their competitive advantage? Third, what was the 

bargaining power of the “suppliers” (other healthcare 

organizations) in terms of compensations offered? 

Fourth, what did our civilian nurses—our “buyers”—

want? And fifth, were there any “potential entrants” 

into nursing with new, innovative best clinical 

practices; optimized technology; and fresh ideas, data, 

science, and evidence; and if so, who were they? Our 

analysis of Army Nurse Corps’ force structure and 

force management processes and strategies was 

sobering. Current Army and AMEDD missions and 

priorities had moved our force structure target such 

that it was no longer aligned with priority requirements 

or well-positioned for the future. Emerging global and 

national trends were shaping requirements in a 

demanding way that outpaced the utility of manpower 

documents. The complexity and challenges of leading 

rather than managing healthcare delivery required 

scrutiny and perhaps a reordering of how we assigned 

our colonels, our most senior nursing strategists, 

against capability requirements. We needed the 

development of forcing functions such as integration 

of talent management concepts into the assignments 

process in order to aggressively best-match officer 

talent to talent requirements inherent in a job position. 

Eight years of persistent conflict mandated a 

comprehensive look at capability, that is, nursing 

skills, knowledge, and behaviors required for current 

and future fights, as well as capacity, the right 

numbers of qualified nurses to do the job. 

As the AMEDD transitions from a healthcare system 

to a system of health focused on wellness and 

prevention, it was imperative that we examined 

innovative ways to exploit current nursing capability, 

as well as define future nursing capability needs in 

order to optimize nursing resources for current and 

future care requirements in a wellness health model. A 

basic tenet of Army Nursing transformation, patientcentered care, mandated that care was organized 

around the patient. Subsequently, we looked for new 

“care configurations” using nursing resources that 

brought care to the patient, rather than the patient 

having to go to a location for the care. We are piloting 

the concept of assigning our Public Health Nurses 

(PHNs) (AOC 66B) into our brigade combat team 

nurse billets. Our PHNs are experts at promoting 

wellness among populations, so it made sense to 

leverage them where our largest Army populations 

exist, in line units. This concept, nicknamed “curbside 

nursing,” precludes Soldiers from having to come to 

hospitals for wellness initiatives such as tobacco 

cessation. Instead, the PHN works with Soldiers in a 

military unit setting in a way that allows establishment 

of long-term therapeutic relationships with these 

individuals. This allows the PHN to determine health 

requirements of the unit and plan education and 

therapies to address those needs. This initiative will 

optimize the medical readiness of units preparing for 

deployment, during deployment, and upon the unit’s 

return to home station. 

CONCLUSION

Although we could neither eliminate nor predict the 

uncertainty of the future, we developed a framework 

Army Nursing: Transforming for a New Century Of Caring 
 October-December 2011 9

THE ARMY MEDICAL DEPARTMENT JOURNAL

that harnessed its opportunities. We developed an 

Army Nursing Campaign Plan that defined a 4-year 

end state reflective of our unique mission, environment, and time in history while providing a 15-year 

blueprint for sustaining a vibrant Nurse Corps, relevant 

for the future. By executing the Campaign Plan, we 

reached our goals to leverage lessons learned from the 

past, engage present innovations, and shape the future 

of professional nursing for the benefit of those we 

serve. My covenant to Army Nursing was to preserve 

the continuum of the Army Nurse Corps’ past, present, 

and future, while leading a nursing transformation 

focused on dedicated service, innovation, and a 

commitment to excellence. I am humbled by the 

phenomenal effort my predecessors devoted to 

creating the strong foundation on which Army Nursing 

stands today. Their successes were our touchstone as 

we moved forward, caring and advocating for our 

patients and their families. I envisioned an Army 

Nursing of the future that would leave its mark on 

military nursing, and would be a leader of nursing 

practice reform at the national level. Our priority was 

always our patients and their families, and our 

common purpose was to support and maintain a 

system for health. United in achieving this purpose, we 

serve with the courage to care, the courage to connect, 

and the courage to change so that we can continue to 

provide the best possible care to those who wear the 

cloth of our nation.

REFERENCES

1. Nursing: Scope and Standards of Practice. Silver 

Spring, MD: American Nurses Association; 2010. 

2. Code of Ethics for Nurses With Interpretive 

Statements. Silver Spring, MD: American Nurses 

Association; 2011. 

3. Field Manual 1: The Army. Washington, DC: US 

Dept of the Army; June 2005:1-18. 

4. Porter ME. The five competitive forces that shape 

strategy. Harv Bus Rev. 2008;13(1):86-104. 

AUTHOR

MG (P) Horoho is the Deputy Surgeon General and the 

Chief of the Army Nurse Corps. She has been 

confirmed to be the 43rd Surgeon General of the Army 

and Commander of the Army Medical Command. She 

will assume those responsibilities in December 2011. 

 The Army Nursing Team Creed 

 Authored by LTC Leigh McGraw 

 I am a member of the Army Nursing Team 

My patients depend on me and trust me to provide compassionate and proficient care always. I nurture the most helpless

and vulnerable and offer courage and hope to those in despair. I protect the dignity of every individual put in my charge.  

I tend to the physical and psychological wounds of our Warriors and support the health, safety, and welfare of every

retired Veteran. I am an advocate for family members who support and sustain their Soldier during times of War. It is a

privilege to care for each of these individuals and I will always strive to be attentive and respectful of their needs and

honor their uniquely divine human spirit.

We are the Army Nursing Team 

We honor our professional practice standards and live the Soldier values. We believe strength and resiliency in difficult

times is the cornerstone of Army Nursing. We embrace the diversity of our team and implicitly understand that we

must maintain a unified, authentically positive culture and support each other’s physical, social, and environmental

well‐being. We have a collective responsibility to mentor and foster the professional growth of our newest Team

members so they may mentor those who follow.

We remember those nursing professionals who came before us and honor their legacy, determination, and sacrifice. We

are fundamentally committed to provide exceptional care to past, present, and future generations who bravely defend

and protect our Nation.

The Army Nursing Team: 

Courage to Care, Courage to Connect, Courage to Change 

Embrace the Past, Engage the Present, Envision the Future 
10 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Planning and executing four years at a time stops today. 

The campaign planning process is our 15-year blueprint 

for continual review, analysis, and execution so that we 

maintain organizational credibility and sustainability. 

MG Patricia Horoho, Army Nurse 

Corps Campaign Planning Conference, 

San Antonio, TX; November 2008. 

In August 2008, the Chief of the Army Nurse Corps, 

MG Patricia Horoho, directed a top-to-bottom review 

of all Army Nursing* clinical, business, and 

professional practice processes as a gap analysis to 

determine campaign planning for the 4 years ahead. 

She directed her staff to align her strategic intent for 

over 40,000 professionals performing diverse missions 

across various care environments with Army Medical 

Department (AMEDD) operational goals and 

objectives in a way that allowed a comprehensive 

measurement of nurse-sensitive patient outcomes. 

MISSION ANALYSIS

The Corps Chief’s guidance was to rethink the purpose 

and goals of Army Nursing (AN) in a much broader 

and more far-reaching way. Considering the military’s 

status as a reactive force concerned with “hedging 

bets,” in 2006, GEN Peter Pace, the Chairman of the 

Joint Chiefs of Staff, observed that, 

We cannot accurately characterize the security 

environment of 2025; therefore, we must hedge against 

this uncertainty by identifying and developing a broad 

range of capabilities. Further, we must organize and 

arrange our forces to create the agility and flexibility to 

deal with unknowns and surprises in the coming 

decades.1 

At a meeting on November 15, 2009, MG Horoho 

summarized her thoughts about the next 4 years and 

AN’s future along those same lines: 

...this uncertainty, along with 7 years of war, requires 

us to resculpt the art of nursing and make us a more 

significant force capable of providing diverse and 

persistent nursing capabilities for an uncertain and 

unpredictable world. 

As a result, the first priority was to answer 2 questions: 

1. What capability is needed currently? 

2. What capability is needed for the future? 

We wanted to consider new ways to leverage current 

nursing capability against a broad spectrum of missions, while also considering new nursing capabilities 

for the future. Furthermore, we were directed to: 

“Build our Bench,”

get “Back to the Basics” of bedside care, 

“Optimize Performance,” and 

develop a “Portfolio of Talent.”

These 4 imperatives became the strategic objectives 

for the AN Campaign Plan.2

 We used the Doctrine, 

Organization, Training, Materiel, Leadership and 

Education, Personnel, Facilities3

 analysis tool to focus 

our gap analysis for each objective. 

INITIAL ANALYSES AND DIRECTION

As an example, to build our bench (leader development), we posited questions, presented in Table 1, that 

focused on refining our efforts towards developing an 

end state for this strategic objective. 

We developed 3 priorities from these questions: 

develop a full-spectrum leader concept, develop a 

leader succession plan, and develop a leader academy 

concept that includes both training and education 

platforms. Following similar analysis of Warrior/patient care delivery systems (back to basics) the Corps 

Chief defined the priority: development of a professional nursing practice model. In order to optimize 

performance (evidence-based practices), she identified 3 priorities: development of a prioritized AN 

research agenda; development of AN evidence-based 

clinical practice standards; and development of an AN 

culture of knowledge management that drives 

decisions for clinical, professional, and business 

practices at all operational levels. The decision relative 

to developing a portfolio of talent (human capital) 

Building the Army Nursing Campaign Plan 

COL Susanne Clark, AN, USA 

SGM Richard Brewer, USA 

*Army Nursing includes the Army Nurse Corps and all elements of professional nursing in the Army Medical Department: Active, 

Reserve, National Guard, and Department of Defense civilian registered nurses, licensed practical nurses, and nursing assistants.
 October-December 2011 11

was a singular focus on recruiting and retention for 

Active, Reserve, Guard, and Department of Defense 

(DoD) civilian registered nurses. From these priorities, 

we crafted a defined end state as supported by 

execution of the objective statements, operational 

tasks, and critical tasks as shown in Table 2. We used 

these operational tool maps to provide guidance and 

direction to the 4 imperative action teams (discussed in 

detail on page 15) via video teleconferences, telephone 

conferences, and working meetings throughout 2009 

and 2010. 

During the mission analysis, we graphically depicted 

many of the processes AN was using across clinical, 

professional practice, and business strata in order to 

visualize gaps and determine the coherence, adequacy, 

and efficiency of the process we were evaluating. In so 

doing, we not only found missing elements internal to 

a single process, but also found that, in some cases, 

several processes had become so disconnected from 

each other that entire networks of processes had become ineffective. In many cases, we found a vacuum 

where processes had once existed, but had either been 

dismantled or had not become part of a written or oral 

handoff during transitions. For example, Figure 1 is a 

graphic depiction of the network of processes we rebuilt to develop capability that was connected to force 

structure development, the AN officer assignments 

Doctrine: “the way we fight,” that is, how we 

deliver nursing care. 

Who are AN’s clinical leaders? 

What competencies do they require? 

What is AN’s succession plan to grow new leaders? 

How do we identify leader talent? 

What are the “fight platforms,” the inpatient, outpatient, ambulatory and deployed care 

environments to optimize leader development? 

How are the processes for identifying and growing AN clinical leaders linked to AMEDD 

and AN strategic goals and business strategy? 

What is AN’s professional nursing doctrine? 

Organization: “the way we’re organized to 

fight.” 

Strategically, how are AN clinical leaders linked in a knowledge management way? 

Operationally, how are we task-organized to optimize nursing professional practice? 

Tactically, how do we deliver nursing care in various care environments? 

How do AN clinical leaders influence nursing practice? 

Training: “the way we prepare to fight 

tactically.” 

What is the priority/focus of AN training platforms? 

How do the training platforms develop capability? 

How are training platforms aligned with AN strategic objectives, the Campaign Plan, and 

business strategy? 

What are the measures of performance/measures of effectiveness for training—what is 

the bulls-eye for success? 

Materiel: “the way we’re equipped to 

operative effectively.” 

What are AN standard operating procedures? 

What are AN core values? 

What skills, knowledge, and behaviors are required for Army Nurses in all care 

environments? 

Leadership and Education: “the way we 

prepare leaders to lead the fight,” that is, 

healthcare delivery. 

What is the right level of educational preparation for the future? 

How is AN Long Term Health Education and Training linked to AMEDD/AN strategic 

objectives, business strategy, the Campaign Plan? 

What new education is needed to produce new capability? 

Personnel: “the way we determine the 

availability of people/leaders.” 

Where do we need AN leader capability? 

What is the process for proactively identifying where we need new or different capability? 

How do we align AN leader force structure with AMEDD/AN strategic objectives, business 

strategy, and the Campaign Plan? 

How are our processes for Nurse Corps leader assignments connected to talent 

management? 

Facilities: “the facilities that support the 

fight.” 

What are the types of care environments where AN leaders direct nursing care delivery? 

What are the AN leader workforce to workload ratio requirements in each care 

environment? 

How are nursing standards of care influenced by AN leaders in different care 

environments? 

Table 1. Questions that focused on refining the efforts towards developing the AN campaign plan strategic objective, leader 

development (build our bench).
12 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

process, and AN training in a way that supported 

execution of our business strategy—the Campaign 

Plan. Using this graphic, we were able to visually 

determine how and where in the process to target 

actions to optimize best efforts, as measured by 

metrics of performance, and generate the best 

products, as measured by metrics of effectiveness. 

PROCESSES AND OUTCOMES

Crafting end states under the Corps Chief’s intent for 

each of the strategic objectives was the most difficult 

task. Our mantra became “start at the end to define the 

beginning” to keep us focused on capability required 

under each of the objectives, that is, what tactics, 

techniques, processes, and products did we want in 

place at the end of 4 years that would ensure a vibrant, 

relevant Army Nursing team poised for current and 

future missions? A focus on patient wellness was 

envisioned, in the context of evidence-based delivery 

of nursing care as the key tenet in positioning AN as a 

force multiplier for Army Medicine now and in the 

years to come. Based on our operational objectives and 

discussion with the Corps Chief and Corps leaders at 

all levels, we deduced that our overarching task was 

synchronization and integration, across nursing care 

environments, of operational efforts along with 

adequate scale, spread, and sustainment plans, to 

enable the Campaign Plan’s strategic objectives. 

Initially, we defined requirements for success: 

 Determination of best methodologies for leveraging clinical nursing knowledge management. 

 Alignment of bedside nursing care delivery 

tactics, techniques, and processes across all care 

environments with the Campaign Plan’s strategic objectives. 

 Determination of best processes and resources 

that enabled unity of effort for shaping and 

transforming nursing care delivery focused on 

quantifiable patient outcomes. 

 Development of metrics of performance and 

effectiveness to qualify and quantify nurseinfluenced patient care outcomes. 

Building the Army Nursing Campaign Plan 

Table 2. The objective statements, operational tasks, and critical tasks developed to guide work towards the AN Campaign Plan 

strategic objective “Leader Development.”* 

Operational Objectives Objective Statement Operational Task Coordinating Points Critical Task 

LD 1.0: Full-Spectrum 

Leaders 

Provide appropriate 

nursing capability 

and capacity in 

support of the Army 

CoS and The Surgeon 

General’s strategic 

objectives. 

Perform gap analysis 

between current 

capability and capacity 

and future requirements. 

 FORSCOM 

 TRADOC 

 EBOD 

 Nurse Consultants 

 APPD 

 Define full-spectrum leaders. 

 Define and validate critical leader 

positions. 

 Develop leader capacity and 

capability plan. 

 Integrate a credible, viable, 

sustainable civilian workforce into 

the AN leadership structure. 

LD 1.A: Leader 

Succession Plan 

Develop and execute a 

leader succession 

plan that ensures 

sustainable mission 

capabilities. 

Develop life cycle models 

with appropriate force 

modeling to ensure 

current and future 

capabilities and force 

structure. 

 APPD 

 Nurse Consultants 

 USAREC 

 ROTC 

 EBOD 

 Life cycle model 

 Clinical tracks 

 Plans for all key leader positions 

LD 1.B: Leader Training 

and Development 

Align training 

requirements with 

“Train as you fight” 

doctrine to ensure 

future capability that 

supports AMEDD 

missions. 

Top-to-bottom review and 

restructure of AN training 

programs. 

 RMCCN 

 Cadet Command 

 DNS/AMEDDC&S 

 EBOD 

 USAREC 

 Assess appropriate utilization of 

external agencies, ie, RAND, TWI. 

 Assess AMEDDC&S AN courses to 

determine what competencies and 

capabilities each produces. 

 Gap analysis between what we have 

and what we need. 

*Leader development is defined as a persistent, sustainable nurse leader succession plan creating full-spectrum leaders who are adaptive to any conditions based 

mission, provide persuasive voices at key echelons of influence in the AMEDD, and develop innovate doctrine to blueprint the future of the Army Nurse Corps. 

Glossary 

AMEDD - US Army Medical Department AMEDDC&S - AMEDD Center & School AN - Army Nurse Corps 

APPD - AMEDD Personnel Proponent Directorate DNS - Department of Nursing Science EBOD - Executive Board of Directors 

FORSCOM - US Army Forces Command LD - Leader development RAND - The RAND Corporation, Santa Monica, CA 

RMCCN - Regimental materiel management center ROTC - Reserve Officers Training Corps TRADOC- US Army Training and Doctrine Command 

TWI - Training with industry USAREC - US Army Recruiting Command 
 October-December 2011 13

THE ARMY MEDICAL DEPARTMENT JOURNAL

 Ensure sustainability of all transformation initiatives. 

To ensure unity of effort on Campaign Plan execution 

across Army Nursing, it was critical to develop a 

conceptual model that delineated priority focus areas for 

the next 4 years. The model also needed to illustrate 

how AN synchronized with and supported The Surgeon 

General’s balanced scorecard (definition on page 25) 

and the Army imperatives developed by the Army Chief 

of Staff: sustain, prepare, transform, reset. 

Subsequently, we developed a line of action (LOA) 

diagram (Figure 2) that melded strategic conditions and 

requirements into operational direction of AN efforts 

towards achievement of strategic objectives and, 

ultimately, toward achievement of the strategic end 

state. Then, we fused traditional military campaign 

planning with balanced scorecard graphics to conceptualize a strategy map as an operational framework for 

executing the Campaign Plan in support of Army 

Medicine objectives. 

The operational tool maps, along with the LOA diagram 

and the AN strategy map, became planning guidance for 

developing courses of action and staff estimates. 

Figure 1. The network of processes for AN capability development that was determined, after evaluation of prior processes, 

to be the best method for connecting capability development to force structure development, the assignments process, and 

training in a way that supported execution of the business strategy—the Campaign Plan. 

Glossary: 

ACSIM - Assistant Chief of Staff for Information Management DCN - Deputy Commander for Nursing 

DOTMLPF - Doctrine, Organization, Training, Materiel, Leadership and Education, Personnel, Facilities [analysis] 

HRC - US Army Human Resources Command HQDA - Headquarters, Dept of the Army 

MOE - Measure of effectiveness MOP - Measure of performance 

MTDF - Medium team development framework PMAD - Personnel management authorization document 

POM - Program Objectives Memorandum RNE - Regional nurse executive 

SAMAS - Structure and Manpower Allocation System TAADS - The Army Authorization Document System 

TDA - Table of distribution and allowances TOE - Table of organization and equipment 

TRADOC - US Army Training and Doctrine Command 

Map Training

to

Competencies Determine Authorizations

(Plan, Program [POM], Budget, Execute)

Document Corps Authorizations

(TAADS, SAMAS, MTDF, TDA)

Acquire/Distribute 

Personnel 

(PMAD) HRC

TRADOC, ACSIM 

HQDA-61 

Behavioral/ 

Job Specific/ 

Functional 

Competencies 

TRAINING PLATFORMS 

Develop Required 

Capabilities 

(DOTMLPF)

LEADER ACADEMY 

TOE / TDA 

Ready Units 

Improved 

Retention 

Decreased 

Time To 

Proficiency 

Full 

Spectrum 

Leader 

RNE / 

DCN 

Army Nurse Corps 

Campaign Plan 

(Determine strategic &

operational goals)

BUSINESS STRATEGY 

Define Capabilities 

Define Strategies 

Define Training Needs 

MOP 

& 

MOE 
14 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

ARMY NURSE CORPS LEADERSHIP INFRASTRUCTURE

Early on, we realized that we lacked a networked 

leader infrastructure to fully execute the Campaign 

Plan. We needed a flatter, more horizontal leader 

structure whose members would act as a compass, 

keeping AN on the Campaign Plan’s azimuth in an 

agile and responsive way. In 2008, at the Corps 

Chief’s direction, we developed a concept of 

operations that aligned senior nursing leadership as 

Regional Nurse Executives within the newly-formed 

AMEDD regional headquarters structure. We then 

developed an Executive Board of Directors for AN 

that best represented the AN triad (officers, 

noncommissioned officers (NCOs), enlisted personnel, 

DoD civilians), comprised of the following: 

 Regional Nurse Executives and their senior 

clinical NCOs 

 Medical brigade chief nurses and their NCO 

counterparts 

 Chief nurses for medical and forces commands 

(Army Medical Command (MEDCOM), Army 

Forces Command (FORSCOM)) 

 Chief nurses for the Army Recruiting Command 

and the Army Cadet Command 

 The AMEDD Integration Officer at Accessions 

Command 

 A DoD civilian registered nurse 

 Chief nurse for the Army Human Resource 

Command, Health Services Division 

 The AN Corps Specific Branch Proponency 

Officer (CSBPO) 

 The Deputy Corps Chief 

Building the Army Nursing Campaign Plan 

To SUSTAIN our Army Nurse Corps,

we must maintain the quality and

viability of the All‐Volunteer Force.

To PREPARE our Army Nurse Corps,

we must maintain a high level

of readiness for the current

operational environments.

To RESET our Army Nurse Corps,

we must prepare our Army Nurses

for future deployments and other

contingencies.

To TRANSFORM our Army Nurse

Corps, we must continuously

improve our ability to meet the

needs of future operations.

Army Nurse Corps 

Strategic Lines of Action 

 Leader Development 

 Warrior Care 

 Evidence-based Care 

 Human Capital 

LEADERSHIP: A persistent, sustain‐

able nurse leader succession

plan created full‐spectrum lead‐

ers who were adaptive to any

conditions‐based mission, pro‐

vided a persuasive voice at key

echelons of influence in the

AMEDD, and innovated doctrine

to blueprint the future of the

Army Nurse Corps.

WARRIOR CARE: Optimized nurs‐

ing care delivery systems; wrap‐

ped nursing capability around

AMEDD strategic goals and mis‐

sions. Warrior/patient/family‐

centered care models embraced

evidence‐based practice to

achieve best patient outcomes.

EVIDENCE‐BASED CARE: Evidence‐

based methodology optimized

business practices and cost ca‐

pabilities by blending analysis,

measurement, and redesign

into daily performance.

HUMAN CAPITAL: The ANC foot‐

print is optimized through vali‐

dation of priorities, and the

force structure is repostured for

conditions‐based capability and

capacity.

END STATE

An organization that

consistently achieved

performance excellence,

fostered innovation, built

knowledge and capabilities,

and ensured organizational

credibility and sustainability.

RESEARCH: Provides organizational

traction and momentum.

STRATEGIC COMMUNICATION: Create and

distribute “Public Diplomacy”; getting

the right message, through the right

media, to the right audience at the

right time and with the right effect.

Figure 2. The line of action diagram displaying the consolidation of strategic conditions and requirements as the directional 

impetus for the achievement of the AN Corps strategic objectives, and the strategic end state. 
 October-December 2011 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

 Deputy Corps Chief, Drilling Individual Mobilized 

Augmentee (DIMA)

 Corps Senior Clinical Enlisted Advisor 

This initial nurse leader framework was the glue that 

bound all nursing care environments together at the 

operational level in order to execute the Campaign 

Plan. We eventually realized that the size of the Board 

was impacting responsiveness of its components and 

so decreased the members of the group to those on the 

the Corps Chief’s special staff (Corps Deputy and 

DIMA; Chief Nurses of MEDCOM and FORSCOM; 

CSBPO; Chief Nurse, Army Human Resources 

Command; Chief Nurses for the Army Recruiting 

Command and the Army Cadet Command; AMEDD 

Integrator; Corps Chief Sergeant Major). The special 

staff provided a balanced focus on priority efforts, 

executed sequenced planning, and delineated decisive 

points and decision points along the Campaign Plan’s 

LOA. The Surgeon General’s nurse specialty 

consultants provided clinical situational awareness that 

refined and guided our AN clinical centers of gravity 

that define the foundation of AN’s 

capability. The AN Research Advisory 

Board was tasked to ensure AN research 

provided evidence-based traction and 

momentum for the Campaign Plan. As a 

result, the Advisory Board developed a 

research agenda that prioritized research 

efforts in support of the Campaign Plan 

and Army Medicine initiatives, and 

connected nurse researchers worldwide. 

Next, we formed imperative action teams 

(IATs) to fully develop the concepts of 

operation necessary to execute the Campaign Plan. Members of the Special Staff 

were appointed as champions for each of 

the 4 IATs. As champions, they identified 

and controlled decisive points along our 

lines of action to maintain momentum on 

outcomes and sustain ongoing initiatives. 

Subsequently, by late August 2009, the 

infrastructure necessary to execute the 

Campaign Plan was in place. 

EXECUTION

Working with the IATs and their 

champions, we provided oversight to 

ensure synchronization between IAT staff 

estimates as well as set decision points that triggered 

briefings to the Corps Chief. These briefings further 

shaped her strategic concept that ultimately informed 

the overall transformation of Army Nursing. Throughout 2009, we met with the IATs to further sequence and 

synchronize their efforts as development of courses of 

action began in earnest. We created and used graphics 

we called “mind maps” that translated the Corps Chief’s 

thoughts and ideas into operational strategy by visually 

depicting her concepts. The mind maps helped the IATs 

to mitigate the time lapses between receiving her 

guidance and planning-to-solution development in an 

“avalanche” type way. For example, Figure 3 depicts a 

discussion with MG Horoho about her concept of a 

professional practice model for Army Nursing. Each 

level of the “structure” illustrates requirements she 

initially delineated for the practice model. We used the 

Campaign Plan and AN strategy map as our business 

strategy to task each IAT with identifying competencies, practices, and capabilities we needed to achieve 

mission success. Priorities also included developing 

methods to map our training platforms to any 

the System of Care 

How We Practice CORE CAPABILITIES

NURSING ETHOS: 

ANA STANDARDS

ANA CODE OF ETHICS

What We Believe 

How We Operate DELIVERY SYSTEMS

THE PROFESSIONAL PRACTICE

of 

ARMY NURSING

Figure 3. The structural concept of the professional practice model 

for Army Nursing. 
16 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

identified required competencies, and re-cueing our 

recruiting and education platforms to buy or grow the 

right capability needed. Finally, each IAT was tasked 

to develop a strategic communication plan and a plan 

for leveraging evidence, data, and best practices to 

optimize courses of action and staff estimates. 

At the end of years 2009 and 2010, key AN leaders 

met to review campaign planning from the previous 

year and establish direction for the next year. Using 

this ongoing campaign planning process allowed us to 

meet new challenges quickly while dealing with day-today AN operations in a very flexible and agile way. As 

a result of these synergistic meetings, we realized the 

AN professional practice model was too limited in its 

scope of concept in that it only addressed professional 

practice and did not meet the Corps Chief’s intent to 

develop: 

A nursing care delivery system that transcends all 

nursing care environments in a way that allows us 

to measure and improve patient outcomes. 

A nursing care system that illuminates and clearly 

articulates what we believe as nurses (professional 

practice), how we practice as nurses (clinical 

practice), and how we 

operate as a Corps and 

nursing team (business 

practices). 

Subsequently, the professional practice model was 

reconceptualized, using 

evidence-based data, to 

become a nursing system 

of care called the Patient 

CaringTouch System. As 

work continued on this 

task, the need for a more 

muscular infrastructure to 

operationally manage 

components of this system 

after implementation 

became clear. As a result, 

the IAT working on evidence-based practice was 

tasked to develop the 

concept of an AN Practice 

Council that would be the 

hub for evidence-based 

inquiry and act as a clearinghouse for evidence-based 

best practices that would be integrated at the patient 

care bedside. Furthermore, as senior AN leaders’ input 

became crucial in support of IAT efforts, the Special 

Staff developed the concept of a Corps Chief’s AN 

Advisory Council to ensure validation of effort between those leaders at the frontline of patient care and 

the Corps Chief. The AN Advisory Council members 

include the Chief Nurses for MEDCOM and FORSCOM, Regional Nurse Executives, and Medical Brigade 

Chief Nurses along with their NCO counterparts. 

SUSTAINING TRANSFORMATION

At a planning meeting in 2010, we discussed how best 

to meet the Corps Chief’s final directive: sustain 

transformational change. We decided on a sustainment 

“keyboard” that displayed the elements of the Patient 

CaringTouch System horizontally across the top, and 

the Campaign Plan’s strategic imperatives vertically 

along the side. The keyboard allowed us to crossreference the CaringTouch System against the 

Campaign Plan in an integrated way, while also 

allowing us to archive those gaps we had identified, 

actions, and products under each appropriate number. 

Building the Army Nursing Campaign Plan 

Figure 4. An interactive briefing tool developed to display the transformation initiatives and 

identified gaps in clinical practice and business strata processes mapped to each core element 

of the Patient CaringTouch System and a strategic objective (AN Corps imperative). Selection of a 

key opens a link that displays a list of the related initiatives and gaps. 

Army Nurse Corps Imperatives 

Core 

Elements 
 October-December 2011 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

We used the keyboard to brief senior leaders at 

planning meetings for the Campaign Plan in order to 

“articulate the connections between new behaviors and 

organizational success” that John Kotter identifies as 

key to successful transformation efforts.4

We will use the keyboard as a legacy tool to inform 

the next Corps Chief team and their efforts in a 

focused way to “Embrace the Past” (lessons learned, 

gaps identified); “Engage the Present” (actions 

executed, state of the Corps); and “Envision the 

Future” (emerging missions, capability and capacity 

requirements). 

CONCLUSION

MG Horoho directed a 4-year Campaign Plan that 

established standards for AN leader development, 

optimized nursing care and nursing business processes, 

and developed methodologies focused on optimizing 

AN’s human capital footprint. Her vision focused on 

building a nursing care system that connected all 

members of Army Nursing who have the capacity to 

improve patient care to the system’s purpose of 

benefiting all those entrusted to Army Nursing’s care. 

Using the military campaign planning process allowed 

us to clearly define what constituted success at the end 

of 4 years, as well as establish a 15-year blueprint for 

the future of Army Nursing. 

ACKNOWLEDGEMENTS

We wish to recognize the phenomenal support provided 

to us by COL (Ret) Eileen Malone and COL (Ret) 

Claudia Bartz, US Army Nurse Corps. Their insight, 

wisdom, intellectual rigor, and gentle guidance 

throughout our Army Nurse Corps transformation 

journey made possible all of our successes. Thank you. 

REFERENCES

1. Pace P. Chairman’s Assessment of the 2006 Quadrennial Defense Review. In: Quadrennial Defense Review Report. 

Washington, DC: US Dept of Defense; February 6, 2006: A-6. Available at: http://www.defenselink.mil/pubs/pdfs/

QDR20060203.pdf. Accessed August 8, 2011. 

2. US Army Nurse Corps. The Army Nurse Corps Campaign Plan. Available at: http://armynursecorps.amedd. 

army.mil/campaign/campaignplanonwebpagemarch09.pdf. Accessed August 8, 2011. 

3. DOTMLPF Analysis. Defense Acquisition University web site. Available at: https://acc.dau.mil/CommunityBrowser. 

aspx?id=28870&lang=en-US. Accessed August 8, 2011. 

4. Kotter JP. Leading change: why transformation efforts fail. Harv Bus Rev. 1995; March-April 1995:59-67. Available at: 

http://lighthouseconsultants.co.uk/wp-content/uploads/2010/08/Kotter-Leading-Change-Why-transformation-effortsfail.pdf. Accessed August 8, 2011. 

AUTHORS

COL Clark is the Deputy Chief of the Army Nurse Corps. 

SGM Brewer is the Senior Clinical Enlisted Advisor, Office of the Army Nurse Corps. 

Articles published in the Army Medical Department Journal are indexed in 

MEDLINE, the National Library of Medicine’s (NLM’s) bibliographic database of 

life sciences and biomedical information. Inclusion in the MEDLINE database 

ensures that citations to AMEDD Journal content will be identified to researchers 

during searches for relevant information using any of several bibliographic search 

tools, including the NLM’s PubMed service. 
18 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

By August 2009, the structure to implement the Army 

Nursing Campaign Plan* was in place. As work began 

to make the Campaign Plan a reality, it became clear 

that the Department of Nursing Science at the Army 

Medical Department Center and School (AMEDDC&S) 

would have to recue training platforms to ensure the 

development of the capability that was rapidly being 

identified. Once the Leadership Imperative Action 

Team (a task force appointed by the Chief, Army 

Nurse Corps) produced desired competencies framed 

in levels of leadership, the work to design the training 

platform began. The staff completely reviewed and 

redesigned the platform in less than 12 months, the 

result of which is the Army Nursing Leader Academy. 

TRAINING PLATFORM ANALYSIS

Armed with the work of the Leadership Imperative 

Action Team and the newly published US Army 

Learning Concept for 2015,1

 the staff conducted an indepth analysis of the existing nurse leader 

development courses. This analysis included a 

literature review to identify best practices, extensive 

cross-referencing of competencies to training 

objectives, and consultation of subject matter experts. 

Care was taken to not replicate the leadership training 

courses offered outside of the Department of Nursing 

Science, but to fill identified gaps. The newly 

organized Leadership Imperative Action Team was 

augmented by a chartered nursing education advisory 

council that consisted of senior Army Nurse (AN) 

officers, senior enlisted staff, a retired AN officer, and 

senior civilian nursing education experts. The staff of 

the Department of Nursing Science, with assistance 

from the AN Imperative Action Team, and the AN 

Leader Academy Advisory Board held multiple 

planning sessions over several months to determine 

and validate the unifying concepts of the Leader 

Academy and the associated curriculum threads. 

The results of the analysis showed that although 

valuable courses already existed within the 

Department of Nursing Science, they were not 

completely aligned with the newly identified 

competencies and did not always address career-long 

nurse leader development. In some cases the teaching 

strategies were outdated and, by some accounts from 

the field, less than effective. The courses were few in 

number with the content often being driven by 

Designing and Implementing the 

 Army Nursing Leader Academy 

COL (Ret) Kathleen Dunemn, AN, USA 

COL Denise L. Hopkins-Chadwick, AN, USA 

COL Tina Connally, AN, USA 

COL Kelly Bramley, AN, USA 

ABSTRACT

In 2008, the Chief of the Army Nurse Corps directed a thorough review of existing training programs available to and 

provided for Army Nursing personnel for the development of full-spectrum leaders for Army Nursing. The review 

provided the gap analysis necessary to restructure courses provided by the Department of Nursing Science at the Army 

Medical Department Center and School. This new grouping of courses is referred to as the Army Nursing Leader 

Academy. The Army Nursing Leader Academy is the first of its kind in that it addresses career-long learning of all 

Army Nursing by focusing on building skills, knowledge, and behaviors to produce sustainable, full-spectrum leaders. 

The Nursing Leader Academy consists of a series of sequential nurse leader development courses combined with a web 

based resource center. Grounded in the Patient CaringTouch System, guided by nurse competencies, and gauged by the 

Leader Capabilities Map, the Nursing Leader Academy provides learning that is relevant and timely designed to 

reinforce enterprise values and culture to ensure readiness for successive roles and positions. Full implementation of the 

Nursing Leader Academy will include the evidence-based elements of formal schooling, coaching, self-development, 

functional/technical (competency attainment), and professional experiences. 

*See “Building the Army Nursing Campaign Plan” on page 10. 
 October-December 2011 19

available presenters. The largest gap was lack of 

unifying concepts among courses. Compounding the 

problem was the fact that, although the target audience 

for each course was identified, an audit of attendees 

indicated that in some cases more than 50% of the 

attendees did not meet the description of the target 

audience—the wrong people were attending. Finally, 

even if the content of the courses was relevant, most of 

the courses were optional, making it impossible to 

guarantee that the message was reaching the target 

audience. 

DESIGN OF THE NURSING LEADER ACADEMY

Growing adaptive and competent Soldier and civilian 

leaders is a major objective of the Army Campaign 

Plan 2011, as well as the Army Nursing Campaign 

Plan. Leader development is one of the most 

researched topics in behavioral science literature. 

