NBSIR 73-285 (yf

)

Structure Analysis and Program

Planning Study of the Army Nurse

Corps (ANCj

John W. Rowen, Ralph B. Swisher, Patsy B. Saunders

Technical Analysis Division

Institute for Applied Technology

National Bureau of Standards

Washington, D. C. 20234

October 1, 1973

Final Report: Project No. 431 4487

(The findings in this report are not to be construed as an official Department of the Army position.)

Prepared for The Department of the Army

Office of The Surgeon General

Washington, D. C. 20314

Part I

NBSIR 73-285

STRUCTURE ANALYSIS AND PROGRAM

PLANNING STUDY OF THE ARMY NURSE

CORPS (ANC)

John W. Rowen, Ralph B. Swisher, Patsy B. Saunders

Technical Analysis Division

Institute for Applied Technology

National Bureau of Standards

Washington, D. C. 20234

October 1, 1973

Final Report: Project No. 431 4487

(The findings in this report are not to be construed

as an official Department of the Army position.)

Prepared for The Department of the Army

Office of The Surgeon General

Washington, D. 0. 20314

Part I

U. S. DEPARTMENT OF COMMERCE, Frederick B. Dent, Secretary

NATIONAL BUREAU OF STANDARDS, Richard W. Roberts. Director
ACKNOWLEDC^IENTS

A number of persons contributed to the Structure Analysis and Program

Planning Study of the Army Nurse Corps. It would be virtually impossible

to acknowledge the efforts of all those who have supported the project and

study. The authors would, however, like to place on record their appreciation for the specific assistance of several individuals.

Colonel Irene R. Pishak served as the study sponsor's representative

during January through June 1972. Colonel D. S. Frazier assisted Colonel

Pishak and the National Bureau of Standards staff in the development of

the questionnaire and survey instruments . The authors particularly wish

to mention the support, suggestions and continuing guidance of Lieutenant

Colonel Cassandra M. Smith, who served as the sponsor's representative

during the period of June 1972 to October 1973, and who worked long and

hard to bring every phase of the study to successful completion.

A very special acknowledgment must go to Dr. Robert J. Cunitz, who

served as co-project leader (representing the Behavioral Sciences Program

Area) during the period January through August 1972 . During this time

Dr. Cunitz contributed much to the original study design, the development

and field validation of the survey instruments, and the format for final

data analysis and reporting.

Dr. Michael E. Thomas, currently Professor at the University of Florida,

and Dr. Neal D. Classman, now at the Office of Naval Research, both former

members of the Bureau staff, were instrumental in early stages of

development of the force structure simulation model. Dr. June R. Comog,

ii
Program Manager, TAD, for Behavioral Sciences, Elaine Bimten and Dr. Lynn

Llewellyn were all instrumental in formulating, testing and validating

the worldwide questionnaire and MEDDAC survey instruments.

The authors gratefully acknowledge the participation of the following

persons during the study:

9 Dr. Julius Lieblein and James A. Lechner, who wrote, edited, and

rewrote most of Section 4, Part I, and all of the statistical

sections in Annex II. Dr. Dennis Eisen provided support to those

sections in Part I dealing with the quality of patient care and

the treatment of the MEDDAC data.

• The authors were provided with programming support by Janet A.

Yellen, Elizabeth E. Leyendecker, Walter D. Urban, Richard H.

Jackson and John Scotch.

• Mary L. Friend, with the aid of Roy P. Mullinax, Carol R. Naas

and Arthur I. Cohen spent many hours in preparing drafts of the

final report for review and made a variety of contributions

including style, figures and format. Elizabeth A. Robertson

assisted in Behavioral Sciences tasks including those relating to

instrumental format development and validation, and supervising

the manual processing of questionnaire data.

• John C. Flannagan, Dr. Alan J. Goldman, and Peter W. Finkel all

read the entire report and spent many hours reviewing and discussing

all parts of the report with the authors. In addition, Mr. Finkel

assumed overall responsibility for the study in September 1972,

coordinating the efforts of his staff (Public Policy and Program

Analysis Area) , the Behavioral Sciences staff and interacting

with the sponsor.

iii
TABLE OF CONTENTS

: , > Part I , Page

1.0 Introduction 1-1

1.1 Study Goals , 1-2

1.1.1 Organization of Report 1-3

1.2 The Army Nurse Corps Force Structure

Model (ANCFSM) . 1-3

1.3 The Quality of Patient Care 1-4

l.If Data Base 1-5

1.5 Preface of Accomplishments, Findings,

and Results 1-5

1.5.1 The Force Structure Model 1-5

1.5.2 The MEDDAC 1-6

1.5.3 The Worldwide Questionnaire 1-7

2.0 Method and Issues 2-1

2.1 The Survey Instruments 2-3

2.2 Field Testing and Modification of

Questionnaires 2-4

2.3 Use of Models in Force Configuration

Analysis, Calculations, and Simulation. . . 2-6

3.0 Analysis of the ANC Worldwide Questionnaire. . . 3-1

3.1 The Corps in Profile 3-14

3.1.1 Age, Sex, and Grade Distribution . . 3-14

3.1.2-3 Marital Status and Dependents, . . 3-16

3.1.4 Professional Qualifications

(Education and MOS ) 3-16

3.1.5 Professional Orientation 3-1^

3.1.6 Programs Through Which Army Nurses

Enter the Corps 3-21

3.1.7 Regular Army Officer Patterns. , . , 3-21

3.2 Attrition, Personnel Policies, and

Attitudes Toward Aspects of Army Nursing. . 3-22

3.2.1 Response to Policy Proposals .... 3-27

3.2.2 Aspects of Army Nursing 3-43

3.3 Current Assignment 3-79

3.4 Assignment Preference 3-79

3.5 Summary of ANC Officer Worldwide

Questionnaire 3-^0

iv
Page

4.0 The MEDDAC - The Operating Environment of

the ANC 4-1

4.0.1 Original Survey Instruments 4-2

4.0.2 The MEDDAC Data Base 4-4

4.1 Staff/Workload/Quality-of -Care

Relationships 4-7

4.2 MEDDAC Relationships and the Army Nurse

Corps Force Structure Model 4-9

4.3 The MEDDAC Regression Model 4-10

4.4 Examples of Results 4-12

4-4.1 Several Variables 4-12

4.4.2 One Variable 4-14

4.4.3 The MCCU Variable 4-16

4.5 Data Analysis 4-19

4.5.1 Analysis of MOS Data 4-19

4.5.2 Graphical Relationships 4-26

4.5.3 Geographical Distribution 4-32

4.6 Quality of Care 4-34

4.6.1 Theory 4-35

4.6.2 Application 4-3^

5.0 ANC Force Structure Simulation Model (ANCFSM) . . 5-1

5.1 Input Data and Output Formats 5-3

5.2 ANCFSM Model Structure and Description. . . 5-10

5.3 Validation and Initial Results of

Simulation 5-15

6.0 Discussion and Conclusions 6-1

6.1 Future Uses of Models and Data 6-1

6.2 The ANC Force Structure Simulation Model. . 6-5

6.2.1 Model Projections of Future Staffs

Under Current Policy 6-5

6.2.2 Model Variables, Corps Profile, and

Policy Testing 6-6

6.3 The MEDDAC 6-?

6.3.1 Hospital Requirements 6-7

6.3.2 Quality of Patient Care 6-S

I

V
6.1\. The Worldwide Questionnaire 6-8

6.4.1 Retention—Staying or Leaving. . . . 6-8

6.4.2 Minimizing the Major

Dissatisfactions of ANC Officers • . 6-9

6.4.3 Nursing and Army -Wide Officer

Selection for Promotion. ...... 6-10

6.4.4 Professionalism: Military and

Nursing 6-12

6.5 Specific Configurations via Education

and Training. ....... 6-13

6.6 Accomplishments, Findings, and Conclusions. 6-15

6.6.1 The Force Structure Model 6-15

6.6.2 The Worldwide Questionnaire 6-17

6.6.3 The MEDDAC 6-18

vi
LIST OF FIGURES

Part I

Figure

' Number Title Page

2-1 ANC Promotion System 2-9

3-1 Professionalism in Nursing and the

Military 3-9

3-2 ANC Sex Distribution by Age 3-15

3-3 Primary MOS Distributed According to Sex,

Service Component, and B.S. Degree. . . . 3-1?

3-4 Staying or Leaving by Age 3-23

3-5 Program of Entry by Staying or Leaving. . 3-25

3-6 Four Patterns of ANC Response to Policy

Proposals by How They Feel About an Army

Career 3-29

3-7 How Army Nurses Feel About Staying or

Leaving Related to Whether They Agree

That Nursing Questions Are Settled by

Rank Instead of Professional Knowledge. . 3-46

3-S How Army Nurses Feel About Staying or

Leaving Related to Agreement with Assuming

Responsibility for Additional Medical

Procedures 3-55

3-9 ANC Feelings as to Whether Advancement

Depends Too Much on Formal Education

Related to Staying or Leaving 3-64

3-10 Whether ANC Officers Agree That They Do

Not Have Enough Opportunities for Direct

Patient Care Related to How They Feel

About Staying or Leaving 3-6S

3-11 How Army Nurses Feel About Staying or

Leaving Related to Whether They Agree That

the More Rank ANC Officers Obtain the More

They are Concerned with Promotion instead

of Patient Care • . . . 3-72

vii
Figure

Number Title Page

3-12 - Army Nurses Feelings about Staying or

Leaving Related to Agreement with

Dissatisfaction over Dependency and

Benefit Differences between Male and

Female Officers 3-76

4- 1 Three Variable Predictor Equation

for Nurses 4-13

4-2 Fitted Value of Number of Professional

Nurses (Single Variable) 4-15

4-3 • Old MCCU Predictor Equation 4-1?

4-4 New MCCU Predictor Equation 4-16

4-5 Requirements for MOS 3442 (Pediatrics). . 4-22

4-6 MEDDAC Mos Required Current and Future. . 4-24

4-7 Nurses vs. Number of Beds Staffed .... 4-2S

4-8 Nurses vs. Average Number of Beds

Occupied 4-29

4-9 Nurses vs. M.D.'s 4-30

4-10 Hospital Infection Rate vs. Hospital

Size 4-39

4-11 Average Stay, All Procedures

vs. Hospital Size 4-40

4-12 Average Stay, General Surgery,

vs. Hospital Size 4-41

4-13 Average Stay, Appendectomy,

vs. Hospital Size 4-42

4-14 Average Stay, Hernia, vs. Hospital Size . 4-43

4-15 Average Stay, Cholelithiasis,

vs. Hospital Size 4-44

viii
Figure

Number Title Page

i+-l6 Care Complaints vs. Hospital Size .... 4-45

4-1? Unusual Occurrences vs. Hospital Size . , 4-46

4-lS Quality of Patient Care, ANC Officers

Opinions vs. Hospital Size 4-47

4-19 Overall Quality of Care vs. Hospital

Size 4-49

4-20 Alternative Overall Quality of Care

vs. Hospital Size 4-52

4-21 Overall Quality of Care vs. Residual

Nurses 4-53

5-lA

5-lB

5-lC

5-lD

5-lE

5-2

5-3

5-4

Selected Sheets of Inputs and

Outputs of the ANCFSM

Overview of Steps in the Simulation

of ANCFSM

Projection of Structure of Corps —Total

ANC Officer Strength—Initial vs. 1975.

Projection of Structure of Corps —Army

Nurse Corps Profile

5-4

5-6

5-7

5-S

5-9

5-11

5-17

5-19

ix
LIST OF TABLES

. ' Part I

Table

Number Title Pag-e

3-1 . Measures of Personal and Professional

Orientation of Army Nurse Corps

Officers 3-19

3-2 Reasons for Joining the Army Nurse Corps

, and Reasons for Deciding to Stay 3-26

3-3 Interest in Clinical Nursing Courses

Reported by ANC Officers with Different

MOS's 3-i+l

If-l Data Matrix of MEDDAC in Columnar Format. . i+-5

4-2 MEDDAC MOS Requirements Compared with

Available Nurses (Under Two Specific

Policies) 4-21

4-3 ANC Duty MOS for All Registered Nurses

for Each MEDDAC 4-2?

4-4 Identification and Statistics of

MEDDAC Variables 4-33

4-5 Rank-Ordered Composite Quality of Care. . . 4-50

X
GLOSSARY OF ACRONYMS AND DEFINITIONS

AFMS - Active Federal Military Service

AFCS - Active Federal Commissioned Service

AHS - Army Health Service

AlVEDD - Army Medical Department

ANC - Army Nurse Corps

ANCFSM - Army Nurse Corps Force Structure Model

ASNP - Army Student Nurse Program

AUS - Army of the United States

BOD - Bed Occupied Days

Cat - A category of variables, viz., S, W, QC, OV

COIN - Contract Office Incentive Pay

Configuration - TO Strength

Command

Class I - MEDDAC under field commander

Class II - MEDDAC under surgeon general command

CONUS - Continental United States

COPO-11 Reports - Chief Of Personnel Operations, Report No.

Corps - Army Nurse Corps

DAC RN - Department of the Army Civilian Registered Nurse

DCSPER - Deputy Chief of Staff for Personnel

FCS - Federal Commissioned Service

FY - Fiscal Year

xi
IMPRESS - Interdisciplinary Machine Processing for Research and Education

in the Social Sciences

M^CU - Medical Care Composite Unit

MEDDAC - Medical Department Activities

MOS - Military Occupational Specialty

MRM - MEDDAC Regression Model

NBS - National Bureau of Standards

OTSG - Office of The Surgeon General

OV - Derived and Other Variables

PCS - Permanent Change of Station

PMOS - Primary Military Occupational Specialty

QC - Quality of Care Variables

QOC - Quality of Care

2 R - Correlation Coefficient

RA - Regular Army

RAP - Relative Attrition Propensities

RES - Reserve

RN - Registered Nurse

RNSP - Registered Nurse Student Program

S - Staff Variables

WRAIN - Walter Reed Army Institute of Nursing

TAD - Technical Analysis Division [of NBS)

TO - Table of Organization

TR - Turnover Rate

USAR - U.S. Army Reserve

Variable - A descriptive item of information in the MEDDAC Data Matrix

W - Workload Variables

xii
WW - Worldwide

WWQ - Worldwide Questionnaire
I* i \
STRUCTUEE ANALYSIS AND PROGRAM PLANNING STUDY ON THE ARMY NURSE CORPS

1.0 INTRODUCTION

This report presents an Army Nurse Corps (ANC) force structure plarming

model, an analysis of staffing in Army Medical Department Activities (MEDDAC)

,

and an attitudinal survey of Army nurses. The project was conducted by the

Technical Analysis Division (TAD) of the National Bureau of Standards (NBS)

for the Office of The Surgeon General (OTSG), U. S. Amy.

Contemplation during 1967-1970 of restructuring the Army Nurse Corps

led the Office of The Surgeon General and the Chief of the ANC to the concept

of a multipurpose Structure Analysis and Program Planning Study. In addition

to force structure planning, the effort would include a survey of the

activities, attitudes, and professional opinions of ANC officers; and a

survey of nursing personnel and hospital operations. The project was

conceived during a period of manpower transitions and changing personnel

policies. In 1967 Congress removed certain inequities and restrictions on

women officers, and after reaching a peak in 1967, the level of U. S.

military strength in Southeast Asia began to decrease.

Four principal components were developed by the project. The first

is an Army Nurse Corps Force Structure Model (ANCFSM) , a planning tool which

projects alternative future ANC configurations under given policy assumptions,

in terms of grade, military occupational specialty (MOS) , years of service,

and Regular Army (RA) , Reserve (USAR) , and Army of the U. S. (AUS) . The

second is an examination of the MEDDAC working environment obtained through

regression and correlation analyses which determine the sensitivity of

relationships among workload factors, staffing, and quality of care indicators.

The third component is the Army nurse attitudinal analysis focused on

1-1
factors affecting attrition, retention, and professionalism in the Army

nursing environment. The last component is an extensive computerized, and

easily accessible data base.

1. 1 Study Goals

The OTSG and the ANC are developing a range of nursing policies, plans, and

techniques related to six personnel management functions: recruitment, training

promotion, retention, separation, and retirement. The study was funded

under an approved OTSG program entitled "Structure Analysis and Program

Planning Study on the Army Nurse Corps." Representatives of OTSG indicated

several basic objectives:

1. Insight into important attitudes, preferences and responses of the

ANC to a wide range of proposals on personnel, policies and

professional qualifications;

2. Determination of the number of nursing personnel, by specialty,

that the U. S. Army utilizes, and the number available under

specific statements of policy;

3. Determination of policy alternatives which appear to offer the

most effective and efficient control of the recruitment, training,

promotion, retention, separation, and retirement of nursing

personnel ; and

4. Prediction of the effect and impact of specific policy alternatives

upon future ANC organization and activities.

These broad, complex goals were investigated at the detailed level of

career factors, grade structure, years of service, military occupational

specialties, staffing requirements of the medical department activities,

and other factors of the ANC. In order to meet these goals, NBS

undertook the following tasks:

1. Develop, test, distribute worldwide, and collect responses to a nursing questionnaire and a MEDDAC survey; prepare computerized

data bases of nursing personnel information and medical department

activities from the responses;

2. Analyze the responses and:

a) extract relationships between nursing personnel and their

activities, workloads, and other parameters, and

b) quantitatively describe the ANC Force Structure and the MEDDAC;

1-2
3. Construct and test a methodology using a simulation model which

will generate configurations of the ANC, under policy alternatives

for study.

1.1.1 Organization of Report

Tlie completed tasks of this study are described in Sections 2-5 and

the annexes and appendices to this report. The main results are summarized

in Section 1.5 of Part I. Section 2 discusses the issues to be

addressed and the methods and techniques developed for responding to these

questions. Section 3 is based on the analysis of data obtained in a

worldwide survey of all Army Nurse Corps officers as of September 1972.

The 50-page survey is an extensive questionnaire which covers some 500

items of interest, with responses from some 3,481 officers of the ANC.

Section 4 is a survey of the medical department activities, the organizational environment in which the nurses carry on their professional activities. The MEDDAC is comprised mainly of Army hospitals, dispensaries, and

troop medical and health clinics. Section 5 describes a computerized model

employing officer data and policy parameters (e.g., year-end strengths)

for calculating and simulating the available staff and its specific annual

changes in personnel. The annexes are found in Part II; Part III includes

a detailed description of the ANC Force Structure Model, and the Appendices.