Among this literature there is support for a blending of 

formal academic/didactic and experiential/practice 

leadership learning.2-4 The Army Nursing Leader 

Collaborative Learning Framework (Figure 1) was 

created to illustrate the different modalities used to 

facilitate learning. Taken from available literature, this 

framework shows essential interconnected and 

interdependent modalities: formal schooling, coaching, 

self-development, functional/technical (competency 

attainment), and professional experiences. 

It was initially thought that the restructured Army 

Nursing Leader Academy would begin by addressing 

the formal school modality depicted in the model, and 

eventually move to capture the other modalities as 

well. As depicted in the model (Figure 1), formal 

schooling includes programs or courses that provide 

didactic and structured learning experiences related to 

one or more of the expected leader competencies and/

or capabilities. In the nursing context, these courses 

could be military or civilian-hosted, focused on both 

clinical skills and leadership principles, and 

progressive in nature with each course becoming a 

building block for the next. These courses provide the 

“science” of the application of clinical and healthcare 

leadership. Examples include Basic Officer Leader 

Course Nurse Track, BG (Ret) Anna Mae Hays 

Clinical Nurse Transition Program, clinical specialty 

courses (trauma nurse, obstetrics nurse, perioperative 

nurse, etc), Captains’ Career Course Nurse Track, 

clinical nurse OIC and NCOIC* courses, national 

organization-sponsored manager development courses, 

and master’s degree in nursing or health care 

administration programs. 

Coaching is the art and practice of inspiring, energizing, and facilitating the performance, learning, and 

development of an individual by a supervisor, peers, 

and/or subordinates.5

 Its goal is to guide vision, urge 

excellence, and empower the one being coached.6

 It is 

a partnership in a thought-provoking and creative process that should inspire an individual to maximize their 

personal and professional potential.6

 Coaching continues throughout one’s career, if not for a lifetime. Army 

Nursing professionals will undoubtedly coach and be 

coached many times during their career journey. 

Self-development is assuming personal responsibility 

for one’s own learning and development. This 

development occurs through a process of assessment, 

reflection, and action.7

 Army Nursing leaders take 

responsibility for their own learning and development 

by becoming involved in professional organizations; 

conducting a self-assessment of current knowledge, 

skills, and behaviors (usually conducted during 

quarterly counseling with a supervisor, the Army 

Nursing Leader Capabilities Map (Figure 2) would be 

used with AN officers); creating a personal development plan that identifies their learning needs and goals 

with a timeline; finding a mentor who can provide support, advice, and assistance in career direction; reading 

professional journals; becoming certified where 

certifications are offered; and identifying and attending 

clinical and leadership development seminars and 

classes to address learning needs and goals. 

Self 

Development 

Functional/ 

Technical 

Coaching 

DOD CIVILIANS 

Army 

Nursing 

Leader 

Formal 

Schooling 

Professional 

Experience 

*OIC: officer-in-charge. NCOIC: noncommissioned officer-in- Figure 1. Army Nursing collaborative learning framework. 

charge. 
20 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Functional/technical competencies are the measurable 

or observable knowledge, skills, abilities, and behaviors critical to successful job performance. The American Organization of Nurse Executives Nurse Executive 

Competencies,8

 as delineated in the Army Nursing 

Leader Capabilities Map (Figure 2), serve as a foundation for self-assessment and as a guideline for minimum 

expectations and evaluations of more senior Army 

Nursing leaders. Leader competencies for Army Nursing are stratified by the complexity of management skill 

application (tactical/direct, operational, and strategic). 

Once the modalities for facilitating leader training 

were identified, the process of curriculum development ensued. The most common steps used in curriculum mapping9

 were adapted to modify or create the 

Army Nursing Leader Academy courses: 

 Determine the key concepts (what should the 

learner know). 

 Identify the skills/competencies and capabilities 

(what should the learner be able to do). 

 Develop and align the performance objectives 

based on level or complexity of skill application 

and acquisition (for example, tactical, operational, 

or strategic; novice to expert). 

 Select and align course content. 

 Select teaching/learning strategies, and develop 

assessment methods and course outcome measures. 

Assumptions for the design phase were that 

realignment and design would be a continuous process, 

blended learning techniques would be leveraged, and 

deliverables (for example, active individual and group 

learning, such as projects/papers) would be required. 

Additionally, courses and course content would be 

sequenced for progressive learning and be as resource 

neutral as possible. 

IMPLEMENTATION OF THE NURSING LEADER ACADEMY

The Army Nursing Leader Academy web-based 

resource center* was developed and fielded in early 

2010. Its purpose is to provide a virtual link from the 

classroom to the workplace. This resource center 

features links to sites such as the Communities of 

Practice Pages, each hosted by an Army Nurse 

Consultant to The Surgeon General. Once fully 

developed, it will be a web-based, single-source center 

for Army Nursing leaders, containing information (or 

links to information) about military and civilian 

courses, a leader academy course catalog, selfdevelopment activities such as reading lists and video 

gaming programs, competency and capability 

documents, clinical management tool kits, and the 

course materials for all Army Nursing Leader 

Academy courses. The web-based resource center has 

unlimited potential for leader development support. 

The Nursing Leader Academy is grounded in the 

Patient CaringTouch System, guided by nursing 

competencies, and gauged by the Leader Capabilities 

Map. Academy courses are organized in 3 main blocks 

(Figure 3). Block A consists of courses that address the 

tactical level of leadership on the Leader Capabilities 

Map. Block A courses equip Army Nursing Leaders to 

execute the Patient CaringTouch System. An example 

of the specific leader behavior targeted for 

development in a Block A course would be for the 

nurse to execute the vision or Patient CaringTouch 

System by first understanding, then incorporating 

clinically, followed by demonstrating ability to 

articulate specific job functions that support the Patient 

CaringTouch System. Block B consists of courses that 

address the corresponding Leader Capabilities Map 

operational level of leadership. These courses equip 

Army Nursing Leaders to lead a team in the Patient 

CaringTouch System. An example of the specific 

leader behavior targeted for development in Block B is 

under foundational thinking: interpret the vision. At 

the operational level, nursing leaders will receive the 

vision and communicate at all levels, then provide 

feedback to strategic leaders on relevancy of the vision 

to tactical execution, and finally identify key 

stakeholders and incorporate feedback into the vision. 

Block C aims for the strategic level with courses 

which prepare the nursing leader to lead teams of 

teams. An example of a nursing leader behavior 

targeted for development at this level is, again, under 

foundational thinking: provide visionary thinking or 

develop realistic, credible, and attractive organizational vision. The Block C level courses equip the 

strategic level leader to evaluate strategic environment 

and develop clear vision for the organization, 

consistently communicate the vision, ensure its 

relevance to organizational mission and the external 

environment, and foster creativity in other leaders’ 

ability to identify strengths and weaknesses of 

Designing and Implementing the Army Nursing Leader Academy 

*Available at: https://www.us.army.mil/suite/page/618697 (restricted access) 
 October-December 2011 21

THE ARMY MEDICAL DEPARTMENT JOURNAL

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 



Tactical/Direct Operation/Organizational Strategic 

Foundational 

Thinking 

Executes the vision. Demonstrates unit-level evidence-based decision 

making. 

Develops and expresses awareness.

Interprets the vision. Critically analyzes organizational issues. Is mindful of self and others when influencing change. 

Provides visionary thinking or develops realistic, 

credible, attractive organizational vision. 

Critically analyzes strategic issues to drive policy. Uses adaptive leadership to affect 

transformational change. 

Personal Journey 

Disciplines 

Seeks direct feedback and adjusts accordingly. Applies new knowledge at work. Learns from setbacks and failures as well as 

successes. 

Sets initial personal, professional, and career goals. Identifies positive role models and seeks advice. 

Integrates feedback from multiple sources. Shares new knowledge to benefit the organization. Applies lessons learned. Establishes and implements plan to achieve goals. Establishes mentoring relationships with respected 

role models. 

Values diverse perspectives and integrates into 

the enterprise decision making. 

Develops and supports a culture of inquiry. Uses lessons learned to effect change. Defines and adjusts goals and plans; role models 

balance between professional and personal life. 

Expands professional community and mentors 

others. 

Systems Thinking Understands unit level processes and the interrelatedness of interdisciplinary roles, functions, and 

responsibilities. 

Expresses and builds concern for unit's success. Understands unit goals in concert. with the 

Commander's lines of effort 

Responds to divergent inputs and chooses best practices. 

Understands organizational processes and their interrelatedness. Takes responsibility for building loyalty and 

commitment throughout organization. 

Aligns section goals in concert with Commander's 

lines of effort. 

Assimilates knowledge and integrates divergent 

viewpoints. 

Promotes and values systems thinking within and 

across healthcare systems. 

Inspires loyalty and commitment. Aligns organizational goals with the AMEDD and 

Army's balanced scorecard and the current geopolitical environment. 

Synthesizes and adapts internal and external 

viewpoints for the good of the organization. 

Succession 

Planning 

Self motivated and motivates others. Develops a succession plan for own position. Prepares self for next leadership level. Identifies and develops talent in staff. 

Inspires, motivates, and guides others towards 

mission accomplishment. 

Develops succession plans for subordinate positions 

in addition to own position. 

Prepares self for next leadership level and provides 

opportunities for staff preparation. 

Identifies and supports the development of talents in 

staff and matches talents to positions. 

Intrinsically motivated to lead organizations; 

envisions the future with creative solutions. 

Manages and supports the execution of 

succession planning for system, profession, self and subordinates. 

Actively participates in, or self-nominates for next 

leadership level. 

Matches talents to jobs, roles or assignments. 

Change 

Management 

Identifies gaps in unit processes. Utilizes evidence-based theoretical framework to 

initiate unit change. 

Adapts to changes and contingencies in transforming 

environments. 

Suggests and is receptive to innovations. 

Identifies gaps in organizational processes and 

develops resolutions. 

Utilizes evidence-based theoretical framework to 

implement, manage, and evaluate outcomes at the organizational level. 

Assesses and evaluates the environment to cultivate 

change to transform the organization. 

Fosters and facilitates an environment conducive to 

innovation. 

Evaluates the need for organizational change and 

guides implementation 

Provides the strategic environment that fosters 

change and innovation. 

Conveys the strategic and operational objectives 

of the Army and Department of Defense. 

Supports creativity for positive change and 

evaluates outcomes. 

Education BOLC, AOC/ASI Course, JECC, C4, ACCC 

Graduate Course Work 

ILE, Clinical Masters, Anesthesia School, Baylor HCA Senior Service College, Interagency Course, 

AMEDD Executive Skills, PhD, DNP 

Duty Positions Staff Nurse, Charge Nurse, Clinical Nurse OIC 

Faculty/Instructor, TOE Staff/Charge Nurse, AMEDD Recruiter, ROTC Nurse Counselor, Division Nurse 

Section/Department Chief, MEDCEN Clinical Nurse 

OIC, Course Director, Staff Officer 

Deputy Commander for Nursing, Hospital 

Commander, Senior Staff Officer, OTSG Consultant 

2LT 1LT CPT MAJ LTC COL BG, MG, LTG, GEN 

Time in service (yr) Rank 

Figure 2. The Army Nursing Leader Capabilities Map, showing the relationship between the professional capabilities, time in service, and military grade throughout a career. 

Glossary: ACCC - Army Captains Career Course; AOC/SI - Area of concentration/Additional skill identifier; C4 - Combat Casualty Care Course; HCA - Healthcare Administration; 

ILE - Intermediate level education; JECC - Joint Enroute Care Course; MEDCEN - Medical center; BOLC - Basic Officer Leader Course; OIC - Officer-in-charge; 

OTSG - Office of The Surgeon General; ROTC - Reserve Officer Training Corps; TOE - Table of organization and equipment 
22 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

subordinate leaders. Blocking the courses in this way 

enables the Corps to use the Leader Capabilities Map 

to gauge/measure the desired leader development 

impact. 

Career-long nurse leader learning begins at the portal 

of entry, the Basic Officer Leader Course (BOLC) 

Nurse Track. The BOLC Nurse Track is designed to 

introduce the new nurse to the Patient CaringTouch 

System. Beginning with the Corps Chief’s vision and 

continuing on through every element and component 

of the Patient CaringTouch System, the learner leaves 

with an introductory experience that prepares them for 

the follow-on clinical practicum, the BG(R) Anna May 

Hays Clinical Nurse Transition Program (CNTP), the 

24-week standardized transition program that pairs 

newly graduated nurses with trained preceptors. At the 

completion of CNTP, nurses begin their practice as 

tactical leaders of the Patient CaringTouch System. 

During this period, they revisit the Leader Academy, 

stepping in and out of it as needed. Progressive opportunities include attendance at one of the Army Nursing 

specialty courses and continuing nursing education to 

the masters’ level. The Captains’ Career Course (CCC) 

Nurse Track represents another opportunity to check 

back in with the Academy. Attendees will find that the 

CCC Nurse Track now offers nursing context to the 

operational/deployment principles that they have 

learned in the non-Corps specific portion of the CCC. 

Block A (tactical level) is topped off with the completely redesigned Clinical Nurse OIC and Clinical 

NCOIC I course. For the first time, Clinical Nurse OIC 

(CNOIC) and Clinical NCOIC (CNCOIC) teams are 

attending training geared to their assigned level of 

leadership together, reinforcing the absolutely critical 

teamwork aspect of effective healthcare delivery. 

Block B (operational level) begins with the web-based 

CNOIC/CNCOIC II course. Recognizing that management and leader skills increase with span of control 

and complexity, a second CNOIC/CNCOIC II course 

is being developed. As with the existing course, the 

Designing and Implementing the Army Nursing Leader Academy 

Block A 

(Tactical Level) 

 Basic Officer Leader Course Nurse 

Track 

 Clinical Nurse Transition Program 

 Area of Concentration/Additional 

Skill Identifier 

 “CJ Reddy”†

 Captains Career Course Nurse Track 

 Clinical OIC/NCOIC I

 Long-term Health Education and 

Training* 

Block B 

(Operational Level) 

 Clinical OIC/NCOIC II (under 

development) 

 Intermediate Level Education* 

 Training with Industry Fellowships* 

 Entry Level Executive Nursing 

Course 

Block C 

(Strategic Level) 

 AMEDD Executive Skills Course,*

Deputy Commander/Assistant 

Deputy Commander for Nursing 

Track 

 Interagency Institute of Federal 

Healthcare Executives* 

 Medical Strategic Leadership 

Program* 

 Regional Nurse Course (proposed) 

 Senior Service College* 

Training platform in existence. 

Training platform under development. 

The Army Nursing Leader Academy 

Grounded in the Patient CaringTouch System 

Guided by Nursing Competencies 

Gauged by the Leader Capabilities Map 

Figure 3. The organization and hierarchy of training programs and courses available through the Army Nursing Leader Academy. 

*Training not provided by the Dept of Nursing Science, AMEDDC&S. 

†

C J Reddy is an annual Army Nurse Corps conference for junior officers who are competitively selected for participation.
 October-December 2011 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

additional course is being designed as a web-based 

course so that nurses can stay at their unit of 

assignment, embedded in context as they apply the 

methods learned in the course. This is also the time in 

an officer’s career when he or she attends intermediate 

level education and could be selected for training with 

industry fellowships. Finally, Block B culminates with 

the Entry Level Executive Nursing Course, a redesign 

of the former Advanced Nursing Leader Course. One 

major difference is that the redesigned course now 

includes a 5-day resident phase in addition to the 

distributive learning phase. Each topic has been carefully mapped to the competencies necessary to make 

the leap from operational level leader to strategic level. 

Block C (strategic level) addresses the Army Nursing 

leader who is at the assistant or deputy commander of 

nursing or equivalent level. This block contains a 

series of sequential courses designed to prepare the 

nurse for regional leadership. At this point, selected 

nurses are attending Interagency Institute of Federal 

Healthcare Executives sessions and medical strategic 

leadership programs. The final course, now under 

development, in the Army Nursing Leader Academy 

will target the regional leader. 

SUMMARY

Since its inception in 2008, the Army Nursing Leader 

Academy has had approximately 3,792 encounters to 

produce full-spectrum leaders in support of Army 

Medicine. The Army Nursing Leader Academy was 

intentionally structured such that, in response to the 

emergency of new missions, it can be adjusted and 

reoriented to continue to produce full-spectrum leaders 

who are adaptive to any conditions-based mission. The 

Army Nursing Leader Academy is one way that Army 

Nursing is wrapping capability around Army Medicine 

goals and objectives. 

REFERENCES

1. TRADOC Pamphlet 525-8-2: The US Army Learning 

Concept for 2015. Fort Monroe, VA: US Army Training and Doctrine Command, US Dept of the Army; 

June 6, 2011 [updated issue]. Available at: http://www. 

tradoc.army.mil/tpubs/pams/tp525-8-2_CH1.pdf. 

2. Alleyne J, Jumaa MA. Building the capacity for evidence-based clinical nursing leadership: the role of 

executive co-coaching and group clinical supervision 

for quality patient services. J Nurs Manag. 2007;15

(2):230-243. 

3. MacMillan-Finlayson S. Competency development for 

nurse executives. J Nurs Adm. 2010;40(6):254-257. 

4. Wolk GA, Bradle J, Greenhouse P. Investment in the 

future: a 3-level approach for developing the healthcare 

leaders of tomorrow. J Nurs Adm. 2006:36(6):331-336. 

5. Medland J, Stern M. Coaching as a Successful Strategy 

for Advancing New Manager Competency and 

Performance. J Nurses Staff Dev. 2009;25(3):141-147. 

6. Luecke R, Ibarra H. Coaching and Mentoring: How 

to Develop Top Talent and Achieve Stronger 

Performance. Boston, MA: Harvard Business School 

Press; 2004. 

7. Rothstein MG, Burke RJ, eds. Self-Management and 

Leadership Development. Northhampton, MA: Edward 

Elgar Publishing Limited; 2010. 

8. AONE Nurse Executive Competencies. Association of 

Nurse Executives Web site. Available at: http://chhs. 

gmu.edu/pdf%20files/office_of_academic_outreach/

pdf/2010-NAL-AONE.pdf. Accessed May 24, 2011. 

9. Jacobs HH, Johnson A. The Curriculum Mapping Planner: Templates, Tools, and Resources for Effective Professional Development. Alexandria, VA: ASCD; 2009. 

AUTHORS

COL (Ret) Dunemn is an Associate Professor, 

University of Northern Colorado, Greeley, Colorado. 

COL Hopkins-Chadwick is Chief, Department of 

Nursing Science, AMEDD Center and School, Fort 

Sam Houston, Texas. 

COL Connally is Deputy Chief, Department of Nursing 

Science, AMEDD Center and School, Fort Sam 

Houston, Texas. 

COL Bramley is Chief, Nursing Division, General 

Leonard Wood Army Community Hospital, Fort 

Leonard Wood, Missouri. 
24 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

The Army Nurse Corps is undergoing a historic 

transformation. The Corps has always been a key component of the Army Medical Department (AMEDD), 

providing essential delivery of quality, state-of-the-art 

nursing care to Soldiers and beneficiaries in garrison 

and deployment settings across the globe. However, 

the time had come to reevaluate the Corps’ “corporate” 

principles and to ensure alignment with the strategic 

visions of the Army Chief of Staff (CoS) and The 

Surgeon General. The Army Nurse Corps Campaign 

Plan* has been developed and implemented to ensure 

that the Corps has the right capability and capacity to 

meet the current and future needs of the US Army. 

One essential component of Army Nursing is leader 

development, aligning with Army CoS vision of 

developing adaptable leaders that have the capability 

to lead across the full spectrum of operations, depicted 

in Figure 1. Understanding the operational environment and demonstrating adaptiveness and flexibility in 

ambiguous and adverse conditions are crucial leader 

competencies necessary to achieve tactical, operational 

and strategic mission success.1 

The AMEDD plays a major role in every aspect of fullspectrum operations. Soldiers cannot conduct 

operations without the healthcare team in place and 

ready with the skills and competencies to 

maintain or restore their health. Regardless 

of the type of operation or lead element, 

Army Nurses play a critical role in 

delivering high-quality patient care that 

contributes greatly to improved survival for 

wounded Soldiers, Marines, Sailors, and 

Airmen. Army Nurses are leading the way in 

all types of diverse settings, from planning 

and leading strategic operations during 

complex base realignment and closure 

operations at major medical centers, to 

commanding hospitals and split operational 

Leader Development Transformation in the 

 Army Nurse Corps 

MAJ Tamara S. Funari, AN, USA 

COL Kathleen Ford, AN, USA 

COL Bruce A. Schoneboom, AN, USA 

ABSTRACT

The Army Nurse (AN) Corps is undergoing a historic transformation. Under the leadership of its Chief, MG Patricia 

Horoho, the Corps developed and implemented the AN Campaign Plan to ensure that the Corps has the right capability 

and capacity to meet the current and future needs of the US Army. 

This article describes the work conducted by the AN Corps Leadership Imperative Action Team (Leader IAT) to develop 

full-spectrum leaders for the future. The mission of the Leader IAT is derived from both the AN Campaign plan as well as 

the operational objectives defined in the AN balanced scorecard. As a result of the analysis conducted during preparation 

of the AN Campaign Plan, several key gaps were identified regarding the Army Nurse Corps’ ability to match leadership 

talents with the diverse demands of current missions, as well as its adaptability and flexibility to be prepared for unknown 

future missions. This article also introduces the Leadership Capability Map and other initiatives implemented to ensure the 

development of full-spectrum leaders who will be effective in the future military healthcare environment. 

Figure 1. Army forces conduct 3 types of operations—offensive, defensive, 

stability and reconstruction—as part of overseas joint campaigns. Army 

forces conduct civil support, offensive, and defensive operations in support 

of homeland security. The mission dictates which type of operation 

predominates. Source: Field Manual 3-01

Offense 

Stability and 

Reconstruction 

Defense 

Offense Defense 

Stability and 

Reconstruction 

Stability 

and 

 Reconstruction

Offense 

Defense 

Offense 

Civil 

Support 

Defense Civil 

Support

Offense 

Defense 

Homeland Security 

(within the United States) 

Joint Campaigns (overseas) 

*See “Building the Army Nursing Campaign Plan” 

on page 10. 
 October-December 2011 25

elements in the austere conditions of Afghanistan and 

other theaters where our military is engaged. Many 

Army Nurses are leading healthcare organizations in 

roles such as clinical nurse officers in charge (OICs), 

section supervisors, deputy commanders, and 

commanders in both garrison and field environments. 

For this reason, it is imperative that the Army Nurse 

Corps “builds the bench” with adaptive and innovative 

full-spectrum leaders.2

 

This article describes the work conducted by the Army 

Nursing Leadership Imperative Action Team (Leader 

IAT) to develop full-spectrum leaders for the future. 

The mission of the Leader IAT is derived from both 

the AN Campaign plan, as well as the operational 

objectives defined in the AN balanced scorecard.* As 

a result of the analysis conducted during preparation of 

the AN Campaign Plan, several key gaps were 

identified regarding the Army Nurse Corps’ ability to 

match leadership talents with the diverse demands of 

current missions as well as its adaptability and 

flexibility to be prepared for unknown future missions. 

MG Patricia Horoho, the Chief of the Army Nurse 

Corps, made her intent very clear that actions must be 

taken to develop full-spectrum leaders through 

education, coaching, mentoring, and self-awareness 

strategies.2

 Her goal is to ensure that full-spectrum 

leaders have ongoing, sequential opportunities to build 

the necessary capabilities to contribute in a variety of 

AMEDD strategic priorities. 

BACKGROUND: THE BASIS FOR CHANGE

Field Manual 6-22,

3

 the Army’s foundational 

document for leader doctrine, describes leaders as 

change agents and states that adaptive leadership is an 

essential characteristic for successful leadership. 

Adaptive leaders are needed for all units to 

successfully meet the full-spectrum operational 

mission. Leaders must be able to assess their 

environment, focus on key aspects of that 

environment, have the ability to change their 

leadership style and behaviors, and have the ability to 

motivate organizational change.4

 The former Chief of 

Staff of the Army, GEN (Ret) George W. Casey Jr, 

stressed the need for agile and adaptive leaders during 

his keynote address at the 2007 Association of the 

United States Army Annual Meeting: 

Lastly–agile/adaptive leaders. In this era of persistent 

conflict, it is absolutely essential that we can develop 

leaders who can handle the challenges of full-spectrum 

operation. Our leaders in the 21st century must be 

competent in their core competencies, brought up to 

operate across a full spectrum of conflict, able to 

operate a joint interagency and combined environments, 

at home and in other cultures, and courageous enough 

to see and exploit opportunities in the complex 

environments that they will be operating in.5

In 2008, MG Horoho told MAJ Tamara Funari, then a 

student at Command and General Staff College, “We 

need to build our bench with adaptive and resilient 

nurse leaders; if you are interested in this topic, I 

would like for you to explore it” (oral communication, 

August 2008).In October 2008, the first Army Nursing 

Campaign Planning conference was held. The 

document produced at this conference detailed MG 

Horoho’s 4 strategic objectives. Among these four was 

leader development. Her vision was to set the 

foundation for a continued legacy of excellence by 

integrating a succession plan that would create fullspectrum leaders who would be adaptive, provide a 

persuasive voice for communicating with key leaders 

in the AMEDD, and create innovative doctrine that 

would be a persistent and sustainable guide for fullspectrum leader development.6

 

A qualitative descriptive study was conducted by MAJ 

Funari in direct response to the Corps Chief’s guidance 

as part of a master’s thesis7

 at the Command and 

General Staff College in 2008. The study examined the 

Army Nurse Corps Lifecycle Model and explored the 

meaning of full-spectrum operations as it relates to the 

AMEDD and nursing. Themes from this study 

illustrated a need for revising leadership education, 

training, and developmental pathways, as well as the 

importance of selecting individuals with the right 

capabilities for the positions to which they are 

assigned. The qualities of an adaptive leader were 

explored and surfaced as a major theme in the area of 

needed development in the Army Nurse Corps. As a 

result, the following definition of the Adaptive Army 

Nurse Leader was approved by MG Horoho: 

An adaptive ANC leader is one who is a clinical expert 

and can alter leadership styles to be effective across the 

horizontal and vertical organizational structures to meet 

*The balanced scorecard is a strategic planning and management system used to align business activities to the vision and 

strategy of the organization, improve internal and external 

communications, and monitor organizationally performance 

against strategic goals. Source: The Balanced Scorecard Institute (Cary, NC). Information available at: http://www.balanced 

scorecard.org/Home/tabid/36/Default.aspx
26 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

the full-spectrum operational mission. The adaptive 

leader is effective in both garrison and austere 

deployment environments. The adaptive ANC leader 

must be knowledgeable in Army and Joint doctrine, must 

understand the strategic and operational objectives of the 

Army, and have the ability to view problems holistically 

and turn ambiguous challenges into opportunities.4

The Leader IAT has explored other areas4: 

 The lifecycle model and its usefulness in guiding 

nurses across the career spectrum. 

 The process for selecting nurses for clinical nurse 

officer-in-charge positions focusing on leadership 

competencies and characteristics. 

 Back-to-basics campaign, encouraging Army 

Nurses to build a medical surgical nursing 

foundation prior to selecting a clinical specialty. 

 New and innovative methods for coaching, 

teaching, and mentoring nurses and how to 

challenge them while providing a safe environment that facilitates growth. 

 Analysis of current developmental education programs to ensure appropriate leadership education 

is integrated and builds upon previous level.4

 

LEADERSHIP IMPERATIVE ACTION TEAM

Parallel to the previously described study in progress, 

the Leader IAT was chartered in October 2008 to 

redefine Army Nursing leadership development in 

order to meet the complexities of current and future 

strategic requirements. The Army Nurse Corps needs 

clinical leaders who understand how to tactically 

manage healthcare delivery and strategically manage 

increasingly complex systems of health. The team was 

to address the first objective in the Army Nursing 

campaign plan: 

Leader Development – Build our bench: a persistent, sustainable nurse leader succession plan 

created full-spectrum leaders who were adaptive to 

any conditions-based mission; provided a 

persuasive voice at key echelons of influence in 

the AMEDD, and innovated doctrine to blueprint 

the future of the Army Nurse Corps.6

 

Comprised of specially selected active duty, reserve, 

retired, and noncommissioned officers, as well as 

senior civilian nurses from across the AMEDD, the 

team’s strategic objective was to devise a sustainable 

nurse leader succession plan creating full-spectrum 

leaders, adaptive to any conditions-based mission. The 

operational objectives tasked to the Leader IAT: 

 LD 1.0 – Full-spectrum Leaders: Provide appropriate nursing capability and capacity in support of 

the Army CoS and The Surgeon General’s 

strategic objectives. 

 LD 1.A – Leader Succession Plan: Develop and 

execute a leader succession plan that ensures 

sustainable mission capabilities. 

 LD 1.B – Leader Training and Development: 

Align training requirements with “Train as you 

Fight” doctrine to ensure future capability that 

supports AMEDD missions. 

Operational tasks accomplished were in direct 

alignment with the Army Nurse Corps balanced 

scorecard operational objectives. 

Early work of the Leader IAT included adoption of the 

American Organization of Nurse Executives (AONE) 

core leadership domains and nurse executive 

competencies8

 (shown in the Table) and the approved 

Adaptive Army Nurse Leader definition as the 

foundation for a capabilities-based leader development 

model for the Army Nurse Corps. 

The definition of the Adaptive Army Nurse Leader 

was studied by the Leader IAT and used to develop the 

approved definition of the Adaptive Clinical Nurse 

officer-in-charge (OIC)/noncommissioned officer-incharge (NCOIC) (Figure 2). The title clinical nurse 

OIC/NCOIC replaced the titles head nurse and ward 

master, better aligning these positions to the Army 

command structure. 

Continued Leader IAT work included development of 

the Army Nursing Leader Academy*

 as a career-long 

leadership development resource center to support succession planning and leader development across the 

lifecycle, initially for Army Nurses then for civilian 

nurses. Using the AONE framework and Army Leader 

doctrine to guide them, the Leader IAT developed a 

Clinical Nurse OIC position description, provided 

position coding recommendations for various Clinical 

Nurse OIC positions (ie, levels I and II), and drafted a 

standardized competency tool to support development 

Leader Development Transformation in the Army Nurse Corps 

*See article “Designing and Implementing the Army Nursing 

Leader Academy” on page 18.
 October-December 2011 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

and assessment of required leadership competencies. 

As a result of the first 2 years of effort of the Leader 

IAT, the Army Nurse Corps was able to 

significantly advance the Corps Chief’s strategic 

vision by laying a theoretical foundation of nursing 

leadership capabilities and the structure for building 

coursework to support leadership skill development 

for Army Nursing, beginning with the tactical leader. 

STRUCTURED APPROACH TO CHANGES IN ARMY

NURSING LEADER DEVELOPMENT: THE WAY AHEAD

In May 2010, the Leader IAT was directed to complete the last 2 operational tasks of the ANC balanced scorecard: develop a new lifecycle model for 

the Army Nursing that is focused on capabilities 

rather than roles and assignments, and reevaluate and 

adjust the Army Nursing Leader Academy coursework to ensure that every course directly contributed 

to the development of desired competencies as 

reflected on the lifecycle model. As a result of their 

efforts, the Army Nursing Leader Capabilities Map 

(AN LCM) (Figure 3) replaced the legacy Army 

Nurse Corps Lifecycle Model (Figure 4).7

The AN LCM transformed the previous linear 

approach to developing and progressing leaders forward through leader levels (based on schools 

attended, promotions received, and positions held) 

to progression focused on the achievement of expected 

skills, knowledge, and behaviors. The emphasis on 

capabilities is transformative as it allows officers of all 

ranks to make an informed career journey, with every 

capability they achieve increasing their ability to 

contribute full-spectrum leadership skills to any 

mission. Rather than the “check the block” approach 

of the legacy AN Lifecycle Model, the AN LCM 

focuses on the outcome of capability development. 

The present generation of nurses is technologically 

proficient at an early age, therefore, a fully interactive, 

computerized tool was developed. Highlights of the 

AN LCM include integration of all of the key AONE 

leadership’s dimensions with distinct interpretation for 

each of 3 Army Leader levels (tactical, operational, 

and strategic); clear guidance depicting tasks, 

standards, schooling, and job experiences that may 

contribute to the achievement of each capability; and 

an interactive web model* that allows an individual 

the opportunity to explore and assess their own leader 

capabilities. Objectives necessary to grow as an 

adaptive Army Nurse leader are linked to each 

capability at the tactical, operational, and strategic 

levels of leadership and performance. Choosing any of 

the objectives will produce a list of measurable goals 

to guide the officer in developing a road map to 

achieve that objective. 

The American Organization of Nurse Executives core leadership 

domains and nurse executive competencies. 

Core Leadership 

Domains Nurse Executive Competencies 

Communication and 

relationship building 

Effective communication, relationship management, influence of behaviors, ability to 

work with diversity, shared decision making, 

medical staff relationships, academic relationship, community involvement. 

Knowledge of the health 

care environment 

Clinical practice knowledge, patient care delivery models and work design knowledge, 

health care economics knowledge, health 

care policy knowledge, understanding of 

governance, understanding of evidencebased practice, outcomes measurement, 

knowledge of and dedication to patient 

safety, understanding of utilization management, knowledge of quality improvement 

and metrics, knowledge of risk management. 

Leadership Foundational thinking skills, personal journey disciplines, the ability to use systems 

thinking, succession planning, change management. 

Professionalism Personal and professional accountability, 

career planning, ethics, evidence-based clinical and management practice, advocacy for 

the clinical enterprise and for nursing practice, active membership in professional 

organizations. 

Business skills Understanding of health care financing, human resource management and development, strategic management, marketing, 

information management and technology. 

*Available at: https://akosecured.detrick.army.mil/nurse/ako/

ANLeadershipCapMAPinteractivefordMar2011.ppsx. 

(Note: restricted access) 

Adaptive Clinical Nurse 

Officer-in-Charge 

and 

Noncommissioned Officer-in-Charge 

An adaptive, clinically proficient nurse/medic 

leader (manager) who effectively coaches, 

motivates, and leads a unit level team in fullspectrum operations. Knowledgeable and 

supportive of organizational mission, vision, and 

goals to promote evidence-based patient/family 

centered care. Views problems holistically and 

turns ambiguous challenges into opportunities. 

Figure 2. The approved definition of Adaptive Army Clinical 

Nurse Leader which was developed by the Leader IAT. 
28 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Leader Development Transformation in the Army Nurse Corps 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 



Tactical/Direct Operation/Organizational Strategic 

Foundational 

Thinking Demonstrates unit-level evidence-based decision 

Executes the vision. 

making. 

Develops and expresses awareness.

Is mindful of self and others when influencing change. Critically analyzes organizational issues. Interprets the vision. Provides visionary thinking or develops realistic, 

credible, attractive organizational vision. 

Uses adaptive leadership to affect Critically analyzes strategic issues to drive policy. 

transformational change. 

Personal Journey 

Disciplines 

Learns from setbacks and failures as well as Applies new knowledge at work. Seeks direct feedback and adjusts accordingly. 

successes. 

Identifies positive role models and seeks advice. Sets initial personal, professional, and career goals. Establishes mentoring rela

Establishes and implements plan to achieve goals. Applies lessons learned. Shares new knowledge to benefit the organization. Integrates feedback from multiple sources. 

tionships with respected 

role models. 

Values diverse perspectives and integrates into 

the enterprise decision making. 

Defines and adjusts goals and plans; role models Uses lessons learned to effect change. Develops and supports a culture of inquiry. 

balance between professional and personal life. 

Expands professional community and mentors 

others. 

Systems Thinking Understands unit level processes and the interrelatedness of interdisciplinary roles, functions, and 

responsibilities. 

Understands unit goals in concert. with the Expresses and builds concern for unit's success. 

Commander's lines of effort 

practices. Responds to divergent inputs and chooses best 

Understands organizational processes and their interrelatedness. Takes responsibility for building loyalty and 

commitment throughout organization. 

Aligns section goals in concert with Commander's 

lines of effort. 

Assimilates knowledge and integrates divergent 

viewpoints. 

Promotes and values systems thinking within and 

across healthcare systems. 

Aligns organizational goInspires loyalty and commitment. 

als with the AMEDD and 

geopolitical environment. Army's balanced scorecard and the current 

Synthesizes and adapts internal and external 

viewpoints for the good of the organization. 