1. 2 The Army Nurse Corps Force Structure Model (ANCFSM)

It is possible to develop alternative force structure configurations

under changing missions by use of the force structure flow model developed

in this study. However, it is first necessary that the systems analyst

comprehend the facets of the total nursing-grade structure system. This

system is complex with multiple causal forces, statutory regulations, and

1-3
individual officer decisions all interacting with each other and further

described in Annexes II -1 and II- 2.

The detailed computer program, ANCFSM, developed to capture the

significant factors, including Federal statutes, historical transfers in

MOS, Army components, and retention/separation states, integrates all the

factors into a simulation model which processes observed changes in the

force structure over a period of time. The model is discussed briefly in

Section 5, and in considerable detail (including programmer instructions)

in Part III. - "

1.3 The Quality of Patient Care

It is important to understand the relationship that may exist between

the force structure and overall quality of patient care. Tliat is, to what

extent does the overall quality of patient care vary with reductions or

additions to the ANC? Since it is not possible at this time to make

controlled experiments in this area, this question has been formulated along

the following lines: Are shortages or surpluses of professional nursing

staff, where observed, correlated in any way with individual and overall

indicators of quality of patient care used in this study?

To answer this question, it is necessary to arrive at a workable

definition of the overall quality of patient care as measured by the indicators of tliis study. This is done in Section 4.6 where a composite variable

approach is taken. There the overall quality of patient care and its components are studied as a function of a number of variables including

hospital size and apparent staff shortages and surpluses.

1-4
1.4 Data Base

An extensive data base has been created by this study. It is

accessible for a far greater range of analyses than were possible or

planned for this report. The data can also be used in conjunction with the

Officer Master File and Officer Separation File (described in Part III).

The data sets, in a sense, constitute a "snapshot" of the ANC and nursing

services and departments as of September 30, 1972.

1. 5 Preface of Accomplishments, Findings, and Results

The basic results of the study of the Army Nurse Corps can be

roughly grouped into three categories:

• The force structure model

•

' The MEDDAC—^the operating environment of the ANC

• The worldwide questionnaire

1.5.1 The Force Structure Model

The force structure model was designed as a planning tool for

forecasting future ANC configurations and officer shortages and surpluses,

collectively and by nursing specialty, under alternative policy

assumptions

• Annual Projections of the Force Structure Model

Certain accomplishments and results are indicated in this

introduction to the report. The characteristics of cohort

groups (groups of nurses with similar service characteristics)

of ANC officers comprising the force structure may now be

annually projected by a computer model designed and developed

at the NBS.

• Relative Attrition Propensities

It was found that attrition, a necessary subroutine in the

model required a special approach to minimize simulation

model differences with real world fluctuations. It was determined that relative attrition propensities (RAP's)

defined by a function of attrition rates are useful and in

1-5
agreement with recent historical data over the period of 1968-

1972. However the RAP's must be used cautiously, further

,t ; ; validated with 1973 data, when available, and further updated

with the new data made available each year.

• Preliminary Trends in Annual Simulations with Specific "Reduction

m Force" Scenarios

Although the computer model has been operated numerous times,

and estimates of future shortages and surpluses in nursing

specialties have been observed and reported, time has not

permitted extensive research of the effects of changing parameters

which would operate under contract incentive scenarios.

However, in preliminary testing runs a scenario of "reduction

in force" for the next several years with low recruitment levels

created a small initial decrease in the number of officers with

less than one year of service. It was found that in the model's

graphical outputs, which display the force structure (number of

officers vs. years of service) for each year being simulated,

there appeared a "valley" which "moved" along the horizontal

axis (years of service) as the graphs were viewed in chronological

order. Mien the initial (1972) profile of these simulation runs was compared with profiles obtained for 1975 the most pronounced

effects of the reduction in force appeared in the 1975 profile

for officers with less than seven years of service. The profile

of officers with more than seven years of service was relatively

unaffected.

1.5.2 The MEDDAC

The MEDDAC analysis determined the sensitivity of relationships

among workloads, staff, quality of patient care indicators, and other

IVEDDAC- related variables.

« Increase in Future Hospital MPS Mismatches

Data supplied in the survey of over 70 U. S. Army hospitals

worldwide indicate a number of current mismatches between

hospital duty MOS's and ANC primary MOS's. Projections of

the force structure model indicate this degree of mismatch

will possibly widen in the next few years unless appropriate

policies of recruitment, training and retention are instituted.

• Fitted Relationships between Staff and Workload Variables

It was found possible to derive a wide range of fitted

relationships between staff and workload variables in Army

hospitals throughout the world.

1-6
• Bed Occupied Days (BOD) and Medical Care Composite Units (MCCU)

A reliable single indicator of staff requirements is the number

of bed occupied days at a given hospital. An improved weighting

of the four factors used in calculating the Medical Care

Composite Unit (MCCU) resulted in an increase in correlation

with nursing staff as- a variable.

• Patient Care, Hospital and Nursing Staff Sizes

The observed shortages or surpluses in nurses were found to

have little influence on, or correlation with, the study

indicators of the quality of patient care. On the other

hand, the overall quality of patient care, as measured by

the composite indicators of this study was found, in

general, to increase with decreasing hospital size,

1.5.3 The Worldwide Questionnaire

Analysis of the officers opinions on 48 proposals revealed those

salient proposals of interest to the ANC nurses. The analysis of other

parts of the worldwide questionnaire signalled the possibility of

continuing high attrition rates among junior ANC officers and revealed

the principal issues associated with Army nurses' decisions to leave the

service.

• Opinions on 48 Policy Proposals

ANC officers gave their opinions on 48 policy proposals.

Analysis showed that basic pay and major allowances and

benefits are especially important to those who expect to complete

a full career in the Army. Educational requirements and professional status as reflected in appointment criteria and professional pay are important to many, but relatively unimportant to

a substantial minority. The introduction of policies removing

inequities based on sex and marital status are highly important

to female officers. The most salient proposals in this category

deal with liberalizing maternity regulations and giving status

to civilian spouses of female officers as is the case with male

officers.

• Expectation of Staying or Leaving the ANC

Over 701 of all the younger nurses (20-24 year age group)

indicated a high expectation of leaving the service upon

completion of their obligation. The highest retention rate.

1-7
by an overwhelming margin, is among RN's who enter the service

through direct appointment from civilian status. ANC officers

view Army nursing as offering excellent professional opportunities,

but tend to view Army life and institutions, especially for female

officers, as including a number of frustrations and inequities.

Army Student Nurse Degree Programs

Army student nurse degree programs have lower retention rates

than the diploma program. The degree program improves career

opportunities and can therefore be assumed to result in greater

mobility.

Professionalism in the MEDDAC—A Dominant Issue

A dominant issue in attitudinal responses was a conflict between

professional nursing and military bureaucracy in the MEDDAC

environment. The higher the level of professional orientation

of an Army nurse the more difficult it becomes to adapt to the

system of rank, seniority, and authority in a military organization,

especially when that system overrides the nurse's professional

judgment.

The Generation Gap

Both junior and senior officers tend to feel there is a "generation

gap" or "communications gap." Most frequently emphasized issues

can be interpreted as junior officer reaction to the ways senior

officers have adapted to military life, and to changes in the kinds

of education and training nurses of differing ages experienced

at the beginning of their careers—and whether they show an interest in continuing to update their nursing skills and knowledge.

Administration, Facilities and Reputation of the ANC

Over half of those who expressed an opinion feel that the Army

hospital administration is generally competent, but not particularly

responsive to patient's needs. About the same proportion tend to

agree that the Army medical facilities and equipment are often

obsolete. From submitted material it was learned that most nurses agree that nursing services in their organization enjoy a good

reputation and that the quality of patient care is generally

good.

Expanded Nursing Role and Current Assignments

The nurses gave strong support to the expanded role of the

nurse and showed an interest in nurse clinician programs.

Analysis of questionnaire material related to individual skills

1-8
and current assignments revealed that about two -thirds o£ the

Corps believe that their present assignments utilize their

skills properly. Most of the Corps were satisfied with their

current work assignments and geographic locations, although a significant proportion indicated they were neither consulted

nor given their preference in their current assignments.

These results—the attitudinal analysis, the relationships resulting

from the MEDDAC statistics, and the force structure model—will enable

management planners to evaluate tlie future characteristics of the ANC as

specified by certain inputs and policies. It is anticipated that

management functions will encompass a wide range of military as well

as civilian manpower planning decisions with respect to recruitment,

training, retention, promotion, separation and retirement. The succeeding

sections of Part I, supported by Parts II and III and the data base,

provide a more detailed discussion of the study and its results.

1-9

2.0 METHOD AND ISSUES

A basic issue posed by the sponsor was the need to plan an Army

Nurse Corps force structure for the future, that is, to project the

configuration of the ANC (RA, USAR, and AUS conponents) by recruiting,

training, retaining, promoting, separating, and retiring ANC officers in

the various MOS's. A second issue of interest to the sponsor was the

relationship, if any, between the nursing staff and the workloads; a

third issue was the attitudes, preferences, and professional judgments

of the individual Array nurses.

Discussion of the three basic issues during the planning phase led

to additional specific and detailed related questions. Resolving the

questions further led to a clarification of their precise nature and

relationship to the major issues. These related functions tended to

affect the choice and development of the methods, techniques, and procedures used to answer the specific questions. Questions related to the

three basic issues are:

Category #1 - Organization of the Nurses (the Force Structure)

1. Is there an effective way to quantitatively describe the annual

changes in the ANC grade structure?

2. Is is possible to develop a model of the ANC which can generate

specific configurations?

3. How many lieutenants are required for initial entry by phased

year to attain and maintain a specific configuration?

4. How long will it take to achieve a specific configuration?

Category #2 - The Environments in Miich the Nurses Work (MEDDAC Data)

1. Miat is the effect of the hospital size and specific command

(Class I and Class II) on the nurse/workload relationships?

2. Is there an effect of the hospital size and hospital staff on

the quality of patient care?

3. Are there observable trends in the military/ci"vilian nurse MDS

ratio?

4. What is the correlation between workloads and the number of nurses required by the hospitals of the MEDDAC?

2-1
5. Given the current promotion, separation, and retirement policies,

will the number of nurses having specific primary NDS's and/or

categories of MDS be, in five years, less than or more than the

number required by the NEDDAC?

6. Will the attrition and retirement of current nurses in the ANC

result in an unacceptable military/civilian ratio in specific

instances?

7. Is it possible to identify, in the MEDDAC data matrix, a workload

quantity which correlates more highly with the required number of

nurses than does the currently enployed I^dical Care Conposite

Unit (MCCU)?

Category # 5 - Attitude Questions (Worldwide Questionnaire)

1. How do ANC officers feel about an Army career?

2. What percentage of nurses with less than four years of service

plan to leave the service?

3. Why will they leave or remain in the service?

4. What can OTSG do to diminish attrition and to retain needed

nurses?

One technique developed in the course of this study for answering

questions in both the force structure and nursing environment categories

above is, as mentioned earlier, a simulation model. The model will

answer several "what if" questions in testing and evaluating proposed

changes in regulations and trends. For example, the model can be used

to determine the configuration of the ANC projected for five years when:

(1) promotions are delayed by one year and (2) attrition increases by a

certain percentage. It can also be used to project the important profile

(officers vs. years of service) when obligations are extended under incentive

contracts. Finally, it can project the ANC configuration when the number

of Regular Army appointees are increased by specified increments over

a fixed time interval.

2-2
2.1 The Survey Instruments

Mien restructuring of the Army Nurse Corps was being contenplated,

it seemed appropriate to the OTSG and to the Chief of ANC to investigate

the current attitudes of ANC officers towards many issues that would

affect their welfare and working environment. As a result, ANC headquarters personnel began to assemble a list of questions that would form

the basis for a survey of nurses' opinions. After two years of work,

which included many conferences with and reviews by chief nurses of the

MEDDAC, a structured information requirements schedule was ready. The

instruments were to include not only nurses' preferences with regard to

various policy and usage changes but were also for validating the information in automated personnel files.

The instruments were to obtain information about the attraction

value of various recruitment methods, to determine educational interests

of ANC officers (both for additional, specialized nursing skills and for

general background, degree- directed course work) , to obtain some measure

of the interest among certain groups of nurses in an Army career, and

to characterize those persons most likely to be interested in such a

career. Many management and military policies were also broached for

consideration to determine officers' attitudes and how these might affect

an officer's intent to remain in the service.

Data collected by NBS from the MEDDAC and from individual ANC

officers were obtained through mailed questionnaires. The Survey of

Nursing Personnel questionnaires were designed for conpletion by MEDDAC

staff to furnish aggregate data on all nursing personnel and their organization

2-3
and workloads, and to provide input for the development o£ indicators of

the quality of patient care. The ANC epaestionnaire was conpleted by

virtually all officers of the Corps who had served at least one month of

a normal tour of duty after completing officer basic training.

The data obtained from the two kinds of NBS survey instruments and

the Army data systems were combined for utilization in the model. Along

with the data set created for attitudinal analysis, they constitute a

large and valuable data base not only for the present effort but also for

future analyses. Where necessary, data have been edited and, in some

cases, normalized for use in the force structure model.

2. 2 Field Testing and Modification of Questionnaires

When NBS was chosen as the task group to study the Army Nurse Corps,

the schedule of information requirements was sent to the TAD Behavioral

Science group to serve as a guide for the two kinds of final data collection

instruments: (1) the Army Nurse Corps Officers worldwide (WV) questionnaire,

to be answered by every ANC officer, and (2) the Administrative Survey

of Nursing Personnel, to be completed by MEDDAC staff reporting on hospital

organization and facilities, staffing of nursing services, patient and

training workload, and indications of the quality of patient care.

The following sequence of steps was then taken to obtain the survey

data needed for the study:

(A) The original questionnaires were pre- tested in January 1972 on

a small sample of nurses at two hospitals to determine the

effectiveness of question formats and whether the kinds of

answers received would provide the information desired.

As is to be expected in any kind of survey work, results of this

field test indicated a need for revisions to the survey instruments.

(B) Representatives of ANC Headquarters staff met with the NBS social

scientists to modify the questionnaires. All items retained

2-4
fulfilled the criteria: Who wants to know this? What level

of priority does the information have? How will the answers be used?

Items with low priority or of interest but not of consequence

were discarded in an effort to shorten the form, which originally

required two to four hours for completion.

(C) Tlie revised questionnaires were pre- tested in April 1972 on a worldwide sample of 12 hospitals, four each in the Orient,

Europe, and the U.S. These applications clearly indicated the

need for further revisions. The questionnaires were revised

with extensive interaction between sponsor representatives and

the NBS personnel who had done the pre- testing. Approval for

changes was obtained from ANC before fielding the instruments

again.

(D) The questionnaires were validation- tested in early August 1972 on nurses at two Army hospitals in the U.S. Final revisions

were conpleted by the end of August 1972.

(E) The full survey was launched in September 1972, when questionnaire

parcels were mailed to non-ANC officers in all hospitals. These

individuals had been designated as project controllers who would

supervise the distribution of the questionnaires. Sections of

the Survey of Nursing Personnel were given to appropriate MEDDAC

staff members. ANC WW questionnaires were distributed to all

Army nurses. Their personnel records were made available for

reference in answering questions. The completed ANC WW questionnaire

was individually mailed to NBS by the respondent, a measure adopted

to preserve the anonymity of all nurses. Project controllers

collected a tally form for each questionnaire completed.

Individual officers were asked to respond to attitude and activity

questions in terms of their current assignments. All information was

requested as of September 30, 1972, even though a few questionnaires were

not completed until November of that year. Completed forms were received

from virtually all nurses.

(F) After a majority of the questionnaires had been received, NBS

representatives visited three hospitals in the U.S. and three in

Germany during November and December 1972. These visits were to

validate the manner of data collection and to insure the understanding of selected questions on the worldwide survey.

(G) Responses from the returned questionnaires were key-punched.

Members of the NBS staff compiled, edited, and corrected the

data to produce the Army Nurse Corps Officer File. All elements

2-5
of the file were categorized and cross -tabulated by use of

the IMPRESS (Interdisciplinary Machine Processing for Research

and Education in the Social Sciences) , a computerized system

maintained at Dartmouth College Kiewit Computer Center.

The basic information requirements had been established by ANC

Headquarters personnel prior to the time NBS began work on the study.

NBS made a contribution in those areas of the final questionnaire devoted

to measuring professional values of MC officers. NBS was also responsible

for streamlining the format, eliminating certain low-priority items, and

pulling the schedule together into a unified whole.

The results of the individual officer's questionnaire proAn.de a valid

accounting of the attitudes, opinions, preferences, and reactions of all

ANC personnel to a wide variety of Am^ policies and projected management

activities. The information is provided by rank, age, sex, NDS code, and

conponent (RA, USAR, AUS) . The data were cross-referenced so that

opinions of small cohort groups can be retrieved. For exanple, if there

is a need to know how male anesthetists with the rank of major feel about

increased subsistence pay for overseas areas, this detail can be recovered.

Analysis of the data from the questionnaires is discussed in much greater

depth in Section 3.

2.3 Use of Models in Force Configuration Analysis, Calculations, and

Simulation

This section introduces the future structure of the ANC and describes,

in nontedmical terms, the effects of the statutory and regulatory policies,

recruitment, training, promotions, changes in MDS, separations, retirements,

and other factors upon the structure of the ANC. These career factors

2-6
profoundly inpact upon the ANC leadership and nursing skills , thus directly

influencing the quality of patient care (discussed in depth in Section 4.6).

Rules and precepts characterize the real flow of manpower through

the ranks. An Army officer's career through the ranks and through

specialized training is determined not only be legislative statutes (10

U.S.C.A. § 3001), but in large part by the individual officer's capabilities

and experience. Some aspects of an officer's service are controlled by

legislative requirements and by specific policies iirposed by the Deputy

Chief of Staff for Personnel (DCSPER) . For exanple , DCSPER sets the zone

of consideration, the all-inportant promotion points and the year-end

strength. These rules alone do not directly provide for modelling,

training opportunities, voluntary transfer (e.g., from USAR to RA, from

one NDS to another) , or attrition rates (voluntary separation or retirement) .

The force structure simulation model utilizes the rules of these

categories of precepts. The first category consists of the statutes and

regulations. The second category includes budgetary constraints and annual

policies made by DCSPER, GTSG, and/or any other policy-making groups such

as the Secretary of the Army, DOD, Congress and 0MB. The third category

consists of the historical data, properly normalized, and extrapolated

into the near future. After this third category has been properly built

into the model, annual forecasting is inproved by incorporating the latest

extrapolations into the input data.

The career flow of an ANC officer usually begins with the rank of

lieutenant, moving steadily in an orderly progression through tiv^o or all

of three systems—RA, USAR, and AUS—until the officer is eventually

2-7
retired. The steps encountered and promotions passed in the long (20-25

years) career of the officers are sketched in Figure 1 (taken from data

in Annex II-l). It is necessary that all steps of this process, including

the three component systems operated by the Army, described in Annex II-l

be understood so that a higher- level flow diagram of a simulation may be

prepared. When the calculations involve several thousand individual

officers for each annual projection, this becomes a very time-consuming

task. It has been reported that a minimum of 2,000 man hours was necessary

for the 1967 annual calculation for officers' projection for DCSPER.—

The model ANCFSM described in this report uses data obtained by

computer extraction of pertinent information from the OTSG Officer I4aster

File and/or from the worldwide questionnaire. The input data usually

permits the model to present the composition of the Corps in terms of

component, permanent and temporary grade, time in permanent

and teirporary grade, and primary WS,

The reader will become aware of both the potential and flexibility

of the model as a tool. It can and should be modified to approximate

any number of situations of interest to the ANC and OTSG. The model can

be only as accurate as the input parameters, data, coded regulations, and

policies. Since it is impossible to determine exact values for future

parameters, it is wise to exercise the model several times, permitting

parameters of interest to assume several values within a reasonable range.

— Leon W. Transeau, User's Guide to a Computer MDdel for Projecting the

Impact of Officer Procurement, Promotion, and Retention Policies, Research

Analysis Corporation, McLean, Virginia, December 1967.

2-8
m PROMOTION SYSTEM

3.0 ANALYSIS OF THE ANC WORLDWIDE QUESTIONNAIRE

Introduction

The voice of the Army Nurse Corps was heard through questionnaires

completed by 3,481 ANC officers in the fall of 1972. Respondents

answered nearly 400 questions concerning their attitudes and professional

judgements on many aspects of Army Nurse Corps service. In addition,

demographic and professional profile data was collected, as well as

information on inservice education and training and military status.

The Army Nurse Corps Officer Worldwide Questionnaire appears in

Annex II -7 of this report.

The principal thrust of the analysis relates the profile variables

to attitudes and professional judgements in order to understand better

what the members of the Corps are saying to the Office of Tlie Surgeon

General. The attitudinal analysis in this report focuses selectively

on data related to recruitment and retention of ANC officers. Part

of this data concerns ANC responses to some forty- eight current or

proposed policies, on which the Corps was asked to comment.

*With a few exceptions, questionnaires were completed during September.

Army nurses with less than one month on active duty assignment after

basic officer training were excluded from the analysis and are not

included in the 3,481 nuirfcer used in this report. This exclusion

introduces a slight systematic bias into the data, especially on demographic variables, since the excluded officers, approximately 300 in

number, would swell the reported numbers in the lower age categories,

lieutenant grades, the 3449 Primary Military Occupational Specialty

(PMOS), and those with not more than 3 1/2 years service.

3-1
Implications of ANC Attitudes for the Future Composition of the Corps

The feasibility of linking the attitudinal data from Army nurses with

the projections of the force structure model (ANCFSM) using the Officer

Master File is one of the potentially valuable results of this project. The

linkage allows analysis of the responses of officers to policy changes, that

is, permits analyses that include comparisons of ANC officer responses to

policies that would be implemented, perhaps to achieve an alternative force

structure.

Hie Army Nurse Corps Force Structure Model, presented in Section 5,

is a planning tool designed to simulate the effects of current trends and to

test the effects of changes in policy decisions on the future configuration

of the Corps. That is, what will current trends or trend alterations produce

in the future matrix of officer specialties and grades? The model, in other

words, is a force structure model responsive to policy decisions.

The interaction of transitions in manpower requirements, changing social

values, the attitudes of Army nurses, and the changing roles of different

members of the health professions, along with whatever other forces inpinge

on the process, will influence heavily the future of the Army Nurse Corps.

The interaction of policy and personal decisions governs the answers to

the questions: Who enters the Army Nurse Corps? Who remains, and for how

long? In what specialties do they qualify? Who leaves, and at what point

in their military careers?

3-2
In this section we focus on those themes that the individual ANC

officer data suggest would affect nurses' career decisions. This will

allow conparison with actual attrition propensities, and help to identify

means of influencing attrition.

Interpretation and Presentation

The analysis and interpretation of the individual officer data is

quite selective. The data base is exceptionally large and rich. The

scope of the analysis reported here was determined on the basis of

OTSG priorities and resource limitations.

The discussion of ANC officer responses is based on a virtually

100% response from the relevant population, and on a great number of

analytic tables—far too many to include in the main text.

Some explanations are in order for interpretations unaccompanied by

tables in the main text. First, although a large number of statistical

tests were made to measure the strength of variations among groups

of nurses with particular attributes, the probability that any but the

smallest variation is due to chance is ruled out because we have data

from virtually the entire corps of Army nurses who have service experience.

The statistical probability that any relationship reported is due to chance

is less than one in a thousand (p < .001) throughout Section 3. The

adequacy of the sample cannot be an issue.

Second, we have often used words instead of numbers to indicate the

approximate degree of difference between responses of different subgroups.

3-3
All of tlie responses to proposals and the general attitudinal data are

on a five point scale from strongly positive to strongly negative. We

usually speak of "very slight" differences \^/flen the responses of subgroups

vary by more than 5^ but less than 10%; "slight" differences if the

variation is more than 10% but less than 20%; "moderate" in the range

from 20-35%; "strong" when differences run from over 35% to around 55%;

and "very strong" or "intense" differences if the spread is about 60%

or more

However, these are not precise definitions, and other factors go into

the choice of terms. Interpretations consider the distribution between

moderate and strong points on the scale. More often than not findings

are based on several tables. The terms used reflect in part the

consistency of the variation between groups when a series of tables related to

the same independent variable form the basis of an interpretation.

Finally, the interpretation often considers the degree of variation

in relation to the context of the question. For example, a 20% difference

between the attitudes of two subgroups toward specific medical procedures

involved in the changing role of the nurse would be considered more

inportant than a 20% variation in the numbers in the subgroups who had

ever performed the procedure. Statistically, one figure is no more

significant than the other, but one is more noteworthy.

Principal Attitudinal Issues: Professionalism, Pay, and Inequities

The dominant issue that emerges from the attitudinal analysis is a

conflict of two fields of professionalism, nursing and military , and

3-4
between professionalism and bureaucracy in Army hospitals. The issue

is pervasive in the attitudinal data. The higher the level of professional

education and orientation a nurse achieves, the more difficult it becomes

to adapt to the system of rank and authority in the military bureaucracy,

especially when the system tends to use hierarchical authority to override

the professional judgement of the individual nurse.

The conflict between professional and bureaucratic norms arises from

the inlierent noncongruence of the hierarchical structure of authority on

the one hand and the division of tasks based on expertise on the other.

The problem is not unique to the Army or to the health professions. It

is, however, exacerbated by two characteristics of U. S. military institutions: The military bureaucracy is highly articulated in 1) the division

of labor and assignment of specific responsibility and accountability, and

2) the authority and mechanisms of control built into the hierarchical

system of command and control.

There is no single, definitive statement of what distinguishes a

profession from nonprofessional vocations, nor is there consensus on a

definition of nursing that clearly discriminates nursing from all other

health professions. For our purposes we can use prominent definitions

from military sociology and other literature concerning the professions

as operating definitions.

3-5
One definition of what constitutes a profession, prominently used

by military sociologists,* rests on three distinguishing characteristics:

expertise, responsibility, and corporateness. That is,

...The professional .. .is an expert with specialized knowledge

and skill in a significant field....

...the essential and general character of his service and his

monopoly of his skill inpose . . . the responsibility to perform

the service when required by society ... .The responsibility to

service and devotion to his skill furnish the professional

motive. Financial remuneration cannot be the primary aim of

the professional man qua professional man. . .

The members of a profession share a sense of organic unity

and consciousness of themselves as a group apart from laymen.

This collective sense has its origins in the lengthy discipline

and training necessary for professional conpetence, the common

bond of work, and the sharing of a unique social responsibility.

A fully consistent definition from the fields of education, health,

charitable professions, etc., used by William J, McGlothlin,** rests on

seven criteria: 1) intellectual, carrying personal responsibility for

choice and judgement; 2) learned, based on a body of knowledge; 3) practical, that is, applied; 4) possesses a body of techniques and skills;

5) is organized to foster the profession and regulate practitioners;

6) is guided by altruism or the professional motive; and 7) deals with

matters of great urgency and significance for society.

*Samuel P. Huntington, The Soldier and the State . (Cambridge: Harvard

University Press, 1957) , p.p. 7-11.

**William J. McGlothlin, The Professional Schools . New York: 1964, the

Center for Applied Research in Education, Inc. p.p. 3-4. McGlothlin draws

his first six criteria from Abraham Flexner, "Is Social Work a Profession?,"

Proceedings of the ^National Conference of Charities and Correction . Chicago: 1915, Hildmann Printing Co., p.p. 576-590.

3-6
Professor Huntington distinguishes the military from other professions

* in terms of principal function:

The direction, operation, and control of a human organization

whose primary function is the application of violence [in the

interests of national security] is the peculiar skill of the

[military] officer. . . . It distinguishes the military officer qua

military officer from the other specialists which exist in the

modem armed services. . .basically auxiliary vocations. . . (in)

relation to the expertise of the (military) officer...

The New York State Nurses Association gives this definition of

professional nursing:

The practice of the profession of nursing as a registered

professional nurse is defined as diagnosing and treating human

responses to actual or potential health problems through such

services as casefinding, health teaching, health counseling,

and provision of care supportive to or restorative of life and

well-being, and executing medical regimens prescribed by a licensed or otherwise legally authorized physician or dentist.

A nursing regimen shall be consistent with and shall not vary

any existing medical regimen.

For the special case of Army nursing, the subject of this report, the

application of the definition is directed toward the protection and

conservation of the fighting strength of the Army.

The conflict of nursing, as an auxiliary profession, with the

military profession and bureaucracy rests in part on the difference in

principal functions, in part on the varying modes of operation inherent in

differing sets of skills, and in part on the pervasive noncongruence

between professional expertise and hierarchical administrative authority

in a bureaucratic institutional setting.

The MEDDAC environment contains elements of both the military and

Og^. cit . , p. 12.

Report , The official newsletter of the New York State Nurses Association.

Vol. 4, No. 2 (March-April 1972) p. 2.

3-7
health professions. Military traditions of rank, discipline, and courtesy

prevail in tandem with the military organization's system of command authority.

Physicians command the health professions within the MEDDAC. Nurses

operate under domination of the military profession and the physician as

well as the bureaucracy. The inescapable clash of certain aspects of each

is exacerbated by the aspirations of the professionally oriented nurse

struggling for full professional status.

It is a complex issue that surfaces most directly in the matter of

professional competence versus rank and authority. None of the ensuing

discussion should be interpreted as saying that the military are opposed

to high professional standards in nursing. Rather, the conflict involves

noncongruent professional patterns of expertise and authority.

The pattern of professionalism emerges in a variety of ANC responses.

Here we have sketched only the broader frame of reference. The remainder

of Section 3 presents the responses to specific proposals and statements

about many aspects of Army nursing.

Professionalism is an unportant factor in two areas of general

importance to the future of the Corps: 1) retention of nurses with a highly

professional nursing orientation is assumed to be advantageous to the

delivery of the best possible health care for the Army; and 2) professionalism in the operational context in which nurses practice in the Army, along

witli organizational effectiveness in the Army should enhance the effectiveness of those who will provide the Army Nurse Corps with leadership in the

future. Figure 3-1 may be viewed as a. field portraying the two professional areas. The location of any nurse or cluster of nurses would be

3-8
MILITARY PROFESSIONALISM

LOW HIGH

FIGURE 3-1

3-9
a function of measures of professionalism in each—nursing and military.

The square is an abstraction of the relationship between the two dimensions.

(The shaded areas are for illustration only and do not present actual

'data.) Empirically, the outer circle probably bounds real cases, although

even within the circle nurses who are very low on both professional

dimensions are rare in the Army Nurse Corps data.

A general review of the data indicates that a high proportion of

nurses who rahk high on measures of nursing professionalism but low on

measures of military and organizational professionalism reflect their

professional mobility and are more likely to leave tlie service. These

nurses tend to have the baccalaureate, show great interest in continuing

professional education and specialization, in the nurse clinician

specialties, and in the expanded role of the nurse. They experience more

difficulty with the military system of rank and authority, and they feel

that promotions and advancement depend too little on professional

competence. Equal status with other groups in the health professions is

important to them.

There is a second group of nurses with high professional orientation

both as nurses and as members of the military system. They recognize

the conflict between the two but are committed to a career as an Army

nurse. They are also likely to have the B. S. degree, often earned

subsequent to a diploma, during their military career. They tend to be

RA, higher in rank, and are likely to feel that in important respects

military values and traditions reinforce the personal dedication needed

to bring forth the highest standards of nursing. They tend to believe

3-10
that the military offers excellent professional opportunities. This

group also wants equal status within the health professions. Within

this group there is considerable variation in opinion about the extent

to which the professional environment of the hospital should be

"demilitarized."

A broad third category of nurses tend to rank lower on both nursing

and military professionalism, angling across the diagram in Figure 3-1

but not falling into the extreme low positions in either quadrant. They

tend to be diploma nurses. Their values tend to be more narrowly focused

on nursing skills than on broader professional perspectives. Their

dedication to nursing tends to be quite high; the frame of reference within which they see their profession tends to be more limited. They tend

to accept the nurse's role as the handmaiden to the physician. In their

military career they are essentially adaptive. From the perspective of

the military system, they can expect timely promotions based on competent

performance.

The foregoing characterizations should be clearly understood as

reflecting aggregate and comparative tendencies only. A variety of

factors not analyzed in this study affect the decision of ANC officers to

choose an Army career or to serve only an initial tour.

The issue of nursing education, and tlie related issue of professional orientation, should be approached with particular caution.

Certainly, simplistic conclusions must be avoided.

Health care is a field of rapidly expanding technology that calls

for the development of new and enhanced skills. However, professionalism

calls for a broader and deeper basis for independent judgement and

3-11
decision; the more the development of the professional bases of decision

keep pace with skills and technology, the less likely it is that new

technology will be inappropriately delegated or utilized.

A principal difference between diploma and degree curricula has been

the relative emphasis on skill training in the former and the broader

interdisciplinary education in the latter. Baccalaureate education has

been seen as providing the individual with a broader base of knowledge

from which to draw in exercising professional judgement. The number of

variables which a nurse must consider in planning patient care, especially

in unfamiliar situations, suggests the need for this type of interdisciplinary approach. Additionally, baccalaureate education provides a

foundation for greater mobility entering into management, teaching, clinical

specialization and research. This preparation is in consonance with the

organizational expectations of nursing in the military. It is no accident,

then, that the baccalaureate degree or active work toward it, tends to be

correlated with a desire for greater professional autonomy and more equal

status for the nurse among health professions.

On the other hand, years of experience will often provide a more or

less comparable professional perspective, especially to a nurse who is

professionally active. Further, the professional motive, the desire to

help protect and preserve life and health, is a shared motivation important

to diploma and degree nurses alike. Finally, such other factors as

personality, opportunity, and socioeconomic origins normally influence

individual decisions and perspectives.

3-12
This report offers only a superficial analysis of the relationship

between the dimensions of professionalism on the one hand and the choice

of an Army nursing career on the other. Factors such as the higher

mobility of baccalaureate nurses, the relative attractiveness of an Army

career to young nurses during and following military involvement in

Southeast Asia, or the effects of social change are beyond the scope of

this study. However, it is safe to assume that those factors do also

affect decisions concerning a career in the Army Nurse Corps.

We have attempted to frame the basic issue that attitudinal data

indicate to be of most importance to the recruitment and retention of

individuals who would constitute a Corps of the highest professional

standards. There are other clusters of issues that are also of great

importance

.

The first of these pertain to financial considerations . For those

nurses who have decided on a career in Army nursing or are leaning

toward such a decision, financial aspects are very important. However,

they are not crucial for most ANC officers malcing the decision to stay

or leave. Only 21% of those definitely leaving agreed that pay and

allowances were a major influence in the decision, whereas 11% of those

definitely staying and 63% of those possibly staying agreed that these

financial considerations were a major influence.

Of great importance to a predominantly female Corps are inequities

based on sex. Although current events may have overtaken this study

with recent court decisions, there is nevertheless a legacy of inequities

clearly reflected in the responses. The issue is of the highest importance

to many of those definitely or possibly leaving the service.

3-13
We now turn to a more detailed ejcajuination of the data. The

remainder of this chapter presents, first, a basic profile of the Corps

demographic characteristics, military status, professional qualifications

3nd professional values. A discussion of ANC officers' feelings about

remaining in the Corps for a normal career is followed by analysis of

responses to the policy proposals and to various aspects of Army nursing.

The section proceeds to a summary of appeals that influenced the respondents

to join the Army and that are among reasons important to them if they

are considering staying in the service. Brief comments on satisfaction

with current assignments and on future assignment preferences conclude the

topics covered in this section.

3.1 The Corps in Profile

3.1.1 Age, Sex, and Grade Distribution

Over half of the Army Nurse Corps is under age 27 and approximately

75% of the Corps are female, as shown in Figure 3-2. The male '251 are

unevenly distributed by age and grade. While only 8.5% of the youngest

(age 20-24) and of the oldest (50 years of age and over) are male, the

middle group from 35-39 are evenly divided between men and women. In

actual numbers there are fewer men in the youngest category (20-24) than

in any other 5-year age agroup under 40, although there are almost twice

as many women in the 20-24 group as there are in the 25-29 bracket, which

is the next largest in size.

Not unexpectedly then, men constitute about one- third of the captains

and majors, which is about twice the proportion of males in the two lower

grades (lieutenants) and close to two and a half times the percentage of

male lieutenant colonels. There were no male respondents in the grade

of full colonel.

3-14
CM

I ro

3-15
3.1.2-3 Marital Status and Dependents

Forty-one percent of the Corps are married; equally, forty- two

percent claim dependents on their tax returns; however, twenty- five

percent report dependents that do not legally qualify as such under Army

regulations in force at the time of the survey.

Inequities based on the difference between legal and actual

dependency obligations appear to weigh most heavily against single women.