Succession 

Planning Develops a succession 

Self motivated and motivates others. 

plan for own position. 

Identifies and develops talent in staff. Prepares self for next leadership level. 

Inspires, motivates, and guides others towards 

mission accomplishment. 

Develops succession plans for subordinate positions 

in addition to own position. 

Prepares self for next leadership level and provides 

opportunities for staff preparation. 

Identifies and supports the development of talents in 

staff and matches talents to positions. 

Intrinsically motivated to lead organizations; 

envisions the future with creative solutions. 

Manages and supports the execution of 

succession planning for system, profession, self and subordinates. 

Actively participates in, or self-nominates for next 

leadership level. 

Matches talents to jobs, roles or assignments. 

Change 

Management Utilizes evidence-based theoretical framework to 

Identifies gaps in unit processes. 

initiate unit change. 

Adapts to changes and contingencies in transforming 

environments. 

Suggests and is receptive to innovations. 

Identifies gaps in organizational processes and 

develops resolutions. 

Utilizes evidence-based theoretical framework to 

organizational level. implement, manage, and evaluate outcomes at the 

Assesses and evaluates the environment to cultivate 

change to transform the organization. 

Fosters and facilitates an environment conducive to 

innovation. 

Evaluates the need for organizational change and 

guides implementation 

Provides the strategic environment that fosters 

change and innovation. 

Conveys the strategic and operational objectives 

of the Army and Department of Defense. 

Supports creativity for positive change and 

evaluates outcomes. 

Education 

Graduate Course Work BOLC, AOC/ASI Course, JECC, C4, ACCC ILE, Clinical Masters, Anesthesia School, Baylor HCA Senior Service College, Interagency Course, 

AMEDD Executive Skills, PhD, DNP 

Duty Positions Staff Nurse, Charge Nurse, Clinical Nurse OIC 

Recruiter, ROTC Nurse Counselor, Division Nurse Faculty/Instructor, TOE Staff/Charge Nurse, AMEDD 

Section/Department Chief, MEDCEN Clinical Nurse 

OIC, Course Director, Staff Officer 

Deputy Commander for Nursing, Hospital 

Consultant Commander, Senior Staff Officer, OTSG 

2LT 1LT CPT MAJ LTC COL BG, MG, LTG, GEN 

Figure 3. The Army Nursing Leader Capabilities Map, showing th

Rank Time in service (yr) 

e relationship between the professional capabilities, time in service, and military grade throughout a career. 

Glossary: ACCC - Army Captains Career Course; AOC/SI - Area of concentration/Additional skill identifier; C4 - Combat Casualty Care Course; HCA - Healthcare Administration; 

ILE - Intermediate level education; JECC - Joint Enroute Care Course; MEDCEN - Medical center; BOLC - Basic Officer Leader Course; OIC - Officer-in-charge; 

OTSG - Office of The Surgeon General; ROTC - Reserve Officer Training Corps; TOE - Table of organization and equipment 
 October-December 2011 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

The AN LCM is intended for use as a coaching and 

evaluation tool as well as a self-development tool. 

Additionally, it will assist leaders in the identification 

of elite performers with exemplary potential. Early 

identification of high-level talent early is important so 

that the Army Nurse Corps may fill capability gaps by 

providing the right leader training and development to 

these officers.9

 The individual Army Nurse can tailor 

the life-cycle to meet their own learning requirements 

as they progress toward the executive or strategic 

leadership levels. This allows officers of the same rank 

to be at different points on the LCM. 

The interactive AN LCM draft was completed in 

December 2010 and was staffed through the Regional 

Nurse Executives for both their input and their 

subordinates’ input. The final approved version was 

posted by the Corps Chief on her Army Nurse Corps 

blog on May 18, 2011.9

The AN LCM is introduced to new AN officers during 

the Basic Officer Leader Course. Courses at all levels 

of the AN Leader Academy use the AN LCM to guide 

the development of future AN leaders in the Active 

Army, the Reserves, and the Civilian Corps. 

Following completion and approval of the AN LCM, 

the Leader IAT tackled their second priority of 

evaluating and adjusting the AN Leader Academy core 

coursework to ensure that the program of instruction 

and individual learning elements all directly linked to 

desired Army Nursing leader capabilities. The team 

partnered with the AMEDD Center & School Department of Nursing Science to examine the curriculum of 

Figure 4. The legacy Army Nurse Corps Lifecycle Model which has been replaced by the Army Nursing Capabilities Map. 

Glossary 

AN - Army Nurse AOC - Area of concentration ASI - Additional skill identifier 

BDE - Brigade BN - Battalion C&S - Center & School 

CBRNE - Chemical, biological, radiological, nuclear, explosive CN - Chief nurse 

C, Nsg - Chief nursing DA - Dept of the Army DCN - Deputy commander for nursing 

DOD - Dept of Defense FST - Forward surgical team GP - Group 

HCA - Health care administration MACOM - Major command MEDCEN - Medical Center 

MTF - Medical treatment facility OBC - Officer basic course OAC - Officer advanced course 

OBV - Obligated volunteer OTSG - Office of The Surgeon General RMC - Regional medical command 

ROTC - Reserve Officer Training Corps SSC - Senior service college TDA - Table of distribution & allowances 

TOE - Table of organization & equipment TSG - The Surgeon General TWI - Training with industry 

USAREC - US Army Recruiting Command VI - Voluntary indefinite 

Education 

Clinical/

Operational 

Assignments 

Professional 

Development 

Research 

Administration 

Career Status 

Promotion 

Military Training 

Years of Service 

INITIAL INTERMEDIATE ADVANCED EXECUTIVE 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 

OBV VI Regular Army 

2LT 1LT CPT MAJ LTC COL 
30 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

the Basic Officer Leaders Course, Captain’s Career 

Course, Clinical Nurse OIC Course, and Advanced 

Nurse Leadership Course. They completed an analysis 

of the content, then cross-referenced that content 

against both the AN LCM Capabilities and elements of 

the Patient CaringTouch System (then called the Army 

Nursing System of Care) to ensure that every offering 

contributed to leader development. As a result, courses 

were revised and content formatted in a comprehensive, sequenced fashion to promote progressive 

capability development across the career lifecycle. 

One key change implemented was the reorganization 

of the Clinical Nurse OIC course into 2 separate 

courses, gearing the level I course to tactical level 

leaders and the level II course towards OICs who 

would be leading a staff of 50 or more personnel. 

CONCLUSION

The Army Nurse Corps has implemented many changes 

to facilitate the development of nurse leaders. This 

article describes the work conducted by the Army Nurse 

Corps Leader IAT to develop full-spectrum nursing 

leaders who are prepared for future military healthcare 

environments. Over the past 3 years the Leader IAT has 

been diligent and successful in accomplishing all 3 

operational tasks assigned and completing the ANC 

balanced scorecard objectives. Currently the Leader 

IAT is developing a strategic marketing plan to 

facilitate current leaders’ knowledge of the Leadership 

Capability Map and an education program to maximize 

its intended utilization. Together with the Department of 

Nursing Science and the Army Nursing Leader 

Academy, the Leader IAT continues its work to ensure 

the development of future full-spectrum Army Nursing 

leaders. As the military operational environment 

evolves, continued research and development will be 

needed to allow the Army Nurse Corps to continue 

development of full-spectrum leaders who will be 

effective in new and ambiguous environments. 

REFERENCES

1. Field Manual 3-0: Operations. Washington, DC: US 

Dept of the Army; February 27, 2008. 

2. Horoho PD. Adaptive and innovative nurse leaders. 

Army Nurse Corps Blog. August 28, 2010. Available 

at: https://blog.amedd.army.mil/nurse/?

Page=PostViewMulti&displayMonthlyArchives=Aug

ust%26nbsp%3B2010&month=8&year=2010. 

Accessed December 14, 2010. 

3. Field Manual 6-22: Army Leadership - Competent, 

Confident, and Agile. Washington, DC: US Dept of 

the Army; October 12, 2006. 

4. Funari TS, Gentzler K, Wyssling PW, Schoneboom 

BA. Building adaptive nurse leaders for future Army 

full spectrum operations. Mil Med. 2011;176:186-191. 

5. Casey GW Jr. General George W. Casey, Jr.'s 

Eisenhower Luncheon Address at AUSA Annual 

Meeting. Association of the United States Army Web 

site. October 15, 2007. Available at: http://www3. 

ausa.org/webpub/DeptHome.nsf/byid/WEBP77ZUXW. Accessed December 14, 2010. 

6. US Army Nurse Corps. The Army Nurse Corps 

Campaign Plan. Available at: http://

armynursecorps.amedd.army.mil/campaign/

campaignplanonwebpagemarch09.pdf. Accessed 

December 14, 2010. 

7. Funari TS. Building Adaptive Nurse Leaders 

forFuture Army Full Spectrum Operations [master’s 

thesis]. Fort Leavenworth, KS: US Army Command 

and General Staff College; 2009. Available at: http://

cgsc.contentdm.oclc.org/utils/getfile/collection/

p4013coll2/id/2482/filename/2533.pdf. Accessed 

August 17, 2011. 

8. AONE Nurse Executive Competencies. Association 

of Nurse Executives Web site. Available at: http://

c h h s . g m u . e d u / p d f % 2 0 f i l e s / o f f i c e _ o f _ 

academic_outreach/pdf/2010-NAL-AONE.pdf. 

Accessed May 24, 2011. 

9. Horoho PD. The Army Nursing Leader Academy. 

Army Nurse Corps Blog. May 18, 2011. Available at: 

https://blog.amedd.army.mil/nurse/?

Page=PostViewMulti&displayMonthlyArchives=Ma

y%26nbsp%3B2011&month=5&year=2011. 

Accessed May 24, 2011. 

AUTHORS

MAJ Funari recently returned from deployment with 

the Task Force 86th Combat Support Hospital in 

Baghdad, Iraq. She is a Certified Clinical Nurse 

Specialist at Brooke Army Medical Center, Fort Sam 

Houston, Texas. 

COL Ford is the Deputy Commander for Nursing, Fort 

Belvoir Community Hospital, Fort Belvoir, Virginia. 

COL Schoneboom is the Army Nurse Corps Specific 

Branch Proponency Officer, AMEDD Center and 

School, Fort Sam Houston, Texas. 

Leader Development Transformation in the Army Nurse Corps 
 October-December 2011 31

Talent management broadly refers to a strategic human 

resources program which maximizes an organization’s 

workforce productivity. The last 10 years have seen an 

emergence of this new field of talent management 

within a human capital strategy. This covers a range of 

human resource functions focused on attracting, 

retaining, managing, and developing a high-quality 

workforce. According to Hunt, talent management 

...includes performance management, staffing, learning 

management, talent development, and succession 

planning. The growing interest in talent management is 

primarily a result of increased recognition of the impact 

talent management practices have on business growth 

and profitability and the role talent management plays 

for dealing with the shortage of skilled labor in the 

workforce....Talent management is about getting the 

right people in the right jobs doing the right things.1

This requires predictions as to how people will act in 

the future, and then influencing them to act differently 

than they acted in the past. 

BUSINESS NEED

In 2008, MG Patricia Horoho, Chief, Army Nurse 

Corps, identified capability building as an important 

element in the transformation of Army Nursing. This 

need was identified under the Army Nursing 

Campaign Plan* (the organization’s business strategy). 

In order to ensure that Army Nursing continues to be a 

force multiplier for the Army Medical Department 

(AMEDD), MG Horoho’s priority was to transform 

Army Nursing into a patient-centric organization that 

provides world-class nursing care to all those entrusted 

to Army Nursing’s care. To achieve this end, the 

Corps needed to relook at how it developed, retained, 

and managed the talent within the organization. In 

2009, the Strategic Studies Institute (SSI) at the United 

States Army War College identified the need to once 

again relook at the human capital strategy, especially 

for the officer corps.2

 The SSI’s position was 

enthusiastically supported by the Army’s most senior 

leadership, including the Army Chief of Staff. 

CONCEPT

Talent management is a mission critical process that 

ensures the Army Nurse Corps has the quantity and 

quality of leaders in place to meet the current and 

future AMEDD missions and priorities. Talent 

management covers all key aspects of an Army 

Nurse’s life-cycle selection, development, succession, 

and performance management. To a large extent, the 

definition of talent management resembles those 

defined by a number of successful Fortune 500 

organizations in the business world. The Army Nurse 

Corps also established a strategic talent management 

process which helps define the roles and expectations 

of the major stakeholders in a successful human capital 

strategy. Those stakeholders include the Army Nurse 

ABSTRACT

Large organizations, including the US Army Medical Department and the Army Nurse Corps, are people-based 

organizations. Consequently, effective and efficient management of the human capital within these organizations is a 

strategic goal for the leadership. Over time, the Department of Defense has used many different systems and strategies 

to manage people throughout their service life-cycle. The current system in use is called Human Capital Management. 

In the near future, the Army’s human capital will be managed based on skills, knowledge, and behaviors through 

various measurement tools. This article elaborates the human capital management strategy within the Army Nurse 

Corps, which identifies, develops, and implements key talent management strategies under the umbrella of the Corps’ 

human capital goals. The talent management strategy solutions are aligned under the Nurse Corps business strategy 

captured by the 2008 Army Nurse Corps Campaign Plan, and are implemented within the context of the culture and 

core values of the organization. 

Human Capital Strategy: 

 Talent Management 

MAJ Michael Nagra, AN, USA 

*See article “Building The Army Nursing Campaign Plan” on 

page 10. 
32 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Corps officers and their chain-of-command, the Corps 

Chief, the Army Nursing Advisory Council of senior 

leaders, and the Nurse Corps assignment officers and 

leadership at the Army Human Resource Command 

(HRC). The strategic talent management process 

directly impacts how future assignments are made 

throughout the Corps. The goal of the process is to 

allow the Corps to retain, develop, and manage those 

officers who have the right skill to accomplish current 

and future missions, especially those functions that are 

considered mission critical and mission essential. In 

the future, this officer talent management strategy will 

potentially be used to develop civilians and the 

Enlisted Corps leaders, as these groups are the foundation of the Army Nursing Triad. This strategic process 

facilitates the assignment officers at the HRC to 

change their current primary role of officer assignments and learning management to the practices of 

performance and competency management, succession 

planning, and leader development. These new business 

practices will allow the assignments process to fall in 

line with the primary goal of talent management. For 

example, an officer’s rater and senior rater will 

provide direct input on their skills, knowledge, and 

behaviors (SKB) in order identify not only future 

potential, but also capability gaps that make the officer 

competitive for the new assignment. This marked shift 

in business practice allows a more objective assessment of the officer’s performance and potential. 

TALENT MANAGEMENT TOOLS

Under the talent management program, a number of 

tools, listed in the Table, were developed to identify 

capabilities and the future potential of an officer. 

Capability-based Assignment 

The capability-based assignment (CBA) method 

matches the skills, knowledge, and behaviors (acquired 

or developed) of an individual with the organizational 

strategy, goals, and mission in order to identify the 

individual who best fits a role. The CBA requirements 

are identified based on the mission and the type of 

organization. These requirements include generic as 

well as unique capabilities—the higher the match, the 

better suited an individual is for the role. Currently, the 

most familiar tool used by senior leaders and the HRC 

for identifying past and current performance is the 

Officer Evaluation Report (OER). It is well understood 

that direct input by an officer’s immediate supervisor 

and his or her senior leadership in generating a talent 

profile has many advantages. For example, the 

collaborative efforts between the Deputy Commander 

for Nursing (DCN) and the HRC will: 

 Allow the implementation of CBA. 

 Identify high performers/high potentials for future 

key positions. 

 Identify and facilitate succession planning for key 

positions to ensure a highly flexible and 

responsive Corps. 

 Provide learning that is relevant and timely to 

ensure readiness for successive roles/positions. 

 Develop leaders that reinforce enterprise values 

and the culture of talent. 

 Allow HRC to align the talent management 

processes and human capital with the Corps’ 

Campaign Plan, strategic goals, and the Patient 

CaringTouch System* of nursing delivery. 

In 2010, the first-ever formalized CBA process was 

implemented with the colonel population within the 

Nurse Corps. The HRC has refined and continued this 

process in 2011, and will subsequently begin a similar 

process for lieutenant colonels. 

Human Capital Strategy: Talent Management 

Talent management tools developed to assist in identifying an 

officer’s capabilities and future potential. 

Tool Definition 

Capability-Based 

Assignment (CBA) 

CBA matches the skills, knowledge, and 

behaviors of an individual with the organizational strategy, goals, and mission in order to 

identify the individual best suited for a role. 

Leaders Capability 

Map (LCM) 

LCM incorporates an officer’s capabilities, 

skills, knowledge, and behaviors (SKB) with 

their current performance and identifies those 

SKBs needed to perform at successively 

higher positions of increased responsibilities. 

Performance-byPotential Matrix 

(PxP) 

PxP matrix is a way to assess a population of 

leaders on 2 important dimensions, their 

performance and their future potential. The 

matrix is used to evaluate an organization’s 

talent pool to identify officers’ capabilities to 

perform mission critical and mission essential 

functions. 

Strategic Leadership 

Assessment (SLA) 

The SLA is a way to quantify the SKBs to 

generate an objective profile of one or a group 

of officers. SLAs are generated for officers of 

the same rank within an MTF, and is updated 

regularly. It is also used to generate the PxP 

matrix during staff engagements. 

Officer Evaluation 

Report (OER) 

The OERs provide information about an 

officer’s job performance in a rating period 

with relevant rater and senior rater comments. *The Army Nursing model for standardization of nursing 

practice.
 October-December 2011 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 



Tactical/Direct Operation/Organizational Strategic 

Foundational 

Thinking 

Executes the vision. Demonstrates unit-level evidence-based decision 

making. 

Develops and expresses awareness.

Interprets the vision. Critically analyzes organizational issues. Is mindful of self and others when influencing change. 

Provides visionary thinking or develops realistic, 

credible, attractive organizational vision. 

Critically analyzes strategic issues to drive policy. Uses adaptive leadership to affect 

transformational change. 

Personal Journey 

Disciplines 

Seeks direct feedback and adjusts accordingly. Applies new knowledge at work. Learns from setbacks and failures as well as 

successes. 

Sets initial personal, professional, and career goals. Identifies positive role models and seeks advice. 

Integrates feedback from multiple sources. Shares new knowledge to benefit the organization. Applies lessons learned. Establishes and implements plan to achieve goals. Establishes mentoring relationships with respected 

role models. 

Values diverse perspectives and integrates into 

the enterprise decision making. 

Develops and supports a culture of inquiry. Uses lessons learned to effect change. Defines and adjusts goals and plans; role models 

balance between professional and personal life. 

Expands professional community and mentors 

others. 

Systems Thinking Understands unit level processes and the interrelatedness of interdisciplinary roles, functions, and 

responsibilities. 

Expresses and builds concern for unit's success. Understands unit goals in concert. with the 

Commander's lines of effort 

Responds to divergent inputs and chooses best practices. 

Understands organizational processes and their interrelatedness. Takes responsibility for building loyalty and 

commitment throughout organization. 

Aligns section goals in concert with Commander's 

lines of effort. 

Assimilates knowledge and integrates divergent 

viewpoints. 

Promotes and values systems thinking within and 

across healthcare systems. 

Inspires loyalty and commitment. Aligns organizational goals with the AMEDD and 

Army's balanced scorecard and the current geopolitical environment. 

Synthesizes and adapts internal and external 

viewpoints for the good of the organization. 

Succession 

Planning 

Self motivated and motivates others. Develops a succession plan for own position. Prepares self for next leadership level. Identifies and develops talent in staff. 

Inspires, motivates, and guides others towards 

mission accomplishment. 

Develops succession plans for subordinate positions 

in addition to own position. 

Prepares self for next leadership level and provides 

opportunities for staff preparation. 

Identifies and supports the development of talents in 

staff and matches talents to positions. 

Intrinsically motivated to lead organizations; 

envisions the future with creative solutions. 

Manages and supports the execution of 

succession planning for system, profession, self and subordinates. 

Actively participates in, or self-nominates for next 

leadership level. 

Matches talents to jobs, roles or assignments. 

Change 

Management 

Identifies gaps in unit processes. Utilizes evidence-based theoretical framework to 

initiate unit change. 

Adapts to changes and contingencies in transforming 

environments. 

Suggests and is receptive to innovations. 

Identifies gaps in organizational processes and 

develops resolutions. 

Utilizes evidence-based theoretical framework to 

implement, manage, and evaluate outcomes at the organizational level. 

Assesses and evaluates the environment to cultivate 

change to transform the organization. 

Fosters and facilitates an environment conducive to 

innovation. 

Evaluates the need for organizational change and 

guides implementation 

Provides the strategic environment that fosters 

change and innovation. 

Conveys the strategic and operational objectives 

of the Army and Department of Defense. 

Supports creativity for positive change and 

evaluates outcomes. 

Education BOLC, AOC/ASI Course, JECC, C4, ACCC 

Graduate Course Work 

ILE, Clinical Masters, Anesthesia School, Baylor HCA Senior Service College, Interagency Course, 

AMEDD Executive Skills, PhD, DNP 

Duty Positions Staff Nurse, Charge Nurse, Clinical Nurse OIC 

Faculty/Instructor, TOE Staff/Charge Nurse, AMEDD Recruiter, ROTC Nurse Counselor, Division Nurse 

Section/Department Chief, MEDCEN Clinical Nurse 

OIC, Course Director, Staff Officer 

Deputy Commander for Nursing, Hospital 

Commander, Senior Staff Officer, OTSG Consultant 

2LT 1LT CPT MAJ LTC COL BG, MG, LTG, GEN 

Time in service (yr) Rank 

Figure 1. The Army Nursing Leader Capabilities Map, showing the relationship between the professional capabilities, time in service, and military grade throughout a career. 

Glossary: ACCC - Army Captains Career Course; AOC/SI - Area of concentration/Additional skill identifier; C4 - Combat Casualty Care Course; HCA - Healthcare Administration; 

ILE - Intermediate level education; JECC - Joint Enroute Care Course; MEDCEN - Medical center; BOLC - Basic Officer Leader Course; OIC - Officer-in-charge; 

OTSG - Office of The Surgeon General; ROTC - Reserve Officer Training Corps; TOE - Table of organization and equipment 
34 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Leaders Capability Map 

An important tool developed by the Nurse Corps is the 

Leaders Capability Map (LCM), shown at Figure 1. 

The LCM incorporates the older life-cycle model for 

Nurse Corps officers with capabilities depending on 

the officer’s SKBs. The older life cycle model was 

static and rigid, and based on rank rather than 

capability. The LCM allows the flexibility to have 

officers move in and out of each of the 3 levels, 

depending on the role and capability of future 

assignments. The objectives, scopes of responsibilities, 

and the level of SKBs required to achieve these 

objectives will increase at each subsequent level. 

When correctly used, the LCM allows the officer’s 

capabilities to be matched with their current 

performance and function. The officer is made 

aware of any identified capability gap. In 

addition, the LCM is used as a tool to identify 

those SKBs needed to perform at higher levels, 

as well as for successive positions of increased 

responsibilities. The LCM also identifies 

education and training needs, and any stretch 

goals an officer will require to prepare for 

successive roles. While training on the correct 

use of LCM is being provided at the Army 

Nursing Leader Academy,* this tool is now 

being used actively throughout the Corps. 

Performance-by-Potential Matrix 

The Performance-by-Potential Matrix (PxP), an 

example of which is presented in Figure 2, is a 

simple way to assess a population of leaders on 

2 important dimensions, their performance and 

their future potential. The matrix is used to 

evaluate an organization’s talent pool and facilitates a 

dialogue amongst the Corp’s senior leadership to 

assess an officer’s capabilities to perform missioncritical and mission-essential functions. For example, 

the Corps Chief and a Regional Nurse Executive, with 

input from the HRC, may use the matrix to identify the 

next DCN at a medical activity. The stakeholders use 

the matrix to calibrate their expectations and ratings of 

one or more potential candidates, while allowing an 

open debate with multiple perspectives to end with a 

more accurate assessment. The use of the matrix 

facilitates a shared sense of ownership for the 

organization’s talent pool, and is the most practical 

and objective way to identify the right talent as well as 

any developmental needs. In the notional PxP matrix 

shown in Figure 2, 10 colonels were assessed and 

placed in the 9 grids. The grids for both elements, 

performance, and potential are categorized from 

average to exceptional. The population is broken into a 

10% –80% –10% profile to match the current OER 

rating profile. The best officers (maximum of 10%) are 

placed in the top right-most grid of the PxP Matrix 

(Exceptional Performance and Exceptional Potential). 

Conversely, 10% of the population will fall in the 

bottom left grid (Average Performance and Average 

Potential). Similar profiles are created for each rank 

within each facility. During calibration meetings, the 

PxP Matrix profile for an officer is matched or 

calibrated with the profile at HRC to ensure subjectivity 

and personal opinions are minimized. 

A PxP Matrix is developed using a number of inputs. 

For example, an officer’s performance includes current 

OERs, current and previous assignments, education 

and training, and inputs from the LCM. Similarly, the 

officer’s potential for future roles includes such inputs 

as the OERs, interviews, supervisory and senior leader 

(ie, DCN, RNE) input on an officer’s behaviors, LCM, 

and HRC profile. 

Strategic Leader Assessment 

One of the most important roles every Nurse Corps 

leader plays is to generate realistic, reliable, and 

effective OERs. The rater has a clearly defined role 

and must define performance expectations and hold 

open one-on-one staff engagements to identify 

developmental needs and gaps. The efforts to generate 

Human Capital Strategy: Talent Management PERFORMANCE 

POTENTIAL 

Average 

Potential 

High 

Potential 

Exceptional 

Potential 

Exceptional 

Performance 

(10% Population) 

COL Alpha 

LTC (P) Juliet 

COL Tango 

COL Foxtrot COL Delta 

High Performance 

(80% Population) 

COL Charlie 

COL Bravo 

LTC (P) Yankee 

COL Golf 

Average Performance 

(10% Population) 

LTC (P) Oscar 

NOTIONAL REGION

LTC (P) – COL POPULATION (10) 

Performance: Based on current OERs, assignments, education (leaders capability map) 

Potential: Based on OERs, interviews, RNE input on behaviors, leaders capability map, 

Human Resources officer management levels 

Figure 2. A representation of the Performance by Potential Matrix used 

to assess AN officers across the 2 dimensions of performance and 

future potential. 

*See article “Designing and Implementing the Army Nursing 

Leader Academy” on page 18. 
 October-December 2011 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

impactful OERs require careful planning, a high level 

of commitment, and establishment of appropriate 

expectations. One of the tools that will enhance this 

goal is the Strategic Leadership Assessment (SLA).3

The SLA is a way to quantify the SKBs to generate an 

objective profile of one or a group of officers. The 

SLA includes other value-generating variables, such as 

below the zone promotions and competitive awards 

from nonmilitary organizations, for example, Advance 

Military Practice awards for field-grade officers 

presented by the Army Nurse Corps Association (an 

organization of retired Nurse Corps officers). An SLA 

is generated for officers of the same rank within a 

medical treatment facility and remains a live document 

that is regularly updated. The SLA is used to generate 

the PxP Matrix, and also during staff engagements. 

Officer Evaluation Report 

Perhaps one of the most significant changes proposed 

under the talent management program is the enhanced 

use of the current OER system to capture and identify 

data on leader behaviors. The OERs provide information on an officer’s job performance in a rating period 

with relevant rater and senior rater comments. However, the OER provides little relevant or reliable information to allow a senior leader or the HRC to 

confidently identify a future role for an officer.4

 As a 

single tool to identify future potential, the current OER 

system is a failure. One of the drawbacks of the current OER is the lack of documentation regarding the 

rated officer’s behaviors which are integral to 

developing a talent profile. Although Army Values are 

listed on the OERs, except for a cursory check-off of 

these behaviors, there are rarely any comments on an 

officer’s behaviors relative to current and future roles. 

Behaviors are mostly identified if there were documented negative incidents that impacted performance 

in a rating period. 

The goal of talent management practices, such as 

selecting the right person to do the right job and 

succession planning, is to predict what leaders will do 

if placed in certain positions in the future. There are 2 

basic ways to do this. One is to measure a person’s 

past accomplishments and performance and use this to 

predict future performance. This approach is based on 

the fact that one of the best predictors of future 

behavior is past behavior in similar situations.5

 The 

problem with this approach is that many talent 

management decisions require a determination 

whether someone is likely to succeed performing tasks 

that he or she may never before have had an 

opportunity to perform. For example; the challenge of 

evaluating whether an officer will be a successful 

brigade commander while deployed in a combat zone, 

when that officer may have never held a command role 

before. Another way to predict future performance is 

to use psychometrically designed assessments that 

measure underlying behaviors related to various 

personality and ability traits.6

 When appropriately 

designed and applied, these behavior assessments are 

often the single most accurate predictors of future 

performance. 

Under the talent management program, behaviors will 

be captured on the OER. The Nurse Corps has 

identified core and unique behaviors that will become 

part of the comment section for raters and senior 

raters. Core behaviors are applicable to all officers and 

comments on unique behaviors will be needed for 

mission critical roles such as Chief of the HRC, DCN, 

senior executive nurse at a medical command, or a 

regional nurse executive. Core behaviors include 

adaptable, decision maker, inspires trust, develops 

others, team player, and builds relationships. The core 

behaviors are specifically identified on the LCM under 

various objectives. Unique behaviors include change 

agent, mentor, strategic, visionary, influences others, 

and values diversity. A combination of unique and 

core behaviors will be addressed on the OER so a 

comprehensive SKB profile may be created for the 

rated officer. This additional level of information on 

an officer, in addition to the other tools discussed 

above, will allow a more objective and practical prediction of an officer’s potential. 

FEEDBACK TOOL

In addition to the tools discussed above, there are 

others that remain unusable or unavailable, including a 

360° multirater feedback to measure and capture 

behaviors, and a formalized mentoring and coaching 

program. For example, the Department of the Army 

(DA) currently uses a feedback tool at the senior 

services schools and other academic institutions which 

has been identified by users as impractical. Therefore, 

DA is now developing a 360° feedback tool that will 

be usable at all levels and organizations, regardless of 

size. Once developed, the Army Nurse Corps will 

adopt the tool for its talent management strategy. A 

successful multirater 360° feedback allows senior 

leaders, peers, team members, and customers (patients) 
36 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

to provide anonymous feedback to the officer. In the 

absence of a multirater 360° feedback tool, the rater 

and senior rater will use the clinical peer feedback, 

which captures clinical performance. The peer feedback tool, although limited, will provide raters with 

some objective data on an officer. In addition, although 

an informal mentoring and coaching program remains 

available for use to mentor and coach, a formal 

mentoring policy is currently under development. 

SUCCESSION PLANNING

As indicated in the Table, talent management will also 

facilitate succession planning in the Corps. Succession 

planning is the process of identifying and monitoring 

an organization’s talent pool in order to address the 

future needs and goals of the organization. Army 

nursing employs succession planning strategies to 

ensure that high-potential successors have been 

identified for key positions. Succession planning 

focuses not just on key leadership positions, but on key 

positions at all levels; tactical, operational, and 

strategic. Clearly defining the competencies and 

behaviors leaders need to achieve is critical to ensure 

high-potential successors are available to fill future 

leader roles. Succession planning also ensures that 

leaders with critical skills do not prematurely leave 

Army Nursing, potentially leaving the organization 

without the right capabilities. In addition, as stakeholders, the officers and their chain-of-command are 

equally responsible for ensuring that the right talent is 

developed to meet the future challenges within the 

Corps. To that end, regular collaborative communication, or calibration meetings, are a requirement for 

the successful implementation of talent management. 

Calibration meetings bring together an officer’s raters 

and/or senior raters and the assignment officers at the 

HRC to finalize future potential ratings. The primary 

tool used during these meetings is the Performance by 

Potential matrix. During these meetings, officers’ 

individual results are comprehensively calibrated 

against their peer group, and evaluated against defined 

criteria that include performance relative to objectives, 

job-scope delivery, demonstration of leadership 

competencies, practicing Corps values, and personal 

development. Talent calibration meetings also enable 

senior leaders and the HRC to calibrate their ratings to 

create a consistent set of evaluations, including merit 

lists. These calibration meetings ensure that an 

objective profile for all officers is created as they 

move through their careers. These calibration meetings 

are held at regular intervals based on the officer’s rank 

and position. For example, a section supervisor at a 

medical center participates in staff engagements twice 

a year, and his/her DCN may, in turn, conduct calibration meetings twice a year. 

CONCLUSION

A large amount of research exists highlighting the 

importance of talent development and the significant 

number of resources dedicated to recruiting and 

accessions systems and human resourcing processes 

that support talent management. However, an 

astonishing number of organizations, including the 

Army Medical Department and the Army Nurse Corps, 

lack adequate talent management programs or tools, 

and are continually challenged to fill key leadership 

positions with the right officer who has the right 

capabilities and skills. These challenges continue to 

put a considerable constraint on the organizational 

structure by forcing it to operate at less than full 

effectiveness in its mission. This gap reduces the 

ability to build a culture of trust within an 

organization, and results in less than effective support 

for combatant commanders in their mission to fight 

and win wars. It is critical to identify, develop, and 

retain talent within the Nurse Corps. In addition to 

identification of the skills, knowledge, and behaviors 

of both current and new leaders, it is also vital that 

those leaders with the right capabilities are welldeveloped to become key leaders within our Corps. 

This succession planning can be achieved through 

individual development plans, stretch goals, 

mentoring, and coaching, as well as using other tools 

such as effective evaluations. The bottom line—talent 

management requires organizational and senior 

leadership commitment. “Who will follow?” is not a 

question without an answer. The key to ensuring 

effective leadership in the Army Nurse Corps is talent 

management. 

REFERENCES

1. Hunt SR. Common sense talent management: twelve 

fundamental principles for increasing workforce 

productivity [white paper]. San Mateo, CA: 

SuccessFactors Inc; 2008:3. Available at: http://

www.successfactors.com/resources/download/

common-sense-talent-management/. Accessed 

September 6, 2011. 

Human Capital Strategy: Talent Management 
 October-December 2011 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

2. Wardynski C, Lyle DS, Colarusso, MJ. Towards a 

U.S. Army officer corps strategy for success: a 

proposed human capital model focused upon talent. 

Carlisle, PA: Strategic Studies Institute, US Army 

War College; 2009. Available at: http://www.stra 

tegicstudiesinstitute.army.mil/pubs/display.cfm?

PubID=912. Accessed April 2, 2011. 

3. Horoho, PD. Building the future ANC talent. Army 

Nurse Corps Blog. June 24, 2010. Available at: 

https://blog.amedd.army.mil/nurse/?Page=Post 

ViewMulti&displayMonthlyArchives=June%

26nbsp%3B2010&month=6&year=2010. Accessed 

February 13, 2011. 

4. Dempsey, ME. Dempsey, ME. Remarks at: Prepare 

the Army Forum 04, Army Leader Development 

Strategy for the 21st Century; August 18, 2010; US 

Army Training and Doctrine Command, Fort 

Monroe, VA. 

5. Janz T, Hellvervik L, Gilmore DC. Behavioral 

Description Interviewing. Newton, MA: Allyn and 

Bacon; 1985. 

6. Hunt ST. Hiring Success: The Art and Science of 

Staffing Assessment and Employee Selection. San 

Francisco, CA: Pfeiffer; 2007.

AUTHOR

MAJ Nagra is Chief, Clinical Modeling Branch, Manpower Division, Program Analysis and Evaluation, US Army 

Medical Command, Fort Sam Houston, Texas. 

I am a member of the 

Army Nursing Team. 

My patients depend on me 

and trust me to provide 

compassionate and proficient 

care always. I nurture the most 

helpless and vulnerable and 

offer courage and hope to those 

in despair. I protect the dignity 

of every individual put in my 

charge. 

From the Army Nursing Team Creed*

*Presented on page 9
38 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Army Nursing is transforming nursing care delivery 

from an expert-based practice model to a systemsbased care model. Expert-based practice is best 

illustrated as a mirror—it is like holding up a mirror to 

assess and evaluate nursing practice. In contrast, a 

village has been used as a metaphor for system-based 

care—a nurse must work with a community of health 

care personnel to deliver the most advantageous 

patient care.1

 Systems-based nursing care can also be 

thought of as a way of viewing and understanding the 

interdependencies of the health care system in order to 

make change efforts in caregiving and practice more 

successful. In clinical settings, these models are 

operationalized by asking 2 different but associated 

questions2

: 

The expert-based practice question: How can I 

improve the care for my patients? 