Approximately 150 single officers claim on their tax returns dependents who

are not recognized as such by the Army. Of these officers, 123 are single

women and 29 are single men. ; One hundred and fifteen men over age forty claimed one or more

dependents for tax purposes, compared to 106 women in the older age group.

Of the 484 single women claiming actual dependents (whether or not they

are recognized as such by either the Internal Revenue Service or the Army),

89% reported dependents not recognized by the Army; among single male

officers 83% also claimed such dependents. For married officers the comparable figures are 43% of the women in contrast to 21% of the men.

3.1.4 Professional Qualifications (Education and WS)

Education . Fifty- seven percent of respondents have completed the

B.S. or are working toward a baccalaureate degree.

General nursing is predominant in current work toward a baccalaureate

degree, followed by medical -surgical and anesthesia.

Seven out of every eight ANC officers expressed an interest in pursuing advanced clinical preparation in such courses as intensive care, nurse

clinician specialties, and anesthesiology.

Military Occupation Specialty . Figure 3-3 shows the distribution of

PMOS's according to sex, and RA or reserve component, and degree program

3-16
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education. Among RA men the greatest percentage, 36% each are anesthetists

and medical -surgical nurses (3448). Among women, the ratio of RA officers

to reserves is highest for the administrative MOS 3430 (54 RA/12 RES)

followed by anesthetists (3445) (43 RA/28 RES)

The distribution of male and female nurses among MOS's is markedly

different. Although men comprise only one quarter of the Corps, they

constitute just over three quarters of nurse anesthetists (MOS 3445) and

slightly over half of the neuropsychiatric nurses (MOS 3437).

Three quarters of the respondents say they are satisfied with their

present PM)S. Three closely grouped sets express the greatest satisfaction: 3431 - Army Health Service nurses (94%) ; 3445 - nurse anesthetists

(94%); and 3430 - nurse administrators (93%). Only the first year, general

duty nurse (3449) was significantly below other M3S groups at 45%. Other

than 3449s, the lowest level of satisfaction reported was at 78% by

medical -surgical nurses (3448).

3.1.5 Professional Orientation

The analysis included a set of 21 questions designed to determine

what aspects of Army nursing and personal-professional image were of

greatest importance to ANC officers. (See Table 1.) Questions were divided

into two sets, one tending to reflect the tone of an autonomous person and

the other reflecting greater concern for the opinion or appreciation of

others. In general, three quarters of the Corps chose responses stated

in autonomous or self-reliant terms; only six percent chose the referentoriented answers, and nineteen percent* gave mixed choices.

*These questions were selected as a general set of indicators, and would

require retesting and refinement to quality as a valid and reliable scale.

3-18
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3-19
Further ajialysis indicated that female officers appear to be slightly

more independent and self-assertive than males [11% to 68%). The greatest

contrast emerges within the older group of nurses with no dependents (80%

female to 64% male.) Among MOS groups the greatest autonomy is shown by

Army Ifealth Service nurses (3431 = 82%) and nurse administrators (3430 = 81%),

while nurse anesthetists (3445) were least autonomous at 70%. None of

these variations, however, change the dominant self-reliance of Army nurses;

all groups appear substantially more self-reliant than dependent.

The specific aspects of nursing that respondents say are most important

probably approximate the image of the ideal nurse. In the seven item set

phrased in self-reliant or autonomous terms, these three elements received

unanfciguous choice as the three most important:

My own knowledge that I am giving good nursing care to my patients

My image of myself and the value of the work I do as a nurse;

Personal standards of performance that I set for the work I do.

These same values dominate when we look at the set of items stated more

in other-oriented terms:

Performance recognized as excellent.

Appreciation of patients for the care I give.

What other people think of me as a person.

Data was compiled which shows the number of times each item was chosen in

each rank order position, from 1_ to 7_.

In both cases, but especially among the autonomous set, career considerations and organizational aspects ranked well below the "good nurse"

image.

Organizational and professional items are slightly more in5)ortant to

the RA officer than to the Reserve. The orientation also varies moderately

3-20
(but significantly) for some MOS groups. For example, professional recognition is considerably higher and personal performance and professional

standards lower for nurse administrators and anesthetists in comparison

to others, but the opposite relationship holds for Army Health Service

nurses and psychiatric nurses. Other ^OS's range between the four mentioned.

Professional standards and recognition do tend to become more important

with age.

3.1.6 Programs Through Which Army Nurses Enter the Corps

The largest number of nurses in the Corps entered by a direct

commission. This is true for every MOS group except first year, general

duty nurses, the majority of whom do not remain after their first tour

of duty. Seventy- six percent of the first year nurses are from the

Student Nurse Programs (diploma and degree) . The highest proportions

of direct commissions are among nurse administrators (3430, 851) and nurse

anesthetists (3445, 64%). A higher proportion of Army Health Service

nurses come through the Army Student Nurse Degree Program (421) than do

any other MOS except 3449. Second highest in proportion, 25% of Army

Student Nurse Degree Program recruits are medical -surgical nurses (3448).

By a slight margin, the Walter Reed Army Institute of Nursing (WPAIN)

program also tends to bring nurses into the Army Health Service MOS (121

of WRAIN nurses), and that MOS is closely followed among WKLli nurses by

neuropsychiatric (10%) and pediatric nurses (9%)

.

3.1.7 Regular Array Officer Patterns

The 814 RA respondents became RA officers at the following grades

second lieutenant for 12%, first lieutenant in 37% of the cases, captain

for 46%, major for only 7%, and less than one percent (3 individuals) at

lieutenant colonel.

3-21
Fifty-three percent o£ the RA officers said counseling helped influence them to apply for an RA commission. Twenty- four percent of the USAR

officers who reported counseling by senior officers also said that the

counseling helped to influence them to apply for RA status. However,

most of these RES officers did not report applying for RA. Forty-six

percent of those who did report applying said their application was pending; 251 said they had not applied but still might.

The ages at which RA officers made the transition from the USAR

correspond to what would be expected from the transition by grade , as do

the years of service.

_ RA males dominate the nurse anesthetist MOS. The female RA officers

constitute a large percentage of the nurses in the following specialties:

nurse administrators, Army Health Service nursing, and operating room and

obstetrical nurses

3.2 Attrition, Personnel Policies, and Attitudes Toward Aspects of

Army Nursing

Staying or Leaving the Service . The questionnaire asked members to

indicate their present feelings toward "staying for twenty or more years

of active duty." This section discusses their answers and relates them

to other factors -- demographic, military status, their responses to policy

proposals, and general attitudes toward serving as an ANC officer.

As expected, those who say they are least likely to remain in the Army

are the youngest age group. Figure 3-4 reveals a high rate of expected

attrition among those officers in the youngest age groups. Only 1.3%

of the women in the 20 to 24 age group say they definitely intend to make

3-22
Age 50-81 Age 20-24

Stay = 98% |N = 129)

Lv = 3% (N = 4) Undec = 1% |N = 1) (Tota: N = ::^]

Age 45-49

Stay = 95% [N = 195)

Lv = 5% [N = 10)

Undec = 1% [N = 1) (Total N = 206)

Age 40-44

Stay = 90% |N = 244)

Lv = 5% (N = 13) Undec = 5% [N = 14)

(Total N = 271)

Stay - 13% (N = 161)

Lv = 68% (N = 864)

Undic = 19% (N = 241)

[Total N = 1266]

Age 35-39

Stay = 84% (N = 264)

Lv = 7% IN = 21) Undec = 9% (N = 28]

(Total N = 313]

Age 25-29

Stay = 43% [N = 321)

Lv = 36% |N = 274)

Undec = 21% (N = 158)

(Total N = 760)

Age 30-34

Stay = 76% (N = 347)

Lv = 11% (N = 51]

Undec = 14% (N = 62)

(Total N = 460)

(Percentages rounded)

Figyre 3-4.

staying

Leaving

j |

Undecided

3-23
a career of Anny nursing, and 9.71 say they will possibly stay, with another

18.31 undecided. Thirty eight percent of this age group say they will

definitely leave and 32% say they will possibly leave. The expected

retention figures increase rapidly in older age groups.

In this section we noted that there is a small number of male nurses

in the lower grades. However, those men who do obtain an ANC commission

are more likely to remain in the service for a full career. Retention

appears better among the younger groups of male officers. Male officers

in the oldest age groo^ are more likely to leave the Army, possibly

reflecting a willingness to begin a second career early (after 20 years)

in order to meet family obligations.

Respondents with service agreements in force (or which terminated in

1972) were, as expected, most certain about whether they were staying or

leaving; the closer the termination date the more sure they were of their

intentions. For example, 1972 service agreement terminations show 52%

definitely leaving and another 24% possibly leaving, 11% undecided, only

7% who will definitely stay and 6% possibly staying.

There is considerable variation among nurses who entered the Army

Nurse Corps through different programs with respect to staying in or

leaving the service. (Figure 3-5.) The greatest expected retention

rate appears to be among the direct appointments from civilian status,

and next highest among entrants through the Army Student Nurse Diploma

Program (ASNP: Diploma). Degree programs, such as Registered Nurse

3-24
ProfrM Bf Entry by Stayini or Leavinf

Othir Army Studsnt Nurse Program: Diploma

Stay = 72% (N = 28

Lv = 23% IN = 9) Undec = 5% [N = 2

I Total N = 39

Intirsirvlce Transfir

Stay = 70% (N = 12) Lv = 18% IN = 3) Undec = 12% (N = 2) (Total N = 17)

Direct Appointment from Civilian Status

Stay = 77% |N = 998)

Lv = 13% (N = 172) Undec = 9% |N = 121j (Total N = 1291)

Stay = 43% (N = 323)

Lv = 41% (N = 313) Undec = 16% (N = 120)

Total N = 758)

Army Student Nur$e Program: Degree

Stay = 24% (N = 224)

Lv = 57% (N = 527) Undec = IT/. (N = 181) (Total N = 932)

alter Reed Army institute of Nursing

Stay = 11% (N = 30)

Lv = 68% (N = 183) Undec = 21% (N = SI)

(Total N = 271)

Registered Nurse Student Program: Degree

Stay = 57% (N= 46)

Lv = 24% (N = 19] Undec = 20% (N = 16)

(Total N = 81)

(Percentages rounded)

Figure 3-5

Staying

Leaving

| |

Undecided \mf\

3-25
Student Degree Program (RNSP: Degree); and the Army Student Nurse Degree

Program (ASNP: Degree) reflect a lower expected retention rate.

A low proportion of all nurses who obtain their nurse's education

with the financial support of the Army are likely to serve more than

the required obligation incurred to obtain their education. Financial

assistance and security may be strong inducements for recruitment,

but retention among nurses entering through financial support programs

will remain low. However, those who leave active duty do help maintain

a reservoir of reserve nurses who could be recalled in a national

emergency

A review of expected retention rates among different MOS groups is

consistent with other factors. Nearly 93% of the nurse administrators,

71% of the nurse anesthetists and 63% of both the psychiatric and

operating room nurses expect to stay. The first two specialties tend

to be older, senior grade, RA officers. Other than first year, general

duty nurses (14% will or may stay) , pediatric nurses are lowest with

only 42% saying they will or may remain in the service.

Nurses were asked to give their reasons for staying in the Army if

they think they might remain. Up to three reasons were cited by each

respondent and the pattern is consistent among first, second, and third

reasons given. First among reasons given are pay, allowances and benefits,

followed closely by professional opportunity. Educational opportunity

ranked in the third position, and the belief that the Army would be a good

3-26
place to practice nursing placed fourth. Nurses were more inclined to

include "to serve my countr)'-" among their second and third reasons than

they were as a first reason. (Table 3-2)

The principal reasons ANC officers joined the Corps initially were,

above all, the opportunity the Army provided for obtaining a nursing

education (1029 nurses gave this reason) , followed by professional

opportunity (457 respondents) and the pay, allowances and benefits (406

nurses)

.

j^jTiiy Nurse Corps recruiting counselors are given unambiguous first

place among the sources of information that led Army nurses to apply for

an ANC appointment. A variety of other persons such as parents, friends,

family physicians, ministers, and nurses with previous military experience

comprise a strong second information source that led to joining the Corps,

followed by ANC recruiting mail or brochures

.

3.2.1 Response to Policy Proposals

We have mentioned that pay, allowances, and benefits were major

advantages to ANC officers if they decided to remain in the service. A

group of specific proposals were presented to the nurses concerning pay,

allowances, and benefits as well as others concerning educational qualifications, appointments and grade at the time of commissioning. Responses

were on a five point scale: major advantage, minor advantage, unimportant

minor disadvantage, and major disadvantage.

Figure 3-6 portrays four types of response patterns to the several

proposals: responses to basic economic issues, which tend to be most

3-27
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3-29
important to those staying in the Army; stronger reaction by those

leaving to issues that most affect the female nurses; reactions that are

stronger among those leaving which show a professional interest in

assuming new responsibilities for medical procedures formerly conducted

by physicians; and the pattern in response to a relatively trivial proposal

judged unimportant by Army nurses,

1. ) Pay, Allowances, and. Benefits

In this and succeeding subsections, responses to specific proposals

reflect the basic importance of pay and allowances to the career ANC

officer, as shown in Figure 3-6. All proposals received the endorsement

of the majority if they proposed to give ANC officers increases in pay,

allowances, or benefits. However, the margins of support and the variation between groups that would be most and least affected by the proposal

do vary between "gut" issues and minor benefits.

Compensatory time for extra hours is slightly more important to most

Army nurses than is differential pay for holidays , weekends and nights

Officers with dependents are more inclined to support compensatory time

proposals, while those without dependents are more likely to support

differential pay; the differences between the groups is in the order of

101.

Incentive pay for critical M)S's is favored by the Corps, with 901

of the nurse anesthetists but only 501 of the Army Health Service nurses

calling this a major advantage. Female nurse administrators (12^) are

the only group which sees incentive pay as a disadvantage.

3-30
It may be worth noting that two patterns surface intermittently

among the answers of nurse administrators. First, they appear to be the

only group whose responses to proposals visibly reflect awareness of

budgetary considerations or any limit on the nuntier of proposals that

could be implemented. Second, they are the most responsive to proposals

that will rectify inequities for other groups of nurses. Males,

especially older men, are least likely to be responsive if their own

interests are not directly involved. Finally, both sexes, while they

are in their thirties, are least responsive to the interests of other

groups of ANC officers, while nurses 4Q years of age and over tend to be

most responsive to proposals that would benefit other nurses but not

themselves.

A proposal for military nurses to receive the same pay as civilian

nurses tends to have a more even distribution from "advantage" to "disadvantage," perhaps reflecting the pay levels in the geographical areas best

known to respondents. The proposal tends to be supported most by nurse

anesthetists, by second lieutenants, and by older female nurses. Inclusion of all benefits in base pay appears to be the greatest

disadvantage to male nurses with civilian spouses and least important to

female nurses with military spouses

.

Pay and allowances rated slightly more inportant to FA officers

than to reserves as an influence to remain in the service.

By nearly twice the margin over reserves , RA officers feel that

early retirement with reduced pay would be a disadvantage. Further, the

more dependents the greater is the disadvantage. Older nurses in more

senior grades also consider this a greater disadvantage. It is only

3-31
slightly less disadvantageous to nurses with military spouses than to

those married to civilians, Interestingly, there is virtually no

difference between the responses of single officers and those with

civilian spouses. The oldest group see the proposal as only slightly

less disadvantageous , presumably because they feel less likely to be

affected by it. Finally, among younger age groups, the greater the

number of dependents, the higher the concern.

2.) Housing, Subsistence, Transportation, Dislocation

These proposals are also in the category of advantages but

not crucial criteria for choosing a nursing career in the Army. A proposal to adjust the off-post housing allowance to conform to local prices

in high cost areas was heavily endorsed by both married and single officers.

Of greatest importance to those 30 years of age or older, the proposal is

only slightly less advantageous to middle aged single officers than it is

to their married colleagues. The proposal to adjust the subsistence

allowance to the cost of living induced a parallel pattern of responses.

Among the least important issues is the proposal to pay transportation

costs to and from work. The importance attached to this item was lowest

among proposals included in the survey.

The proposal to give a permanent change of station dislocation

allocation allowance consistent with actual expenses was of less concern

to younger officers. A majority see it as advantageous, on the whole,

but not important.

The older the officer and the more dependents, the more important

is enough government housing for all officers . The issue is especially

3r32
important to the group aged 25 to 29 having four or more dependents, to

vdiomi heavy family expenses are particularly burdensome.

The proposal that all ranks should be given the option of off-post

housing was very strongly endorsed by all ages and ranks and by both sexes

,

with no group falling under 851 support.

3. ) Retention Bonus and Retention Pay

An annual retention bonus for ANC officers who extend their

service is least important to RA women and most important to male reserve

officers. However, the basic division is between RA women and others;

591 of RA females regard the proposal as a major advantage compared to

66% of the female reserves, 73% of the male RA's, and 78% of the male

reserve nurses

.

Special professional pay to ANC officers is, of course, favored.

Men regard the proposal as more important than women, with nurse administrators, anesthetists, and then operating room nurses leading, followed

closely by other specialties

.

A proposal to prorate professional pay to all of the AMEDD Corps

received a slightly lower vote, although all groups support the proposal

as a major advantage. The proposal has greatest support among nurse

anesthetists and least among pediatric nurses

.

4. ) Fringe Benefits

Fringe benefits as a whole do not receive the same level of

attributed importance as most of the other proposals. Even so, only

among reserves aged 35-39 with military spouses, and among reserves aged

50 or over with civilian spouses does the level of endorsement as a major

advantage fall below 50% to 39%.

3-33
These issues- -allowances , retention bonuses , and fringe benefits--

may have potential for prolonging a career, but are unlikely to make the

crucial difference in choosing a career with the ANC in many cases.

5.) Inequities Among .ANC

5a Sex . Proposals that touch on inequities between male and

female and between single and married officers tend to induce the greatest

variation between the responses of affected groups and those not affected

or less directly affected. Proposals in this area have potential for

increasing retention of female officers. For exanple, the proposal to

liberalize maternity regulations has only younger females , especially

married women, strongly in su^Dport.

Response to the proposal that female officers receive the same

survivor benefits as male officers shows a parallel pattern, although a

larger percentage in each age and sex group responded in strong support

of the proposal.

Interestingly, in both cases married females gave the strongest

support and married males the least, with unmarried groups falling between.

Greater agreement was found on the basis of sex than marital status.

The proposal to establish the same tour provisions for men and women

finds more support among older officers, most strongly among older women.

Younger women gave it the least support.

5b Marital Status and Dependents . Proposed government housing for

female nurses with civilian husbands receives least support from younger,

male officers and most support from married women. The proposal to give

the housing allowance to both husband arid wife if both are military is

3-34
naturally si^^ported most strongly by those who are directly affected,

those with military spouses . Single women support the proposal slightly

more than single men, and, in contrast, women with civilian husbands are

far more supportive than male ANC officers with civilian wives, by a

margin of 6A% to 29%.

Acconpanied tours for civilian husbands gets a resounding 93% vote

from women married to civilians, 82% with those married to military husbands,

74% from single women, but only 42% from male Army nurses with civilian

wives. Provisions of medical and dental services for civilian husbands

reflect approximately the same response pattern: 95% from- women with

civilian husbands, only 45% from men with civilian wives, and 54% from

single men. Permanent -change -of- station transportation allowance for

civilian husbands receives a similar response pattern from women, but this

time even less si:5)port was forthcoming from those unaffected by the proposal.

Further support to the proposal that husbands receive the same benefits as

wives of military men came from 96% of the ANC officers with civilian

husbands, but only 46% of the male nurses with civilian wives supported it.

The proposal to grant the same privileges for post recreation and

welfare activities to guests of single officers as to guests of married

officers is most important for older single officers. Only those over 30 --

both male and female -- register these privileges as a major advantage in

more than 50% of the cases. The proposal is generally rated as unimportant

compared to most of the proposals.

Extra pay if marital status or dependents do not limit geographic

assignments is another proposal that received only moderate siqDport compared

3-35
to most others. Generally, the proposal is more favored by males than

females. There is a slight tendency for single officers with from one

to three dependents to favor the proposal more than bachelors with no

dependents . The rationale here may be the same as the apparent reasons

for greater male support. That is, although male officers may have

dependents, their dependents are unlikely to limit their assignments. Age

also appears to influence the pattern of support, with little variation

between the sexes . Single MC officers in their thirties and forties

,

more likely to have peers with dependent minor children, tend to favor the

proposal more than their single colleagues in the youngest or oldest age

groups. To a slightly lesser degree, the same differences in response

pattern occur among married officers with from one to three dependents.

The related proposal to provide regulatory restrictions for those ANC

members whose marital status or dependent relationships do limit geographic

assignments received limited endorsement among most groups . Approximately

40 to 50% of older married officers said the proposal would be a major

advantage. Those with no dependents and male nurses were most likely to

approve

6.) Education Proposals

Education proposals touch directly on the professionalism issue.

Because educational qualifications vary among nurses, reactions to proposals

that would set stiffer requirements or demand additional educational achievement tend to divide the Corps. All such proposals received significant

opposition as well as strong support .

3-36
The continuing practice of appointing baccalaureate graduates at a

higher rank than graduates o£ other basic nursing programs was more often

considered a major advantage by the very youngest group, by the oldest

officers, by nurse administrators, Army Health Service nurses and obstetrical nurses among MDS groups, by those with the B.S. degree more than by

those with other qualifications, and was considered a major disadvantage

only by comparable numbers of those nurses without the baccalaureate.

A majority of only one groi^) -- diploma nurses who are also nurse

administrators -- said it would be a major advantage to limit direct ANC

commissions to licensed registered nurses with a baccalaureate degree . Amy Health Service diploma nurses also give a majority vote to the proposal

when those who say it would be a minor advantage are also counted. Nurses

over 40 years of age tend to see the proposal as more advantageous than do

younger nurses, perhaps because the senior nurses feel less likely to be

affected

.

The proposal to require nurses to acquire the B.S. before a specified

cut-off date received a generally similar response, although this proposal

has more support among younger nurses and reflects less divergence of

opinion among IDS groups than the direct commission proposal. The oldest

and the youngest respondents are more likely to agree with the cut-off

date proposal; those in their late twenties and thirties are less inclined

to see it as an advantage.

Hie proposal to require any ANC officer desiring to remain on active

duty longer than five years to obtain a B.S. degree or show satisfactory

coursework toward that end received less negative reaction than the

3-37
preceding proposals, which were similarly designed to encourage Army

nurses to acquire the baccalaureate. Positive responses also tended to

be moderate. Sixty percent of diploma nurses responded positively to the

proposal for a five year cutoff to acquire the baccalaureate; 30% said it

would be a disadvantage, and 101 said it was unimportant. Among all the

proposals designed to encourage acquisition of the B.S. degree, the five year

cutoff proposal received the greatest number of positive responses from

diploma nurses.

Regardless of whether they have already taken courses toward a degree,

nurses agree that it would be a major advantage to assign ANC officers where

they could attend civilian schools part-time in order to conplete the baccalaureate. Support is not affected appreciably by years of active federal

military service. However, those with 12 to 24 years service are slightly

more in favor of the proposal. Degree nurses see it as somewhat less of an

advantage than do nurses without the B.S. The number of credits already

earned appears to have almost no effect on the level of support.

ANC officers who received direct appointments were most likely to say

the proposal to eliminate subsidized education and to procure nurses by

direct appointment would be a major advantage. Opinion was more divided

among officers from other programs of entry, more officers responding that

the proposal is a disadvantage than an advantage, and the "unimportant"

category received more answers than any other.

There is a slight trend for those who have earned credits toward a

degree, and who will or might remain in the service, to say that granting

leave without pay to nurses who wish to attend school would be advantageous.

3-38
The fewer credits officers have already earned, the greater merit they

see to the proposal, but this trend is also slight.

Senior niirses are more likely to say they strongly disapprove of

the proposal to appoint two-year junior college associate degree graduates

as warrant officers in the ANC than are their younger colleagues, and women

are more inclined to disapprove than men among senior officers . Only

scattered and slight variations occur among MOS groups in responding to

the proposed warrant officer appointment. Nurse administrators. Army

Health Service nurses, and medical -surgical nurses are most opposed.

The alternative proposal to appoint such graduates to the ANC as

second lieutenants is most strongly disapproved by the nurse administrators,

and most intensely by male but not female second lieutenants. Although,

if the "strongly disapprove" and "disapprove" categories are combined, the

general percentages are the same for both sexes. There is apparently no

difference between the attitudes of diploma nurses and others.

The appointment of hospital diploma school graduate nurses as warrant

officers in the Army Nurse Corps is generally opposed by the Corps, although

Amy Health Service nurses tend to include a larger proportion who approve,

followed by first year, general duty nurses. ^'Iale second lieutenants

strongly disapprove, as do both male and female lieutenant colonels, in

coiiparison to the remaining grades.

Responses to proposals pertaining to educational qualifications and

grade of appointments indicate that advanced clinical preparation and

continuing education are more important to nurses on active duty than

3-39
educational qualifications for entry (unless the officer is in a group

threatened by one of the proposals) . About 86% of the Corps indicated an

active- interest in attending advanced clinical courses in nursing specialties (Table 3-3). About 2,000 of the 3,481 nurses have or are working on

baccalaureate degrees; 1,084 took courses within the past five years.

Approximately 1,875 nurses have a Bachelor degree in nursing, and another

150 nurses have Bachelor degrees in fields other than nursing. There are

400 nurses who have or are working on advanced degrees.

7.) Role Relations

Professional roles and reactions to proposals for change obviously

touch on professionalism and professional status perceptions. Responses

to proposals in this area are not clearcut measures of professionalism, but

they are indicators of professional perceptions

Training enlisted personnel to become physicians assistants in the

Airoy is unaffected by differences in ANC educational qualifications , is

slightly more favored by women tlian by male nurses , and supported more by

specialist MOS's than by generalists, with the major exception of first year,

general duty nurses. Except for the youngest group support for physicians

assistants varies little among different ages. V^Tien compared to two other

attitude questions about physicians assistants (orders from physicians

assistants to nurses and assigning to physicians assistants procedures

previously done by physicians themselves), negative reactions are consistent

in each case. However, it is interesting that those nurses who say they

like the expanded role of the Army nurse are also most likely to approve

of the role of the physicians assistants. The proposal to appoint physicians

3-40
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3-41
assistants as warrant officers in the Anny receives a nearly identical

pattern of support and opposition. However, the percentages :n favor of

the warrant officer appointment tend to be slightly lower across the board

than the proposal to train them for the role.

On the proposition that tJie authority of the Selective Service Act

should be extended to permit drafting any group of persons whose skills

are essential to the national health, safety arid interest , the Corps is

divided: 44% for, 32% against, and 24% say that the proposal is uninportant

to them. Nurse administrators and anesthetists are most likely to adhere

to the proposal, followed by neuropsydiiatric nurses. First year, general

duty nurses are least enthusiastic about the idea (only 19% approve).

In summary, nurses tend to support all proposals that accrue to

their benefit, and to endorse them more enthusiastically when the proposal

strikes at basic economic and professional interests and touches on the

rectification of inequities that affect them personally. They value

educational opportunity more than enforced education standards. Women

nurses are more responsive to inequities and hardships among their colleagues

than are the men, and thosp who a-re either in their t^^^enties or ^0

years of age and older are more responsive to the needs of other nurses

than are those in their thirties. The nurse administrator is the only

respondent that typically considers proposals in the light of scarce

resources and options; the anesthetist is least likely to identify with

the Corps as a whole, as is the older male officer, \ho dominates this

MOS field. The older nurses often see the enphasis on the B.S. as discriminatory, althou^ nurse administrators tend to support more strongly the

proposals to encourage the B.S. degree.

3-42
The next section discusses responses to general topics on aspects of

Army nursing, many of which are related to the proposals just considered

as well as to the principal themes: Professionalism; military life and

institutions; inequities based on sex and marital status; and pay, allowances and benefits.

3.2.2 Aspects of Army Nursing

This subsection reviews responses to one hundred and two statements on

various aspects of Army nursing. The statements include a broader range of

items than the proposals just discussed.

Half of the 102 statements are positive, worded in support of the Army,

AJ4EDD, and so forth, or supporting the status quo. The other 51 are phrased

negatively, critical of some aspect of Army nursing. Positive and negative

statements are divided as evenly as possible under each subtopic. The words

like "complaint" or "support" in the remainder of this section should be

interpreted in this context.

Opinions expressed by ANC officers will be related to three characteristics: A composite demographic profile (age: to 28/29 and over; sex;

dependents/no dependents) ; a composite military profile variable (less than/

over three and one half years commissioned service; RA/RES; and a statement

of how the respondent feels about choosing an Army nursing career. Responses

are on a five point scale: "Strongly agree," "agree," "no opinion," "disagree," and "strongly disagree." Two additional options, not on the scale

and not included in the analysis, were given in the questionnaire: "I don't

care" and "does not apply."

3-43
A brief explanation o£ the three compound independent variables will

help the reader to understand the responses. The demographic variable combines three measures, and the military profile variable contains two. Each

measure was dichotomized to simplify its incorporation into a compound

variable. For the demographic variable, age was cut between 28 and 29 years

to approximate the line between junior and senior captains. This cut was

believed to provide a division in work experience and responsibility. In

the military profile variable, commissioned service was dichotomized at

three years to approximate the completion of one obligated tour. The categories were designed so that the youngest group included virtually all

officers still in their first tour of duty.

The third variable is the nurses' feelings about staying in the Army

Nurse Corps. These feelings are probably overstated in the direction of

leaving. The question emphasized that respondents were in no way committed

to their answers, and the question was probably used by some officers to "let

off steam." The margin of overstatement is not known, and can only be ascertained by comparing actual attrition rates from separation files with the

data reported here.

The 102 attitudinal questions are discussed under the following

seventeen topical subsets.

1) Military Life and Institutions

These measures are among those that most strongly reflect the conflict

between nursing professionalism and the military setting. Approximately 70%

of the nurses agree that nursing questions are settled on the basis of rank

rather than professional knowledge , with approximately 12% more of the

officers under age 28 agreeing with the statement than those 29 and over.

3-44
Reserves are more inclined to agree with the statement than Regular Army

officers serving beyond their first tour. A majority in every category

tends to agree with the statement; 58% of those who will definitely stay

say they are bothered by this conflict between rank and professional

knowledge, while 78% of those who will definitely leave take this position

(Figure 3-7)

.

A statement asserting that upper echelons are responsive to the needs

of the individual officer received an interesting response pattern, comparing ANC age and sex groups. Disagreeing most strongly that upper echelons

are responsive are the older male nurses with no dependents (74%) and the

younger females with dependents (73%) . Those least critical of upper

echelon responsiveness, but still critical in the majority, are the older

female nurses with dependents (51%) and with no dependents (57%) . Further,

the Regular Army officer, young or old, is less inclined than the reserve

officer to rate upper echelons unresponsive. And, not surprisingly, the

difference between those who strongly disagree and moderately disagree with

the statement is reflected between nurses who will definitely leave and who

will definitely stay in the Army Nurse Corps (81% to 54%)

.

A pattern conparable to that just described surfaces throughout this

and remaining topics that have to do with general aspects of military

life, institutions, regimentation, uniforms, etc. Two points should be

made to further qualify this general pattern. First tour Regular Army

officers are atypical of their age group in that they tend to react more

cautiously to statements reflecting on the Army as an institution, and on

rank, authority and so forth. Second, there is a large group of first

tour younger officers comprising almost half of the corps -- approximately

3-45
How Army Nurses Feel About Stajfins or Leaving

Relateii to Whether They Agree That Nursing Questions

Are Settled by Rank Instead of Professional Knowledge

DEFINITELY LEAVE DEFINITELY STAY

UNDECIDED

A tree = 79% |N = 388j Disaerea = 11% |N = 54) No Opinion = 10% |N = 51| (Total N = 493)

(Percentages rounded)

Figure 3-7

3-46

A»ree

Disagree | |

No Opinion
1700 responses -- vdio tend to react more negatively toward the Army and

Army nursing than the rest o£ the corps. They are also predominant in the

groups that say they will definitely leave, possibly leave, or are undecided

about remaining for a full career.

The majority of the Corps, by approximately 75^, finds mandatory

social activities unattractive or irritating; they see human dignity

and personal privacy suffering in the military. The older women, however,

include a strong minority of approximately 20 to 11% who feel the Amy

is misinterpreted on the matter of human dignity.

2) Administration - Staffihg- Equipment

Items concerning hospital administration, staffing, and equipment tend

to relate to a mix of organizational values and nursing professionalism.

By a margin of approximately 47% to 38% the nurses feel that the administration of Army hospitals is generally conpetent. However, 731 feel

that hospital administration is not generally responsive to patient needs .

Again, the most noticeable spread is between regular and reserve officers,

and between those who say they are definitely leaving the Army and those

who are definitely staying.

Fifty-six percent of all nurses disagreed with the statement that

the nuiriber of Army Nurse Corps officers in their organization is adequate.

Older male nurses are the only group who tip toward the opposite point of

view (44%) ; and those whose responses indicate the strongest disagreement

with the assertion of adequate Army Nurse Corps officers in their organization are the younger female nurses (63%). The younger Regular Army officers

disagree most strongly with the statement that the number of Army nurses is

adequate. Their position here is that there should be proportionately more

Army and fewer civilian nurses.

3-47
VJhen responding to a statement on the ratio of military to civilian

nurses , the older reserve officers at 86% assert most strongly that the

Army Hospital staff should be more Army Nurse Corps and less civilian.

Four fifths of the Corps takes this position, with variations on either

side of that figure running to less than 101.

Approximately 601 of the nurses do not feel that there are adequate

enlisted nursing personnel in their medical activity. There is little

variation among groups on this question, although the older officers do

tend to include a small but significant group who feel that there are

adequate enlisted nursing personnel. Reserve officers show less concern

than the Regular Amy nurse about the number of enlisted nursing staff,

but again the margin of difference is relatively slight. No iiiportant

difference emerges in a judgment on the adequacy of enlisted nursing

personnel when those who are leaving are coiq)ared with those staying.

Forty nine percent of the nurses agree that Army medical facilities

are often obsolete , compared to forty -one percent who disagree. The

older male officers are most prone to say facilities are obsolete. Little

difference shows up when contrasting Regular Amy with reserve, or young

with old officers on this question. Nor is there a meaningful difference

when contrasting those who are definitely leaving with those definitely

staying. There is a slightly greater tendency among those who will

probably stay in the Amy to disagree that facilities are obsolete, but

this group ranges only from 11 to 15% higher than those who will probably

leave

In reponse to an assertion that the equipment in Army Hospitals

makes Amy nursing satisfying, there is a dispersal of opinion running from

approximately 101 who strongly disagree to approxijnately 161 vAio strongly

3-48
agree. The largest proportion o£ the Corps agrees (37%); next are those

who disagree (281); and 9% expressed no opinion. Examining the Militaryprofile gives slightly different results . The younger RA officer and the

older RA and reserve officer tend to agree, in a range of 60 to 66%; 421

of young reserves agree, and those who strongly agree are less than half

of any other category. There is also a strong positive relation between

those remaining in the service and those agreeing that equipment in Army

Hospitals malces nursing satisfying. Only 34% of those definitely leaving

agree with this positive appraisal while 70% of those definitely staying

agree.

3) Military Discipline and IMiforms

Again, these items constitute direct measures of military professional

values vis- a-vis those of the nursing profession. Seventy-five percent

of the Corps disagrees with the statement that the military system of

rank , seniority , and command is the best way of insuring that those with

the best professional e:5^erience and competence will be given responsibility.

The group most likely to agree with the statement are the older women;

the younger women are least likely to endorse the military system of rank,

seniority, and command. Though very few strongly agree with the statement, an interesting contrast does emerge in the more moderate "agree"

category. The young RA officer appears to be the staunchest advocate of

the military system; the young reserve is its greatest critic. Not

surprisingly, those who are definitely leaving have a stronger tendency

to criticize the military system. However, of those definitely staying

63% are also critical.

3-49
Reactions are more moderate to the statement that military discipline is out of place in a professional environment. Fifty percent of the

Corps disagrees with that statement, including about 711 of the older women,

and 32% of the younger female officers, the lowest figure. Only 18%

strongly agree that military discipline is out of place, and the younger

female officers and most numerous among these at 25%, compared to under

10% of the older women. Young reserve officers are most critical of military

discipline in the professional environment, and older RA officers are

the most supportive.

Possibly in partial justification of the career decision they have

taken, those who are definitely leaving are by far the most critical of

military discipline in the hospital environment. Three quarters of those

definitely leaving feel military discipline is out of place in an Amy

hospital, and only 20% disagree.