The system-based care question: How can I 

improve the system of care? 

This new systems view underpins the Patient 

CaringTouch System, formerly the Army Nursing 

System of Care, and is critical to understanding how to 

best obtain optimal patient outcomes and safe 

healthcare environments, while maximizing the value 

and quality of the military healthcare benefit. 

Research and evidence-based practice are overarching 

and core constructs in the Army Nursing Strategic 

Plan, and evidence-based decision making is a 

supporting leg of the Army Nursing System of Care. It 

is, therefore, not surprising that the first areas of Army 

Nursing to undergo transformation are those 

supporting research, evidence-based practice, and 

decision support. Tenets of system-based care, 

translational research, and knowledge integration are 

being used to guide this transformation. 

Consistent with systems-based care principles, 

outcome goals of the transformation include systems 

resourcing, health care economics, teamwork, costbenefit considerations, and practice management. 

Implementation of the transition incorporates an 

integrative systems-thinking framework. Steps in this 

framework include development and application of 

systems methods and processes, building and 

maintaining network relationships, building systems 

and knowledge capacity, and encouraging transformation to a systems culture.3

 Using these steps will help 

to build a better, standardized nursing support system 

to tackle critical Army nursing issues. 

Translational research and knowledge integration 

tenets were also incorporated into the nursing support 

service transformation in order to capitalize on 

common ground upon which to build a platform for 

translating what we know about nursing into what we 

do in practice and policy. Ideas proven to improve 

evidence-based care and decision-support such as 

expert panels, literature review and synthesis, and 

concept mapping were used to develop a framework 

that would build a team of teams with expertise in 

research, clinical practice, and business management 

analysis. This will provide a systems-oriented 

approach to integrating evidence into action and 

moving system-based knowledge gaps to the forefront 

to expedite generation of research studies (Figure 1). 

Key to this transformation is the consolidation of 

various types of nursing experts to better meet the 

needs of frontline nurses and nursing executives. For 

the nursing research community, this change involves 

transitioning the existing 9 Nursing Research Services 

to 5 Centers for Nursing Science and Clinical Inquiry 

(CNSCI). As shown in the Table, the mission of these 

new centers will include nursing research, nursing 

decision support, and the integration of evidence-based 

practice at the point of care. 

The largest Army MTF in each region will house a 

CNSCI: Brooke Army Medical Center, Landstuhl 

Transforming Army Nursing Support 

 Services to Centers for Nursing Science 

 and Clinical Inquiry 

Lori A. Loan, PhD, RNC 
 October-December 2011 39

Regional Medical Center, Madigan Army Medical 

Center, Tripler Army Medical Center, and Womack 

Army Medical Center. The centers will be staffed by 3 

Army nurse scientists (formerly called nurse 

researchers); 3 selected clinical nurse specialists 

(CNSs); and one nurse methods analyst (NMA). This 

staffing model will result in permanent teams of nurse 

experts with a shifting emphasis that capitalizes on the 

4 Army Nursing imperatives—evidence-based 

management, warrior care, leader development, and 

human capital—while addressing diverse priorities as 

well as local, regional, and Army Nurse Corps needs. 

Generating and using research evidence for the 

improvement of nursing care delivery and patient and 

system outcomes are core goals for the CNSCIs. The 

scientific discovery processes commonly associated 

with nursing research initiatives are the initial phase of 

the action-research cycle in which CNSCI nurse 

scientists work closely with nursing personnel, nursing 

leaders, NMAs, advanced practice nurses, and 

policymakers to translate their findings into improved 

therapeutic, preventive, and business practices. 

Clinical nurse specialists provide the collaborative 

contexts in which research findings produced by nurse 

The products provided by the Centers for Nursing Science and Clinical Inquiry and the respective responsible staff members.

Product Responsible Staff* 

Evidence-Based Practice Products 

Development of EB guidelines CNS, NS 

Updates of EB guidelines CNS (NS) 

EB guideline education CNS 

Consultant for EB guideline translation into practice and sustainment CNS 

Consultation, consolidation and reporting of guideline compliance NMA, CNS 

Nursing Practice Products 

Assistance in developing plans of care for complex patients, and facilitation for the execution of those plans CNS 

Review, critique, and dissemination of relevant evidence, research findings, and professional standards for nursing. CNS (NS) 

Collaboration with nursing leaders and multidisciplinary teams to define/develop population-specific patient care 

initiatives NS, CNS, NMA 

Consultant to the MTF, section and unit Nurse Practice Councils NS, CNS 

Nursing Decision Support Products 

Development, measurement and reporting of nursing sensitive outcome indicator measures to evaluate MTF and 

unit-level staffing effectiveness, EBP projects, and the Army Nursing System of Care NMA ( NS) 

Consultation regarding data interpretation or drill down NS, NMA 

Evidence summaries to assist in policy development or revisions NS 

Collaboration with Informatics Nurses to improved nursing care CNS, NMA, NS 

Cost evaluations NMA, NS 

Micro and macro analysis of data pulled by MTF analysts’ NMA ( NS) 

Surveys of customers and staff NMA ( NS) 

Subject matter experts for nursing related TJC compliance CNS, NMA (NS) 

Advanced statistical analysis to augment nursing decision support NS 

Scholarly Nursing Products 

Externally funded studies relevant to MTF and Army Nursing missions NS 

Publications to showcase the MFT or Army Nursing NS, CNS 

Internal studies to improve nursing care and processes NS 

Internal, regional and national presentations to showcase the MFT, Army Nursing and facilitate Magnet-like traits NS, CNS, NMA 

Individual counseling and mentoring for members of the Army Nursing team planning and pursuing graduate 

degrees in nursing NS 

LTHET and internal staff master’s and doctoral student support for scholarly work relevant to MTF and Army 

Nursing missions NS 

*Parentheses indicates the responsible staff member is acting in a consultant role. 

Glossary 

CNS – clinical nurse specialist EB– evidence-based 

MTF – medical treatment facility NMA – nurse methods analyst 

NS – nurse scientist
40 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

scientist teams are translated into practical 

applications. The new model also emphasizes 

systems thinking and teamwork, so that 

bedside nurses can consult with CNSs who 

know the evidence supporting their practices. 

Nurse methods analysts will turn numbers to 

knowledge and, when paired with the CNSs 

who have the bedside knowhow, will help to 

expedite getting evidence to the point of care. 

Maintaining mission balance will be a 

challenge. Research, for example, should not 

outweigh implementation of evidence or the 

use of data for decision-making. 

Working together in CNSCIs will enable 

CNSs, NMAs, and nurse scientists to more 

rapidly move evidence from question to 

answer to translation to evaluation. Consolidating 

inquiry assets will also increase the capacity and 

capability for evidence-based management and 

evidence-based practice. When the transformation is 

complete, the centers will include all essential 

elements of a translation-focused, systems-based care 

network as depicted in Figure 2. 

REFERENCES

1. Ziegelstein R, Fiebach N. The mirror and the village: 

a new method for teaching practice-based learning 

and improvement and systems-based practice. Acad 

Med. 2004;79:83-88. 

2. Johnson JK, Miller SH, Horowitz SD. Systems-based 

practice: improving the safety and quality of patient 

care by recognizing and improving the systems in 

which we work. In: Culture and Redesign. Rockville, 

MD: Agency for Healthcare Research and Quality; 

2008. Henriksen K, Battles JB, Keyes MA, Grady 

ML, eds. Advances in Patient Safety: New Directions 

and Alternative Approaches; vol 2. Available at: 

http://www.ahrq.gov/downloads/pub/advances2/vol2/

Advances-Johnson_90.pdf. Accessed January 24, 

2011. 

3. Stokols D, Hall KL, Taylor BK, Moser RP. The 

science of team science: overview of the field and 

introduction to the supplement. Am J Prev Med. 

2008;35(suppl 2):S77-S89,S96-S115. 

AUTHOR

Dr Loan is Consultant to The Surgeon General for 

Nursing Research at the Madigan Healthcare System, 

Tacoma, Washington. 

Transforming Army Nursing Support Services to Centers for Nursing Science and Clinical Inquiry 

Figure 1. Fundamental shift in nursing support assets from expert-based 

practice to system-based care. 

Figure 2. Essential elements for Centers for Nursing Science 

and Clinical Inquiry. 
 October-December 2011 41

A component of the Army Nurse Corps Patient 

CaringTouch System of Care—the Army Nursing 

model for standardization of nursing practice—is the 

establishment of a process for the development, 

dissemination, implementation, and impact assessment 

of evidence-based nursing practice across our military 

medical treatment facilities in our worldwide garrison 

and deployed settings. This article summarizes the 

nursing evidence-based practice journey utilizing 

Army nurse scientists and a council of nursing leaders 

to develop and implement Army nursing evidencebased clinical practice guidelines (AN CPGs) within 

our Army medical treatment facilities. 

As with other healthcare fields, nursing practice often 

varies considerably with the development of institutional policies and procedures not consistently based 

on best-practice evidence, but rather upon personal 

experiences or non-peer reviewed literature accounts. 

Titler et al1

 defined evidence-based practice “as the 

conscientious and judicious use of the best evidence to 

guide delivery of health care services.” Melnyk and 

Fineout-Overholt2 identified 5 steps in the evidencebased practice process: asking the clinical questions, 

collecting the most relevant evidence, subjecting the 

evidence to critical appraisal, integrating clinical 

expertise, integrating patient preference and values in 

making a practice change, and then evaluating the 

practice change. While few would argue that basing 

nursing practice on the best evidence available is 

optimal, there are barriers to the actual implementation 

of best evidence in nursing practice, with a gap of up 

to 17 years from sufficient research evidence to actual 

change in practice.3

 The challenge for organizational 

nursing leaders is to establish a framework for evidence-based practice development and implementation that includes all levels of nursing, from the nurse 

at the patient’s bedside to the director of nursing, and 

is embraced by the institution as an essential element 

in the provision of nursing care. Unfortunately, many 

nurses lack the background knowledge or the time to 

critically review literature and determine applicability 

to practice.4

 A positive trend is the addition of 

evidence-based practice curriculum to nursing academia which has resulted in a new generation of nurses 

who enter the healthcare organization with the ability to 

ask clinical questions and critique available evidence. 

These new nurses may actually drive the transition of 

practice from tradition to best practice evidence and 

become the change agents in healthcare organizations. 

The challenge for nursing leadership is to ensure that 

the organization is structured so that leadership establishes a supportive environment that encourages nurses 

to not only ask the clinical question, but to also seek 

the best practice answer. This requires nursing leaders 

to create an organizational framework that has the 

clinical nurse specialists and nurse scientists readily 

accessible and responsive to the nurses who are providing direct patient care. 

The Army Nurse Corps has a long history supporting 

nursing research. Annually, Army Nurse Corps 

officers are selected for long-term doctoral health 

education and training followed by utilization tours as 

nurse scientists in the large medical centers. Currently, 

there are over 40 nurse scientist manpower 

Establishing A Methodology for Development 

 and Dissemination of Nursing Evidence- 

 Based Practice to Promote Quality Care 

COL Carol J. Pierce, AN, USA 

ABSTRACT

Reducing nursing practice variance by standardization of practice guidelines based on supportive literature has demonstrated improvements in the quality of patient care and positive patient outcomes. The challenge is to link the bedside 

nurse providing nursing care to subject matter experts well-versed in the critical analysis of clinical practice recommendations. This article discusses the restructuring of nursing research departments within Army healthcare facilities to 

facilitate nursing practice based on supportive evidence and the development of a senior nursing leadership practice 

council to support dissemination of approved nursing practice guidelines across all Army inpatient medical facilities. 
42 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

authorizations (military and civilian) across the Army 

Medical Command. In addition, military nursing 

scientists are deployed in combat theaters of operation 

to support theater research programs. While nursing 

scientists are actively engaged in clinical research, 

there has been considerable variation in the utilization 

of nurse scientists which has detracted from the ability 

to integrate nursing research into clinical nursing 

practice. Often, the nursing research that was 

conducted appeared to arise from the nursing 

scientist’s personal area of interest, with only limited 

application to the clinical issues and nursing care 

practice most impacting their assigned institution or 

the entire Army Medical Command. Additionally, 

often the research did not involve replication studies to 

build a body of knowledge in support of definitive 

practice changes, or to enhance application of the 

findings across diverse populations and other facilities. 

Recently, through the strong direction of the Nurse 

Scientist Consultant to The Army Surgeon General, 

the nurse scientist community has established nursing 

research priorities aligned with the Corps’ vision of 

implementation of nursing evidence-based practice, 

and reduced practice variation across our healthcare 

system. In order to synchronize clinical and nursing 

research activities, the Nurse Scientist Consultant is in 

the process of realigning nurse scientists, nurse clinical 

specialists, nurse method analysts, and nurse 

informatics officers into regional Centers for Nursing 

Science and Clinical Inquiry (CNSCI). Bridging the 

gap from research to bedside practice requires a coherent strategy linking the nursing scientists, advanced 

practice nursing clinicians, medical informatics 

technology support, and administrative leadership. The 

restructuring of the nursing research sections into 

regional clinical inquiry cells better supports an 

evidence-based practice model within each medical 

treatment facility (MTF), and nursing practice across 

the entire Army Medical Department. Bedside nurses 

in any MTF may now reach out to these subject matter 

experts from regional CNSCIs for assistance with 

patient care practice issues. The nurse clinical specialists working with nursing staff identify clinical issues, 

while the nurse informatics officers and nurse methods 

analysts facilitate maximal use of clinical information 

technology and business analytical tools in support of 

evidence-based practice initiatives. Additionally, each 

regional CNSCI has defined nursing research and 

evidence-based practice priorities, based on identified 

research focus areas, with the goal to transition from 

the past model often characterized as individual 

research interests to an integrated methodology 

addressing common bedside nursing practice issues. 

The nurse scientists assist nursing staff in the conduct 

of comprehensive literature reviews and evaluation of 

the strength of supportive evidence, and, if indicated, 

develop research protocols to build a body of knowledge if current evidence is lacking or inconclusive. In 

other, nonmilitary healthcare organizations, a similar 

strategy has been linked to quality care processes, as 

hospital-based nursing research cells provide the infrastructure and the processes to promote and sustain 

evidence-based practice. Such cells are also integral to 

the success of hospitals in the achievement of Magnet 

status, a marker of excellence in hospital care.5

 It is 

critical to success for nursing executive leadership in 

the organization to ensure that evidence-based practice 

language is incorporated in the mission, values, and 

philosophy of care, and that resources are made available to support the implementation. 

Within the CNSCIs, the nursing scientists use the Iowa 

Model of Evidence-Based Practice framework1

 to 

assess the strength of the evidence supporting nursing 

practice changes. Each regional CNSCI conducts a 

thorough review of literature and grades the strength of 

the evidence. The Iowa Model of Evidence-Based Practice framework structures a decision making process 

evaluating available research, case reports, consensus 

of experts and scientific principles. Based upon the 

evidence, the nurse scientists may develop a nursing 

clinical practice guideline in collaboration with clinical 

nurse specialists and clinical nursing staff. If insufficient evidence exists, the nurse scientists may develop 

an appropriate research protocol in order to establish a 

body of knowledge ultimately sufficient to support 

standardization of clinical practice. If the practice guideline involves other non-nursing healthcare team members, recommendations are forwarded to the Army 

Medical Command proponent for clinical practice guidelines. The first application of this strategy involved the 

CNSCI nurse scientists assigned to the Madigan Army 

Medical Center, Tacoma, Washington. 

Patient falls remain a prevalent problem in healthcare 

institutions, despite a plethora of literature related to 

the identification of at risk patients and actions to 

mitigate falls. Within the Army medical treatment 

facilities, the patient falls prevention strategy 

frequently differed as to risk assessment tools, 

documentation, and mitigation strategies. The 

Establishing A Methodology for Development and Dissemination of 

Nursing Evidence-Based Practice to Promote Quality Care 
 October-December 2011 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

challenge was to conduct an exhaustive review of the 

literature and grade the strength of evidence to 

determine the best practices that should then be 

standardized for each facility. The nurse scientists 

within the CNSCI were responsible for the initial 

review of the evidence and the development of the 

Falls Prevention Army Nursing clinical practice 

guideline (AN CPG) in collaboration with clinical 

nursing staff, clinical nurse specialists, and nursing 

leadership. Their findings, recommendations, and the 

Falls Prevention AN CPG were then forwarded to 

other regional CNSIs for review and validation. As 

concurrent with the Patient Falls AN CPG 

development, the Army Medical Command Patient 

Safety Section developed a Patient Falls prevention 

policy. The nursing practice guideline was then 

matched against the policy to ensure consistency in 

practice recommendations. The final products were the 

Falls Prevention AN CPG and the Army Medical 

Command Patient Safety policy standardizing the 

patient falls risk assessment tools for adults and 

children, risk mitigation actions, documentation, and 

outcome evaluative metrics. 

Implementation of an evidence-based practice model 

in one institution is daunting. Building a framework 

for the sharing of evidence-based practice guidelines 

and enforcing their consistent application across 

several institutions can be overwhelming. Standardization of elements of nursing practice in multiple 

organizations worldwide requires not only the support 

of each nursing leader, but the administrative and 

communication processes necessary to disseminate 

and enforce implementation and systematic outcomes 

evaluation. Pearson et al6

 described the challenge of 

disseminating nursing innovations through large 

healthcare organizations comprised of multiple 

institutions. As a part of the Robert Wood Johnson 

Foundation initiative, Transforming Care at the Bedside (TCAB), 3 large healthcare systems were asked to 

evaluate how large hospital systems spread changes in 

nursing care processes across multiple medical 

surgical units within their institutions. They defined 

the term “spread” as the active dissemination of new 

ways to organize or provide care from one healthcare 

setting to another. The example initiative, evolved 

from concerns brought by frontline staff, was a change 

to facilitate smooth, safe, patient-centered nursing shift 

changes. One of the healthcare organizations involved 

in the TCAB initiative implemented a centralized or 

“top-down” approach to dissemination of specific 

innovations from one institution to another, whereby 

senior leaders introduced the innovation to a new 

location and encouraged staff nurses to implement 

changes. Conversely, the other 2 organizations used a 

“bottom-up” approach, whereby education on the 

TCAB improvement processes and team formation 

were provided to nursing staff, with staff nurses then 

responsible for implementation of the processes on 

their units. Both the top-down and bottom-up strategies for dissemination of practice innovations were 

equally effective. Both strategies required considerable 

resources and leadership support. The TCAB review 

team concluded that the top-down approach may be 

most useful when innovations have been previously 

implemented and tested, and the desire is to establish 

uniform, consistent adoption across the entire 

healthcare system. The advantage of the bottom-up 

approach is that it allows the nursing staff at unit level 

to effect the change with potentially more “buy-in” to 

the innovation. 

Early in the development of the CNSCI concept, the 

Chief, Army Nurse Corps requested information on the 

strategy for dissemination of AN CPGs across all 

MTFs. In an impromptu discussion with the Corps 

Chief, the AN Corps Specific Branch Proponency 

Officer (AN CSBPO) diagrammed a process for generating nursing evidence-based practice priorities, the 

development of AN CPGs, and a review process involving senior nursing leaders. From this discussion, 

the Army Nurse Practice Council (ANPC) concept 

evolved as a method for senior nursing leaders across 

the Army Medical Command to prioritize nursing evidence-based practice initiatives and approve AN CPGs 

for dissemination and application into the nursing 

practice environment of our garrison MTFs and in our 

deployed healthcare settings. With multiple, worldwide MTFs, the centralized top-down strategy for dissemination of nursing practice innovations seemed the 

most feasible vehicle for AN CPG standardized application to each inpatient nursing unit. A charter for the 

ANPC defined its purpose: provide oversight and direction for nursing practice and nursing care delivery 

through standardization of evidence-based clinical 

practice guidelines within the domain of nursing. The 

ANPC is a deliberative body charged with providing 

recommendations to the Chief, Army Nurse Corps. 

The charter designated the AN CSBPO and the Army 

Medical Command Patient Safety Officer as ANPC 

cochairs with additional voting members, including the 

regional nurse executives, a medical brigade chief 
44 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

nurse, a nurse scientist from each region, and a senior 

enlisted advisor. As needed, the chairperson may 

invite subject matter experts to discuss specific topics 

within their area of expertise. 

When the clinical inquiry cell has completed the 

review of the AN CPG, it is submitted to the ANPC 

chairperson who then distributes it to the ANPC membership for review and feedback. Based upon final 

recommendations, the AN CPG is subjected to ANPC 

vote. If approved by the majority of ANPC membership, the AN CPG is disseminated to each regional 

nurse executive for implementation across their region. 

An element of each ANPC review will be determination of performance and outcome metrics. The nurse 

method analysts and nurse informatics officers in the 

regional CNSCIs will assist in development of 

measurement tools, training aids, and improvements in 

the electronic medical record system to support the 

practice change. Multiple strategies have been 

implemented to ensure optimal dissemination of AN 

CPGs. The AN CPG is made accessible on the Army 

Medical Command Clinical Practice Guideline website 

(https://www.qmo.amedd.army.mil/pguide.htm). 

Additionally, each AN CPG will be incorporated into 

the web-based clinical training and competency 

assessment program available at each facility. 

The establishment of the ANPC and the 

implementation of AN CPGs based on best evidence is 

a component of the Patient CaringTouch system of 

nursing care. Through standardization of many of our 

direct nursing care processes, the end state is the 

provision of consistent, evidence-based nursing care 

across all of our medical treatment facilities and 

reduce practice variance. The Falls Prevention AN 

CPG was the first nursing evidence-based practice 

guideline approved by the ANPC. An Army Medical 

Command operational order for the ANPC and AN 

CPG dissemination is currently in staffing. When 

approved, each additional AN CPG will be 

disseminated through operational order updates to the 

original operational order. Currently in development is 

a second practice guideline to standardize nursing 

processes and procedures as they relate to nursing 

hourly patient rounds, including standardized 

assessment of patients, interventions, documentation, 

and outcome metrics. To ensure that AN CPGs remain 

current and relevant, the CNSCIs and the ANPC will 

establish review dates for nurse scientists’ proponents 

responsible for the review of literature and updates to 

previously approved AN CPGs. Recommendations 

will be reviewed by the ANPC membership for 

approval prior to the incorporation of changes. 

Transitioning nursing practice from tradition-based to 

practice driven by evidence often requires a 

realignment of organizational structures. Nursing 

research cells were reorganized into regional CNSCIs 

and an ANPC was established to create an enduring 

infrastructure for the standardization of nursing 

practice based on best evidence across all of our 

healthcare institutions. While only in the beginning 

phase, the long-term goal is to ensure that patients in 

every Army healthcare facility receive nursing care 

within a standardized framework of evidencesupported clinical practice. That framework formalizes 

the linking of practice questions from nurses in direct 

patient care with a responsive infrastructure of clinical 

nurse specialists and nurse scientists to ensure 

facilitation of best-evidence answers. 

REFERENCES

1. Titler M, Kleiber C, Steelman V, et al. The Iowa model 

of evidence-based practice to promote quality care. 

Crit Care Nurs Clin North Am. 2001;13(4):497-509. 

2. Melynk B, Fineout-Overholt E. Evidence-Based 

Practice in Nursing And Healthcare: A Guide to Best 

Practice. Philadelphia, PA: Lippincott, Williams, and 

Wilkins; 2005. 

3. Bondmass M. Implementation strategies for evidencebased practice. Nevada RNformation. 2011;20(1):14. 

4. Staffileno B, Carlson E. Providing direct care nurses 

research and evidence-based practice information: an 

essential component of nursing leadership. J Nurs 

Manag. 2010;18:84-89. 

5. Ingersol G, Witzel P, Qualls B. Meeting magnet and 

evidence-based practice expectations through hospitalbased research centers. Nurs Econ. 2010;28(4):226-236. 

6. Pearson L, Upenieks V. Spreading nursing unit 

innovation in large hospital systems. J Nurs Admin. 

2008;38(3):146-152. 

AUTHOR

When this article was written, COL Pierce was the 

Army Nurse Corps Specific Branch Proponency 

Officer, AMEDD Center and School, Fort Sam 

Houston, Texas. 

Establishing A Methodology for Development and Dissemination of 

Nursing Evidence-Based Practice to Promote Quality Care 
 October-December 2011 45

THE EARLY YEARS

In 1910, CPT George Gosman, US Army Medical 

Corps, modified an aircraft to show that casualties 

could be successfully transported in aircraft. However, 

there was no mention of an attendant. He then 

submitted a report to the Secretary of War describing 

this process. The report was not acted upon because it 

was felt that, although the need was compelling, the 

airplane was not sufficiently developed for such 

transport.1

 Between World Wars I and II, in 1920, 4 

airplanes were modified to carry 2 litter patients and 

an attendant, and were used along the Mexican border. 

After using this transportation for several Soldiers, an 

after action report stated “...no longer will the luckless 

injured recruit...be jolted for hours in a rough ride 

automobile over cactus and mesquite, but borne on 

silvery wings, cushioned by a mile of air...to the rest 

and comfort of a modern hospital.”1(p5)

In 1921, the Army took delivery of a Curtis Eagle 

airplane that carried 4 litter and 6 sitting patients. 

Unfortunately, this airplane crashed, killing all seven 

on board, which halted any further development of 

aircraft for evacuation before World War II.1

 In 1930, 

a civilian pilot named Lauretta Schimmoler envisioned 

the idea of flight nursing. Out of this vision came an 

organization known as the Aerial Nurse Corps of 

America. This organization was founded independent 

of the military services, however, Schimmoler’s 

intention was that her organization would provide 

flight nurses to the American Red Cross and the US 

Army.2

 Her ideas were not as acceptable to the 

American Red Cross and the Army as she had hoped, 

as shown in a response from MAJ Julia O. Flikke, Superintendant of the Army Nurse Corps from 1937-1943: 

...any well-trained nurse to whom air travel is not 

distasteful, could be assigned, so that at present time at 

least there seems to be no factual justification for a 

group of nurses being segregated and called aerial 

nurses.2(p1177)

Later Schimmoler was informed that nurses would be 

assigned from the Army Nurse Corps for air 

evacuation, and further, members of her association 

could join the Army Nurse Corps which had many 

Nursing and En Route Care: 

 History in Time of War 

MAJ R. Scott Davis, AN, USA 

COL Linda K. Connelly, AN, USAR 

ABSTRACT

The mission of the en route caregiver is to provide critical care in military helicopters for wounded Warriors. This care 

minimizes the effects of the wounds and injuries, and improves morbidity and mortality. This article will focus on the 

history of Army Nursing en route care. 

From World War II through Vietnam, and continuing through the War on Terrorism in Iraq and Afghanistan, Army 

nurses served in providing en route care in military airplanes and helicopters for patients being transported to higher 

echelons of care. From aid stations on the battlefield to forward surgical teams which provide life, limb, and eyesight 

saving care, to the next higher level of care in combat support hospitals, these missions require specialized nursing 

skills to safely care for the high acuity patients. Before the en route care concept existed, there was not a program to 

train nurses in these critical skills. There was also a void of information about patient outcomes associated with the 

nursing assessment and care provided during helicopter medical evacuation (MEDEVAC) of such unstable patients, 

and the consequent impact on the patient’s condition after transport. 

The role of critical care nurses has proven to be essential and irreplaceable in providing full-spectrum care to casualties 

of war, in particular, the postsurgical patients transferred from one surgical facility to another in theatre. However, we 

have only recently developed the concepts over the required skill set, training, equipment, functionality, evidencedbased care, and sustainability of nursing in the en route care role. Much of the work to quantify and qualify nursing care 

has been done by individuals and individual units whose lessons learned have only recently been captured. 
46 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

vacancies. In October of 1937, MG C. R. Reynolds, 

Surgeon General of the Army, discouraged the 

American Red Cross from organizing a corps of “flight 

nurses,” since the Army did not see a need for specially trained nurses for air evacuation. 

WORLD WAR II 

The Second World War brought about a significant 

change in the US Army’s attitude toward the concept 

of “flight nursing” to accompany wounded Soldiers 

during air evacuation transport from forward surgical 

hospitals to tertiary facilities. Medical evacuation from 

the battlefield by air was brand new to the Army. Prior 

to the war, wounded were taken from the fight in 

trucks, field ambulances, and even the venerable old 2-

wheeled handcart. The primary problem with these 

older forms of transport was the lack of speed in 

moving the injured to rear areas. Moving the wounded 

quickly to clean hospitals that had surgeons and life 

saving drugs—things that could not be found in an 

active combat zone—did lower the morbidity and 

mortality among battlefield casualities. 

Increased use of airplanes in World War II made it 

necessary to train special nurses to accompany 

wounded men on evacuation flights to the rear. 

Standards and training were developed for flight 

nursing in response to the need. The first flight nurse 

training program was created at the Army Air Force 

School of Air Evacuation in Bowling Green 

Kentucky.3

 They learned crash procedures, received 

survival training, and learned the effects on patients of 

different altitudes. The first class of Army Flight 

Nurses, who were exceptional nurses that could pass a 

flight physical, completed training in February 1943.3

Following this class, air evacuation of patients began 

in North Africa and eventually became a standard. 

Medical evacuations with attending flight nurses flew 

in all theaters of operations during World War II.4

 The 

wounded troops were picked up from rear area 

hospitals, out of harm’s way. Following the landings in 

Normandy (June 1944), medical transport C-47 

airplanes, each with one flight nurse and one medical 

technician, were first flown into a hot combat zone in 

the European theater. These specially crewed airplanes 

eventually were deployed to every theater of the war. 

Over one million patients were evacuated by air during 

World War II. On one particular day, airplanes 

transported 4,707 wounded. All the wounded of World 

War I were returned to the United States on hospital 

ships or troop transport ships. During World War II, 

one-fifth of all patients returned to the United States 

by air evacuation. By the end of the war, the Army Air 

Corps had established 31 Medical Air Evacuation 

Transport Squadrons staffed by 500 flight nurses.4

Within the "chain of evacuation" established by the 

Army Medical Department during World War II, 

nurses served under fire in field hospitals and evacuation hospitals, on hospital trains and hospital ships, 

and on medical transport planes as flight nurses. The 

skill and dedication of these nurses contributed to the 

extremely low postinjury mortality rate among 

American military forces. Overall, fewer than 4% of 

American Soldiers who received medical care in the 

field and underwent evacuation died from wounds or 

disease. Rapid evacuation by airplane did lower the 

battle casualty fatality rate, but it cost the lives of 17 

flight nurses. 

Airplanes were scarce and valuable, so none were 

devoted entirely to medical evacuation. Airplanes for 

air evacuation also transported military supplies, and 

could not, under the Treaty of Geneva (also known as 

the Red Cross Treaty), display a red cross to indicate 

noncombat status. Without the red cross symbol, the 

evacuation flights were open to enemy attack. Due to 

the dual mission of the aircraft, there were frequent 

snarls in communication, sometimes causing nurses to 

fly into an area aboard a plane loaded with ammuNursing and En Route Care: History in Time of War 

Student flight nurses at the US Army Air Force School of 

Evacuation, Bowman Field, KY, learned how to prepare and 

handle patients using a mock-up fuselage of a C-47 transport. 

Photo courtesy of the National Museum of the US Air Force. 
 October-December 2011 47

THE ARMY MEDICAL DEPARTMENT JOURNAL

nition only to discover that there were no patients 

waiting to be evacuated. On the return trip, the empty 

plane and its crew remained vulnerable to an enemy 

attack. Equally frustrating to the nurses was the lack of 

emergency equipment on many evacuation aircraft. 

Further, many of the wounded patients had never been 

away from home before joining the Army, never been 

injured in combat, and never been on an airplane. 

Those factors combined with the 13-hour flight from 

Europe to New York to create a stressful environment 

for both patients and flight nurses. 

These pioneering nurses assigned to field and 

evacuation hospitals as flight nurses became 

accustomed to taking the initiative, making quick 

decisions, and adopting innovative solutions to a broad 

range of medical-related problems. They learned 

organizational skills by setting up and moving field 

and evacuation hospitals while following the troops. 

They developed teaching and supervisory skills while 

training the medics under their command. Paperwork 

no longer intimidated them, as circumstances forced 

them to deal with increasingly complex administrative 

chores. This legacy of flexibility, dedication, and 

professionalism set the standard for all who have 

followed. 

THE KOREAN WAR

During the Korean War which began in 1950, nurses 

were the only female military personnel allowed to 

serve in the combat zone. From 1950 to 1953, nurses 

served aboard ships, in mobile surgical hospitals and 

even on hospital trains and MEDEVAC flights. Due to 

terrain that was rugged, primitive, and forbidding, 

evacuation of the wounded by ground transportation 

during the Korean War was very difficult. The “chain 

of evacuation” medical doctrine was a holdover from 

World War II, and only included fixed-wing aircraft. 

However, since practical, reliable rotary-wing 

technology had been developed prior to the Korean 

War, it was the first military conflict in which 

helicopters were available in significant numbers. 

Early in combat operations, it was demonstrated that 

the helicopter could evacuate wounded Soldiers by air 

directly from the battlefield environment for the first 

time. On August 5, 1950, a US military helicopter 

supporting combat operations in Korea responded to 

an emergency call and transported a wounded Soldier 

to a mobile army surgical hospital. In an after-action 

report, the hospital commander stated: 

...the helicopters proved to be well worth their cost for 

use in removing patients from the front...making a 

fifteen minute air trip which would have been several 

hours by ground ambulances from the front to this 

hospital.5

Their value in rapid evacuation from the point of 

injury to advanced medical care was quickly 

recognized, and helicopters were dedicated as medical 

assets, ultimately transporting approximately 20,000 

patients.5

 In November 1952, The Surgeon General of 

the Army activated an aviation section to strengthen 

medical control over MEDEVAC.5

VIETNAM

During the Vietnam conflict, approximately one 

million patients were transported by helicopter.6

 When 

placed in MEDEVAC operations, the Bell UH-1 

helicopter was large enough to hold patients and have 

medical personnel provide care during the flight to the 

field hospital. In limited cases, nurses traveled with 

MEDEVAC patients but no records exist to describe to 

what extent this occurred, and no nurse training 

program was created to address helicopter transport. 

However, the value of helicopter transport of patients 

was firmly established and shown to positively impact 

the survival rates of wounded Soldiers.7

 

THE MODERN COMBAT ENVIRONMENT

Medical evacuation of casualties has come a long way 

since World Wars I and II, Korea, and Vietnam. 

Technology advances and systems have responded to 

the ever-increasing complexity of modern warfare. 

The battlefield of the past with clear lines of 

demarcation has been replaced with a combat zone that 

spans wide areas, including towns, cities, and the 

home base of operations. 

In today’s combat theater, level I care is typically 

provided by the first responder at the point of injury, 

the medic that is assigned to a unit and its organic 

battalion aid stations. Level II care includes initial 

emergency resuscitative and stabilization surgery, 

coupled with life and limb saving actions. The level II 

facility, the forward surgical team (FST), provides a 

mobile surgical capability as close to combat 

operations as possible. Level III provides essential care 

within theater, characterized by the combat support 

hospital (CSH). The core of ensuring quality health 

care to our forces and the key to success is the ability 
48 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

to continue treatment started at levels I and II, and 

evacuate the wounded to definitive health care while 

maintaining stabilization and providing emergency 

intervention during the medical evacuation. 

Transporting wounded Warriors quickly through the 

echelons of care is vital, delays in their receipt of more 

definitive life-saving care can lead to loss of life or 

limb. En route care occurs between levels II and III, 

and beyond—level III to level III, and out of theater, 

involving Air Force evacuation airplanes. 

The need to transport postsurgical critical patients by 

helicopter first arose with the development of the FST. 

Patients treated at these facilities often must be 

transported while recovering from surgical intervention and are in critical condition. These patients are 

often intubated and on vasoactive intravenous 

medications that require monitoring by medical 

personnel trained in critical care. The condition of this 

type of patient is beyond the original mission concept 

of MEDEVAC, which emphasizes quick movement of 

multiple, newly injured patients rather than the 

transport of one or 2 patients requiring advanced 

monitoring and significant medical equipment. Such 

care for critical, postsurgical patients requires skills 

not normally found in EMT-level personnel. The 

transfer of patients from an FST or CSH with only the 

attendance of an EMT-trained medic could seriously 

decrement the level of care. Specialized nursing skills 

are required to support these missions due to the high 

acuities of the transported patients. 