Interestingly, only one third of the younger reserve officers

agree that military discipline is necessary to insure a high quality of

nursing care, compared to two thirds of the older reserves. In one of

the several instances in which the proportions differ noticeably, the

younger woman with dependents is more inclined to agree that military

discipline is necessary to good care than is the younger woman with no

dependents. At 67% and 75% respectively, the older male and female

officers with dependents are most in agreement with the statement that

military discipline is necessary to good care.

Tne corps is divided as to whether regimentation is out of place in

today's Army: 43% say it is and 48% say regimentation is not out of place.

3-50
Only among the younger female officers , overwhelmingly reserves , does a

clear majority agree with the statement. Over 50% of all of the other

groups disagree.

The percentages contrast sharply in relation to the question about

how the nurses feel about an Amy career. Of those definitely staying

only 241 agree that regimentation is out of place, while 65% of those

definitely leaving are in agreement. Of those possibly leaving 57%

agree, and the undecided group agrees at just a shade under 50%, with

13% expressing no opinion and 37% disagreeing.

The older nurses, especially the women, are more inclined to feel

that Army Nurse Corps uniforms are below standards . The Corps as a \\tiole

is divided on the statement in a ratio of 51 to 42%. The young reserve

officer, who most frequently doesn't expect to wear the uniform long, is

least critical of the uniform.

With respect to wearing the uniform., the distribution of responses

shifts: 66% of the nurses agree that headgear should be required only

in military formations; 53% disagree that the white cap should always be

worn with the white hospital uniform by female nurses

.

4) Quality of Care - Competence

Professional standards of care in the Army receive generally high

marks . Sixty-nine percent agree that the quality of patient care in their

organization is generally good; 24% disagree. Although a majority of no

group disagrees with the statement, the young RA officers break their

usual pattern of m.oderation, 29% disagreeing in this case. Only 21%

of young reserves disagree, compared to 18% of older reserves, and 14%

of the older RA's. The endorsement of those definitely leaving the Pormy

3-51
is weaker at 56% than is that o£ those definitely staying at 78%.

A majority of the Corps believes that the reputation of nursing

service is good in their organization. The figures range from approximately 55% among the younger women to 75% among the senior women. By a

very slight margin, younger reserve officers are more likely to respond

that the reputation of Nursing Services is not good. And a pattern

reemerges in which those definitely leaving are most critical -- 35% of

those definitely leaving are critical of Nursing Services' reputation.

Most Amy nurses (78%) agree that in their experience the quality

of Amy nursing care is very good. The figures range from 65% for younger

women with dependents to 90% for the older women with dependents. However,

those leaving the service are more moderate in their endorsement of the

quality of Amy nursing care; only 55% agree that it is excellent.

In response to a statement that the prestige of the Army ^fedical

Department is low, 55% of the respondents disagree and only 29% agree.

Interestingly, the group that was proportionately most willing to agree

that the prestige of the Amy Medical Department is low were the older

single male officers. At 37%, they contrast with the young single males,

among whom only 24% agreed with the statement. A majority of no group

agreed with the criticism. Even among those definitely leaving only 33%

agreed with the low estimate of Amy Medical Department prestige.

On the whole, however, the Amy Nurse Corps does not agree that the

Amy Health Team esprit de corps is excellent. Only 35% agree that it is,

while 57% disagree. Only the older women with dependents, at 55%, agree

that the esprit de corp is high. Miile 45% of the older Regular Amy nurses

3-52
believe that the Array Health Team esprit is excellent, only 11% of the

younger RA officers agree. Three-quarters of those definitely leaving

the service disagree, compared to 46% of those definitely staying .

This is probably a reflection of their decision as much as the judgment

influencing their decision.

The young single m^le Army nurse is least complimentary to his colleagues.

A majority of each category agrees with the statement that they are

impressed by the conpetence of fellow ANC officers. However, only 53% of

single young men agree with this endorsement; the older single male

at IVo and older RA's at 72% are most conplimentary . There is only a

slight difference between those definitely leaving the service and those

possibly leaving . Those definitely staying register the best opinion of

their fellow ANC officers' competence.

Seventy-nine percent of the older female nurses are impressed by

subordinate ANC officers ; only 61% of the younger single male officers

and sixty percent of the young RA's are impressed by subordinate

officers. However, 82% of the older RA officers agree with the endorsement of subordinates. Tlie contrast between younger and older reserves is

slightly less. Of those definitely leaving 61% say they are iiiqDressed by

subordinate officers vdiile among those definitely staying the figure

rises to 81%.

Half of the nurses disagreed with the statement that they were,

individually, more competent than their supervisors . Only 28% agreed with

the statement, 21% expressing no opinion. There is little variation among

groups. Interestingly, there is no difference on this point between those

definitely leaving and definitely staying.

3-53
5) Professional Role and Relations

This set o£ items relates to the status of the nursing profession.

Sixty-four percent of Arn^ Nurse Corps officers like the expanded role

of the Army nurse, 17% do not, and 19% expressed no opinion. The young

RES officer reflects slightly less interest, and those definitely leaving

tlie Army express even less, but even among them the majority approves of

the expanded role of the Army nurse by 3 to 2,

Four out of every five officers say that they like the responsibility

for assuming medical procedures previously performed only by doctors in

an expanded role. Those apparently most enthusiastic are the young

male officers; older women are least enthusiastic. Nevertheless, the percentages in those two cases are 81% and 58% respectively - a positive

majority in all cases. The young ANC reserve is most enthusiastic ^.en

we conpare i^^serve and regular, and separate first tour and longer service

categories). This is one of the very few cases in which the distribution

does not reflect very high correlation between those definitely leaving

and the young reservists. Those possibly leaving, agreeing at 75%,

constitute the largest group. This may indicate that this issue has some

appeal for retention. (Figure 3-8)

The older male officer with dependents experiences the least frustration between viiat he was trained to do and what he actually does . He also

tends to be a diploma nurse who has entered either the nurse anesthetist

or neuropsychiatric nursing fields. The younger female nurses are most

frustrated by this problem. The Corps as a whole is divided on the issue:

52% not bothered compared to 44% who are frustrated. Of older males with

dependents, only 24% agree with the complaint. On the other hand, younger

3-54
How Army Nurses ht\ About Stayint or Leavini Related to Agreement

with Assuming Responsibiity for Additional Medical Procedures

DEFINITELY LEAVE

Agrti = 72% |N = 4551 Disagrtt = 18% |N =116)

No Opinion = 10% |N (Total N = 6321

POSSIBLY LEAVE

Agree = 75% |N = 434)

Disagree = 16% |N = 90) No Opinion = 10% |N = 56^

(Total N = 580)

DEFINITELY STAY

= 66% )H = 704)

ret = 25% (H = 265)

Opinion = 9% (N = 95) N = 1064)

POSSIBLY STAY

Agree = 70% (N = 382)

Disagree = 20% (N = 107) No Opinion = 10% |N = 54)

(Total N = 543)

UNDECIDED

Agree = 73% (N = 3601 Disagree = 14% (N = 87) No Opinion = 13% (N ^ 63)

(Total N = 490)

(Percentages rounded)

Agree

Disagree

No Opinion

Figure 3-6

3-55
women with dependents agree 59% of the time. The older Regular Army

officer disagrees with the conplaint 70% of the time, conpared to the

young reserves, of whom 39% disagree. Forty percent of the

young RA's agree with the conplaint conpared to only 27% of the older

Regular Army officers. The conplaint is also positively related with

those who are definitely leaving the service althou^ the responses are

not overwhelmingly critical among that group. IWo thirds of the Corps

apparently feel that their assignment utilizes their skills ; 30% say it

does not. Variations among groins are relatively meaningless on this

question.

Three-fourths of the nurses disagree with the allegation that

enlisted men carry out patient care activities that should be dbiie by

registered nurses . No group varies from this opinion, although slightly

fewer among the young single male nurses talce this position than do

those in other categories. Only 25% of the Corps say they do not like

assigning physicians assistants to do procedures previously done by

physicians , 52% disagree with that statement and 22% e^ressed no opinion.

Although only 17% of the younger females say they don't like the physician assistant's role, approximately 31% of the older women take this

position. Other grot^s range between the two. However, the young>

Regular Army officers tend to agree with the older officers; only the

young reserves fall in the 17% range, the figure for

that group who are definitely leaving , while the 31% range holds for those

definitely staying.

3fS6
In reaction to the statement that orders by physicians assistants

would not be acceptable, 40% of the nurses agree with that statement,

26% expressed no opinion, and 33% disagree. The younger single female

officer at 30% is least likely to resent orders by physicians assistants.

The older single male officer is most likely to resent them (55%).

About the same difference holds between young reserves at 31% and old

RA's at 53%. Those staying would resent orders by physicians assistants

in approximately 50% of the cases while those definitely leaving would

resent them in only 32% of the cases.

Responses to a set of questions about working relations among ANC

officers and with other groups in the Amy Nfedical Department (DA

ci-vilian RN's, physicians, enlisted, and other AMEDD Groups) indicated

that nurse administrators (3430) are more likely than other MOS groups

to say relations are excellent or very good, and neuropsychiatric nurses (3437) are least likely to say so. Airoy Health Service

nurses (3431) usually agreed with the positions taken by psychiatric

nurses, that is, relatively less positive about relations among various

AMEDD groups. However, nurse administrators change their position with

respect to physicians. Only the Army Health Service nurse rated ANC

relations with physicians lower than did the nurse administrators . The

latter group^ as noted, rated the relationships between Army nurses and

with all other groups but physicians highest among the MOS groups.

6) Assignment - Location and Facility

Sixty-nine percent of the Corps are satisfied with their present

location . Seventy-one percent like their present facility . No important

variation occurs among subgroups . Only 18% say that their assignments

3-57
have been disappointing. Again, there is little variation among groi:^s.

The single young male officer, 311, is a little less satisfied with his

assignments than the older single male or the older RA officer in general

- in each case approximately 101 expressing dissatisfaction.

Three quarters of the Corps say they would like more stability in

assignments. Although there is not- much variation, male officers with

dependents are a little stronger in their desire for stability in assignments than other groups. The issue has no apparent relation to the decision

to stay or leave.

Eighty three percent of the Corps say they like to travel . The

younger male officer with dependents is a little less enthusiastic --

only 11%. It does appear to make some difference to those who are definitely staying conpared to those definitely leaving the Amy Nurse Corps;

951 of those staying like the opportunities for travel, but only 58^ of

those definitely leaving take the same position.

About one-third of the Corps says that working overseas is a difficult

experience for them, compared to 61% who disagree with that statement.

Forty percent of those in the Pacific agree that it is difficult, but only

231 of those in Europe express difficulty. Again, the young male officer

with dependents has the most difficulty (581) , while the older women with

no dependents have the least difficulty (14%). The younger the officer,

the fewer years commissioned service, and the fewer PCS's, the more likely

is the response to express difficulty with overseas assignments. The young

reserves at 39% tend to have more difficulty than other groins. About half

of those definitely leaving the service agree that working overseas is

3-58
difficult, but only one-fourth of those definitely staying agree with

this position. The question was not asked directly, but it can be

inferred from other responses that those who have never served overseas

were more likely to agree that serving overseas would be difficult.

7) Career Advancement

This set of responses appears to indicate that it is not the lack of

nursing experience and challenge that fails to appeal to a nurses 's professional and career interests, but the military system of career advancement . The Corps overwhelmingly agrees that Army nursing allows them to

work as responsible professionals (87% agree, 10% disagree). Little

variation occurs among groups , although the older and Regular Army

officer is most inclined to agree with this statement. Those definitely

leaving the service agree to a sli^tly lesser extent.

Seventy percent of the Corps disagree with the statement that professional accomplishment is limited in the Army. The greatest contrast

in opinion on questions of professionalism is between the older women at

approximately 18% and the younger women with dependents , of whom 35% say

that professional acconplishment is limited in the Army Nurse Corps.

Approximately the same contrast exists between older Regular Army officers

(13%) and young reserves (32%) . Only 15% of those definitely staying in

the Amy feel this limitation, while 38% of those definitely leaving

express dissatisfaction.

Three quarters of the respondents agree that the Amy gives them

an opportunity in their specialty , the hi^est proportion being the older

male officers, probably influenced by the proportion of these who are

3-59
anesthetists and psychiatric nurses. Although still in the majority in

their subgroi:^), only 581 of the younger women with dependents say they

have an opportunity in their specialty, and the younger males with no

dependents (61%), are next lowest. And while only 55V of those definitely

leaving say the Army gives them opportunity in their specialty, 90% of

those staying say so.

The majority of the Corps, 54%, feel you can get ahead faster in

military than civilian nursing . Only 45% of the young single male officers

agree with this statement, but 67% of the older female officers with

dependents agree. The younger reserve officer is less inclined to agree

(46%), and those who are definitely leaving the Army (27%) are less likely

to agree than those who are definitely staying , of whom 66% feel they can

get ahead faster in the military.

Only the younger women express appreciable reservations about their

ability to assume the next higher grade . Four out of every five Army

nurses feel they are capable of assuming the next hi^er grade, but only

two-thirds of the younger women do. Considering the general division

between younger and older officers, the differences in confidence between

those definitely leaving and definitely staying reveals nothing unexpected.

Three quarters of the nurses say that prom.otions are not made on the

basis of professional competence . The strongest minority on this point

is among older women with dependents, of whom 36% disagree with the statement. The greatest contrast occurs between those definitely staying , of

whom 64% agree, and those definitely leaving , of whom 83% say promotion is

not based on professional conpetence.

3-.60
8) Job Satisfaction

Job satisfaction is apparently a more pedestrian reflection of basic

reactions to nursing in a military setting. Only 24% of the respondents

say they do not like their present job ; 72% disagree with that statement.

There is little variation between older and younger officers, or between

Regular Am^ and reserve - less than 10%. However, while only 17% of

those who will definitely stay in the Army Nurse Corps do not like their

present job, 59% of those definitely leaving say they dislike it.

The figures are almost identical in response to the general statement

that job satisfaction in the Army Nurse Corps is hi^. Three-fourths

agree with the statement and 18% disagree. There is approximately a 20%

spread between the younger males and the older male and female officers -

approximately 66% to a range of 86 to 90%. The young reserve is again

least inclined to say job satisfaction in the Army Nurse Corps is hi^,

63% taking this position, whereas all other groups are over 80%. The

figure becomes even lower for those who are definitely leaving the service

(48%). They are the only group among whom less than 50% say job satisfaction is high. Of those definitely staying , on the other hand, 93%

say job satisfaction in the Army Nurse Corps is high .

Direct support to the nurse's patients is an important element of

job satisfaction: 98% agree with this statement, 85% strongly, one

percent expressed no opinion, and one percent disagree. Four out of five

nurses say they like the challenge in their work. There is only a moderate

variation among age groups: approximately 75% in the younger age group

to over 90% in the older. Even among those who are definitely leaving.

3-61
65% say they like the challenge in their work; 92% of those definitely

staying say so.

The nurses also say they have opportunities to use their own

initiative in the Army Nurse Corps . Again the spread from younger males

with no dependents and young women with dependents , each approximately

70%, and older nurses, 90%, is a difference of approximately

20%. And the young reserve, just under 75%, makes the difference. The

figure drops to 64% for those who are definitely leaving the service,

compared to 92% for those definitely staying .

Knowing what is expected of them makes their work more satisfying

for 75% of the nurses, with disagreement from only 17%. A small range of

10% from the younger married women to the older married nurses is the only

variation among demographic groups. However, the young RA. responds positively to the statement, at 95% in contrast to 69% among the young reserves.

Those definitely leaving find satisfaction in knowing what is e:xpected of

them at only the 58% level vdiile those definitely staying answer at 85%.

In response to the statement that "I came into the Amy to take care

of the Military and not civilians or dependents ," 73% of the Corps disagree

(42% strongly), 21% agree with the statement while 6% expressed no opinion.

There is a slightly greater proportion of those who will possibly or

definitely stay to agree with the statement (26% and 24%) than there is

among those who are leaving or undecided (approximately 17% to 19%)

Orientation to their duty station was good for 58% of the nurses

,

while 38% said it was not good. No inportant variation shows up when

looking at other variables. Sixty percent of the nurses say that orientation for their duty position was good. In this case 37% disagree. And

3-62
again, the only noteworthy variation is a slightly greater tendency

among those definitely leaving the service to be critical.

9) Education and Training

Professional education and advanced clinical preparation are issues

vital to the Corps and the individual officer. Seventy-seven percent of

the Corps feel they are well prepared for their present job ; 20% disagree.

There is a range of approximately 10% from the younger women to the older

males, with the most marked difference being the degree of confidence expressed by younger males compared to young women. This is again reflected

in a slightly lower figure for young reserves, most of whom say they will

definitely leave the Army.

The Corps is almost evenly divided on the proposition that advancement depends too much on formal education . Approximately 43% agree with

the statement while 47% disagree and 10% express no opinion. Only 30%

of the young Regular Army officers say advancement depends too much on

formal education, while 55% of older reserves and 42% of the older

Regular Army officers agree. A slightly lower proportion (37%) of young

reserves agree. Those definitely leaving the Arm.y are only slightly

more likely to complain about the emphasis on formal education (41%)

than the younger officers as a whole. This does n£»t appear to

be an important reason for leaving the service, although it does tend to

influence slightly a minority of diploma nurses. Details are graphically

displayed in Figure 3-9.

About half (49%) of the nurses believe that in-service education at

their duty station is limited, while 43% feel no such limitation. The

3-63
ANC Fnliiiis is to whitlier Advanceinent Depends Too Much

OR Fornil Education Related to Stayini or Leavini

DEFINITELY LEAVE DEFINITELY STAY

Agrti = 41% IN = 285) Diuini = 45% IN = 288) No Opinion = 14% |N = 87

ITotil N = 840)

POSSIILY LEAVE

Airti = 37% |N = 222) Disairio = 47% |N = 278 No Opinion = 18% |N = 94

ITotal N = 994)

Agret = 48% |N = 519) Disagrti = 49% |N = 544) No Opinion = 5% |N = 55)

(Total N = 1118)

POSSIBLY STAY

'Agree = 45% |N = 249) Disagree = 48% |N = 255) No Opinion = 9% |N = 52) (Total N = 556)

UNDECIDED

Agree = 43% (N = 215) Disagree = 48% |N ^ 229)

No Opinion = 12% |N = 58)

(Total N = 502)

IPercantagos rounded)

Agree

Disagree | |

No Opinion | |

Fifirt 3-9

3-64
percentages run from 601 among younger single males to 40% among the

older women. No great difference emerges between regulars and reserves,

and only a slightly greater proportion of those definitely leaving the

service express dissatisfaction with in-service education limitations at

their duty station.