The requirement for critical care personnel in the 

MEDEVAC mission became obvious during the 

conflicts in Bosnia-Herzekovina and Kosovo, 

beginning in 1997. In operations supported by the 67th 

FST, the critical patients were moved from the FST to 

the Mobile Aeromedical Staging Facility accompanied 

by advanced cardiac life support trained personnel. 

These operations were continued with the arrival of the 

67th CSH. The problems with the need for nonstandard medical equipment on helicopters and the 

limited availability of critical care personnel continued 

throughout operations in those conflicts. 

Since early 2003, Army nurses have functioned as en 

route care providers in numbers not seen before due to 

the high number of critical patients being transported 

within the theaters of Iraq and Afghanistan. Approximately 20,000 aeromedical missions were conducted 

from 2003 to 2010, with two thirds requiring provision 

of critical care.8

 Approximately 20% of those missions 

moving patients between level II and level III 

facilities, or level III and level III were supported by 

nurses. The Army nursing en route care program 

evolved in Operation Iraqi Freedom from 2006 to 

2009, and the challenges of these missions remain the 

same in Iraq, Afghanistan, and other overseas 

contingency operations. 

FLIGHT NURSE TRAINING

In 2002, senior Army nursing leadership advised the 

Chief of the Army Nurse Corps, BG William Bester, 

of the gap in critical care management during aeromedical transfers in helicopters in the new combat environment of Afghanistan. As the battlefield stretched 

with expanded rapid access to FSTs and split-based 

combat support hospitals for damage control resuscitation and surgery, the need for critical care postoperative and advanced clinical management during patient 

transport became increasingly obvious, especially with 

the initiation of combat operations in Iraq. This gap 

was directly attributed to a skill-to-requirement mismatch in the clinical training of Army flight medics. 

While the flight medics were given a significant foundation in point of injury, trauma, and acute medical 

evacuation management, they did not have sufficient 

capability to provide the advanced critical care 

management required during interfacility transfers. 

Under BG Bester’s guidance to address this issue, one 

Critical Care Nurse was assigned to the Army School 

of Aviation Medicine at Fort Rucker, Alabama. Over 

the next 3 years, the Joint En Route Care Course 

(JECC) was developed and implemented. The JECC 

provides concise, realistic, relevant, and current 

training on en route trauma transport to care providers 

involved in aeromedical helicopter operations. A 14-

member board of subject matter experts consisting of 

flight medics, helicopter pilots, nurses, and physicians 

from the Army, Navy, and Air Force convened to 

review and validate the course in 2006. 

The course consists of 10 days of mentally and physically challenging training, with a focus on providing 

didactic and practical applications of advanced aeromedical and trauma management concepts, effective 

communications, and roles. These duties are integrated 

into safe operational performance in a combat environment in a tactical helicopter. The course includes trauma 

team concepts taught at the Army Trauma Training 

Nursing and En Route Care: History in Time of War 
 October-December 2011 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

Center in Miami, Florida, and accepted as best practices 

in trauma centers throughout the United States. 

CURRENT COMBAT OPERATIONS

As Operations Enduring Freedom (OEF) and Iraqi 

Freedom (OIF) evolved, intheater units addressed 

problems with en route care as they arose. From 

October 2005 to October 2007 in OIF, the 30th 

Medical Brigade addressed concerns with the medical 

regulation of MEDEVAC patients, equipment issues, 

standardization of care for neurological patients, and 

packaging patients for flight. They reported that 10% 

to 20% of patients required inflight emergency 

intervention by the nursing personnel. The efforts of 

the 30th Medical Brigade were continued and 

expanded by succeeding units. Those local efforts 

began to be integrated into existing programs and 

concepts for the Army Nurse Corps. 

In 2007, as part of their efforts to standardize and 

improve trauma care in theatre, the Joint Theatre 

Trauma System (JTTS) developed an Intratheater 

Transport Clinical Practice Guideline (CPG) in 

collaboration with subject matter experts in Army 

medicine. This document established guidelines for 

transporting critical patients and serves as a guide for 

nurses providing en route care. The CPG states that 

polytrauma patients require medical management 

beyond flight medic capability, and recommends that a 

physician or nurse with critical care experience 

manage these patients.9

During the years of the surge in Iraq (2007-2009), there 

was an increase of critical injured patients. In response, 

the 62nd Medical Brigade tasked the 86th CSH to 

standardize and measure the effectiveness of en route 

care. Nursing-related patient outcomes were measured 

and tools were developed to capture nursing workload. 

The metrics included interventions during transport, 

equipment issues, and clinical performance improvement initiatives which were used to determine priorities and improve care. These initiatives attempted to 

create a system of evidence-based care and workloaddriven staffing that is normally conducted in medical 

treatment facilities. The selections of these metrics were 

based on the clinical recommendations of the JTTS. 

Data collected and analyzed during the period 2007-

2009 clearly showed that nursing was making a 

difference in patient outcomes as measured by 

reductions in hypothermia, acidosis, and mortality. 

Nurses were performing critical interventions, such as 

managing hemodynamic changes, making adjustments 

in ventilator settings, or troubleshooting critical 

medical equipment approximately 70% of the time. 

This data validated the need for critical care nurses in 

the provision of en route care for postsurgical and 

other critical patients transported between level II and 

higher capability medical units. 

LOOKING AHEAD

The surge of casualties resulting from recent events in 

Afghanistan have stimulated significant improvements 

in the process of en route care. Task Force 62 Med 

(OEF 2010) created several initiatives that drew upon 

past efforts to standardize en route patient care. 

Among those improvements are further definition of 

the qualifications of en route care nurses, dedication of 

nursing personnel to this specific mission, and integration of the medical brigade, JTTS, and the Joint 

Combat Casualty Research Team (JC2RT) efforts in 

tracking data for the purpose of performance improvement. The initial finding of JC2RT indicate that 

the en route critical care nurses are instrumental in 

maintaining homeostasis in the acute post-damagecontrol resuscitation/surgical transfer patients, as 

measured by oxygenation, through advanced airway 

management and advanced intravenous pharmacological support, such as vasoactive, analgesic, sedative, 

and paralytic medication management. Further, the 

assignment by Task Force 62 MED of nursing personnel to the aviation brigade and MEDEVAC units 

improved casualty care through ongoing training of 

flight medics by critical care nurses, and resulted in a 

team-based care environment. 

Currently, the Army has significantly revised and 

improved training nurses in trauma care. A new 

trauma nursing training program, the 66T Area of 

Concentration course, has been implemented to train 

nurses in critical and emergency care of trauma 

patients. This program has included en route care in its 

curriculum, and its graduates will be able to apply the 

lessons learned to future en route care missions. 

The future of en route care requires a flexible response 

to changes in both combat conditions and patient 

needs. This will require collaboration among medical 

personnel and their skills sets; development on new 

capability through training, data collection and 
50 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

analysis to develop evidenced-based care; and the 

allocation of appropriate equipment and resources. The 

collaboration of skill sets and the improvement of 

patient outcomes has been a successes of the en route 

care program.8

Army nursing has been integral in the improvement of 

patient outcomes through the provision of essential 

skills in critical care, and through data collection and 

analysis. The analysis of the data collected will foster a 

learning environment in which best practices will 

emerge as supported by evidence. These practices will 

continue to promote standardized training and 

preparation for en route care nurses, allowing such 

trained critical care nurses to deploy to use their skills, 

knowledge, and abilities in caring for those critically 

injured as they are transported to higher echelons of 

care. Army nursing will continue to be in the forefront 

of “aerial nursing” as it has been since World War II 

when Army Nurses stepped forward to fill a capability 

gap. In so doing, they established and developed an 

entirely new discipline, dedicated to the survival and 

care of our wounded Warriors as they are rushed from 

the battlefield to the highest echelons of medical care. 

REFERENCES

1. Whitcomb D. Call Sign–Dustoff: A History of U.S. 

Army Aeromedical Evacuation from Conception to 

Hurricane Katrina. Fort Detrick, MD: Borden 

Institute, Office of The Surgeon General, US Dept of 

the Army; 2011. 

2. Barger J. Origin of flight nursing in the U.S. Army 

Air Forces. Aviat Space Environ Med. 1979;50

(11):1176-1178. 

3. Stroup LB. Aero-medical nursing and therapeutics. 

Am J Nurs. 1944;44(6):575-577. 

4. Harl V. WW II Flight Nurse. Available at: http://

www.chuckhawks.com/flight_nurse.htm. Accessed 

September 15, 2011. 

5. Driscoll R. US Army helicopters in the Korean War. 

Mil Med. 2001;166(4):290-296. 

6. Howard WG. History of Aeromedical Evacuation in 

the Korean War and Vietnam War [master’s thesis]. 

Fort Leavenworth, KS: US Army Command and 

General Staff College; 2003. Available at: http://

handle.dtic.mil/100.2/ADA416927. Accessed August 

25, 2011. 

7. Mabry RL, De Lorenzo RA. Sharpening the edge: 

paramedic training for flight medics. US Army Med 

Dep J. April-June 2011:92-100. 

8. Hudson TL, Morton R. Critical care transport in a 

combat environment: building tactical trauma 

transport teams before and during deployment. Crit 

Care Nurse. 2010;30(6):57-66. 

9. US Army Institute of Surgical Research. Intratheater 

Transfer and Transport of Level II and III Critical 

Care Trauma Patients. November 2008. Available at: 

http://www.usaisr.amedd.army.mil/cpgs.html. 

Accessed August 25, 2011. 

AUTHORS

MAJ Davis was a Trauma Nurse Coordinator for the 

Joint Theatre Trauma System, Operation Enduring 

Freedom, from April 2007 to October 2007, and 

Operation Iraqi Freedom from April 2009 to October 

2009. He is currently assigned to the Office of the 

Chief, Army Nurse Corps. 

COL Connelly was the Deputy Commander of the 

345th Combat Support Hospital from April 2008 to 

May 2009. Currently she is the Deputy Chief, Army 

Nurse Corps, Drilling Individual Mobilized Augmentee. 

Nursing and En Route Care: History in Time of War 

CORRECTIONS

The Acknowledgements section of the article, “Effectiveness of Pedometer Use in Motivating Active Duty and Other 

Military Healthcare Beneficiaries to Walk More” on page 117 of the July-September 2011 issue contained an 

incorrect statement regarding funding of the research project. The correct statement is as follows: 

The BAMC Department of Clinical Investigation provided funding for this research in support of 

Graduate Medical Education. 

Also in the July-September 2011 issue, coauthor LtCol John D. Childs of the article “Reliability of Lower Quarter 

Physical Performance Measures in Health Service Members” was incorrectly identified as LtCol John C. Childs. 
 October-December 2011 51

INTRODUCTION

The Combat Healthcare System is a complex mix of 

interrelated and interdependent systems which 

provides a continuum of medical treatment from the 

point of injury (POI) or wounding, through the chain 

of healthcare delivery to definitive, rehabilitative, and 

convalescent care in the United States, if needed. 

Medical evacuation (MEDEVAC) is the system that 

provides the vital en route patient care during transport 

between echelons of care, and includes emergency 

medical interventions to improve patient outcomes, for 

example, improved prognosis for recovery and/or 

minimization of potential disabilities. 

The intratheater patient movement and en route care 

during medical evacuation occurs at the battlefront 

(tactical), between echelons of care (level II and level 

III) within the theater (operational), and during 

intertheater transfers (strategic). It requires the synchronization and integration of the Army, Navy, and 

Air Force medical evacuation resources. The intratheater patient movement system is unlike the intertheater 

worldwide patient movement and evacuation system, 

operated by the US Transportation Command, which 

moves patients to the United States from all combat 

theaters. Army medical evacuation is a multifaceted 

program accomplished by a combination of dedicated 

ground (ambulances/other vehicles) and air (helicopters) evacuation platforms synchronized to provide 

direct MEDEVAC within the joint operations area. At 

the tactical level or at the POI, first responders from 

the organic unit provide the medical evacuation 

resources to locate, acquire, treat, and evacuate 

wounded Warriors to an appropriate level II/level III 

facility. Damage control surgery is often performed by 

forward surgical teams (FST) in relatively austere 

environments (level II). The stabilized patients require 

rapid evacuation by helicopter to a level III combat 

support hospital (CSH) or theater hospital, since there 

is no intensive care unit in which to continue the 

resuscitation. Patients often undergo 2 to 3 damage 

control surgeries along the way. At the CSH, the goal 

is to stabilize, prioritize, and, if required, prepare for 

further evacuation to a higher-level capability, either 

within the joint operations area, at an overseas facility, 

or in the United States. The transport of critically ill 

patients from a CSH to level IV (Landstuhl, Germany) 

and or level V (medical treatment facility in the United 

States) is the responsibility of the Air Force Critical 

Care Aeromedical Transport Team. 

Optimizing Wartime En Route Nursing Care 

 In Operation Iraqi Freedom 

MAJ Michael Nagra, AN, USA 

ABSTRACT

Throughout combat operations in Iraq and Afghanistan, Army nurses have served in a new role—providing en route 

care in military helicopters for patients being transported to a higher level of care. From aid stations on the battlefield 

where forward surgical teams save lives, limbs, and eyesight, to the next higher level of care at combat support 

hospitals, these missions require specialized nursing skills to safely care for the high acuity patients. Little information 

exists about patient outcomes associated with the nursing assessment and care provided during helicopter medical 

evacuation (MEDEVAC) of such unstable patients and the consequent impact on the patient’s condition after transport. 

In addition, there are no valid and reliable tools to capture care delivery, patient outcomes, and associated nursing 

workload and staffing requirements. 

During Operation Iraqi Freedom, a new process was implemented over a 2-year period to measure nursing related 

patient outcomes during MEDEVAC, and to capture the nursing workload. The use of standard metrics to establish 

patient priorities and improve nursing care during MEDEVAC allowed the level II forward surgical teams or their 

equivalents and level III combat support hospitals to make structural, process, and outcome improvements in the en 

route care programs throughout the Iraq theater of operations. Implications of this program were broad, including 

establishment of a process to support decision making based on data driven metrics, improvement of quality of nursing 

care, and defining nurse staffing requirements. 
52 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The Army’s medical evacuation system uses the 

following principles to guide patient transport1

: 

 Conformity. Medical evacuation support is arrayed 

on the battlefield in the right place at the right 

time, and synchronized across operational 

commands to maximize responsiveness and 

effectiveness. 

 Continuity. Medical care provided during medical 

evacuation is effective and continuous to prevent 

interruptions in the continuum of care. 

 Control. Control is exercised over the execution of 

medical evacuation operations. The medical evacuation system is responsive to changing 

requirements and tailored to effectively support 

the forces within an area of operations. The system 

also complies with the combatant command 

guidance and intent, and maximizes the use of 

scarce medical evacuation resources. 

 Proximity. The speed with which medical 

evacuation is initiated is extremely important in 

reducing morbidity, mortality, and disability. 

 Flexibility. The medical evacuation plan must be 

designed to ensure flexibility and agility as well as 

enhance the ability to rapidly task-organize and 

relocate medical evacuation assets to meet 

changing battlefield requirements. 

 Mobility. Mobility and survivability ensures that 

medical evacuation resources can rapidly respond 

and that evacuation routes do not become too 

lengthy. 

The en route care program developed for the Iraq 

theater of operations (ITO) ensured compliance with 

these principles, with special attention to continuity. 

BACKGROUND

In mid 2007, MG Patricia Horoho, the new Chief of 

the Army Nurse Corps, presented her vision for 

fundamentally transforming the Army Nurse Corps 

into a force multiplier for both Army Medicine and the 

Army. That vision eventually evolved into the need to 

establish an Army Nursing System of Care, now called 

the Patient CaringTouch System, to transition nursing 

delivery from an expert-based to a systems-based 

nursing care model. The 5 major elements that make 

up the Patient CaringTouch System include: 

Enhanced communication 

Capability building 

Evidence-based 

Healthy work environment 

Patient-family centered care 

Patient-family centered care addressed the need to 

deliver the highest quality care to those wounded in 

battle, and to support their families and loved ones 

back home. MG Horoho and senior leaders of the 

Army Nurse Corps highlighted en route care in a 

combat environment as an area that not only needed 

major improvements, but would have a substantial 

impact on healthcare delivery to wounded Warriors. In 

addition to improving the quality of care provided to 

our Warriors in combat, the Patient CaringTouch 

System would also promote standards, allow 

measurement of nurse-sensitive outcomes, and monitor 

the impact of practice innovations. 

In late 2007, the 86th CSH (Task Force 86 (TF86)), 

located in Baghdad, Iraq, was selected to establish a 

theater-wide en route care program that would address 

and meet the combatant commanders’ responsibilities 

of intratheater patient movement in their areas of 

operations. TF86 was selected not only because of the 

large number of en route care missions that were 

originating from that facility, but also because of the 

high acuity of patients admitted to and transported 

from it. The surge of combat operations in 2007 vastly 

increased the number of deployed military members to 

the ITO. This surge resulted in increased combat 

operations and resulting casualties and injuries 

throughout the theater. Being one of the premiere level 

III trauma facilities in Iraq, with specialized trauma 

teams, TF86 was heavily involved in supporting the 

intense combat operations in and around Baghdad. 

TF86 had inherited a substantial en route care program 

from the previous deployed task force which had been 

in theater for 15 months. TF86 was therefore able to 

influence the much needed changes in the en route 

care processes and procedures. The need to improve 

Warrior care delivery in theater also coincided with the 

theater medical commander’s insistence to refocus the 

task force’s mission of providing top notch care for all 

wounded and ill brought to medical treatment 

facilities. The en route care program directly supported 

the commander’s major strategic goal of “providing 

world-class Warrior healthcare to US and Coalition 

Optimizing Wartime En Route Nursing Care In Operation Iraqi Freedom 
 October-December 2011 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

forces,” with the end point of optimizing the return of 

Soldiers to duty and conserving combat power. Initial 

assessment of the en route care program in Operation 

Iraqi Freedom (OIF) showed fragmented care delivery 

and the lack of standards and standardization of the 

nursing role during en route care missions. However, 

the assessment also showed that there were examples 

of excellence at many medical facilities, as was 

expected in an expert-based care delivery model. The 

previous task force had left a legacy of a working en 

route care model, and MG Horoho challenged TF86 to 

enhance the model to allow both development and 

dissemination of en route care best practices 

throughout the ITO. The need to make a deliberate and 

effective shift towards systems-based care delivery 

was quickly established. The systems-based delivery 

model was supported by the development and 

implementation of clinical practice guidelines, and 

effective, efficient, outcome-based metrics. 

Since the beginning of the ongoing combat operations 

in early 2003, Army nurses have functioned in their 

role as en route care providers, transporting patients 

from level II and level III facilities on MEDEVAC 

helicopters throughout Iraq and Afghanistan. Although 

the en route care program discussed 

in this article was developed in OIF, 

the challenges of undertaking this 

mission under rugged and dangerous 

combat conditions remains the same 

in OIF, Operation Enduring Freedom (OEF), the current Operation 

New Dawn in Iraq, and other overseas contingency operations (OCO). 

Transfers from the point of injury to 

level II/level III are primarily 

provided by Army MEDEVAC units assigned to 

dedicated geographical sectors. The primary healthcare 

provider on these transfers are Army (or other service 

equivalent) flight medics, and/or flight surgeon or a 

physician’s assistant. These healthcare providers are 

specially trained for providing urgent and routine en 

route care on helicopters. On the other hand, the nurses 

selected to perform the en route care mission in the 

early years of combat operations had minimal or no 

formal training to function as sole providers in a 

helicopter. Informal surveys among MEDEVAC flight 

nurses during the 15 months of OIF 07-09 (2007-2009) 

indicated that approximately 14% of Army nurses 

providing en route care in the ITO had received formal 

military (Joint En Route Care Course) or civilian 

training to function in the role, while over 96% of the 

nurses providing en route care self-reported critical 

care or emergency room training (Table 1).* The 

patient case-mix of those medically evacuated during 

OIF 07-09 is presented in Table 2.†

The typical MEDEVAC flight in either combat theater 

lasted 25 to 60 minutes.†

 Besides operating in a dangerous active combat corridor, the en route care nurses 

also operated in constrained environments with limited 

to no light, high decibel noise, and severe vibrations 

that impacted not only basic patient assessment and 

interventions, but also high to very high equipment 

failure rates. Regardless of the limitations, both the 

medical task force and the combatant commanders 

expected en route medical care to 

maintain the same standards of 

nursing care as found in a fixed 

facility. During OIF 07-09, a period 

of 15 months, approximately 18% 

(over 700) of over 3,800 total aeromedical evacuation patients from all 

level II and level III facilities in the 

ITO required en route care nurses to 

provide the higher level of nursing 

care.†

CLINICAL PROBLEM

Transport of any critically ill patient begins with a 

careful consideration of the necessity of the transport, 

assessment of the patient condition, defining command 

and control for the process, communication between 

care teams, preparation and packaging of the patient 

for transport, premovement equipment checks, 

transportation and en route care, transfer of care at the 

staging facility, proper documentation, and 

consideration for events reporting and process 

Table 1. Self-reported sources of training of available en route 

care nurses in Iraq during Operation Iraqi Freedom 07-09 

(N=72).*

En route Care Training Source No. % N 

Military trained (Joint En Route Care Course) 8 11% 

Civilian en route care trained 2 3% 

Critical care or emergency room trained nurses 69 96% 

*Informal surveys by the author during deployment. 

Table 2. The patient case mix of medical evacuees during Operation Iraqi 

Freedom 07-09.* 

Combat Injuries >40% 

Disease and nonbattle injuries 40% 

Others <20% 

US casualties (military and civilian) >70% 

Pediatric 8% 

Burns 5% 

*Data sourced and compiled internally by military 

analysts during deployment, not available to 

the general public. 

*Self-reported to the author during informal surveys in theater. 

†Data extracted and compiled by military analysts during 

deployment, not available to the general public.
54 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

improvement.2

 Considering the complexities of 

transporting patients, the importance of evidencebased decision making in a resource-constrained 

combat environment in the delivery of quality 

healthcare is well understood. The program discussed 

here focused not only on the problem of lack of 

indicators to measure en route care nursing workload, 

but also the lack of benchmarks to measure the quality 

of en route nursing care in a combat environment. 

For the first time in MEDEVAC operations in OIF, a 

set of 5 metrics were developed to quantify both the 

workload and the quality of care. The 5 metrics not 

only allowed the level III facilities to capture the 

workload, but also allowed the medical treatment 

facility commanders and nursing leaders to make 

informed, data-driven decisions to improve en route 

care processes. To quantify the workload, a new 

Operational Interfacility Transport Acuity Workload 

Tool, developed by the Army Medical Department 

Center and School Directorate of Combat and Doctrine 

Development, was used by all level II and level III 

facilities in the ITO. Operational metrics were used to 

measure, analyze, control, and improve local operations in a process workflow. The qualitative metrics 

measured those processes that are not easily quantifiable but define the standards of en route care 

delivered during the en route care missions. In addition 

the program also supported performance improvements while sustaining efficiencies, allowed appropriate levels of internal controls and incorporated best 

practices from current and civilian aeromedical evacuation programs. The performance metrics were 

benchmarked3

 (benchmarking identifies “best-in-class 

organizational performance”) and improved processes 

were applied to achieve superior results. 

PERFORMANCE METRICS

The performance metrics developed under the operational category include throughput and patient workload, while the qualitative category includes metrics 

which measure processes not easily quantifiable but 

define the standards of en route care. These metrics 

include nursing/medical interventions during en route 

care, equipment failure-related interventions; and performance improvement initiatives. Throughput was defined as the output of a process over a specified period 

of time. with results displayed as a percentage.3

 Patient 

workload measured the actual workload and reported 

patient acuities as acuity category (category 1-6). 

Acuity categories 5 and 6 are considered severely ill, 

similar to the patient acuity profile provided by the 

Workload Management System for Nursing at a 

United States or overseas Army medical treatment 

facility with inpatient capability. Within qualitative 

metrics, nursing/medical interventions included all 

nursing/medical interventions, such as titrating paralytics, sedation, fluids/blood, adjusting oxygenation, etc, 

during each en route care flight. The interventions 

included actions such as reversing/supporting hemodynamic changes, ventilator support, manual oxygenation support efforts via the bag-valve method, and 

medications and blood transfusions among others. 

Nursing/medical intervention was entered for each 

patient workload acuity category. Equipment failure 

interventions (EFI) included patient interventions due 

to equipment failures, such as failure of ventilators/

ventilator settings, Propaq (Skaneateles Falls, NY) 

monitors, medication infusion pumps, oxygen tanks, 

and other onboard equipment to maintain patient safety 

and stability. An EFI was also entered for each patient 

workload acuity category. Finally, the performance 

improvement (PI) initiatives at each CSH/level II 

facility were captured as a metric. Each facility was 

allowed to improve a site-specific process because of 

very dissimilar combat and operational environments. 

For example, patient acuities at level II and level III 

facilities with head trauma teams would be vastly 

different and require completely different equipment, 

as well as different patient en route care protocols. 

Allowing each facility the leverage to focus on their 

site-specific deficiencies allowed ownership and added 

effort. Each facility conducted an assessment of priority 

of initiatives needed to improve patient care and/or 

processes. Example of PI results in this study included 

improved patient outcomes for mechanically ventilated 

patients and initiatives to reduce hypothermia. 

PERFORMANCE METRIC OUTCOMES

The data presented in Figure 1 are site-specific to 

TF86 in Iraq from September 2007 through September 

2008. The data compiled during the 12-month period 

provided the en route care program officer-in-charge 

(OIC) an overview of the structure of the en route care 

processes, including pretransport assessment, and preparation and discharge transportation and documentation processes. In addition, this metric highlighted 

for the hospital command the quality of triage, 

registration and care processes, staffing requirements, 

and specialist and diagnostic availability. Clinical 

Optimizing Wartime En Route Nursing Care In Operation Iraqi Freedom 
 October-December 2011 55

THE ARMY MEDICAL DEPARTMENT JOURNAL

quality management was able to use this metric to 

assess the emergency medical treatment (EMT) unit, 

the intensive care unit, the intermediate care ward, the 

operating room (OR) capacity, bed availability and 

tracking, and interaction between EMT, OR, and 

inpatient sections. As a lagging indicator, throughput 

allowed the leaders to match periods of 

high intensity combat operations in the 

areas of operations with the increased 

need for en route care nursing staff. For 

example, in May 2008, there was a large 

spike in the number of en route care 

missions concurrent with an increase in 

operations in many parts of Baghdad. The 

use of this metric as a predictor to adjust 

staffing based on increases in combat 

operations requires further investigation. 

Patient workload measures the patient 

acuities over a period. The Operational 

Interfacility Transport Acuity Workload 

Tool was used for the first time in any 

combat theater to capture the workload 

data (Figure 2). The workload capture tool 

was tested for reliability and validity. The 

inter-rater reliability of the workload tool, 

tested at 5 facilities in the ITO, was 0.933 and showed 

a high validity. This metric functioned as an indicator 

to plan, monitor, and evaluate the en route care nurse’s 

performance, as well as allow the en route care 

program OIC, the MEDEVAC committee, and senior 

nurse leaders to monitor variances between patient 

0%

10%

20%

30%

40%

50%

60%

SEP 07 OCT 07 NOV 07 DEC 07 JAN 08 FEB 08 MAR 08 APR 08 MAY 08 JUN 08 JUL 08 AUG 08 SEP 08

Month

CAT 1 CAT 2 CAT 3

CAT 4 CAT 5 CAT 6

Figure 1. Distribution of acuity level categories by percentage for patients transported on en route care 

missions in Iraq by TF86 assets for each month from September 2007 through September 2008. Categories 

represent increasing severity of injury/sickness from 1 (lowest) to 6 (very seriously injured/ill). 

Source: Data extracted and compiled by military analysts during deployment, not available to the general public. 

0%

5%

10%

15%

20%

25%

30%

35%

CAT 1 CAT 2 CAT 3 CAT 4 CAT 5 CAT 6

0.0%

9.1%

31.0%

29.5%

20.4%

10.0%

Patient Acuity Category

Percentage of Total Workload 

Figure 2. Distribution of patient acuity categories by percentage of the total 

number of patients transported on en route care missions in Iraq by TF86 

assets from September 2007 through September 2008. Categories 

represent increasing severity of injury/sickness from 1 (lowest) to 6 (very 

seriously injured/ill). Source: Data derived and compiled by the author. 
56 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

outcomes and take corrective actions. This was 

accomplished through documentation that was 

standardized throughout the ITO. 

Prior to this theater-wide program, major variances 

were noted, not only in what was documented, but also 

the different forms used to capture the patient care 

data. The use of standard processes enhances the 

validity of a workload capture system and a reliable, 

validated nursing workload capture tool is a key source 

of information.4

 The results of the workload metric 

provided the decision makers and researchers a 

retrospective view of the patient workload in the ITO, 

something that had not been accomplished since the 

beginning of the war. The results determined by the 

metric highlighted the category of patients transferred 

during en route care missions, with over 30% patients 

categorized as severely or very severely injured/ill, as 

shown in Figure 2. Qualitative metrics, nursing 

interventions, and equipment failure interventions 

answer the question of the value-added of an en route 

care nurse operating in a helicopter. All MEDEVAC 

missions (routine through urgent) include a flight 

medic, a specially trained crew member capable of 

providing necessary critical patient care in prehospital 

settings and in the aviation environment, and is 

certified in basic trauma life support, advance cardiac 

life support, and pediatric advanced life support.5

However, the majority of patients were either 

postsurgical stabilized, or had received initial 

interventions/resuscitation in the emergency rooms. 

This added complexity of postsurgery medication 

management or the unstable status of the patient 

required a higher level of care. 

For example, the management of complex ventilator 

settings, in addition to the use and management of sedation and paralytics in head trauma patients, clearly 

required skills that are maintained by nurses and 

physicians with formal critical and/or emergency room 

training or experience. As shown in Figure 3, en route 

care nurses intervened during 40% and 80% of total en 

route care missions. The EFI highlighted as high as 

20% of the en route care missions required the en route 

care nurse to take corrective actions with patient 

equipment. The value added of this metric was the evidence of a successful transition to standardize patient 

equipment in January 2008. Beginning in early 2008, 

the trend showed a decrease in the number of EFI. 

Finally, the last metric measured at TF86 was PI. The 

PI metric at TF86 measured the number of 

hypothermia cases per month. Combat trauma patients 

have a high percentage of penetrating or burn injuries. 

Hypothermia is a prehospital physiologic marker, and 

independent contributor to overall mortality. 

Optimizing Wartime En Route Nursing Care In Operation Iraqi Freedom 

0%

10%

20%

30%

40%

50%

60%

70%

80%

SEP 07 OCT 07 NOV 07 DEC 07 JAN 08 FEB 08 MAR 08 APR 08 MAY 08 JUN 08 JUL 08 AUG 08 SEP 08

Month

Nurse/Medical Interventions

Equipment Failure Interventions

Percentage of Flights 

Figure 3. Percentage of en route care missions in Iraq by TF86 assets requiring nursing/medical or equipment failure 

interventions by onboard flight nurses for each month from September 2007 through September 2008. 

Source: Data extracted and compiled by military analysts during deployment, not available to the general public. 
 October-December 2011 57

THE ARMY MEDICAL DEPARTMENT JOURNAL

Prevention of hypothermia could reduce resource use 

and improve survival. In a study6

 of 2,848 patients in 

Iraq, 18% were found to be hypothermic with 

temperatures below 36°C. Hypothermia was 

significantly correlated (P<.05) with admission 

Glasgow Coma Scale,* tachycardia, hypotension, 

lower hematocrit, and acidosis. Hypothermic patients 

had a significantly higher blood product and factor 

VIIa requirement. Hypothermia was an independent 

predictor of operative management of injuries, damage 

control laparotomy, factor VIIa use, and overall 

mortality (P<.05). Prior to a standardized packaging 

process at TF86, between 12% and 15% patients had 

recorded hypothermia during or after medical 

evacuation. With the implementation of a standardized 

process, including the use of the Hypothermia 

Prevention and Management Kit (HPMK) and warmed 

intravenous fluids prior to the evacuation, the 

hypothermia cases had dropped to less than 3% during 

the 12-month period. The HPMK is a NASA-developed, lightweight, strong, and flexible self-heating 

liner with reflective reinforced shell, designed to 

maintain temperatures up to 41°C. These low cost 

liners were one-time use items, and management of 

hypothermia was successfully achieved, especially 

during the low temperatures at night in the Iraq desert. 

OTHER OUTCOMES

A number of other structural and process 

improvements were also documented after the implementation of the theater-wide en route care program. 

Notably, the success of the program was heavily 

influenced by the establishment of a multidisciplinary 

MEDEVAC committee and the use of clinical practice 

guidelines, developed by the Joint Theater Trauma 

Registry (JTTS). The MEDEVAC committee, initially 

established by the preceding task force, was 

responsible for the oversight of all en route care 

missions and operations at TF86. The committee also 

ensured the efficacy of the standardized processes in 

place for en route care, and reported directly to the 

TF86 Executive Council. The TF86 Medical Director 

served as the supervising medical consultant for all en 

route care issues. The en route care program director 

(additional duty of intensive care unit and emergency 

medical treatment clinical nurse OIC), provided direct 

supervision of the en route care nursing competencies 

and reported to the deputy commander of nursing. 

Another role of the committee was to perform periodic 

risk assessment on 10% of records per month to ensure 

there was no deviation from en route care policies. 

This audit role not only ensured standardization of 

practice during en route care, but also standardized 

documentation forms and procedures, as well as the 

equipment and supplies carried by the en route care 

nurse. Another outcome was the standardization of 

medications carried by the en route care nurse. Based 

on the patient’s diagnosis, standardized medication 

packets were carried, including intravenous fluids, 

sedatives, paralytics, vasoactive/vasopressors, and 

controlled medications (narcotics). Special focus was 

also placed on head trauma, considering the limitations 

and special equipment required during en route care. 

For example, from a therapeutic perspective, the use of 

hypertonic saline for hyperosmolar therapy in 

traumatic brain injury (TBI) is beneficial in disaster 

and wartime practice, not only because of its ability to 

effectively lower intracranial pressure, but also due to 

its ability to preserve or improve hemodynamic 

parameters in patients who have experienced polytrauma.7

 A 3% Hyperosmolar solution was a standard medication during patient transfers with head trauma/TBI. 

The JTTS clinical practice guidelines on the 

intratheater air transport of patients from a level II 

facility to a level II or III facility, and from a level III 

facility to a level III facility provided guidelines for en 

route care activities during such transport. The JTTS, 

like civilian trauma systems, was designed to provide a 

seamless transition in combat casualty care from the 

point of injury through each echelon of care to further 

integrate casualty care resources at all echelons among 

all services, and to ultimately achieve improved 

combat casualty outcomes. The contributions of the 

JTTS have resulted in improved combat casualty 

outcomes through the development of a number of 

clinical practice guidelines for medical care in a 

combat theater. In addition, with data collected on over 

17,000 combat casualties, the JTTS standardized 

methods of medical documentation, and supported 

implementation of a sophisticated performance 

improvement program.8 

*The Glasgow Coma Scale is a quick, practical, standardized system for assessing the degree of consciousness in the critically ill 

and for predicting the duration and ultimate outcome of coma, primarily in patients with head injuries. The system involves eye

opening, verbal response, and motor response, all of which are evaluated independently according to a rank order that indicates

the level of consciousness and degree of dysfunction. Source: Mosby’s Medical Dictionary. 8th ed. St Louis, MO: Mosby-Year 

Book, Inc; 2009.
58 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

SUMMARY

En route care in an austere environment, such as the 

battlefields of Iraq and Afghanistan, definitely presents 

many challenges. The many lessons that were learned 

in the Iraq theater demonstrate the need for adequate 

preparation of nurses involved with the en route care 

missions. The intratheater transport system is a unique 

and significant part of the Force Health Protection 

concept for “clearing the battlefield.” Medical evacuation is the timely, efficient movement and en route 

care of patients by medical personnel from the 

battlefield and/or medical facilities to a higher level of 

care during the full spectrum of military operations. 

The goal is to provide every patient who is injured on 

the battlefield or in the areas of operations with the 

optimal opportunity for survival and the maximum potential for a functional recovery. Combatant commanders expect clinicians to provide expert care at medical 

facilities and during transport to a higher level of care. 

With a standardized approach, we were able to make 

many structural and process improvements to the program, making it not only robust and flexible to meet 

the unique challenges in an area of operation, but also 

easily exportable to any area of combat operations or 

disaster relief. The new Operational Interfacility Transport Acuity Workload Tool, with a high reliability and 

validity, can be effectively used in any environment, 

peacetime or combat. The tactical deployment of 

clinical practice guidelines resulted in positive patient 

outcomes throughout the continuum of healthcare 

delivery. In addition to the outcomes mentioned in the 

study, strategic implications of the en route care 

program for senior leaders include the establishment of 

a process to support decision making based on data 

driven metrics, improvements in quality of nursing 

care delivery, and decision making ability of needsbased nurse staffing requirements. Future research 

could focus on further refinements of the workload 

capture tool in humanitarian and peacekeeping/peacetime missions, both at home and abroad. Further study 

is indicated to establish a process to predict increased 

need for medical assets, both for en route care and to 

ensure continued healthcare delivery during hightempo combat operations in the theater of operations. 

REFERENCES

1. Field Manual 4-02.2: Medical Evacuation. Washington, DC: US Dept of the Army; May 8, 2007. 

2. Pauldine R, Gerold KB. Transport of the critically ill 

patient. Contemp Crit Care. 2008:5(8):1-11. 

3. George ML, Rowlands D, Price M, Maxey J. The 

Lean Six Sigma Pocket Toolbook. New York: 

McGraw Hill; 2005. 

4. US Army Office of Business Transformation. Lean Six 

Sigma. 2011. Available at: http://www.armyobt.army. 

mil/cpi-kc-tools-lss.html. Accessed April 15, 2011. 

5. US Army School of Aviation Medicine. Flight Medic 

Course, Medical Medic Course (300-F6). Available 

at: http://usasam.amedd.army.mil/fmc.htm#History. 

Accessed February 2, 2011. 

6. Arthurs D, Cuadrado D, Beekley A, Grathwohl K, 

Perkins J, Rush R, Sebesta J. The impact of 

hypothermia on trauma care at the 31st Combat Support Hospital. Am J Surg. 2006;191(5):610-614. 

7. Venticinque SG, Grathwohl KW. Critical care in the 

austere environment: providing exceptional care in 

unusual places. Crit Care Med. 2008;36(suppl 7): 

S284-S289. 

8. Smith KK. Critical care nursing in an austere environment. Crit Care Med. 2008;36(suppl 7):S297-S303. 

AUTHOR

MAJ Nagra is Chief, Clinical Modeling Branch, 

Manpower Division, Program Analysis and Evaluation, 

US Army Medical Command, Fort Sam Houston, Texas. 

Optimizing Wartime En Route Nursing Care In Operation Iraqi Freedom 
 October-December 2011 59

TRAUMA SYSTEM

Participation in the trauma center verification process 

almost invariably results in significant improvements 

in patient care, along with enhancement of institutional 

pride and commitment to care of the injured patient.1

Further, implementation of trauma systems in the 

civilian sector has long been known for the resulting 

impact on decreased morbidity, hospital mortality, 

length of stay, and costs, with correlating improved 

contribution margin.2,3 Wounded combatants of 

today’s conflicts suffer a variety of injuries not 

encountered in the civilian sector, specifically related 

to improvised explosive devices where primary, 

secondary, and tertiary blast and blast overpressure 

phenomena produce devastating injuries. Therefore, 

implementation of the trauma model in the military 

medical system was sought on the premise that trauma 

care within the military is constant and long-term, 

whether during war or peace. No one is more 

deserving of this enhanced care than our Soldiers, 

Marines, Sailors, and Airmen. 

TRAUMA CENTER DEVELOPMENT AND LESSONS

LEARNED

Landstuhl Regional Medical Center, the US military 

echelon IV medical treatment facility (MTF) in 

Germany, was a low acuity, low volume institution 

before Operation Iraqi Freedom (OIF) and Operation 

Enduring Freedom (OEF). A surge in patient volume 

with increasing complexity in treatments required 

multiple resources and expertise to enhance care, 

which is typically available at civilian trauma centers. 

Landstuhl is the evacuation hospital and main referral 

center for casualties coming from OIF and OEF and, 

consequently, now is the center of the largest trauma 

system in the world. The facility receives patients from 

echelon III MTFs in Iraq, Afghanistan, Africa, and 

Europe. After restabilization, further surgery, and 

preparation for flight, combat casualties are transferred 

to the United States. Landstuhl has been described as 

the “prism,” centered in the evacuation chain which 

takes in a chaotic, complex compilation of nationalities, diagnoses, medical records, and damage control 

care processes from combat theaters, as represented in 

Figure 1. The output is a stable group of patients with 

consistent, clinical practice-guided evaluations and 

complete and organized medical records who are 

evacuated to facilities throughout the world. 

Army leadership committed to level II trauma center 

verification in 2005. As shown in Figure 2, key 

positions such as trauma medical director, trauma 

nurse director, trauma performance improvement nurse 

coordinator, trauma nurse coordinator, and trauma 

registrar were then created. The trauma program nurse 

director position has responsibility for multiple aspects 

of the trauma program, such as trauma-related 

performance improvement, registry, injury prevention, 

research, publications, consultation, and involvement 

in national trauma organizations. The key 

responsibility of the trauma performance improvement 

coordinator is to assist nurses and other associated 

services in the coordination of a plan of care. This is 

accomplished through collaboration with physicians, 

nurses, and other associated services in developing a 

comprehensive plan of care and identifying variances 

Optimizing Performance in the 

 Combat Casualty Continuum 

Kathleen D. Martin, RN, MSN 

Mary Ann Spott, MPA, MSIS 

Elizabeth Schell, RN, MSN 

Sheryl Neal, RN, MBA 

Figure 1. Representation of the Landstuhl Regional Medical 

Center’s position in the military trauma system in support of US 

and coalition combat operations in Europe, Asia, and Africa. 
60 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

in that plan of care, thus enhancing outcomes for 

combat casualties. Key to the continuum of care of 

military trauma patients is feedback to both referring 

(combat theater) and receiving (United States) military 

treatment facilities. 

The education and trauma multidisciplinary 

committees were implemented in early 2006, and the 

timeline shown in Figure 3 was established. A 

comprehensive gap analysis was undertaken in 

November 2006, outlining areas of noncompliance 

with the criteria of the American College of Surgeons 

Committee on Trauma.4

 Additional facility capabilities 

were harnessed, including the development of a webbased joint patient tracking application and an allencompassing case management system, creation of a 

Deployed Warriors Medical Management Center, and 

establishment of a distinct trauma program. A 

comprehensive military trauma registry, the Joint 

Theater Trauma Registry, and performance 

improvement processes were then implemented. The 

trauma program was enhanced by the creation of a 

weekly clinical video teleconference (VTC) to discuss 

specific patient issues and provide feedback across the 

continuum of care (Iraq, Afghanistan, Germany, and 

the United States) and establishment of a monthly 

worldwide trauma VTC to quickly identify and resolve 

common system issues. Care was enhanced with the 

development of combat-related clinical practice 

guidelines, development of critical capabilities 

(including dialysis), and implementation of an acute 

lung team including critical care transport nurses who 

are able to treat and transport patients with 

catastrophic pulmonary injury.5

 Additional education 

and clinical practicum were undertaken to train 

Landstuhl providers and critical care nurses at a 

German facility (Regensburg Hospital) in use of 

portable extra-corporeal membrane oxygenation which 

can be used enroute from theater to Landstuhl. 

Resulting improvements in care and outcomes, 

examples of which are shown in the Table, are 

reflected in a system-wide standardization of care 

coupled with a robust concurrent performance 

improvement process, which led to further 

improvements in care. 

Optimizing Performance in the Combat Casualty Continuum 

Figure 2. Timeline of development of the Landstuhl Regional Medical Center trauma center. 
 October-December 2011 61

THE ARMY MEDICAL DEPARTMENT JOURNAL

TRAUMA REGISTRY

Early in both Operation Enduring Freedom and 

Operation Iraqi Freedom, collection of combat 

casualty data was independently completed via 

spreadsheets or home-grown databases at multiple 

MTFs worldwide. In an effort to improve care 

throughout the trauma care continuum, especially 

the battlefield, the Joint Theater Trauma System 

(JTTS) was developed. The Joint Theater Trauma 

Registry (JTTR), the data depository collecting and 

hosting all US military trauma casualty related data, 

is a component of the JTTS. This unique trauma 

registry allows for direct data input from all 

echelons of combat casualty care, and is used for 

data abstraction and analysis by Active and Reserve 

nurses of the Army, Air Force, and the Navy. 

The first JTTS team, consisting of a trauma medical 

director (trauma surgeon) and 6 trauma nurse 

coordinators, deployed in 2004. The JTTR was 

implemented at Landstuhl in January 2007, and 

fielded in theater with the trauma nurse 

coordinators the following July.10 Expansion of the 

JTTS trauma coordinators to allow enhanced 

coverage in Afghanistan, and at coalition sites such 

as Kandahar and Bastion, began in 2009. In 

addition, JTTS nurses have taken responsibility for 

the growth of medical evacuation (MEDEVAC) data 

acquisition and MEDEVAC performance 

improvement with a specific focus on improvements in 

transport times following combat casualty injuries. 

Currently, data is directly input by echelon II mobile 

surgical teams deployed throughout the Iraq and 

Afghanistan theaters, more permanently based echelon 

III combat support hospitals, a sustaining echelon IV 

medical center in Germany (Landstuhl), and 

established echelon V military treatment facilities in 

the United States. The information in the JTTR also 

draws data abstracted from multiple electronic 

datasets, including the US Transportation Command 

Regulating and Command & Control Evacuation 

System, the Theater Medical Data Storage, the 

Composite Health Care System, and Essentris 

(CliniComp, International, San Diego, CA), the 

electronic medical record system. Information is also 

abstracted from paper medical records. 

Military specific data elements within the JTTR 

include expanded demographic data, including military 

branch, rank, and military occupation. Casualties may 

have been treated in as many as 4 distinct MTFs before 

arrival at the echelon IV facility in Landstuhl. Varying 

data from each echelon along the combat casualty’s 

route of evacuation are entered into the JTTR. 

In addition to ICD-9* and standard Abbreviated Injury 

Scale (AIS) codes, all injuries are coded using a 

military version of the AIS. The military version of the 

AIS was developed through a collaboration of military 

physicians and the Association for the Advancement 

of Automotive Medicine in order to better represent 

the compound injuries from improvised explosive devices. It allows for a heavier weighting of lower extremity injuries, penetrating head injuries, and 

calculation of the abbreviated injury score from the 3 

worst injuries. The traditional injury severity score 

allows you to take only the worst injury in each region, 

which greatly underserves penetrating injury and blast 

injury. 

A robust performance improvement tracking system is 

integrated into the JTTR to allow clinical providers 

and trauma coordinators to concurrently track 55 user 

Category Outcome/Lessons Learned 

Burn care 

Implementation of the burn flowsheet with 

documentation of continuous fluid resuscitation 

decreased morbidity and mortality from burn wounds.6

Compartment 

syndrome 

ALARACT (all Army action) memo mandated a high index 

of suspicion for compartment syndrome and a 

standardized approach to guide providers in the 

evaluation and treatment of patients with extremity war 

wounds, including the role of prophylactic and 

therapeutic fasciotomy.7

Infection control/

prevention 

Early recognition of Mucor and Aspergillus fungal 

infection, which allowed initiation of a clinical practice 

guideline designed to combat angioinvasive fungal 

infections. 

Mild traumatic 

brain injury 

Development of a comprehensive screening process of 

all Warriors for incidence of traumatic brain injury 

before they are returned to duty or manifested to the 

United States.8

Nutrition 

Optimization of nutritional status with early initiation 

and ongoing nutritional support of the critically ill or 

injured patient.7

Post-splenectomy 

immunization 

Implementation of a clinical practice guideline which 

ensured that all post-splenectomy wounded warriors 

receive appropriate vaccination and nursing 

documentation of its administration.7

Skin integrity 

Implementation of clinical guidance in the assessment 

and management of skin integrity in order to assess 

patients for risk of pressure ulcers, prevent pressure 

ulcers, and treat pressure ulcers using standards of 

nursing practice guidelines.9

Examples of improvements in care and outcomes realized from the 

implementation of level II trauma center capability at the Landstuhl 

Regional Medical Center. 

*International Classification of Diseases, 9th Revision 
62 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

defined audit filters and 61 specific complications, as 

well as document primary, secondary, and tertiary case 

reviews. The JTTR at the echelon IV MTF requires 

routine collection of 367 data elements for each 

casualty. Despite the high number of required data 

elements, the need to access multiple widespread data 

sources worldwide, and a short inpatient length of stay, 

data abstraction is still routinely completed within 7 

days of discharge. The data is validated and closed 

within 2 weeks of discharge in more than 90% of 

cases. The national benchmark is to close charts within 

6 weeks of abstraction. The strength of the trauma 

registry program at Landstuhl has earned the praise of 

the American College of Surgeons Committee on 

Trauma. 

Based upon the positive accomplishments of the 

deployed JTTS trauma coordinators in theater, the 

Army Nurse Corps resolved to assign a colonel to the 

JTTS leadership in the Joint Trauma System structure in 

San Antonio to ensure the capture of lessons learned. 

The objective is to transition the lessons learned into 

data and evidenced-based clinical practice guidelines, 

which would drive the composition and design of 

training at the US Army Nursing Leader Academy.* 

PERFORMANCE IMPROVEMENT

Trauma performance improvement is a continuous 

multidisciplinary effort to measure, evaluate, and 

improve both the process of care and the outcomes. 

The American College of Surgeons Committee on 

Trauma defines it as “the continuous evaluation of a 

trauma system and trauma providers through 

structured review of the process of care as well as the 

outcome.”4

 The trauma performance improvement 

program at Landstuhl was developed with the goals of 

monitoring the process and outcome of patient care, to 

ensure the quality and timely provision of such care, to 

improve the knowledge and skills of military trauma 

care providers, and to provide the institutional 

structure and organization to promote improved 

outcomes for wounded Warriors. The focus of the 

development of the program began with structure, 

which included staffing, equipment, education, and the 

physical space. The second phase centered on 

development of a system-wide clinical practice 

guideline which was implemented both in the theaters 

of operations and Landstuhl. As the program matured, 

Optimizing Performance in the Combat Casualty Continuum 

Figure 3. Timeline for trauma specific education in preparation for opening the Landstuhl trauma center. 

*See “Designing and Implementing the Army Nursing Leader 

Academy” on page 18.
 October-December 2011 63

THE ARMY MEDICAL DEPARTMENT JOURNAL

the focus shifted more to outcomes such as morbidity, 

mortality, process parameters, and compliance with 

clinical practice guidelines. The primary purpose of 

the trauma performance improvement program is the 

delivery of optimal care to injured Warriors treated at 

Landstuhl. The care of injured patients depends on a 

complex network of people working together as a 

team.11 The urgent nature of trauma care relies on each 

member of the team to perform well on a regular basis, 

with the goal of optimal communication which results 

in improvements in clinical care and patient outcome 

(Figure 4). 

The performance improvement program is designed to 

monitor the system and determine ways in which it can 

be improved. In order to sustain effectiveness, the 

performance improvement process must be inclusive, 

drawing from the expertise of each individual member 

of the trauma care team. In addition, the performance 

improvement program must always maintain certain 

principles so that it can function in a fair, autonomous 

way. These principles include objectivity; efficiency; 

effectiveness; and a process that is care-directed, datadriven, issue-oriented, education-oriented, and 

nonpunitive. 

The mature trauma performance improvement plan 

was integrated into the overall hospital performance 

improvement plan to support 

the institutional mission, 

vision, and goals. The plan 

was inclusive of the trauma 

scope of care, which includes 

all echelons of care from the 

battlefield through return to 

the United States, and 

captured all-encompassing 

system events, nursing care 

events, provider issues, and 

variances from established 

clinical practice guidelines. 

Landstuhl uses institutionspecific audit filters and a 

selection of pertinent 

American College of 

Surgeons audit filters which 

are continually assessed. 

Intensive care unit nursing 

staff monitor ventilator 

associated pneumonia 

bundles, which include 

elevation of head of bed, sedation holidays, peptic 

ulcer prophylaxis, and oral care. Central line bundle is 

also monitored by nursing, which includes hand 

hygiene, barrier precaution on insertion, Chlorhexidine 

use, optimal site selection, and prompt removal of 

unnecessary lines. Landstuhl has also developed 

institution-specific audit filters unique to combat 

casualty care. Primary review of performance occurs 

concurrently with data abstraction and collection by 

trauma nurse coordinators while the care is still being 

delivered. Issues are identified and validated as they 

occur. This information may be gleaned during 

morning report, patient care rounds, chart review, and 

direct staff/patient interaction. Daily patient rounds are 

multidisciplinary, and include the charge nurse, 

bedside nurse, trauma nurse coordinators, infectious 

diseases, air evacuation team members, and nutrition, 

and are lead by the trauma surgeons and intensivists. 

Daily goals are identified by using input from all 

disciplines. Changes in a patient’s plan of care or 

implementation of clinical practice guidelines may be 

influenced immediately. Prompt feedback to providers 

will occur concurrently. A rounding tool was formatted to enhance all disciplines’ participation, and is 

tracked by the trauma nurse coordinators for compliance. Secondary review of identified events may 

require additional analysis, input from a variety of 

providers, and/or review by the trauma nurse director, 

Figure 4. Schematic illustration of the goal of communication in performance improvement: 

improve care and outcome. 

Performance 

Improvement 

Event 

Communication 

and 

Corrective Action 

Investigation 

and 

Validations 

Feedback 

to 

Referring Facility 

Development 

of 

New CPG or Policy 

Resolution 

Loop Closure 

Re-education 

Turnover 

Lessons Learned 

and Outcome 
64 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

trauma medical director or intensive care unit nursing 

leadership. Issues are validated, supplementary information collected and analyzed In some situations the 

case may be closed. If peer review is indicated, the 

case is forwarded to the Trauma Conference or Trauma Multidisciplinary Peer Review. Criteria for determining which cases go to these committees are: all 

deaths, selected complications, unique patient populations, focused reviews, and all referred cases. Cases 

are reviewed, factor determinations made, preventability established, surgical grading defined, corrective 

actions developed, and loop closure, if indicated at the 

time. Systems issues are reviewed in the Trauma 

Operational Process Performance Committee. 

CONCLUSION

Landstuhl Regional Medical Center strives continually 

to provide world class comprehensive and 

compassionate care to our Warriors, their Families, 

retirees, and all other directed beneficiaries, while 

maintaining unit and personal readiness to meet the 

demands of our nation. Establishment of a verified 

trauma center, with a concurrent performance 

improvement process coupled with implementation of 

the JTTR has resulted in improved outcomes for our 

combat casualties and increased identification and 

closure of performance improvement events. 

Contributions of trauma nurses to care of combat 

casualties have focused on the unique and complex 

care of our wounded Warriors in order that they attain, 

maintain, or recover optimal health and quality of life. 

Because trauma nurses work as part of a team along 

the combat casualty continuum, they are able to assess, 

plan, implement, and concurrently evaluate care. Army 

nursing must continue to focus on nursing as a science, 

and a field of knowledge based on evidence. 

REFERENCES

1. Ehrlich PF, Rockwell S, Kincaid S, Mucha P Jr. 

American College of Surgeons, Committee on 

Trauma Verification review: does it really make a 

difference?. J Trauma. 2002;53(5):811-816. 

2. Piontek FA, Coscia R, Marselle CS, Korn RL, Zarling 

EJ. Impact of American College of Surgeons 

verification on trauma outcomes. J Trauma. 2003;54

(6):1041-1046. 

3. DiRusso S, Holly C, Kamath R, et al. Preparation and 

achievement of American College of Surgeons level I 

trauma verification raises hospital performance and improves patient outcome. J Trauma. 2001;51(2):294-299. 

4. American College of Surgeons Committee on Trauma. Resources for Optimal Care of the Injured Patient. 

Chicago, IL: American College of Surgeons; 2006. 

5. Fecura SE Jr, Martin CM, Martin KD, et al. Nurses 

role in the Joint Theater Trauma System. J Trauma 

Nurs. 2008;15(4):170-173. 

6. Chung LL, Blackbourne LH, Wolf SE, et al. 

Evolution of burn resuscitation in Operation Iraqi 

Freedom. J Burn Care Res. 2006;27(5):606-611. 

7. Joint Theater Trauma System Clinical Practice 

Guideline: Burn Care. US Army Institute of Surgical 

Research Web site. Available at: http://www.usaisr. 

amedd.army.mil/cpgs/Burn_CPG_20_Dec_10.pdf. 

Accessed August 31, 2011. 

8. Dempsey K, Dorlac W, Martin K, et al. Landstuhl 

Regional Medical Center: traumatic brain injury 

screening program. J Trauma Nurs. 2009;16(1):6-12. 

9. Steele N, Ketz A, Martin K, Garcia D, Womble S, 

Wright H. Rewards and challenges of nursing 

wounded warriors at Landstuhl Regional Medical 

Center, Germany. Nurs Clin North Am. 2010;45

(2):205-218. 

10. Glenn MA, Martin KD, Monzon D, et al. 

Implementation of a combat casualty trauma registry. 

J Trauma Nurs. 2008;15(4):181-184. 

11. De Jong MJ, Martin JD, Huddleson M, et al. 

Performance improvement on the battlefield. J Trauma 

Nurs. 2008;15(4):174-180. 

AUTHORS

Ms Martin is the Trauma Program Nurse Director, 

Landstuhl Regional Medical Center, Germany. 

Ms Spott is Deputy Director, Joint Trauma System, 

Army Institute of Surgical Research, Fort Sam Houston, 

Texas. 

Ms Schell is the Trauma Performance Improvement 

Coordinator, Landstuhl Regional Medical Center, 

Germany. 

Ms Neal is the Trauma Data Informatics Coordinator, 

Landstuhl Regional Medical Center, Germany. 

Optimizing Performance in the Combat Casualty Continuum 
 October-December 2011 65

WARRIOR CARE IMPERATIVE ACTION TEAM

The established charter of the Warrior Care Imperative 

Action Team (WC IAT) is to optimize nursing care 

delivery systems by fully integrating nursing capability 

within the stated Army Medical Department 

(AMEDD) and Army Nurse Corps (AN) strategic 

goals and missions. The Warrior-patient and familycentered care models embrace evidence-based practice 

to achieve best patient outcomes. The WC IAT 

objectives were developed from the AN Campaign 

Plan* goals related to leader development, Warrior 

care, evidence-based management, and human capital. 

The WC IAT was tasked with developing care teams 

as a component of the patient advocacy element and 

peer feedback as a component of the enhanced 

communication element of the Patient CaringTouch 

System (PCTS) (Figure 1). 

The goals drive nursing as a key enabler for the 

Military Health System, and posture nursing to deliver 

patient-driven, family-centric, evidence-based nursing 

care while supporting the identification and 

development of full-spectrum leaders in professional 

nursing in the Army. 

The PCTS is comprised of 5 core elements that, when 

optimized in clinical settings, improve patient 

outcomes, patient satisfaction, and nursing staff 

effectiveness. The patient advocacy element focuses 

on the best strategy to develop partnerships between 

the patient, family, nurse, provider, and other members 

of the healthcare team, and place the patient’s 

experience of care and care outcomes as the team’s 

priority. Patient advocacy provides the structure and 

culture for Army Nursing to dedicate our day-to-day 

work toward meeting the physical, emotional, and 

spiritual needs of our patients. Patient advocacy empowers nurses at all levels to become creative problem 

solvers and autonomous decision-makers within 

Optimizing Nursing Care Delivery Systems 

 in the Army: Back-to-Basics with Care 

 Teams and Peer Feedback 

COL Kathy Prue-Owens, AN, USA 

LTC Miko Watkins, AN, USA 

COL (Ret) Kelly A. Wolgast, AN, USA 

ABSTRACT

The Patient CaringTouch System emerged from a comprehensive assessment and gap analysis of clinical nursing capabilities in the Army. The Patient CaringTouch System now provides the framework and set of standards by which we 

drive excellence in quality nursing care for our patients and excellence in quality of life for our nurses in Army Medicine. As part of this enterprise transformation, we placed particular emphasis on the delivery of nursing care at the bedside as well as the integration of a formal professional peer feedback process in support of individual nurse practice 

enhancement. The Warrior Care Imperative Action Team was chartered to define and establish the standards for care 

teams in the clinical settings and the process by which we established formal peer feedback for our professional nurses. 

This back-to-basics approach is a cornerstone of the Patient CaringTouch System implementation and sustainment. 

Figure 1. Care teams and peer feedback as elements of the 

Patient CaringTouch System. 

*See “Building the Army Nursing Campaign Plan” on page 10.
66 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

nursing’s scope of professional practice. Patient advocacy provides clear expectations for nursing by 

defining role responsibility, accountability, and authority in providing patient and family-centered care. 

Enhanced communication provides the traditional 

conceptualization of the appropriate infrastructure to 

support patient safety and improve patient outcomes. 

The focus is shifted from the unit and department to 

the patient-centric system, requiring teamwork, technology, and the use of integrated networks to support 

the best care for patients. Coordination of care takes 

precedence in this type of integrated patient care 

delivery system because decisions made about care in 

any one dimension affect those in the others. Communication and collaboration are integral to effective 

delivery of care and patient outcomes. Effective 

communication is the cornerstone of positive caregiver 

interactions. Improvements in communication require 

not only a standard and effective method of 

communication but also cultivation of a healthy work 

environment where nurses and physicians function as a 

team with open and respectful communication.1

Care teams and peer feedback are key components of 

the patient advocacy and enhanced communication 

elements. Both are part of the overall PCTS 

framework for nursing care that is proactive in 

response to new and different care contingencies, as 

well as facilitating the decrease of practice variance 

and the annotation of nursing workload to workforce 

ratios. The literature supports and cites both of these 

components as best practice initiatives that have been 

identified in the transformation of nursing, the 

optimization of nursing care delivery systems, the 

integration of competent staff into teams, and the 

return of basics into nursing practice.2

CARE TEAMS

The shortage of nurses in the United States forced 

nursing to develop and implement new strategies to 

effectively utilize staff and increase retention in order 

to provide excellence in quality and safe patient care. 

However, some of the strategies being employed are 

not necessarily new. A resurgence of team-nursing 

concepts has been increasing in many facilities across 

the country and abroad, to address quality of nursing 

care deficits, medication error rates, and nursing 

shortages.3-6

According to Fairbrother et al,7

 the Prince of Wales 

Hospital (Sydney, New South Wales, Australia) has 

implemented team nursing to “bring together 

disparately practicing individual nurses, with the goal 

of placing a net beneath the struggling novices.” In a 

recent review of models of care and nurses’ roles, 

Cioffi and Ferguson,8

 determined that more models 

involving team nursing are being used to organize 

nursing care delivery within the New South Wales 

health system. Kirkhart9

 describes “shared care” as a 

team approach for Mercy San Juan Hospital in 

Carmichael, California. She states that the “patientfocused care delivery system gives ‘ownership’ of 

responsibilities to the registered nurse for managing 

the care, rather than providing the care.” Shared care 

includes the family and the patient in the planning 

process and emphasizes improved multidisciplinary 

collaboration. Kirkhart found significant 

“improvement in quality of nursing workplace, in 

terms of support availability for less experienced staff, 

and role clarity among the various categories of 

nursing staff.” Cioffi and Ferguson8

 describe teamnursing “as patient oriented, facilitating accountability, 

encouraging collaboration, enabling better coverage of 

patients, and providing better access to more 

experienced nurses.” Nursing leadership within the 

AMEDD recognized that commitment to 

implementing care teams promotes the establishment 

of a therapeutic relationship with the patient-family in 

a caring and healing environment. The care team is an 

evidence-based, patient-family–centered nursing care 

delivery system that is supported by theoretical 

frameworks of caring, novice-to-expert, and 

relationship-based care.10-12

In collaboration with nursing leaders in our clinical 

settings, the WC IAT developed the standard for care 

teams in PCTS. The care team consists of a lead 

registered nurse (RN) that directs nursing care, and a 

supporting nursing team that cares for a patient 

throughout the length of stay. The goals for the care 

team are to establish consistent care and regular 

communication between patients, families, and the 

nursing and multidisciplinary teams; to create a 

healthy work environment for all members of the 

nursing team under the direction of the RN; to support 

staff to work at the highest level of licensure, scope, 

and competency, providing care for a group of 

patients; and to leverage the capabilities of all nursing 

Optimizing Nursing Care Delivery Systems in the Army: 

Back-to-Basics with Care Teams and Peer Feedback 
 October-December 2011 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

team members to work at their highest level of 

licensure. The impact of establishing these highly 

functioning care teams is coordinated quality care for 

patients and their families, enhanced communication 

and efficiency of the nursing team, and optimized 

performance of all levels of nursing team members. 

As outlined above, the PCTS care teams consist of a 

lead RN and a supporting nursing team that cares for a 

patient throughout the length of stay, improving 

consistency of care and communication. Care teams 

involve multiple members of the nursing team with 

different licensures and competencies (eg, RN, LPN, 

certified nurse anesthetist, medics) to optimize nursing 

care. The lead RN has full responsibility for the 

delivery of nursing care. The lead RN clearly defines 

the boundaries of the care team based on licensure, 

education, competency, scope and standards of practice, experience, patient acuities, and staffing patterns. 

Additionally, clinical nurse specialists, clinical nurse 

leaders, nurse case managers, nurse practitioners, and 

specialty nurses (eg, wound care or performance 

improvement nurses) may provide support and 

guidance in the implementation of the nursing care 

activities and evaluation of patient outcomes. 

Care teams use best practice clinical practice 

guidelines from our quality and patient safety 

programs, as well as from the Army Nursing Practice 

Council, and use enhanced communication tools, 

including collaborative, multidisciplinary rounds; 

hourly nursing rounds; bedside huddles; safety 

huddles; intentional nursing huddles throughout the 

shift; patient whiteboards; and other established forms 

of communication.* The structure of the care team is 

based on some key standards: 

 Charge nurses assign care teams to each patient to 

facilitate continuity of care and use the skills of 

each team member. 

 Unit leadership (clinical nurse officers-in-charge 

and noncommissioned officers-in-charge) assumes 

responsibility for balancing skills and experience 

of nursing team members to ensure appropriate, 

quality care and mentorship. 

 Teams identify and use communication tools to 

most effectively communicate patient needs (eg, 

whiteboards, huddles, hourly rounds). 

 Teams use best practice clinical practice 

guidelines to deliver evidence-based care. 

Although care team sizes and members will vary based 

on patient acuity, competency of staff, and number of 

available staff on a unit, the required standards and 

lead RN are vital to successful implementation 

(Figures 2-5). 

IMPLICATIONS FOR NURSING PRACTICE: BENEFITS TO

UNIT STAFF, FACILITY, AND OUR PATIENTS AND

FAMILIES

Transforming nursing practice by optimizing nursing 

care delivery systems builds a healthcare team in 

whom a patient and family can trust. True 

collaboration, communication, and commitment to 

quality care benefit not only the patient-family, but 

also unit staff and the medical treatment facility itself. 

Benefits to the unit staff include enhanced 

communication with patient and family, enhanced 

communication between staff members, the 

encouragement of efficiency of care by allowing 

nurses to “divide and conquer” care of patients, and 

the enhancement of professional development of care 

team members. A care team that promotes engagement 

and relationship-building between the healthcare team 

and the patient creates an environment that clearly 

presents our patient and family as the priority. These 

types of attitudes add benefits to the facility by 

increasing patient and family satisfaction, increasing 

efficiency and effectiveness of staff, reducing risks of 

medical errors, promoting communication among the 

members of the nursing teams, and enhancing 

interdisciplinary collaboration and alignment between 

providers and nursing team. A care team that responds 

to the needs of the patient and family in a caring 

manner while demonstrating respect and understanding can transform the delivery of nursing care and 

patient outcomes. The benefits to patients and families 

include optimized quality of care at the bedside, a 

single “go to” person on the team for all needs, an 

increased awareness and involvement of the patient 

and family in the care received, enhanced relationships 

between patients and their nursing team, the 

encouragement of patients to express what the nursing 

team can do for them each day, and the demonstration 

that the team approach builds trust with patients and 

families. 

*For example, the Situation-Background-Assessment-Recommendation (SBAR) tool and Team Strategies and Tools to Enhance 

Performance and Patient Safety (TeamSTEPPS) are communication tools to promote safety. Both SBAR and TeamSTEPPS assist 

in creating an environment that fosters improved communication and coordination of care. 
68 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Optimizing Nursing Care Delivery Systems in the Army: 

Back-to-Basics with Care Teams and Peer Feedback 

Structured 

Communication

Elements of the 

A PCTS Care Teams 

Com component

Whiteboards

▪ The PCTS Care Teams 

component is more 

expansive than the Primary 

Nursing model

▪ Lead RNs play a critical role 

in the implementation of 

Care Teams

▪ Care Teams also include a 

number of other key players 

and communication tools to 

enhance collaboration and 

care

Lead RN: 

_________

Today’s Goal: 

________

SBAR

Lead RN

Lead

RN

Care Team 

members

RN LPN CNA

PatientCentered Rounds

Elements of the 

PCTS Care Teams 

Component 

Figure 2. Structure of a Patient CaringTouch System (PCTS) care team. 

Patient Focused Team Focused 

Activity 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 

Charge Nurse assigns care teams for 

oncoming shift, including Lead RN. 

Safety huddle with Charge Nurse and 

oncoming care teams. 

Bedside huddle with off-going and 

oncoming care team members, 

including patient and family (use 

whiteboards); align on roles and 

division of labor for day. 

Intentional huddle #1 with care team 

to communicate patient status. 

Shift activities/provision of care 

Hourly nursing rounds (assess 4 Ps) 

Collaborative rounds with Lead RN 

and providers. 

Intentional huddle #2 with care team 

to communicate patient status. 

Report to Charge Nurse and 

oncoming care team for patient and 

family. 

Previous Shift 

Start of Shift 

Time (TBD) for providers to 

perform rounds on unit 

End of Shift 

5 minutes, all staff Bedside huddle may require 

schedule adjustments for a 15 to 

30 minute overlap of Lead RNs. 

Figure 3. Care team activities during an average 12 hour shift (illustrative). 
 October-December 2011 69

THE ARMY MEDICAL DEPARTMENT JOURNAL

PEER FEEDBACK

Peer feedback is a necessary part of professional 

nursing practice, whether in a formal process or 

informally applied. The implications of peer feedback 

are so great that the American Nurses Association 

(ANA) included it in their magnet status criteria, and 

continue to endorse systematic application of peer 

feedback principles. The ANA defines peer review as 

“a collegial, systematic, and periodic process by which 

registered nurses are held accountable for practice that 

fosters the refinement of one’s knowledge, skills and 

decision-making at all levels and in all areas of 

practice.”1

 The ANA standards of professional nursing 

practice1

 detail 16 standards of practice and professional performance: 

In general, nursing has applied the traditional formal 

peer review process associated with risk management 

to evaluate an individual’s performance. In PCTS, 

nursing leadership determined that in order to promote 

a professional, collegial practice, nurses must have the 

opportunity with peers to reflect on their own practice 

and the practice of their colleagues. Therefore, the 

PCTS defines and endorses standards for peer 

feedback. For purpose of consistency with our 

definition, peer feedback will be used to describe peer 

review in the cited literature. Peer feedback is often 

met with increased scrutiny by the staff, notably due to 

the negative connation. However, not all peer feedback 

is punitive in nature and research has shown many 

benefits to establishing and sustaining a work 

environment that supports positive peer feedback. 

According to Boehm and Bonnel,13 peer feedback 

allows the individual to use feedback to enhance their 

own professional practice. Peer feedback also provides 

the opportunity to “promote professional leadership 

and autonomy”14 and to facilitate the establishment of 

a safety culture within their organization.15

WHAT IS ARMY NURSING PEER FEEDBACK? 

Peer feedback is an objective and confidential process 

that allows all licensed members of the Army Nursing 

team—registered nurses and licensed practical/

vocational nurses—to reflect on their practice 

and develop professionally through feedback 

from colleagues on strengths and opportunities 

for growth. It is an education and development 

tool that enables continuous learning and 

promotes patient safety and best practices. Peer 

feedback is an effective way to identify areas 

for improvement and of praise, and maintain 

professional control over practice, thereby 

giving Army Nursing a way to measure 

professional accountability and responsibility 

for the delivery of quality nursing care 

consistent with the ANA standards of practice 

and professional performance.1 Peer feedback 

is derived from the competencies associated 

with professional practice evaluation. 