By 581 to 11% the nurses agree that shift schedules make it difficult

to obtain further education . Only 48% of the older reserves agree with this

statement, compared to 63% of young reserves. Sixty-five percent of

those definitely leaving say shift schedules are a problem for obtaining

further education, and 50% of those definitely staying say the same.

However, 66% of the nurses disagree with the statement that further

educational opportunities are limited for an ANC officer. Only 28% agree

with that statement. The biggest spread in opinion, though not very

great, is between the older Regular Amy and reserve officers: RA 23%,

RES 32%. More than one-third, (36%) of those definitely leaving express

the limitation, supported by 21% of those who intend to remain in the ANC.

Greater contrast is shown in response to the more positive statement of the issue: formal educational opportunities are better in the

Amy Nurse Corps than in civilian life. There is a slightly greater

spread between the 29% definitely leaving who agree with this statement and

the 52% definitely staying who feel that formal educational opportunities

are better in the military.

10) Authority and Responsibility

Military authority and professional responsibility join in this set

of responses . Sixty-two percent of the nurses disagree with the statement

that because they cannot be commanding officers, Amy nurses cannot really

3-65
assume the responsibility and leadership role that they should. Only

27% agree, with 11% expressing no opinion. Young reserves are least

inclined to agree that the nurse's leadership role is limited, supported

by those definitely or possibly leaving the Corps. Those staying are

slightly more inclined to feel that the leadership role of the nurse is

limited.

The Corps is evenly divided as to v^ether the authority they have

is too little. Older reserve officers are most likely to agree with the

statement, while the young Regular Army officer is least inclined to

agree. Interestingly, the figures revert to an even split when comparing those who will definitely leave (48%) with those vSio will

definitely stay (48%)

Sixty- five percent of the Corps agrees that their professional

responsibilities are superior to those of civilian nurses working at

their duty station. About 24% disagree; 12% e3q)ress no opinion. There

is relatively little variation by age group, although the spread between

young reserves and older RA officers is 57% to 78%. Similarly,

only half of those definitely leaving say their professional responsibilities are superior to those of civilian nurses at the same duty

station, while three fourths of those staying feel they are.

In fact, 80% of the nurses feel they have an opportunity for

responsibility in the ANC that is professionally satisfying , while only

15% disagree with that statement. The small variation of only 10%

spread between younger and older officers suggests this is not an issue

among those saying that they will definitely leave the service. Sixtyone percent of those definitely leaving agree with the statement that
their opportunities for responsibility in the Army Nurse Corps are

professionally satisfying. Only 30?; disagree. While the figure is

considerably higher (901) for those definitely staying, the range is

not excessive given the difference in age, rank and experience.

According to 561 of the respondents. Army nurses do not have enough

opportunities to practice direct patient care . On the other hand, 401

of the nurses disagree with that judgment. Once more, the biggest disagreement on the issue is between the older Regular Army officers and the

young reservists - 42% to 65%. Only 44% of those definitely staying

believe nurses don't practice enough direct patient care in the Army,

while 71% of those definitely leaving agree with this statement. Figure 3-10

provides visual display of these statistics.

In response to the statement, "I would prefer to be assigned directly

to the doctors of an organizational element (OB/GYN, Medicine, Pediatrics,

etc.) rather than the Nursing Department or Service," two-thirds of the

nurse anesthetists prefer direct assignment to physicians . A correspondingly high positive response comes from a heavily overlapping group,

male officers with dependents - both younger and older. However, 60%

of the Corps as a vdiole disagrees with the proposition. The greatest

contrast is between the older women, among whom only 20% agree with the

statement, and the older men with dependents, 51% of whom agree.

Amy nurses are evenly divided, at 45%, on the statement that the

lines of authority in the respondent's present organization are effective.

The young reserves (37%) are least inclined to agree with the statement.

About 61% of those definitely leaving disagree with the statement, while

34% of those definitely staying disagree and 60% agree.

3-67
Whether ANC Officers Apee that They Do Net Have Enou|h Oppertviiities

for Drect Patieit Care Related to Hew Tkey Feel about Stayiif or Leavini

DEFINITELY LEAVE

Agree = 71% (N = 451) Disatree = 27% (N = 172) No Opinion = 2% |N

(Total N-= 638)

POSSIBLY LEAVE

Airee = 63% (N = 369) Disatro " 34% |N = 19 No Opinion = 4% (N = 21) (Total N = 568)

DEFINITELY STAY

Agree = 44%^ (N = 484)

Disagree = 52% (N = 571) No Opinion = 3% (N = )3j

(Total N

POSSIBLY STAY

Agree = 55% (N = 305) Disagree = 41% (N = 227) No Opinion = 4% (N = 20)

(Total N = 552)

(Percentages rounded)

UNDECIDED

Agree = 58% (N = 290)

Disagree = 36% (N = 180) No Opinion = 6% (N = 28)

(Total N = 498)

Fiiwe 3-10

Agree

Disagree

No Opinion

3-68
11) Working Conditions

Thirty percent of the Corps say they find working conditions in Army

Medical facilities unattractive, while 63% disagree with that statement.

Thirty-six percent of the young reserves say working conditions are

unattractive, in contrast to young RA officers, with only 15% agreeing.

The figure rises to 51% dissatisfaction for those definitely leaving and

falls to only 19% for those definitely staying .

Seventy-one percent of the Corps feel that work schedules are fair;

however, 35% of the young women with dependents disagree with that statement. The greatest contrast is provided by the older males, of whom only

14% disagree. Young reserves again stand in greatest contrast to both

young and old RA officers at 62% to 85%. And while only 56% of those

definitely leaving the service believe that work schedules are fair, 85%

of those definitely staying believe so.

Two- thirds of the nurses disagree with the statement that the hours

they work are more disagreeable than those of civilian RN's. No important

variations emerge on this question. However, the single older male officer

is a little more inclined to feel that his hours are more disagreeable than

those of civilians. The young reserves feel somewhat more dissatisfied

than either their older reserve colleagues or the RA officers. The issue

is only slightly associated with those definitely leaving the service (35%)

compared to those definitely staying (20%)

.

Irregularity of \\forking hours is a source of dissatisfaction to 56% of

the Corps. Older officers expressed the least dissatisfaction (45%), while

the younger women with dependents agree with the statement in 65% of the cases.

These nurses tend to be young reserves definitely leaving the service.

3-69
While 60% of the nurses agree that they usually receive conpensatory

time , 361 disagree - 201 of these strongly.

Most nurses (81%) object to being moved from Ward to ward without

consultation. The issue is expressed a little more frequently, 10% more

of the time, by young reserves than by others. The same 10% spread

exists between those definitely leaving and those definitely staying.

Four out of five nurses like the variety of jobs in the Army, the

older nurses a little more than the younger nurses. The difference

between those definitely leaving and definitely staying is typical - 66%

to 88%.

12) Efficiency Reports and Promotions

Virtually all of the Corps (97%) would like to sign their efficiency

reports to prove that they had had an opportunity to read them. No significant variation occurs among different groiqjs. Other items in this set

tend to be more relevant to ANC attitudes toward the military personnel

rating system.

That rating officers make fair judgments is the opinion of 56% of

the respondents. However, 37% disagree. Even though 66% of the older

Regular Army officers agree that rating officers make fair judgments,

their view is shared by only 50% of the young reserve officers.

By 57% to 32% Army nurses would prefer that their efficiency

reports be con^leted by their supervisors , and not by the doctors with

whom they work. Among one group there is an even division: the older

males with dependents. This split, at 45% agree and 45% disagree, is

again probably influenced by the nunfcer of nurse anesthetists reponding.

3-70
Only 121 of the young Regular Army officers agree with the proposal and

68% disagree. Thirty-nine percent of older reserves agree, 10%

higher than either younger reserves or the older Regular Army officers.

A slightly higher percentage among those who will definitely leave the

Arii^ Nurse Corps, 38%, also agree with the proposal. However, this figure

is only 6% to 7% higher than those definitely staying.

Eighty- four percent of the respondents agree that the present system

does not contain adequate safeguards against personality conflicts

influencing efficiency reports. Younger officers e:xpress sli^tly less

concern, and reserves slightly more than RA officers. The issue

has no apparent influence on how respondents feel about an Army career.

The Corps as a whole is about evenly split in their reactions to the

statement that "the more rank Army Nurse Corps officers obtained the more

they are concerned with promotion instead of patient care." Forty-two

percent agree with the statement while 47% disagree, with 11% expressing

no opinion. The older women disagree most strongly; of women with dependents, only 22% agree; of those with no dependents, 29% agree, ^^proximately

51% of the younger women and 60% of the single young male officers agree

with the charge. The conparison of those who will definitely stay (22%)

and those definitely leaving (62%) is quite dramatic. It is evident that

those leaving are much more likely to agree that the more rank ANC officers

attain the more they are concerned with promotion instead of patient care.

Figure 3-11 provides statistical details.

Only 15% of the Corps agree with the statement that the Army's

promotion system is the best way to meet the need for conpetent officers

in higgler grades. Seventy percent disagree with that statement, while

3-71
How Amiii Nrsis Fill Abivt Stapi w LiavMi

Rilitid ti Whitbir TMy Afrii That thi Mori Rai* ANC Oflicirs Obtain

thi Miri Thiy An CmcirMd with Promotion instiad if Patiint Can

DEFINITELY LEAVE DEFINITELY STAY

Airit = 62% IN = 395) Disairti ^ 26% |N = 167) No Opinion ^ 12% |N = 73) [Total N = 635)

POSSIBLY LEAVE

Airoo = 41% IN = 280)

Ditairii = 37% |N = 219) No Opinion = 15% |N = 91] ITotal N = 590)

|Porconta|os roundeij

UNDECIDED

A|roo = 50% IN = 251) Disagroa = 36% |N = 178) No Opinion = 14% |N = 70)

ITotal N

Agrat = 24% |N = 269)

Disagroa = 69% |N = 773) No Opinion = 6% |N = 71)

ITotal N = 1113)

POSSIILY STAY

Agraa = 41% [N = 226]

Disagrea = 48% |N = 268) No Opinion = 11% [N = 63]

ITotal N = 555)

Hfm 3-11

Disagrae | |

No Opinion

3-72
141 expressed no opinion. With the single exception of the older women

with dependents, there is no more than a 10% spread between the response

patterns of the younger and older nurses , whether they are married or

single. Slight differences do emerge among various age groups, with

younger offices less inclined than older officers to agree that the current

promotion system is the best way to get conpetent officers in higher grades.

The RA.'s view of the present promotion system is more positive than is that

of the reserves. Only 71 of those definitely leaving support the

present promotion system.

Thirty percent of the Corps feel that the present promotion system is

fair, compared to 54% who disagree with that statement; 16% expressed no

opinion. Mong the various groups, the older reserve officer is most

likely to disagree with the assertion that the present promotion system is

fair.

Not withstanding the heavy overlap in three groups, the data concerning how respondents felt about an Anny career in relation to the promotion

system indicate a high level of correlation between the generally critical

views of the system shared among those leaving, the younger groups, and

reserves as a group. This correlation is frequently reflected in

previous comments in this section of the report.

13) Pay, Allowances, and Benefits

An examination of the specific items in the set of attitudinal

questions that are concerned with pay, allowances, and benefits, reveals

no new infoimation other than that contained in direct response to the

relevant personnel policy proposals discussed in Section 3.2, with which

they are integrated.

3-73
14) Attitude of Family and Friends

Twenty-eight percent of Anny nurses say that friends and family may

influence them to leave the service, while 65% of their associates

disagree with that statement. The young male officer (40%) appears

to be most susceptible to this pressure. Older men with no dependents

and the older women with dependents are least susceptible, responding in

agreement with this statement only about 10% of the time. Thirty-seven

percent of young reserves say that friends and fajnily may influence them

to leave, and just over half of those who will definitely leave the

service agree with this statement conpared to only 10% of those who will

definitely stay .

The families of 91% of the nurses approve of their being Army nurses.

The only group among whom more than 10% disagree are those who say they

will definitely leave the Amy. Even in this case, only 14% say their

families do not approve of their serving in the ANC.

Support from friends is a little weaker than from families, but

still a clear cut majority for the Corps as a whole and for each subgroup.

Three quarters of the Corps say their friends approve of their being an Army nurse and only 14% disagree with the statement. A mere one-fifth

of young reserves and only 29% of those who way they will definitely

leave say their friends do not approve. i

Fifty-five percent of the respondents say that civilian attitudes

critical of the Array are unjustified. However, 30% disagree, and 15%

expressed no opinion. Only young reserves are approximately evenly

split on the question with 41% an agreement and 40% disagreeing. However,

75% of those definitely staying feel that critical civilian attitudes are unjustified \diile only 30% of those definitely leaving agree with them.

3-74
15) Inequities in Allc^^rances and Benefits

The differences in allowances and benefits based on sex, marital

status and dependents concern the second major theme of importance to

r.etention of younger nurses. Benefit differences between men and women

officers are a source of dissatisfaction with 67% of the Corps . One

fifth expressed no opinion, and 13% disagree. Almost 80% of the older

women express dissatisfaction with such inequities, but only 32% of the

older men do. Younger married males agree with the older men, but single

young men appear to be a little more concerned about the inequities. The

level of dissatisfaction is higher among those definitely leaving , among

reserves, and among those directly affected - the women. This data is displayed in Figure 3-12.

In reaction to the statement that differences in male and female

benefits are a fair reflection of the differences in family responsibility,

62% of the Corps disagree, 17% agree, and 21% expressed no opinion. The

greatest contrast is between the younger females with dependents (79%

disagree) and the young men with dependents (34% disagree) . Generally

speaking, male nurses show much less concern than females. There is only

a sli^t difference, approximately a 10% spread, between those definitely

staying and definitely leaving the service.

In responding to the statement that married Army nurses who have

children are not able to handle all duty and station assignments in either

peace time or mobilization, 48% of the nurses agree, 35% disagree, and 17%

give no opinion. Sixty-three percent of the older nurses with no dependents agr^ with this statement, while only 48% of the older women with

dependents agree. The lowest level of agreement is among the older men

3-75
Amy Nurses FtilMfs ibiit Stiyif ir Limi«

Related to Aireemant witii DissitlslKtlon ever Depndeiicy ui Beiefit Differeices betwen Mileai Feule Officers

DEFINITELY LEAVE DEFINITELY STAY

Agrta = 72% |N Dlsiirii = 9% IN No Opinion = 19% (N

ITotal N = 5981

4291

52)

POSSHLY LEAVE

Airu = 73% IN = 41i) Disigrii - 9% IN ^ 50| No Opinion = 18% |N = 104)

ITotil N = 570)

Aim = 60% |N ^ 111) Ditiini = 21% |N = 209) No Opinion = 19% |N = 194) Total N = 1014)

POSSIILY STAY

Airio = 66% IN = 337)

Disagroi = 13% |N = 67) No Opinion = 21% |N = 110) ITotil N = 514)

UNDECIDED

Agroo = 70% IN = 331) Ditagroo = 10% IN = 49) No Opinion = 20% [N = 94)

ITotal N = 474)

Agrao

IParcantagas roundad) Oiuvu \

1

3-12 N, opjHiiR

3-76
with dependents - 36%. The young reserves are also less inclined to agree

with this statement, by only a small margin, than are the young or older

RA or older reserve officers. Those leaving are only slightly less likely

•to agree that married nurses are limited by their dependents than are those

staying.

Sixty-eight percent of the respondents disagree with the statement

that the difference in benefits paid to married vs. single officers is

fair. Only 11^ agree, and 16% expressed no opinion.

16) Service to Country

Service to country, and the form that that service takes, along with

the international role of the U.S., can be used as an indicator of military professionalism, distinguishing between the military and health care

professional realms. Three out of four nurses say that serving in the

Army Nurse Corps is important to them as a way of serving their country.

Fourteen percent disagree, and 12% expressed no opinion. The range runs

from 64% among young reserves to 81% and 82% among older reservists and

Regular Army officers, down to 59% for young women with dependents. The

strongest agreement with this statement is registered by the older women

with dependents (88%). Among those definitely leaving the service, only

45% agree that serving in the ANC is a way to serve their country; but 88%

of those definitely staying agree.

In response to a statement that Army nursing service means less than

civil ian nurs ing would in fulfilling their duty to society, 76% of the

nurses disagree. Only 12% agree, and 12% expressed no opinion. Interestingly, single young male officers are most likely to agree with this statement

(but only 20% do so) . The groups which is definitely leaving the service is

3-77
the only one in which the figure rises markedly. In this group 34%, still

a minority, agree that Army nursing means less to them than civilian nursing

as a means of fulfilling their duty to society; this compares to the 46%

•from the same group who disagree.

17) U.S. International Role

In reaction to the statement that it is important for the U.S. as a

great power to remain committed to the defense of the free world, 64% of

the nurses agree, 24% disagree, and 13% expressed no opinion. Younger

women with dependents have the lowest level of agreement at 53%. Single

older women and young RA officers register the strongest support (76%)

70% of the older RA's and the older reserves agree. However, the younger

reserves agree only at 55%. The group which includes those who definitely

intend to leave is the only one having less than 50% who agree that the U.S.

should remain committed to the defense of the free world; 46% of these

agree with this statement, 38% disagree, and 16% give no opinion.

In reaction to the statement that they do not like the United States

to be involved in other countries, only 21% agree while 63% disagree and

16% expressed no opinion. Essentially the same pattern occurs on this

question as in the previous one. There is a slight shift in the relationship between the responses of younger and older officers in each of the

reserve and Regular Array categories . That is , the older officers were

less inclined to be critical of U.S. military involvement in other

countries than the younger officers, although the younger officers were

less inclined to have reservations about U.S. commitment to the free

world. It is possible that there was a slight difference of interpretation

as to whether "defense of the free world" includes military involvement

of the Ihited States in the affairs of other countries.

3-78
3.3 Current Assignment

In response to the question asking whether the current duty station

is the nurse's choice or the result o£ the needs of the Army, only a

slight variation occurs among MDS's. Senior (3430) and specialist nurses

limited in number (such as 3431) and those more likely to be needed at one

type hospital than another (3446) are more likely to say that their assignments are a result o£ the needs o£ the Arroy. The preponderance of nurses

in most MOS's say their present job is their choice. General duty and

medical -surgical nurses are least likely to say so, but all groups agree

at the 50^ level or higher (up to 88%) , that their current job is their

first choice. The differences among MOS's disappear in response to the

question asking whether the nurse was given an opportunity to express job

preference

.