Standards for application of peer feedback in 

the PCTS serve to decrease variance in the 

measurement of care delivery across all care 

environments. Anonymous nurse reviews are 

conducted at least semiannually using the ANA 

publication, Nursing: Scope and Standards of 

Practice1

 as the guiding reference; Clinical 

1. Assessment 10. Diagnosis 

2. Outcomes identification 11. Planning 

3. Implementation 12. Evaluation 

4. Ethics 13. Education 

5. Evidence-based practice and research 

6. Quality of practice 14. Communication 

7. Leadership 15. Collaboration 

8. Professional practice evaluation 

9. Resource utilization 16. Environmental health 

Several facilities have experienced positive change from implementation of 

care teams 

From... ...To 

Nursing staff assigned to 

patients on an ad hoc basis 

with little continuity of care 

 Assignment of Lead RN and assigned 

care team for each patient to provide 

continuity of care, develop relationships, 

and ensure all nursing team members 

have adequate skills to meet patient/

family needs 

Variance in nursing care 

across care environments 

 Nursing care provided in a consistent 

manner across care settings, including 

standards for practicing and 

communicating 

Unstructured communication 

between nursing staff and 

patients, resulting in lack of 

awareness regarding care 

 Standards and tools from communication 

with patients and families, for example, 

patient whiteboards, bedside huddles, 

and hourly rounds 

Communication between staff 

members conducted through 

written notes and as-needed 

discussion 

 Structured forums for in-person staff 

communication, both within nursing team 

and between nursing team and providers, 

for example, huddles, collaborative 

rounds with SBAR 

Care provision driven by 

available staff on unit versus 

optimizing for staff members’ 

appropriate skills 

 Efficient care provided by many members 

of the nursing team, each with his/her 

own direct and delegated roles or 

division of labor. 

Figure 4. Benefits of care teams. 
70 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

nurse officers-in-charge (CNOICs) assign 3 or more 

assessors to provide feedback on each recipient. These 

assessors are chosen based on the frequency of 

exposure to the recipient and the same licensure as the 

recipient (eg, RN to RN, LPN to LPN). The CNOIC 

collects feedback from assessors and shares with 

recipients in a timely manner that ensures the 

anonymity of the assessors. The CNOIC will also 

support the recipients as they reflect on their feedback 

and develop goals for their practice. Feedback is used 

primarily as a tool for self-reflection and, if validated, 

will help inform performance evaluations. Officer 

evaluation reports/noncommissioned officer evaluation 

reports and civilian performance plans reflect 

participation in the peer feedback process. 

The impact of peer feedback is the enhancement of 

nurses’ abilities to reflect on their own practice and the 

practice of their colleagues to improve patient care. 

Furthermore, peer feedback is designed to encourage 

regular reflection on nursing practice, establish a 

consistent and objective mechanism for recognizing 

strengths and areas for growth among peers, and to 

create a work environment that fosters honest communication between all licensed members of the nursing 

team. Successful implementation of peer feedback 

necessitates leadership commitment, resources, and implementation of required 

standards at all levels of the organization. 

Using a standardized tool such as those 

shown in Figures 6 and 7, peer feedback 

allows individuals to evaluate their peers in 

a consistent and objective manner. The 

feedback is valuable not only to the unit 

manager or supervisor, but also to the 

evaluated individual. The information can 

be used to facilitate future growth for the 

nurse, by addressing areas where 

improvement is needed as well as identify 

their strengths. However, there are 

challenges with using a peer review tool: 

“the staff believes they are less able to 

assess the patient care questions because 

they do not frequently observe the peer’s 

care processes.”13 However, the peer 

feedback process includes regular checks in 

which members of the nursing team 

provide anonymous feedback to select 

peers with whom they work. A consistent 

peer feedback tool provides a yardstick 

against which to measure professional growth and to 

plan for development. 

IMPLICATIONS FOR NURSING PRACTICE: BENEFITS TO

UNIT, FACILITY, OUR PATIENTS, AND FAMILIES

For over a decade, many healthcare organizations have 

incorporated nursing peer feedback into their formal 

evaluation cycles and clinical advancement programs. 

This feedback is valued for its positive impact on 

nurses’ professional development and the quality of 

patient care. Evidence suggests that peer feedback 

results in increased nurse accountability, staff 

satisfaction and self-awareness, as well as 

improvement in the delivery of patient care.16-21 Fellow 

nursing peers have a true understanding of the reality 

of the nursing care delivery process at the bedside. 

Peer feedback compels nurses to examine clinical and 

interpersonal practice areas in which they may 

improve; it is also often intended to enhance 

professional development, autonomy, and decisionmaking. Rather than reacting to clinical issues 

generated by nursing practices, efforts to strengthen 

positive relationships within the nursing team will 

have added benefit to the patient and family, unit, and 

facility. 

Optimizing Nursing Care Delivery Systems in the Army: 

Back-to-Basics with Care Teams and Peer Feedback 

 A Registered Nurse who is assigned as a patient’s 

Lead RN for the duration of his/her length of stay 

on that ward. 

 Responsible for establishing a therapeutic 

relationship with the patient and an individualized 

patient care plan. 

 Responsible for ensuring that the care plan for 

each of his/her patients is completed, relevant, 

and applied by members of the care team. 

 Directs and delegates care responsibilities to 

other care team members by scope of role and 

capabilities of care team members. 

 Should not carry more than 1 or 2 primary 

patients at a time, if possible, depending of 

patient population. 

 Vital members of the care team that assist the 

Lead RN in providing care to consistent groups of 

patients during the shift. 

 Complete care for patients as directed and 

delegated by the Lead RN, but may only practice 

within scope of role (eg, LPN, CNA, medic). 

 Communicate any changes in patient condition or 

needs to Lead RN. 

 Tailor plan of care for Lead RN and communicate 

change to care team (for an RN that covers for 

Lead RN in his/her absence). 

Figure 5. Care team role responsibilities. 

Lead RN 

Other care 

team members: 

RNs, LPNs, CNAs, 

medics 
 October-December 2011 71

THE ARMY MEDICAL DEPARTMENT JOURNAL

Peer feedback provides numerous benefits to the unit 

staff. These benefits include formalized, regular, 

supportive communication between nursing managers 

and their nursing staff; enhanced communication 

among nursing peers; encouraged reflection on nursing 

practice by reminding nursing staff of scope and 

standards of practice on a regular basis; and promotion 

of professional competence of nurses in the unit to 

enhance quality care. To be an effective team, our 

obligation to quality care extends beyond our routine 

interactions among nurses. Professional obligation has 

added value to the facility, patient, and family. 

Benefits to facility include increased awareness of and 

attention to nursing competence, promotion of nursing 

ownership and autonomy, facilitation of 

communication between staff and promotion of 

teamwork, and improved quality of nursing care. The 

benefits to our patients and families include improved 

quality of care provided by the care team, and 

increased accountability and responsibility of the 

nursing staff. Peer feedback will have a significant 

impact at the strategic level of the Army Nurse Corps. 

Issues identified at the unit level can be elevated to 

higher levels (hospital, region, corps) for further 

evaluation and integration. 

Peer feedback will encourage an effective nursing 

practice by formalizing regular, supportive 

communication between nursing managers and their 

nursing staff. This includes regular discussions 

between nursing leadership and their staff to set 

developmental goals and to encourage both the unit 

manager and the senior nursing leadership to recognize 

high performers. By formalizing the process several 

Assessor (name & title) _____________________________________________________ (RN/LPN) 

Recipient (name & title) _____________________________________________________ (RN/LPN) 

Date of feedback completion _______________ 

Date of developmental discussion _______________ 

Instructions: Please complete the following assessment for your assigned “Peer Feedback Recipient” and return to the CNOIC by stated date. 

Quarter 1 Peer Feedback 

Question ANA 

Standard 

My peer... Very 

Rarely 

Rarely Sometimes Often Very 

Often 

Cannot 

Assess 

Comments 

1 Assessment Elicit the healthcare consumer’s values, 

preferences, expressed needs, and 

knowledge of the healthcare situation. 

2 Diagnosis Identifies actual or potential risks to the 

healthcare consumer’s health and safety 

for barriers to health, which may include 

but are not limited to interpersonal, 

systematic, or environmental 

circumstances. 

 

3 Ethics Delivers care in a manner that preserves 

and protects healthcare consumer 

autonomy, dignity, rights, values, and 

beliefs. 

 

4 Education Seeks experiences that reflect current 

practice to maintain knowledge, skills, 

abilities, and judgment in critical practice 

or role performance. 

 

5 Do you have any other feedback you wish to provide to this colleague at this time to help them enhance their daily practice? 

6 What Peer Feedback questions were most relevant/useful for you as you assessed the Recipient? 

7 What Peer Feedback questions were confusing or least relevant as you assessed the Recipient? 

8 Other suggestions for questions. 

Peer Feedback Tool 

Figure 6. Example of a hard-copy peer feedback tool. 
72 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

times a year, peer feedback encourages reflection on 

nursing practice by reminding nursing staff of scope 

and standards of practice on a regular basis, while it 

supports self-awareness and reflection through 

developmental discussions. It also enhances quality of 

care by promoting the professional competence of 

nurses and the ownership of nursing practice. 

THE WAY AHEAD

The approach to the delivery of nursing care is a 

partnership employing a shared and coordinated effort 

among members of the care team. The care team 

promotes communication, cooperation, commitment, 

and competence among the members of the team with 

the goal of delivering quality nursing care, which leads 

to positive patient care outcomes. Care teams and peer 

feedback are essential components of nursing practice 

that refocus nursing back-to-basics as we fully 

implement and sustain the 5 elements of the Patient 

CaringTouch System. 

REFERENCES

1. Nursing: Scope and Standards of Practice. Silver 

Spring, MD: American Nurses Association; 2010. 

2. Health Workforce Solutions LLC. Innovative Care 

Models. Available at: http://www.innovativecare 

models.com. Accessed July 27, 2011. 

3. Porter-O’Grady T, Alexander DR, Minkara N. Constructing a team model, creating a foundation for evidence-based team. Nurs Adm Q. 2006;30(3):211-220. 

4. Stichler JF. Staff nurse engagement in health facility 

design. J Nurs Adm. 2008;38(7/8):315-318. 

5. Tiedeman ME, Lookinland S. Traditional models of 

care delivery. J Nurs Adm. 2004;34(6):291-297. 

6. Wolf GA, Greehouse, PK. Blueprint for design, 

creating models that direct change. J Nurs Adm. 

2007;37(9):381-387. 

7. Fairbrother G, Jones A, Rivas K. Changing model of 

nursing care from individual patient allocation to 

team nursing in the acute inpatient environment. 

Contemp Nurse. 2010;35(2):202-220. 

8. Cioffi J, Ferguson L. Team nursing in acute care 

settings: nurses’ experiences. Contemp Nurse. 

2009;33(1):2-12. 

9. Kirkhart D. Shared care: improving health care, 

reducing costs. Nurs Manage. 1995;26(6):26-32. 

10. Watson J. The theory of human caring: retrospective 

and prospective. Nurs Sci Q. 1997;10:49-52. 

11. Benner P. From Novice to Expert: Excellence and 

Power in Clinical Nursing. Upper Saddle River, NJ: 

Prentice Hall, Inc; 2001. 

12. Koloroutis M, Manthey M, Felgen J, Person C, 

Kinnaird L, Wright D. Relationship-Based Care: A 

Model for Transforming Practice. Minneapolis, MN: 

Creative Health Care Management, Inc; 2004. 

Optimizing Nursing Care Delivery Systems in the Army: 

Back-to-Basics with Care Teams and Peer Feedback 

Figure 7. An example of a web-based feedback tool. 
 October-December 2011 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

13. Boehm H, Bonnel W. The use of peer review in 

nursing education and clinical practice. J Nurses Staff 

Dev. 2010;26(3):108-115. 

14. Hotko B, Van Dyke D. Peer Review: Strengthening 

Leadership Skills. Nurs Manage. 1998;29(4):41,44. 

15. Diaz L. Nursing peer review: developing a 

framework for patient safety. J Nurs Adm. 2008;38

(11): 475-479. 

16. Fujita L, Harris M, Johnson K. Nursing peer review: 

integrating a model in a shared governance 

environment. J Nurs Adm. 2009;39(12):524-530. 

17. Hogston R. Evaluating quality nursing care through 

peer review and reflection; the findings of a 

qualitative study. Int J Nurs Stud. 1995;32(2):162-

172. 

18. Gagliardi AR, Perrier L, Webster F, et al. Exploring 

mentorship as a strategy to build capacity for 

knowledge translation research and practice: protocol 

for a qualitative study. Implement Sci [serial online]. 

2009. Available at: http://www.implementationsci 

ence.com/content/4/1/55. Accessed February 12, 2011. 

19. Miller WR, Hurley SJ, Wharton E. External peer 

review of skilled nursing care in Minnesota. Am J 

Public Health. 1976;66(3):278-283. 

20. Roper K. The effect of peer review on 

professionalism, autonomy and accountability. J Nurs 

Staff Dev. 1997;13(4):198-206. 

21. Schultz K, Latif D. The planning and implementation 

of a faculty peer review teaching project. Am J 

Pharm Educ. 2006;70(2):1-6. 

AUTHORS

COL Prue-Owens is Deputy Commander for Health 

Services/Nursing, Raymond W. Bliss Army Health 

Center, Fort Huachuca, Arizona. 

LTC Watkins is Chief Medical Information Officer, 

Pacific Regional Medical Command and Tripler Army 

Medical Center, Honolulu, Hawaii. 

When this article was written, COL Wolgast (Ret) was 

the Army Medical Command Chief Nurse Executive 

and Functional Proponent, Fort Sam Houston, Texas. 
74 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

INTRODUCTION

Ensuring available personnel resources for quality 

patient care is a major responsibility of healthcare 

leaders in all facets of healthcare. In order to appropriately manage these resources, leaders require accurate, 

timely information, especially in today’s world where 

budgeting for healthcare is on the forefront of our 

minds. Patient classification systems assist nurse 

leaders in ensuring that they have the acuity based 

tools in place to match patient care delivery to demand 

management. This process and system provides 

leaders with valid tools that assist with improvement 

of patient outcomes, proper staffing, budgeting and 

cost containment and nurse retention. 

CURRENT ARMY NURSING WORKLOAD PRACTICES

Army healthcare leaders face resource constraints 

similar to the civilian healthcare environment. Current 

issues facing the Army Medical Department 

(AMEDD) include ensuring adequate nurse staffing to 

patients within the constraints of a deployed 

workforce, an aging population, a nursing shortage, 

and rising healthcare costs. Efforts are underway to 

improve our leadership’s ability to provide valid, 

reliable, quality data for the practice of nursing while 

balancing efficiency, all the while delivering quality 

patient care. Ongoing discussions regarding the use of 

nurse-to-patient ratios to assess the adequacy of the 

nursing support for the care of the patients are among 

many of the issues being researched. Systems such as 

Workload Management System for Nursing Internet 

(WMSNi) will be critical to the Army as a 

development strategy to determine more accurate 

measures. Among those measures is the ability to 

account for the various factors that contribute to 

resourcing, such as patient acuity and complexity, 

workload, and staffing mix. In particular, the visibility 

of workload to key leaders and front line clinicians 

will influence workload distribution, skill mix 

decisions, patient assignment, and staffing flexibility. 

HISTORICAL BACKGROUND

The original patient classification study was conducted 

in 1955 by Ester Claussen1

 at the Walter Reed Army 

Medical Center and resulted in a “Nine Category Scale 

of Patient Needs.” Subsequently, the Army made 

several quantitative adaptations and prototype changes 

to the model leading up to 1985, when a joint effort of 

the US Army Nurse Corps and the US Navy Nurse 

Corps was established. Through this effort, the Workload Management System for Nursing (WMSN) was 

Measuring Nursing Essential Contributions 

 to Quality Patient Care Outcomes

COL (Ret) Kelly A. Wolgast, AN, USA 

LTC Katherine Taylor, AN, USA 

LTC Dawn Garcia, AN, USA 

LTC Miko Watkins, AN, USA 

ABSTRACT

Workload Management System for Nursing (WMSN) is a core Army Medical Department business system that has 

provided near real-time, comprehensive nursing workload and manpower data for decision making at all levels for over 

25 years. The Army Manpower Requirements and Documentation Agency populates data from WMSN into the 

Manpower Staffing Standards System (Inpatient module within Automated Staffing Assessment Model). The current 

system, Workload Management System for Nursing Internet (WMSNi), is an interim solution that requires additional 

functionalities for modernization and integration at the enterprise level. The expanding missions and approved 

requirements for WMSNi support strategic initiatives on the Army Medical Command balanced scorecard and require 

continued sustainment for multiple personnel and manpower business processes for both inpatient and outpatient 

nursing care. This system is currently being leveraged by the TRICARE Management Activity as an interim 

multiservice solution, and is being used at 24 Army medical treatment facilities. The evidenced-based information 

provided to Army decision makers through the methods used in the WMSNi will be essential across the Army Medical 

Command throughout the system’s life cycle. 
 October-December 2011 75

developed to establish a patient classification system 

that would capture nursing workload based on patient 

acuity and provide guidelines for effective and 

efficient allocation and utilization of nursing 

personnel. In December 1986, the Army Manpower 

Requirements and Documentation Agency approved 

the incorporation of the WMSN into the Manpower 

Staffing Standards System, now known as the 

Automated Staffing Assessment Model Inpatient 

module. To populate the model, information is 

generated by WMSN and used to determine manpower 

requirements for inpatient nursing units Army-wide.2,3

REVALIDATION PROCESS

Since its inception, WMSN has been used to measure 

patient acuity and the complexity of care, and to 

establish manpower requirements for inpatient nursing 

units.2

 However, concerns arose that WMSN had lost 

its validity, since the critical indicators no longer 

reflected current inpatient work practices. With 

changes in inpatient work practices, technological 

advances, regulatory requirements, and the need to 

capture all sources of workload, the nursing care hours 

associated with each critical indicator required updating and revalidation. An Army team made up of a 

nurse researcher, informatics nurse-to-nurse methods 

analysts, and additional staff from each of the 

locations visited, began the process of revalidating 

each of the critical indicators and ensuring compliance 

with current practice standards. This initial phase 

involved a frequency analysis to look at all 99 critical 

indicators at a total of 26 medical treatment facilities 

(MTFs). The information collected led to current 

clinical model revisions, resulting in consolidation of 

some indicators and removal of others. 

The next phase included a series of time and motion 

studies to establish current minimal essential mean 

times for each direct nursing care activity. Timed 

observations were completed on 60 direct care activities generating 3,241 time measurements. These data 

were analyzed to assess the overall mean times for 

each of the activities and processes. The resulting 

patient classification system measures the direct 

nursing care activities and combines it with the appropriate indirect care activities to determine the best mix 

and skill level of care providers for the critical care, 

medical/surgical, obstetric, psychiatric, neonatal, and 

pediatric clinical services. Figure 1 illustrates changes 

in direct care times as a result of the studies. 

WMSNi: A FOURTH GENERATION PATIENT

CLASSIFICATION SYSTEM

Patient classification systems (PCSs) were originally 

adapted from industrial time and motion models. Prior 

to the 1980s, first generation systems were based on 

manual calculations originating from historic 

performance ratios used to estimate staffing needs and 

budgets. Second generation systems were designed to 

focus on patient care as accrediting organizations such 

as the Joint Commission mandated their use. By the 

1990s, third generation patient classification systems 

were critical due to shorter hospital stays and less 

stationary staff. Fourth generation systems now focus 

on prospective modeling, evolving to provide real-time 

matching of caregiver skill profiles to meet staffing 

needs for the current and upcoming shifts.4

The 2 general types of systems commonly used are the 

summative task type and the critical incident or 

criterion type PCS. Summative tasks PCSs usually 

appear comprehensive because they list major tasks, 

and tend to be easier to design and code in order to 

interface with automated documentation systems. However, criterion PCSs can be more easily adapted to the 

organization.4

 Despite the modality selected, benefits 

include data-driven decision-making, standardized clinical documentation which supports evidence-based 

medicine, and easier integration into staffing and scheduling systems.5

 Clinical officers-in-charge can then 

compare scheduled staff to required staff specified by 

patient classification system, and then reallocate staff 

or call in additional staff to accommodate over- or 

understaffed units, ensuring appropriate mix of skill 

levels. Ultimately, patient classification systems provide improved staffing accuracy, streamlined workflow, and enhanced patient outcomes. 

The WMSNi is a summative task PCS that expresses 

patient care requirements as the sum of the frequency 

of tasks. The WMSN-A Refresh project was begun in 

April 2009 and reached full operating capacity in July 

2010. Currently it is used by over 6,500 caregivers on 

a daily basis. Figure 2 presents its current operational 

view. It is an interim solution to ensure the maintenance of the basic functionalities that are needed for 

enterprise level capability. 

The “refresh” has given the application a modern-day 

format as well as many new and convenient features. 

Previously calculated through a subsystem, workload 
76 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

management for postanesthesia care and labor and 

delivery units are now fully integrated into the 

WMSNi, as illustrated in Figure 3. Formerly a 

decentralized managed system at 26 MTFs, WMSNi is 

now a centralized, web-based application with a 

contemporary user interface. Data can be entered 

through easy-to-use features, adding and retrieving 

information are as simple as clicking a button, and 

information entered is immediately employable. 

STAFF FEEDBACK

To assess the users’ perceptions of the legacy WMSN 

and WMSNi respectively, an electronic survey was 

created using the AMEDD Center and School Survey 

Application Tool. The survey was administered at 

preimplementation, and approximately 60 days postimplementation. The preimplementation survey was 

completed by 105 participants, while 47 participants 

completed the postimplementation survey. 

As shown in the Table, 8 of the 11 questions solicited 

opinions of the systems using a 5-point Likert rating 

scale. Three questions were strictly demographic in 

nature, addressing the length of nursing experience, 

where they worked and whether they were military, 

GS civilian, or contract staff. 

Preimplementation survey – Forty-eight nurses (46%) 

had more than 6 years of nursing experience in one of 

the various nursing specialties, the distribution of 

which is shown in Figure 4. 

Significantly, 70 participants (66%) strongly agreed or 

agreed that the legacy WMSN was not optimal nor did 

it meet the their needs. Forty-five participants (43%) 

rated WMSN as frustrating and considered it not an 

effective way to document the inpatient clinical 

workload data. Figure 5 presents the survey results. 

Postimplementation survey – The same survey was 

given as the postimplementation survey. Twenty 

Measuring Nursing Essential Contributions to Quality Patient Care Outcomes

Figure 1. Changes in direct care times determined by observations collecting 3,241 time measurements. 

Nursing Direct Care Activities 

Minutes 

Historical minutes 

Updated times 
 October-December 2011 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

MAINTAIN average monthly workload (average number of patients per category)

ASSESS patients

CLASSIFY patients’ direct nursing care requirements

DETERMINE nursing care hours required

Scheduled staff by facility, unit, day or shift WMSN required staff by facility, unit, day or shift (direct or indirect care)

COMPARE 

ADJUST staff and/or workload to balance deficiencies

DETERMINE inpatient nursing manpower requirements

APPLY M3‐5 staffing standards PERFORM trend analysis

ADJUST staff and/or workload

ALLOCATE or reallocate nursing personnel

Figure 3. The business workflow within the WMSNi system. 

Figure 2. The current operational view of the Workload Management System for Nursing. 
78 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

participants (43%) strongly agreed or agreed that the 

WMSNi was much easier to use and that it met their 

needs. Twenty-eight participants (60%) strongly 

agreed or agreed that WMSNi provides an effective 

way to document the inpatient clinical workload data. 

Figure 6 presents the survey results. 

The surveys also helped to identify any high level user 

requirements that were not previously identified for 

future enhancements to WMSNi. For example, the 

responses indicated that Behavioral Health’s workload 

was not fully identified. Other survey participants 

commented on the technical issues, frequent 

downtimes, speed of application, and the potential that 

WMSNi could provide them, especially with staff 

scheduling and 24-hour report modules. 

WORKLOAD AND STAFFING

As requests for scheduling and 24-hour report 

capabilities increase, Army leaders recognize the 

critical requirement to more objectively make 

assignments for increased staffing equity and patient 

safety. Recent studies indicate that more efficient use 

of staff was associated with lower hospital-related 

mortality, failure to rescue, and other patient 

outcomes.6

 Balancing clinical workload with nurse 

staffing was also associated with better outcomes in 

intensive care units and among surgical patients. 

Several studies also found a significant relationship 

between lower nurse staffing levels and higher rates of 

pneumonia. For example, a multisite study in 

California found that an increase of one hour worked 

by RNs per patient day correlated with an 8.9% 

decrease in the odds of pneumonia among surgical 

patients.6

 Another study found a significant 

relationship between full-time-equivalent RNs per 

adjusted inpatient day and rate of pneumonia—the 

rate of pneumonia was higher with fewer nurses.6

However, other studies have not confirmed these 

findings. For example, there is conflicting evidence 

regarding the impact of nurse staffing levels on 

pneumonia.6,7 As workload is affected by more 

than just staffing levels, a deeper understanding of 

nursing workload is required to better assess the 

impact of workload on patient outcomes. 

Developing a schedule that satisfies staffing needs 

and individual needs of nurses, while at the same 

time satisfying workload and training requirements 

is no easy task without a standardized and centrally 

managed scheduling system that is adaptable to the 

organization’s needs. In planning for the future, 

Army leaders must consider fulfilling staffing and 

workload requirements a priority. Communication 

must be fostered between all levels of supervisors 

and staff concerning scheduling in order to foster a 

positive work environment, avoid burnout, increase 

morale, lower absenteeism, and lessen turnover. 

The management of nursing contract dollars is also 

varied across the Army Medical Command. Several 

Measuring Nursing Essential Contributions to Quality Patient Care Outcomes

Questions used in the pre- and postimplementation survey of 

users’ opinions of the WMSN and WMSNi systems. 

1. How many years of nursing experience do you have? 

2. Where do you work (area of specialty)? 

3. Are you military, GS civilian, or contract staff? 

Indicate your opinion of each of the following statements on a five 

point (Likert) scale: 1=strongly agree, 2=agree, 3=neither agree nor 

disagree, 4=disagree, 5=strongly disagree 

4. Overall the system is wonderful and meets all of my needs. 

5. Overall the legacy system is frustrating and does not meet my 

needs. 

6. The WMSN system is easy to use. 

7. It was difficult to learn how to operate the WMSN system. 

8. The system allows me to perform required tasks in a 

straightforward manner. 

9. The system provides an effective way to document the inpatient 

clinical workload data. 

10. The system provides accurate patient acuity data. 

11. The system has reporting options available to me. 

5

15

0

10

25

35

20

30

Medical, Surgical

Critical Care

Behavioral Health

PEDS

Admin

NICU

RN

OB‐GYN

Labor & Delivery

MBU PACU OR NA

Figure 4. Distribution of nursing specialties represented by 

participants in the preimplementation WMNSi survey (N=105). 
 October-December 2011 79

THE ARMY MEDICAL DEPARTMENT JOURNAL

Number of Responses 

Figure 5. Distribution of responses from participants in the WMNSi preimplementation survey (N=105). 

Number of Responses 

Figure 6. Distribution of responses from participants in the WMNSi postimplementation survey (N=47). 
80 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

tools, including MS Excel, are used to understand and 

manage the large amount of personnel services dollars 

used. Based on current systems, it is challenging to 

obtain a detailed view of contract utilization. 

Capabilities must be identified to ensure more efficient 

utilization. There are clear opportunities to better 

manage contract dollars and improve understanding of 

where the dollars are spent and where we can 

maximize our potential cost savings. 

HOW THE PATIENT CLASSIFICATION SYSTEM SUPPORTS

DECISION MAKING

Evidence-based practice uses the best clinical knowledge to determine interventions and clinical actions 

developed through the rigor of sound research to 

assure the best possible clinical outcomes for patients. 

Similar expectations of our administrative decision 

making are necessary. Multimillion dollar decisions 

are made every day in our organizations. Is evidence 

beyond the anecdotal experience of the leaders 

introduced into these decisions? Do we apply the same 

standard to both clinical and administrative decision 

making, as well as to address adverse outcomes from 

poor decision making? Developing staffing plans, 

adhering to standards, and evaluating the effectiveness 

of the staff are challenges facing leaders every day. 

Because the nursing workforce accounts for the largest 

cost of care in every hospital, achieving and sustaining 

efficiency is critical to managing the delivery of high 

quality patient care. All of this is dependent on timely, 

accurate data. In the past, getting timely access to the 

data was challenging. Often a period of 45 to 90 days 

was necessary to see any data from WMSN. The data 

at the medical treatment facility was maintained in a 

system that was difficult to access, or only on paper. 

This made the data difficult to synthesize and analyze. 

With the implementation of WMSNi, the application 

provides decision makers with real-time, multidimensional reporting analysis capabilities. Several reporting features allow users to analyze trends, then 

devise and implement staffing strategies more quickly 

than ever before. Figure 7 illustrates one of many 

strategic reports available within WMSNi to assist 

leaders with more visibility into their operations. 

Moreover, the Army Nurse Corps has developed a 

standardized nursing practice model for inpatient and 

outpatient settings which incorporates nationally 

recognized standards from professional nursing organizations. This has led to the need to change the skill 

mix for staffing. 

Effective clinical workload management for inpatient 

nursing requires continual review of past work accomplished to evaluate the performance, effectiveness, and 

efficiency of the organization, and identify improvements to work processes. Projected clinical workload 

data is currently being provided using WMSNi to 

determine the manpower and financial requirements at 

all medical treatment facilities. Clinical work must be 

validated in order to be resourced for appropriate 

support for all Warfighters and their families. 

CONCLUSION

The WMSNi is a core AMEDD business system that 

provides real-time, comprehensive nursing workload 

and manpower data for decision making at all levels. 

The WMSNi's expanding missions and approved 

requirements support strategic initiatives for the Army 

Medical Command balanced scorecard (defined on 

page 25), and multiple personnel and manpower 

business processes. In the future should be the creation 

of a validated predictive model leveraging WMSNi 

that is intuitive to users, with strong statistics and 

clinical analytics, which uses other objective patient 

data, such as surgery day and type, diagnosis related 

group, length of stay, etc. Future projects will include 

consolidation of inpatient and outpatient workload data 

in a centralized location. The system would enable 

standardized business practices through automation 

and seamless report delivery with multiple interfaces, 

including census and workload information, with 

acuity, complexity, and staffing recommendations. The 

desired results include a self-schedule module to communicate with the Defense Medical Human Resources 

System Internet and WMSNi. Benefits will include 

improved morale of staff members, decreased turnover 

and absenteeism, improved ability to manage contract 

dollars, and improved dispersion of clinical staff to 

ensure safe staffing based on workload expertise and 

skill mix. Upgrading WMSNi is essential in order to 

reflect current clinical practice and streamline 

operations, reduce contract labor expense for interim 

nursing staff, lessen staff overtime, decrease patient 

length of stays, and minimize staffing turnover. The 

proposed solution will provide well-organized and 

accurate patient classification, improved patient 

outcomes, more precise and effective forecasting, and 

enhanced analysis of patient care requirements.

Measuring Nursing Essential Contributions to Quality Patient Care Outcomes
 October-December 2011 81

THE ARMY MEDICAL DEPARTMENT JOURNAL

REFERENCES

1. Claussen E. Categorization of patients according to nursing care needs. Mil Med. 1955;116,(3):209-214. 

2. Field Manual 8-5-01: Workload Management System for Nursing. Washington, DC: US Dept of the Army; 1991 

[cancelled, not in effect]. 

3. Army Regulation 570-4: Manpower Management. Washington, DC: US Dept of the Army; February 8, 2006. 

4. Harper K, McCully C. Acuity systems dialogue and patient classification system essentials. Nurs Adm Q. 2007;31

(4):284-299. 

5. Van den Heede K, Diya L, Lesaffre E, Vleugels A, Sermeus W. Benchmarking nurse staffing levels: the 

development of a nationwide feedback tool. J Adv Nurs. 2008;63(6):607-618. 

6. Carayon P, Gurses A. Nursing workload and patient safety- a human factors engineering perspective. In: Hughes RG, 

ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare 

Research and Quality; 2008:1-14 

7. Brady A, Bryne G, Horan P, Griffiths C, Macgregor C, Begley C. Measuring the workload of community nurses in 

Ireland: a review of workload measurement systems. J Nurs Manag. 2007;15:481-489. 

AUTHORS

When this article was written, COL Wolgast (Ret) was the MEDCOM Chief Nurse Executive and Functional 

Proponent, Headquarters MEDCOM, Fort Sam Houston, Texas. 

LTC Taylor is the MEDCOM Nurse Acquisition Officer and WMSNi Program Manager, Headquarters MEDCOM, 

Fort Sam Houston, Texas. 

LTC Garcia is the Consultant Nursing Methods Analyst to the Office of The Surgeon General, Headquarters 

MEDCOM, Fort Sam Houston, Texas. 

LTC Watkins is the Chief Medical Information Officer, Pacific Regional Medical Command and Tripler Army Medical 

Center, Honolulu, Hawaii. 

Figure 7. An example of a report available within WMSNi. 
82 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The Army’s greatest resource is its people. Within the 

Army Nurse Corps vision — Embrace the Past, Engage 

the Present, and Envision the Future — a critical process 

is to ensure that the personnel force structure (the 

people) of the Army Nurse (AN) Corps must be 

transformed to support the complex healthcare 

missions of the 21st century. This incorporates our 

lessons learned, both from the garrison (home station) 

daily healthcare missions and the healthcare support in 

multiple combat theaters of operation. This article 

discusses the analytical and business applications used 

to project future AN Corps officer force structure 

requirements and associated Army Medical 

Department Center and School (AMEDDC&S) 

training strategies. Additionally, the article provides 

examples of the synchronization of force structure and 

training strategies to execute the Corps Chief’s vision 

of optimizing human capital in support of the Army 

Medical Department (AMEDD) and Army missions. 

In the autumn of 2009, the Chief, Army Nurse Corps 

reestablished a separate functional staff position of the 

Army Nurse Corps, the Corps Specific Branch 

Proponency Officer (AN CSBPO), previously a “dualhatted” position under the AN Deputy Corps Chief. 

Serving as the coordinator for developing and 

maintaining the Corps’ strategic plan and its 

integration into the AMEDD’s strategic vision, the AN 

CSBPO serves as a special staff officer to the AN 

Corps Chief and Deputy Corps Chief.1

 As such, the 

AN CSBPO primarily serves as the integrator between 

the Corps Chief’s vision and senior AN Corps leaders, 

including the Chief Nurses of the Army Medical 

Command (MEDCOM), Army Forces Command, 

Army Human Resources Command, Army Recruiting 

Command, and Reserve Officer Training Corps 

(ROTC) respectively. Each of these senior AN Corps 

leaders oversee components of personnel management 

within the Corps. Each senior AN Corps leader has a 

different view of the force that provides the AN 

CSBPO essential information required for the 

projection of future requirements. Failure to maintain a 

robust dialogue among these key leaders can 

contribute to gaps in vital information necessary to 

make cogent, strategic, corporate decisions. The AN 

CSBPO position also serves as the linchpin between 

future force structure modeling executed by the 

AMEDD Personnel Proponent Directorate (APPD), 

and associated training strategies executed by the 

Department of Nursing Science, AMEDDC&S. 

The APPD serves as The Surgeon General’s personnel 

analysis activity. It partners with the Medical 

Capabilities Integration Center and Office of The 

Surgeon General (OTSG) Program Analysis and 

Evaluation to perform operating force and generating 

force structure analysis. The APPD provides input to 

life cycle management of all AMEDD areas of 

concentration (AOC), military occupational 

specialties, and civilian occupational series. The 

Personnel Proponent Officers of the APPD Officer 

Personnel Proponent Division (OPPD) are responsible 

for personnel force structure projections and analyses. 

The Division performs analysis and develops AMEDD 

officer personnel policy recommendations and 

strategic initiatives to assist The Surgeon General; the 

Commanding General, AMEDDC&S; and the AMEDD 

Corps Chiefs in support of their roles within the 

AMEDD in accordance with Army Regulation 600-32

and Army Regulation 5-22.

3

 As the AMEDD officer 

personnel proponent integration activity, the OPPD 

recommends personnel management policies to the 

OTSG Human Resources Directorate for AMEDD 

officer and warrant officer personnel, using the Army 

personnel life-cycle management functions (Figure 1).

The Army National Guard and the Army Reserve work 

in collaboration with the Active Army AN Corps on 

specific proponent issues. The Army Reserve OPPD 

Personnel Proponent Officers are not Corps-specific 

and are responsible for overarching Army Reserve 

proponent issues and collaboration on policies and 

plans for Army Reserve AMEDD officers. The 

budgeted end strength for the Army Reserve is 

generated by the Chief, Army Reserve. 

Using Force Structure Analysis to 

 Drive Transformation 

COL Carol J. Pierce, AN, USA 

COL Janice F. Nickie-Green, AN, USA 
 October-December 2011 83

Army Reserve Personnel 

Proponent Officers develop, 

coordinate, and integrate lifecycle issues with the appropriate entities including The 

Surgeon General; Office of 

the Chief, Army Reserve; 

National Guard Bureau; 

Assistant Secretary of the 

Army, Manpower and Reserve Affairs; MEDCOM; 

Army Recruiting Command; 

Army Reserve Command; 

and the Commanding 

General, AMEDDC&S. 

Collaboratively, the APPD 

staff officers responsible for 

personnel force structure and lifecycle projections use 

a suite of tools to support this work. 

The OTSG Human Resources Directorate provides 

APPD with the budgeted end strength for the Active 

Army officer corps. The APPD Army Nurse Personnel 

Proponent Officer is responsible for developing the 

Objective Force Model (OFM) for the Army Nurse 

Corps. The model must be developed within the 

constraints of the Corps’ budgeted end strength. The 

AN Personnel Proponent Officer, in conjunction with 

APPD’s operations research analyst, uses the budgeted 

end strength of the Army Nurse Corps, which includes 

the documented authorizations in both the tables of 

distribution and allowances* and tables of organization 

and equipment,†

 the allocated nonavailable force (not 

available for distribution, such as transients, holdees, 

and students), and the allocated AMEDD branch 

immaterial structure‡

 to determine the number of 

personnel by specialty AOC and grade that are 

required to sustain lifecycles for the respective AOCs. 

The OFM variables include the number of accessions 

by AOC and grade, the promotion rates to major, 

lieutenant colonel, and colonel, and the yearly 

transition percentage from feeder AOCs into other 

AOCs (eg, 66H, Medical-Surgical Nurse to 66G, 

Obstetric and Gynecologic Nurse) as applicable. The 

OFM also considers due course officers (those officers 

who enter the Corps at the grade of 2nd lieutenant) and 

non-due course officers 

(those officers that enter the 

Corps with constructive credit and possibly advanced 

grades based on education 

and/or experience). Using 

well-proven computer-based 

modeling, the total budgeted 

end strength for that year is 

distributed across all AN 

Corps AOCs to ensure that 

each AOC reflects a balanced rank structure and 

optimal inventory at each 

year of service. This is essential to ensure compliance 

with recommended Defense 

Officer Personnel Management Act (DOPMA) (Pub L 

No. 96-513 (1980)) promotion rates for every grade 

and AOC. The AN Personnel Proponent Officer 

presents the OFM to the AN CSBPO and Deputy 

Corps Chief, who then obtain the AN Corps Chief’s 

approval. The AN Corps Chief is the approval 

authority for the Corps’ OFM. Once approved, the 

OFMs are used to support force management 

decisions, including promotions, accessions, training 

requirements, and AOC transitions. Additionally, the 

OFMs prescribe the optimal inventory target at each 

year of service (Figure 2). 

For the Reserve Component, the Reserve Officer 

Personnel Management Act (ROPMA) (Pub L No. 103-

337 (1996)) serves the same purpose as the Active 

Army’s DOPMA. The act synchronizes the Reserve 

Component promotion system with that of the Active 

Army. The fact that ROPMA replaced the fullyqualified system with best-qualified is of significant 

importance for career advancement because it allows 

the Army Reserve to mirror the Active Army for 

promotion purposes. The Army Reserve OFMs present 

a snapshot in time for the force structure by grade, 

year group, and AOC. These models are developed for 

3 Reserve Component segments: Army Reserve 

Selected Reserve (Troop Personnel Unit, Individual 

Mobilization Augmentee); Army Reserve Individual 

Ready Reserve; and Active Guard Reserve officers. 

Figure 1. The AMEDD Personnel Proponent Directorate 

adaptation of the US Army personnel life-cycle management functions. 

*Table of Distribution and Allowances: Prescribes the organizational structure, personnel and equipment authorizations, and 

requirements of a military unit to perform a specific mission for which there is no appropriate table of organization and 

equipment. 

†Table of Organization and Equipment: Defines the structure and equipment for a military organization or unit. 

‡Immaterial structure positions can be filled by any AMEDD Corps, rather than a specific Corps and AOC. 
84 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

The Active Guard Reserve officers are currently in a 

separate competitive category and have separate OFM 

histograms for the personnel structure by year group. 

The Army National Guard has one set of models and 

histograms depicting inventory, but unlike the Army 

Reserve, it does not have separate categories of 

officers. The goal is to have a close relationship 

between the OFM line and the number of officers in a 

respective AOC by promotion year group (Figures 3 

and 4). Like the Active Army, the Reserve Component 

OFMs and histograms are the foundation for many of 

the Army Reserve APPD recommendations and the 

basis for present and future force structure, promotion 

rates, incentives, training, school seats, recruiting 

goals, and sustainment of the force. All models—

Active Army, Army Reserve, and Army National 

Guard—are dynamic in that they change and evolve as 

changes occur within the Army. 

The APPD plays a key role in supporting the decisionmaking process regarding training requirements for 

each specialty area, for graduate and doctoral education, and for the leader development programs to 

include the Basic Officer Leadership Course, Captains 

Career Course, and Army Intermediate Level Education Course. Using the OFM projections and historical 

utilization data, APPD coordinates with the training 

arm of the AMEDDC&S and recommends the appropriate number of training seats to ensure that the correct numbers of AN assets, by specialty, are available 

to meet mission requirements. This coordination 

supports the AMEDDC&S Pre-Structure Manning 

Decision Review process and informs the Army’s 

Structure Manning Decision Review that validates 

training requirements, compares training requirements 

with resource capabilities, and reconciles differences 

into an affordable, acceptable, and executable training 

program to meet readiness objectives.4

The APPD uses the OFM in conjunction with the 

Corps’ strategic vision to support analysis of the 

AMEDD’s Long-Term Health Education and Training 

programs. The AN CSBPO and AN Personnel 

Proponent Officer are the AN Corps’ representatives at 

the AMEDDC&S for implementation of the graduate 

Long-Term Health Education and Training Policy 

established in 2009. This policy established a multiphased process for determination of each Corps’ graduate training requirements based upon current and projected inventory, authorized positions, postgraduate 

utilization assignments, and financial resources. In the 

first year of implementation, the policy has driven comprehensive analyses of personnel authorization documents to validate actual graduate and doctoral civilian 

education level training requirements. This includes 

collaboration with AN consultants to The Surgeon 

General and the AN Branch, Army Human Resources 

Command, to project future utilization tours based on 

personnel authorization documents. Additionally, 

collaboration is done with the AN representative, 

Using Force Structure Analysis to Drive Transformation 

Personnel Strength 

Grade and Year Group 

  COL

  LTC

  MAJ

  CPT

  LT

  OFM

Figure 2. The optimal Active Army AN Corps personnel strength recommended by the Objective Force Model (OFM) plotted 

against the Active Army personnel strength by grade and year group. Data current as of January 2011. Source: Army Medical 

Operational Data System. 
 October-December 2011 85

THE ARMY MEDICAL DEPARTMENT JOURNAL

AMEDDC&S Department of Health Education and 

Training, to project the fiscal costs of graduate 

education. The APPD’s AN Personnel Proponent 

Officer also uses AOC-specific school seat models to 

validate prospective programmed graduate education 

starts, AOC and skill identifier training requirements, 

and to evaluate the need for civilian education level 

coded authorizations. Additionally, Corps Personnel 

Proponent Officers conduct analyses to determine the 

status of, and need for, training seats for the Basic 

Officer Leadership Course, Captains Career Course, 

and Army Intermediate Level Education courses. 

The APPD provides recommendations annually for the 

development of the AMEDD Recruitment Strategy 

Memorandum for the Army’s Accessions Command. 

The memorandum provides the guidance for direct 

accession requirements, including advanced practice 

nurse (eg, certified registered nurse anesthetists and 

family nurse practitioners) direct accession recruitment, and fully qualified AOC or skill identifier-specific 

(eg, critical care, perioperative, medical surgical) 

direct accession recruitment. The basis of the memorandum is the OFM; current AN inventory; projected 

ROTC AN commissions; and candidates in the Army 

Nurse Commissioning Program, the AMEDD Enlisted 

Commissioning Program (AECP), and the Funded 

Nurse Education Program (FNEP). In collaboration 

with AN senior leaders, the AN CSBPO, Accessions 

Command, and the AN Personnel Proponent Officer, a 

“precision recruitment” strategy is formulated to 

balance the accession of newly licensed nursing 

graduates without clinical experience coming from 

ROTC, AECP, or FNEP with the direct accession of 

registered nurses with clinical experience and/or 

advanced degrees. Precision recruitment also balances 

the direct accession of officers with clinical experience 

but without military experience with officers who have 

some past military experiences through ROTC, AECP, 

or FNEP, but limited clinical experience. The goal for 

future accession strategies is to proportionally balance 

recruitment through the available accession portals to 

maintain the inventory within the defined AN Corps 

budgeted end strength, while ensuring accession of 

personnel with needed capabilities. 

Another collaborative initiative between the AN 

CSBPO, AN Personnel Proponent Officer, MEDCOM 

Figure 3. The optimal Army Reserve Component AN Corps personnel strength recommended by the Objective Force Model (OFM) 

plotted against the Army Reserve Component strength by grade and year group. Data as of January 2011. Source: Total Army 

Personnel Database-R. Personnel Strength 

Grade and Year Group 

  COL

  LTC

  MAJ

  CPT

  1LT

  OFM

  2LT
86 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Chief Nurse, Regional Nurse Executives, and the 

AMEDDC&S Department of Nursing Science has 

been the examination of the authorized AN generating 

force structure by AOC and grade to determine if the 

current force structure meets the mission requirements 

of today and tomorrow. The first key area examined 

was the current allocation of AN colonels by location 

and AOC to determine if the grade and AOC were 

appropriate for the location and the mission. The initial 

review indicated that numerous positions were 

identified as AOC-specific, primarily 66H (MedicalSurgical), when the actual duty responsibilities were 

administrative in nature and could feasibly be assigned 

to qualified AN officers within other AN specialty 

nursing practice areas. By recoding these positions 

from 66H to 66N (Operational Nursing), the best qualified officer leader from any AN AOC could be assigned to the position. From a career life-cycle perspective, conversion of senior level positions to 66N opens 

advanced leadership opportunities to AN officers who 

may have felt constrained by the limited number of 

senior positions identified within their respective specialty areas. Positions requiring specific clinical capabilities are not affected by this initiative. This same 

collaborative process will be used to examine the other 

office grades and AOCs within each facility defined by 

a table of distribution and allowances (TDA). 

Additionally, through a work group led by the MEDCOM Decision Support Cell, the nursing requirements 

for several inpatient units within TDA facilities were 

examined to ensure optimization of nursing personnel 

resources based upon workload and changes in 

AMEDD missions. This optimization study provided 

recommendations to the senior AMEDD leadership for 

reallocation of nursing assets to best support the 

corporate AMEDD mission and clinical skills needed 

by AN officers when supporting Army missions. The 

findings of the recent optimization study have been 

incorporated in the decision-making processes of the 

2011 Human Capital Distribution Conference. 

While the AN Personnel Proponent Officer and AN 

CSBPO are primarily focused on future structure and 

training requirements, the roles also intersect with the 

MEDCOM Manpower Division as they examine current manpower requirements and authorizations. Recently, the AN CSBPO joined the Manpower Division 

in an examination of nursing administrative staffing 

models for clinical inquiry cells, research nurses, nurse 

methods analysts, and clinical nurse specialists. While 

currently not approved for implementation, the 

initiative would establish the nursing requirements to 

support the AN Corps Chief’s implementation of the 

Patient CaringTouch System—the Army Nursing 

model for standardization of nursing practice—which 

dovetails with The Surgeon General’s “Culture of 

Trust” imperative. 

In order to build an Army Nurse Corps that can 

support both the garrison healthcare missions and 

wartime healthcare requirements in theaters of 

operation, the AN CSBPO role includes assessment of 

theater lessons learned to revise force structure and 

training strategies as indicated. An example of the role 

Using Force Structure Analysis to Drive Transformation 

Grade and Year Group 

COL

LTC

MAJ

CPT

1LT

OFM

2LT

60 

50 

40 

30 

20 

10 

0 

Personnel Strength 

Figure 4. The optimal Army National Guard AN Corps personnel strength recommended by the Objective Force Model plotted 

against the Army National Guard strength numbers by grade and year group. Data as of September 2010. Source: Total Army 

Personnel Database-G. 
 October-December 2011 87

THE ARMY MEDICAL DEPARTMENT JOURNAL

of the AN CSBPO and AN Personnel Proponent 

Officer in deployment related issues is drawn from 

Corps experiences in 2009. During a Corps update 

brief to the Chief, Army Nurse Corps, the Emergency 

Nurse Consultant to The Surgeon General identified 

significant shortfalls in the distributable inventory of 

qualified 66HM5 (Emergency Nursing) officers. This 

shortfall was exacerbated by the significant 

deployment requirements in support of both Operation 

Iraqi Freedom and Operation Enduring Freedom, 

which presented the potential for 66HM5 officers to be 

redeployed earlier than the allocated “dwell time” 

between theater deployments. The Consultant’s 

concerns led to an intensive analysis of 66HM5 and 

66H8A (Critical Care Nursing) inventory, annual 

training requirements, and retention issues. Key 

problem areas were identified, including “masked 

losses” of these 2 specialty areas to other AOCs, 

specifically 66F (Nurse Anesthetist) and 66P (Family 

Nurse Practitioner), and a proportionally greater loss 

of 66HM5 and 66H8A from the Army Nurse Corps at 

the end of initial service obligations. The analysis also 

revealed a need for additional annual training seats, 

especially within the 66HM5 Emergency Nursing 

Course. In addition, the staff of the Human Resource 

Command AN Branch identified a substantial waiting 

list of applicants for the 66HM5 Emergency Nursing 

Course. The AN CSBPO and AN Personnel Proponent 

Officer expanded the personnel force structure 

analyses to determine inventory shortfalls for both 

66H8A and 66HM5 personnel. While past models 

examined AOC inventory, in this case, for the total 

66H Medical Surgical Nurse population, the skill 

identifier-specific model (coined “school seat models” 

by APPD) scrutinized losses of the skill identifiers 

66H8A and 66HM5 populations. The AN Personnel 

Proponent Officer also added an additional consideration in the model which examined the previously 

unaccounted losses of these 2 skill identifier specialty 

populations as they transitioned into other AOCs. 

With the information derived from the analytical 

modeling and the identified inventory shortfalls, the 

AN CSBPO and AN Personnel Proponent Officer coordinated with the AMEDDC&S Department of Nursing 

Science (DNS) to examine current training strategies 

and training seats for the 2 specialty courses. The DNS 

identified a training capacity constraint within the 

66HM5 Emergency Nursing Course which was conducted only at the Brooke Army Medical Center. 

Based on this assessment, DNS prepared a business 

case analysis in coordination with nursing leadership 

at Madigan Army Medical Center to open a second 

Emergency Nursing Course. The AMEDDC&S approved the initial pilot funding, and the first 66HM5 

course began at Madigan in the fall of 2010. A second 

business case analysis for sustained funding of the 

Madigan 66HM5 course received funding approval in 

November 2010. This initiative doubles the number of 

66HM5 graduates per year, thus expanding the available inventory of 66HM5 nursing personnel for garrison military treatment facilities as well as deployed 

combat support hospitals and forward surgical teams. 

The above initiative was implemented to resolve the 

current shortfalls in distributable inventory, while the 

AN CSBPO, AN Personnel Proponent Officer, and 

DNS work to develop a long term strategy for both the 

66H8A and 66HM5 programs. One of the proposals 

considered by the AN Corps Chief is the creation of an 

AOC that combines the 66H8A and 66HM5 

authorizations, thereby removing them from the 66H 

Medical Surgical Nurse AOC. The Critical Care 

Consultant to The Surgeon General, the Emergency 

Nursing Consultant to The Surgeon General, AN 

CSBPO, and DNS are examining core competency 

requirements and revisions of the current 66H8A and 

66HM5 specialty courses to ensure future applicability 

to all AMEDD and Army missions. The focus is on the 

ability of both specialty categories to provide expert 

patient care, whether in the emergency care or critical 

care environment. Based on theater lessons learned, a 

need for additional curriculum related to the patient 

movement/enroute care of critical care/trauma patients 

has been identified. This includes curriculum related to 

basic patient movement concepts for in-hospital 

transports (eg, to radiology for special procedures) or 

transports to other treatment facilities, and for ground 

or air transports within theaters of operation. This 

requirement is not intended to replace current enlisted 

Health Care Specialist (military occupational specialty 

68W) personnel. It is intended to ensure that 

hospitalized, stabilized, critically ill trauma patients 

(whether in a combat support hospital or forward 

surgical team facility) receive the same level of critical 

care when transported between military treatment 

facilities intratheater, or to Air Force strategic staging 

areas for air evacuation from the theater of operation. 

After consideration of the advantages of combining the 

66H8A and 66HM5 skill identifiers, the AN Corps 

Chief approved the proposal to integrate the critical 
88 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

care and emergency nursing specialties. That change 

process is now underway. The 2 specialties will be 

combined into an AOC titled “Trauma Nursing.” 

The DNS at AMEDDC&S is conducting a similar 

bottom-up review of all AN AOC, skill identifier, and 

professional leadership development courses within its 

purview. The objective is to ensure that the curriculum 

and training strategies for each program will support 

current and future healthcare mission requirements, 

thereby Envisioning The Future. 

Simultaneously, the Army Nurse Corps examined 

other AOC and skill identifier categories to determine 

the optimal alignment of specialty care nurses for 

future missions. Similar to the analyses conducted for 

the 66H8A and 66HM5 populations, the AN Personnel 

Proponent Officer reviewed the current 66G (ObstetricGynecologic Nurse), 66G8D (Nurse Midwife), 66C 

(Psychiatric Mental Health Nurse), and 66CM8 

(Psychiatric Nurse Practitioner) populations to determine if delineation of the advanced practice nurses 

(midwives and psychiatric nurse practitioners) as 

separate AOCs is a feasible course of action. The 

examination and analysis demonstrated that the 

establishment of separate AOCs for those advanced 

practitioners is warranted. As with the critical care and 

emergency care nursing populations, the actual 

distributable inventories of obstetrical/gynecological 

nurses and psychiatric mental health nurses are 

masked when a portion of the population is attending 

graduate training for advanced practice nursing roles. 

By separating the groups into distinct AOCs, the actual 

distributable inventory can be more easily tracked, 

while the required annual specialty training 

requirements can be adjusted to compensate for actual 

losses as nurses transition to advanced practice or 

other roles. Initial analysis indicates that the creation 

of separate AOCs retains promotion rates for each 

group within DOPMA guidelines. Additionally, 

monitoring of the actual distributable inventory would 

be enhanced to better support current and future 

missions. The Chief, Army Nurse Corps has approved 

the strategy to create these new AOCs, and APPD has 

prepared the required documentation. As this article is 

written, staffing of that documentation to all 

stakeholders is in progress.  

The Army Nurse Corps transformation includes 

development of personnel and training strategies 

congruent with future mission requirements. Through 

the analyses of personnel and operational data from 

multiple sources, and with the guidance of the AN 

Corps Chief and Deputy Corps Chief, the AN CSBPO 

and the AN Personnel Proponent Officer have 

established and codified administrative processes to 

ensure continuity, both now and beyond the transition 

of current staff officers from these positions. For the 

AN CSBPO and AN Personnel Proponent Officer, 

Envision The Future served as the mantra for transformation of the AN personnel force structure and training requirements in support of current and future 

healthcare missions in concert with the AN Corps 

Chief’s strategic vision. 

ACKNOWLEDGEMENTS

We thank LTC Gabriella Miller, Army Reserve Personnel Proponent Officer, and LTC Patricia Steinocher, 

Army National Guard Personnel Proponent Officer, for 

their input concerning the Reserve Component and the 

Army National Guard respectively. We also thank COL 

Kaylene Curtis and Mr Keith Parker for their reviews 

and recommendations in preparation of this article. 

REFERENCES

1. MEDCOM Regulation 10-2/OTSG Regulation 10-32: 

Organization and Functions, Headquarters, United 

States Army Medical Command. Fort Sam Houston, 

Texas: Headquarters, United States Army Medical 

Command; September 29, 2010. 

2. Army Regulation 600-3: The Army Personnel 

Development System. Washington, DC: US Dept of 

the Army; February 28, 2009. 

3. Army Regulation 5-22: The Army Force 

Modernization Proponent System. Washington, DC: 

US Dept of the Army; February 6, 2009. 

4. Army Regulation 350-1: Army Training and Leader 

Development. Washington, DC: US Dept of the 

Army; December 18, 2009:10. 

AUTHORS

When this article was written, COL Pierce was the Army 

Nurse Corps Specific Branch Proponency Officer, 

AMEDDC&S, Fort Sam Houston, Texas. 

COL Nickie-Green is the Army Nurse Corps Personnel 

Proponent Officer, AMEDD Personnel Proponent 

Directorate, AMEDDC&S, Fort Sam Houston, Texas. 

Using Force Structure Analysis to Drive Transformation 
 October-December 2011 89

Considering the changing market for registered nurses 

in the United States and the complex factors that 

influence decisions to remain on active duty, The 

Chief of the Army Nurse Corps, MG Horoho, noted at 

the beginning of her tenure that it was important to 

obtain data to support appropriate strategies to recruit 

military nurses. She tasked the nurse researchers to use 

data to evaluate our accession portals and make timely 

changes on how we recruit, retain, and incentivize 

nursing personnel to remain a part of our nursing team. 

Using evidence-based processes to evaluate the data 

allowed her to look at among whom, when, and where 

we have the greatest attrition, and how attrition is 

impacting the care we provide for our beneficiaries. 

This data assisted her in the development of a new 

recruiting strategy, called precision recruiting, 

whereby we are recruiting experienced medicalsurgical and specialty trained nurses from the civilian 

nursing population. This strategy has provided us with 

a balanced force of new nurse graduates with more 

experienced clinical nurses. Leveraging data allowed 

us to determine the need for precision recruiting, ie, 

targeted recruiting of critical low densities. As a result, 

we increased our recruitment of nurse anesthetists, 

behavioral health nurse practitioners, family health 

nurse practitioners, and critical skills such as 

emergency room and critical care trained nursing 

personnel. These skills are especially in high demand 

with our nation’s continued involvement in overseas 

contingency operations. Working closely with the 

Army Accessions Command, we are formulating a 

recruitment strategy that ensures a consistent pipeline 

of Reserve Officer Training Corps, Army Enlisted 

Commissioning Program, and Federal Nurse 

Commissioning Program graduates, balanced with 

direct accessions of experienced nursing personnel. 

In an evidenced-based approach to fulfill the recruiting 

mission for the Army Nurse Corps (ANC), the 

precision recruiting paradigm was developed and 

implemented for fiscal year 2011 and beyond. 

Precision recruiting is the key to optimizing the ANC 

capabilities and capacity to support current and future 

missions of the ANC and Army Medical Department 

(AMEDD). This precision recruiting paradigm is the 

future of AMEDD recruiting, and is vital to the future 

success of the AMEDD, in both the theatre of operations and in the garrison environment. According to 

COL R. S. Dingle, Commander, Medical Recruiting 

Brigade (MRB): 

Precision, whether in the MRB or nonprior service 

mission, is, bottom line, about filling a precise number 

of openings in the specific areas the Army needs filled, 

which greatly impacts Army operations. 

The impact of how we do precision recruiting is going 

to have second and third order effects from the point of 

injury...all the way back to the hospital. It’s incumbent 

upon us, as the Army’s medical recruiters, to fill those 

shortages so the AMEDD can execute its mission. If we 

don’t successfully execute precision recruiting, we will 

always have shortfalls within the Army Medical 

Department. 

Precision recruiting starts with the receipt of precise 

requirements. In the case of the ANC, the senior 

leadership takes into account the current shortfalls in 

the force structure, emerging initiatives and trends, and 

future needs associated with the ANC in establishing 

the specific requirements for the Corps. These 

requirements are the basis for the recruiting and 

accession missions for fiscal years 2011 and beyond 

for not only the Medical Recruiting Brigade, but also 

for the Army Cadet Command. The key Areas of 

Concentration (AOCs) for fiscal years 2011 and 2012 

are 66F (Nurse Anesthesia), 66P (Family Nurse Practitioner), 66E (Operating Room Nurse), 66CM8 (Psychiatric Nurse Practitioner), 66C (Psychiatric Nurse), 

66H8A (Critical Care Nurse), 66HM5 (Emergency 

Room Nurse), and 66G (OB/GYN Nurse). 

In addition to establishing the specific requirements, 

the senior ANC leadership, along with the Army 

Accessions Team, established incentives and other 

programs to support precision recruiting efforts. The 

Precision Recruiting: Building the 

 Optimal Army Nurse Corps 

LTC Anthony J. Bohlin, AN, USA 
90 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

Precision Course Guarantee program was added to the 

ANC recruiting toolkit in fiscal year 2011. This 

program allows nurses with one or more years of 

nursing experience to attend an AOC-producing course 

of their choice upon successful completion of the 

Basic Officer Leaders Course, with follow-on duty as 

a nurse in the chosen AOC. The AOCs offered under 

this pilot program were 66E, 66C, 66H8A, 66HM5 

and 66G. This program proved quite successful in 

recruiting and accessing 10 operating rooms nurses 

and 2 emergency room nurses for the ANC in fiscal 

year 2011. This course will continue in fiscal year 

2012 and will focus on the AOCs mentioned earlier. 

The Health Professional Scholarship Program (HPSP) 

was also extended to ANC recruiting efforts in support 

of the 66F, 66CM8, and 66P AOCs. In fiscal year 

2011, 2 individuals were recruited under this program 

for the 66CM8 and 66P AOCs. The HPSP will be 

extended to the 66F, 66CM8 and 66P AOCs for fiscal 

year 2012. 

The recruiting mission for fiscal year 2012 is more 

precise than in previous years. The 66F effort will 

increase to 10 applicants for the nurse anesthesia 

program, and 10 fully-qualified certified registered 

nurse anesthetists. The MRB will also have, for the 

first time, a mission for 66CM8. the psychiatric nurse 

practitioner population of providers are important 

members of the behavioral health team in both 

fulfilling the garrison and go-to-war missions of the 

ANC. With the increased demand for behavior health 

assets comes a greater demand for providers such as 

the psychiatric nurse practitioner. The MRB will have 

a 66CM8 goal of five in fiscal year 2012. The HPSP, 

as well as an accession bonus and loan repayment 

program, will assist the recruiting force in recruiting 

and accessing this high demand population. 

Precision recruiting impacts all aspects of AMEDD 

recruiting. Marketing and advertising strategies no 

longer focus on the ANC in general, but rather focus 

on specific ANC areas of concentration. The AMEDD 

recruiter also adapted their prospecting techniques and 

recruiting strategies in order to achieve this more 

precise mission. Precision recruiting requires the 

AMEDD recruiter to focus less on the student markets 

and more on the challenging working markets. As 

explained by MRB Command Sergeant Major Luther 

Legg III: 

Each of the AMEDD AOCs, including the ANC AOCs, 

has a different life cycle, and each phase of the life 

cycle requires a different message to show the Army’s 

benefit to the applicant. An example is the student nurse 

who will soon transition to practicing nurse has 

different concerns than a more seasoned practicing 

nurse. Likewise, a medical surgical nurse has different 

concerns than a nurse anesthetist or psychiatric nurse 

practitioner. 

These efforts are combined with those of the second 

leg of the Army Accessions team, the Reserve Officer 

Training Corps, through the US Army Cadet 

Command. The Cadet Command selectively recruits 

the highest quality future ANC officers from throughout the country. Its mission is to provide approximately 

95% of the generic baccalaureate (BSN) degreed 

nurses for the Army Nurse Corps and the AMEDD. 

This cohort of nurses come into the organization with 

a higher degree of proven military leadership skills 

than that typically found in our direct commissioned 

cohort. As part of the Army Accessions Command’s 

long-term effort to fill various AOC shortages, 

distinguished military graduates are granted generic 

course guarantees. After attending the clinical nurse 

transition program, they will be scheduled to attend 

one of the AOC-producing programs which should 

minimize our shortages over time. Precision recruiting 

provides for the conditions-based capability and 

capacity, as well as the talent the Army Nurse Corps 

needs, both for current operations and for future 

missions in the 21st century. 

AUTHOR

LTC Bohlin is the AMEDD Integration Officer, 

Directorate of Officer Accessions Coordination, US 

Army Accessions Command, Fort Knox, Kentucky. 

Precision Recruiting: Building the Optimal Army Nurse Corps 
 October-December 2011 91

THE ARMY MEDICAL DEPARTMENT JOURNAL

The headquarters and primary instructional facility of the Army 

Medical Department Center and School, located on the Military 

Medical Education and Training Campus, Fort Sam Houston, Texas. 
92 http://www.cs.amedd.army.mil/dasqaDocuments.aspx?type=1

THE US ARMY MEDICAL DEPARTMENT REGIMENT

The US Army Medical Department was formed on July 27, 1775, when the Continental Congress authorized a Medical 

Service for an army of 20,000 men. It created the Hospital Department and named Dr Benjamin Church of Boston as 

Director General and Chief Physician. On 14 April, 1818 the Congress passed an Act which reorganized the staff 

departments of the Army. The Act provided for a Medical Department to be headed by a Surgeon General. Dr Joseph 

Lovell, appointed Surgeon General of the United States Army in April 1818, was the first to hold this position in the new 

organization. The passage of this law marks the beginning of the modern Medical Department of the United States Army. 

Throughout its early history, the size and mission of the US Army Medical Department would wax and wane in response 

to military events around the world. There was, however, no formal regimental organization until World War I. Then, in 

the late 1950s, the brigade replaced the regiment as a tactical unit. In the reorganization that followed, some Army units 

lost their identity, their lineage, their history. This loss did not go unnoticed. The US Army Regimental System was 

created in 1981 to provide soldiers with continuous identification with a single regiment. Department of the Army 

Regulation 600-82, The US Army Regimental System, states the mission of the regiment is to enhance combat 

effectiveness through a framework that provides the opportunity for affiliation, develops loyalty and commitment, fosters 

a sense of belonging, improves unit esprit, and institutionalizes the war-fighting ethos. 

The US Army Medical Department Regiment was activated on July 28, 1986, during ceremonies at Fort Sam Houston in 

San Antonio, Texas, the “Home of Army Medicine.” Lieutenant General Quinn H. Becker, the US Army Surgeon 

General and AMEDD Regimental Commander, was the reviewing officer. He was joined by general officers of the US 

Army Reserves and the Army National Guard, representing the significant contributions and manpower of the reserve 

forces in the Total Army concept. 

INSIGNIA

The AMEDD Regimental Distinctive Insignia was designed by the Institute of Heraldry and is one of the oldest crests In 

the Army today. The 20 stars on the crest correspond to the number of states in the Union between December 10, 1817, 

and December 3, 1818. The origin of the crest dates from the Act of April 14, 1818, by which the Medical Department of 

the Army was first organized. 

The alternating red and white stripes on the left side of the shield are the 13 stripes of the American Flag. The green staff 

is the staff of Asclepius (according to Greek mythology, the first healer, the son of Apollo, the sun god); and green was a 

color associated with the Medical Corps during the last half of the 19th century. The phrase “To Conserve Fighting 

Strength” gives testimony to our mission as combat multipliers and guardians of our Nation's strength and peace. 

INFORMATION

The Regimental web site (http://ameddregiment.amedd.army.mil/default.asp) is designed to provide you with useful 

information about the US Army Medical Department (AMEDD) Regiment. Through the web site, you can learn the 

history of the AMEDD Regiment, the symbolism behind our heraldic items, how to wear the Regimental Distinctive 

insignia, and various programs available to you and your unit. 

The Office of the AMEDD Regiment is located in Aabel Hall, Building 2840, on Fort Sam Houston, Texas. The 

Regimental staff can provide further information pertaining to the history of the Army Medical Department and the 

AMEDD Regiment, and assist with any of the services described in the web page. 

For additional information please contact the Army Medical Department Regimental Office at the following address: 

Commander 

US Army Medical Department Regiment 

ATTN: MCCS-GAR 

2250 Stanley Road 

Fort Sam Houston, Texas 78234-6100 

The telephone number is (210) 221-8455 or DSN 471-8455, fax 8697. 

Internet: http://ameddregiment.amedd.army.mil/ 

Email: amedd.regiment@amedd.army.mil 
SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international 

military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, 

and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewed 

print medium to encourage dialogue concerning health care issues and initiatives. 

REVIEW POLICY

All manuscripts will be reviewed by the AMEDD Journal’s Editorial Review Board and, if required, forwarded to the appropriate 

subject matter expert for further review and assessment. 

IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST

1. Related to individual authors’ commitments: Each author is responsible for the full disclosure of all financial and personal 

relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state 

explicitly whether potential conflicts do or do not exist. Authors should do so in the manuscript on a conflict-of-interest 

notification section on the title page, providing additional detail, if necessary, in a cover letter that accompanies the 

manuscript. 

2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this 

assistance, if any. 

3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done 

so in the manuscript. 

4. Related to project support: Authors should describe the role of the study sponsor, if any, in study design; collection, analysis, 

and interpretation of data; writing the report; and the decision to submit the report for publication. If the supporting source

had no such involvement, the authors should so state. 

PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH

When reporting experiments on human subjects, authors must indicate whether the procedures followed were in accordance with 

the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki 

Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki 

Declaration, the authors must explain the rationale for their approach and demonstrate that the institutional review body 

explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether the 

institutional and national guide for the care and use of laboratory animals was followed. 

INFORMED CONSENT

Identifying information, including names, initials, or hospital numbers, should not be published in written descriptions, 

photographs, or pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives 

written informed consent for publication. Informed consent for this purpose requires that an identifiable patient be shown the 

manuscript to be published. Authors should disclose to these patients whether any potential identifiable material might be 

available via the Internet as well as in print after publication. Patient consent should be written and archived, either with the 

Journal, the authors, or both, as dictated by local regulations or laws. 

GUIDELINES FOR MANUSCRIPT SUBMISSIONS

1. Articles should be submitted in digital format (preferably an MS Word document on CD or floppy disk) with one printed copy of 

the manuscript. Ideally, a manuscript should be no longer than 24 double-spaced pages. However, exceptions will always be 

considered on a case-by-case basis. 

2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles 

should conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible. 

Inclusion of a list of article acronyms and abbreviations can be very helpful in the review process and is strongly encouraged.

3. A complete list of references cited in the article must be provided with the manuscript, with the following required data: 

 Reference citations of published articles must include the authors’ surnames and initials, article title, publication title, 

year of publication, volume, and page numbers. 

 Reference citations of books must include the authors’ surnames and initials, book title, volume and/or edition if 

appropriate, place of publication, publisher, year of copyright, and specific page numbers if cited. 

 Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying 

information as possible (location, dates, presenters, sponsors, titles). 

4. Either color or black and white photographs may be submitted with the manuscript. Color produces the best print reproduction

quality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, GIF, BMP) and MS Word 

photo files are preferred. Prints of photographs are acceptable. Please do not send photos embedded in PowerPoint. Images 

submitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of each 

photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and 

photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript. 

5. The authors’ names, ranks or academic/certification credentials, titles or positions, current unit of assignment, and contact 

information must be included on the title page of the manuscript. 

6. Submit manuscripts to: 

EDITOR, AMEDD JOURNAL

AHS CDD BLDG 4011 

2377 GREELEY RD STE T 

FORT SAM HOUSTON, TX 78234-7584 

DSN 471-6301 

Comm 210-221-6301 

Email: amedd.journal@amedd.army.mil