3.4 Assignment Preference

A bare majority of officers (521) say the geographic location of

their present duty assignment is their first choice. Eleven percent

say second choice, and 38% say third or less. However, most MDS groups

are more evenly divided between first and third choices. Medical -surgical

nurses received first choice by 60%, to 10% for second and 30% for third

or less. Because they are the largest single group they tend to bias

overall figures. They also avoid the greater difficulty of assigning

first choice to nurses with specialties held by fewer officers

.

Responses reflect this pattern of geographic assignment preferences:

West Coast, East Coast, Midwest, Germany, Southeast, and Hawaii in that

order, followed by other areas in lesser number.

3-79
I. The more certain the nurses are that they are staying in the Army,

the more professional experience tends to become important as an assignment factor. On the other hand, the more certain officers are that they

are leaving, the more important family and geographic area are as assignment factors.

3. 5 Summary of ANC Officer Worldwide Questionnaire

The Army Nurse Corps officers registered their attitudes, opinions,

and professional judgments on a wide range of topics covering Army nursing

and service life. A number of important themes emerge from their responses.

• Profess ional ism in nursing was a major theme, manifested

not only in the high value ANC officers place on the high

professional standards of their o\m performance, the quality of care for their patients, continuing education and

advanced clinical preparation, and the expanded role of

the Army Nurse, but also reflected in their strong desire

for more equal professional status, their concern that

rank and authority in the military system often override

the most competent professional judgment, and, in each

instance where some aspect of professionalism was juxtaposed to military, organizational, or personal demands,

strongly supporting professionalism.

• Inequities based on sex and marital status were issues of

great importance to the majority of the Corps. Principal

among specific issues were liberalized maternity regulations, equal status for spouses of both female and male

officers in matters of dependent allowances, accompanied

tours, survivor's benefits, and housing allowances.

• Pay, allowances, and benefits are also important. Except

where they touch on professional status and recognition,

however, they are not associated with the primary issues on which career decisions will normally be made, so long as Army nursing is generally competitive with the civilian sec- tor in terms of overall economic security.

• Female ANC officers regard inequities in pay, allowances, and

benefits that are based on sex, marital status, and dependents

as major disadvantages. These issues have undoubtedly affected

retention rates for younger nurses.

3-80
Staying or Leaving . Over two-thirds of the younger nurses

(20-24 year age group) indicated a high expectation of leaving

the service on completion of their obligation. The highest

retention rate by an overwhelming margin is among RN's who

enter the service through direct appointment from civilian

status. Diploma nurses from the Army Student Nurse Program

have the next highest retention rate. Army student nurse

degree programs reflect the higher mobility of baccalaureate

nurses, who have lower retention rates after the initial serv- ice obligation has been met.

A low proportion of nurses vdio obtain their nursing education

through Army financial support programs are likely to serve more than the required obligation. The higher the ;^rofessional

qualifications, orientation, and professional mobility nurses"

achieve, the more likely it is that they will choose to leave

the service .

Both junior and senior officers tend to agree that there is a generation or communication gap . Younger nurses tend to feel

that older nurses rely too mucn on rank and authority rather

than up to date professional knowledge, that the more rank

they attain the more they are concerned with promotion rather

than patient care, and that they have not kept up to date professionally. Older nurses tend to feel that younger nurses

are not mlling to adapt to the requirements of service in the

military or to the need of the hospital as an organization to

insure adequate staffing on all shifts.

Administration and Facilities . Over half of those who expressed

an opinion feel that Army hospital administration is generally

competent, but not particularly responsive to patients' needs.

About the same proportion tend to agree that the Amy medical

facilities and equipment are often obsolete. At the same time,

most nurses agree that the Nurse Corps enjoys a good reputation

and that the quality of patient care is generally good.

An overall view of the responses suggests that the strongest

potential appeals to retain those nurses with the highest professional interests and qualifications, who say that they are probably going to leave the service, are in challenging professional opportunities on the one hand, and in eliminating major

inequities that affect women on the other. These respondents

rated as "major advantages" of an Army nursing career advanced

clinical preparation, expanded role opportunities, more liberal

maternity regulations, coir^arable status for their spouses in

terms of allowances and benefits, and recognition of their actual

dependents, whether or not they are married. Those officers who

have elected to stay or believe they will remain say that pay and

allowances were a major factor. However, those who say they will

3-81
either definitely or probably leave do not rate this as a crucial factor, which probably indicates that military pay,

allowances, and benefits are already competitive and not a major issue.

The broader context within which these issues form a general pattern

is a complex set of relationships, often conflicting, involving nursing

professionalism and status vis-a-vis military traditions, Army bureaucracy, AMEDD organization, the other health professions, and changing

perceptions of the role and status of the nurse. The inescapable clash

of certain aspects of each is exacerbated by the aspirations of the professionally oriented nurse struggling for full professional status.

The conflict of nursing, as an auxiliary profession to the military,

rests in part on the difference between the use of controlled violence and

the preservation of life as principal functions, in part on differing sets

of skills, and in part on the inherent conflict between individual professional judgment and hierarchical administrative authority in a bureaucratic

institutional setting.

As we noted early in this section, the MEDDAC environment contains

elements of both the military and health professions. The conflict between

them is a complex issue that surfaces most directly in the matter of professional competence versus rank and authority. While the military are

seeking to build high professional standards in nursing, the military system

of command and authority, and organizational problems common to all bureaucracies, form obstacles that highly professional nurses find difficult to

accept

At the same time, the Corps has a body of ANC officers dedicated to

bringing the highest standards of nursing to the Army. Achieving this

3-82
professionalism is important in two areas of general importance to the

future of the Corps : 1) Retention of nurses with a highly professional

nursing orientation is assumed to be advantageous to the delivery of the

'best possible health care for the Army; and 2) professionalism in the

operational context in which nurses practice in the Army, along with

organizational capability, should enhance the effectiveness of those who

will provide the Army Nurse Corps with leadership in the future.

3-83

4.0 THE MEDDAC - THE OPERATING ENVIRDNMENT OF THE ANC

This portion of the study had several general objectives: quantitative characterization of the nursing environment; identification and

quantification of relationships among staffing, workload, quality of care

(QOC) , and other possible relevant variables ; conparison of hospitals under

different commands; and (in conjunction with the ANC Force Structure Model,

to be described in later sections) coiiparison of projected strengths with

actual and planned strengths. Detailed descriptions of these aims follow.

The nursing environment was characterized by obtaining, tabulating,

and checking data on many facets of the MEDDAC: number of nurses by NDS,

conponent, grade, etc.; number of doctors; facilities (number of operating

rooms, number of beds, etc.); proportion of "Intensive Carel' cases, and

other variables. The survey instruments used to obtain the data are

described in Section 4.0.1, the resulting data base is described in

Section 4.0.2, and analyses of the data are to be found in Sections 4.3,

4.4, 4.5 and 4.6.

Identification and quantification of relationships between variables

may have been pursued in any or all of several different ways: correlation,

regression, factor analysis, subjective judgment, scaling techniques, discriminant analysis, and possibly others. A combination of correlation and

regression was chosen, as it appeared to offer most promise within applicable time constraints. This approach is described in more detail in Section

4.3, with exariples in Section 4.4; an overall view is found in Section 4.1.

(In order to have a coherent data base to work with, these analyses were

done on a reduced data set corresponding to only the larger hospitals.)
Comparisons between hospitals in different commands , different areas

,

etc., are indicated in two ways: by direct coirparison of tabulated data,

as is found in Section 4.5; or by applying the techniques of the preceding

paragraph to smaller sets of hospitals corresponding to the different areas

,

commands, etc., and then by coirparing the relationships found for the

different sets. The latter procedure was not actually used because of

the variability among MEDDAC and the spottiness of the data.

It was desired to compare the September 1972 MDS and total staff

requirements with annual 5-year projections of all ANC M3S's. Conparison

of the NEDDAC requirements with the annual simulation projections of the

ANC Force Structure Model are described in Section 5.3. This comparison

involves each year's reduction in professional military strengths resulting

from the Deputy Chief of Staff for Personnel (DCSPER) budgetary constraints,

and from statutory separations described in Section 5.0 and in Part III.

The conparisons are of interest because of the OTSG view that the 1972

data is somewhat typical of a partially mobilized or "limited war" scenario.

The NBS survey of MEDDAC activities is described as a "snapshot," possibly

useful for planning, even though the continental United States (CONUS) and

overseas MEDDAC requirements do in fact change slowly with time.

4.0.1 Original Survey Instruments

In the planning stage of this study, NBS was asked by the OTSG to

assist in gathering and analyzing both specific and nonspecific MEDDAC data

regarding personnel, facilities, wards, and clinics. The original data

gathering planning by OTSG was in terms of "MEDDAC Survey" instruments

(herein and hereafter referred to sinply as "Instruments") which had been

4-2
developed by the OTSG work committees. The original Instruments consisted

of the following four sections

(Section A) Activity Identification

(Section B) Personnel Identification Data

(Section C) Task Detail and Duty Identification

(Section D) Distribution and Utilization Data

The large amount of data requested by OTSG included staff-workload

information, memberships in nursing societies, other organizational affiliations (including union memberships) , and military grade distributions by

racial and marital status groi^Ds. The original four sections of the

Instrument did not include data on either the numbers or types (categories)

of patients (e.g., the intensely ill and/or minimal care patients) and

very little data on care indicators. It was, therefore, apparent to the

NBS study team that the OTSG's anticipated broad needs for a wide range of

nursing-personnel data might result in a conplex and obfuscating data base

larger than the more immediate requirements of this study. Therefore, plans

were made by the NBS staff, in accordance v/ith the more limited and specific objectives below, to revise the data requested in the Instruments.

Certain modifications to the original Instruments were made in order

to obtain the desired quantitative characterizations of the MEDDAC. These

modifications were made in work sessions (described in Section 2) attended

by both the NBS staff and the members of the OTSG. A revised survey

form containing four new sections was developed. These sections are:

(Section A) Personnel

(Section B) Facilities and Activities

(Section C) Tasks in Your Ward or Clinic

(Section D) Non-Nursing Tasks

4-2
4.0.2 The MEDDAC Data Base

The data obtained in Sections A, B and C of the Survey Form from

93 MEDDAC installations comprised approximately one-half million data

elements; these were on punched cards, ranging from 75 to 419 cards per

hospital. This data set, the prrmary data base, is known in the project

as Set No. 1; it was abridged to provide two different working sets, as

described in the next paragraphs.

It was deemed neither possible nor productive to attenpt exploration

of all relevant relationships among all MEDDAC: the data base was too

large and too spotty. The first data reduction was elimination of certain

redundant or inconsistent data elements; elements were eliminated that had

too many missing entries ; others were eliminated where MEDDAC were too

small and/or had too many missing data entries. This series of elimination

procedures left 67 hospitals and 93 variables. These data were edited,

formatted, and arranged in matrix form, with each row representing a hospital

and each column a variable; this was designated as Set No. 2. The first

columns of this matrix may be seen in Table 4-1; the conplete matrix may be

found in Annex II- 5.

Finally, Data Set No. 2 was further reduced by elimination of

certain hospitals known to be "unusual" or small, and certain variables

which could be confidently expected to play no inportant role in the

correlation/regression analyses planned, resulting in Data Set No. 3,

consisting of 47 hospitals and 67 variables.

4-4
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4-6
4.1 Staff/Workload/Quality-of- Care Relationships

This section describes in general terms the rationale of and the ^

kinds of relationships sought.

A large hospital, considered as a large system with many constituent

parts and many interrelationships, is not an easy thing to understand.

Surely (for exanple) the number of doctors, the number of critically ill

patients, the proportion of specific workload [e.g., obstetrics), and

many other factors have an effect on how many nurses (of various specialties) are needed. One is led to wonder whether a close look at the relationships between these and other variables might show common features

among different hospitals, since common features in turn could conceivably

result in better understanding and from thence to better (or more economical)

care. It is true, of course, that nursing strength is subject to Army

regulations. However, it is also true that deviations from authorizations

are to be expected because of both fluctuating patient load and local

situations. How do these deviations affect the indicators of the quality

of patient care (QOC) ? Also how do selected indicators relate to the

basic but more elusive quality of patient care? In addition to QOC indicators described in the literature (discussed below) and studied by this

project, how does the number of nurses per doctor, nurses per patient, or

doctors per patient relate quantitatively to the quality of patient care?

Must one also consider other variables in order to explain the variability

in quality?

In a different vein, would it be possible to distill the insight and

experience of many hospitals into (conparatively) siiiple formulas which

4-7
state how many nurses would be required if the patient load were increased

by some given percent, or indicate how many nurses would be needed to staff

a new hospital in a given environment? What kinds of tradeoff can be

made between professional nurses and other nursing personnel?

The questions posed in the preceding paragraph are meant to be

suggestive, not exhaustive. It was not possible to follow up all conceivable relations, of course. Correlation analysis was used to identify

sets of variables that might be related in useful ways ; then these sets

,

and other sets that were of interest even before the correlation analysis,

were treated by regression analysis techniques. The sinple correlation

coefficients of the variables are in correlation tables used in selecting

candidate variables and appear in Annex II-4; their use is discussed in

Section 4.4. The variables chosen a priori included obvious measures of

workload such as number of bed occupied days , number of doctors , proportion

of patients in "intensive care," and the ratio of the numbers of professional

to nonprofessional staff, as well as others.

The general aim of staff/workload/patient care analysis and regression

analysis was to fit mathematical relationships between the variables

(staff, workload, etc.) and to subsequently interpret the results. These

fitted relationships were later used in obtaining the calculated number

of MC officers and the number of Department of the Army civilian (DAC)

registered nurses in each hospital.

Quality of patient care is a very important concept. However,

it is not a sinple concept. A number of "indicators" of QOC have been

proposed in the past, but nothing definitive has yet been acconplished.

Therefore, several potential indicators were investigated in this study

4-8
with the aim of getting an overall measure that would somehow look at more

than one factor. It is reasonable to suppose that at an understaffed,

overworked hospital, the QOC indicators might be lower while with plenty

of staff the QOC indicators might be higher. Can this be quantified and

demonstrated? It was noted early in the study that the QOC indicators

proposed by other researchers were not particularly sensitive to small

perturbations of the staff- to-patient ratios. Some possible explanations

for this apparent insensitivity are discussed in Section 4.6 of this report.

4. 2 MEDDAC Relationships and the Army Nurse Corps

Force Structure Model

Utilization of ANCFSM permits study of the effects of Title 10

(Statutory Law on Armed Servdce) and the consequences of application of

selected regulations and management policies including contract officer

incentive (COIN) pay. The objectives mentioned above are considered

necessary and useful in future OTSG projections relating to preferred

simulation configurations of the force structure. The assembly and

analysis of medical department activities data represented a major portion

of the technical work associated with this study. As mentioned above,

this portion of the report specifically relates to nursing workloads,

staff conposition, quality of patient care, and related variables of the

operating environments of the ANC.

The data obtained with the Instruments make it possible to derive

current MEDDAC needs and then to coirpare needs with available ANC staff

in future configurations of the force structure projected by the model.

This conparison has been made in this study for the nine MOS categories

and is presented in Section 4.5. Responses obtained in the attitudinal

4-9
survey, the Instruments data, and parameters related to applied management

policies are all inputs to ANCFSM and in practice are best considered

s iraul taneous ly

4:3 The MEDDAC Regression Model

This section presents a brief overview of the principal statistical

tool, referred to in this study as the MEDDAC Regression Model (MRM) , for

developing the more inportant relationships between staff and workload

variables. As indicated above, analysis of the large amount of data

collected required advanced statistical methods such as correlation

analysis, multiple regression theory, hypothesis testing, etc. An

exposition of the mathematical and statistical methods is presented in

Annex II- 3 which also contains a detailed list of the major relationships

established among the various staff and workload variables in the MEDDAC

data bank.

One of the first problems faced in the analysis of the data matrix

was the identification and isolation of the more important variables for

fitting equations used to calculate the MEDDAC staff variables. The

results of a correlation analysis indicated that besides obvious variables

relating to beds and staff which would be expected to be included, the

variable, number of Operating Rooms, was highly correlated (i? > .80 in

each case) with the number of M.D. 's, number of ANC officers. Total JCCU,

and Total Bed Occupied Days. Accordingly, the number of Operating Rooms

was included in addition to those variables previously mentioned.

The rationale just described applied mainly to the selection of the

independent variables, the variables appearing on the right-hand side

4-10
of the regression equation. Early attempts to use the variable, niMber

of MC officers, as a dependent variable were not successful. Accordingly,

it was decided to use the staff variable. Total Professional Nurses, consisting of ANC Nurses plus DAC Registered Nurses (DAC-RN) . IVhen this was

attenpted the results were dramatically in5)roved, and it then proved

possible to obtain extremely good fits.

The regression calculations themselves were carried out with the aid

of an NBS statistical package system (OMvIITAB) using the on-site liiivac 1108

conputer. The reader is referred to Annex II- 3 for discussion of the

detailed procedures and methodology.

In order to quantitatively relate the MEDDAC requirements with future

staff projections and future staff availability it was necessary to

determine which fitted equations were potentially useful in conputing

nursing staff from available statistical data. The collected quantitative

data of the variables of each ^EDDAC fell into four categories : (1) Staff

variables (S) , (2} workload variables (W) , (3) quality of care variables

(QC) , and (4) derived and other variables (OV) . The numbers and types of

each of these variables are shown in Annex II-5; "other variables" include

turnover rates of types of nursing staff and Dining Room Rations. Exanples

of "derived" variables are ratios of military to civilian nursing staffs,

of physicians to nurses, and of professional to nonprofessional staffs.

One independent variable of special interest is known as the

"I^dical Care Conposite liiit (^^CCU}." This workload unit includes the

following statistical data: Beds, admissions, births, and clinic visits.

Closely related variables such as Total Bed Occipied Days (BOD) , Average

4-11
Daily Patient Census, Beds Staffed, Average Beds Occupied/Day, and similar

statistics, covering various time intervals and categories of patients,

have also been included in the NBS data bases.

4.4 Exanples of Results

4.4.1 Several Variables

An example of the results produced by the MEDDAC Regression Model

is the prediction of the professional nursing staff, using the three

variables. Bed Occupied Days, Visits, and Births. The fitted equation

obtained takes the form

y = 8.927 + . 7707x10" + . 4238xl0"^x-|^5 + .6493xl0"^x^4 (1)

where the variables are as follows

y =^ Number of (ANC + DAC-RN) nurses

x^-7 = Number of Bed Occupied Days (BOD) FY 72

^15 ^ Total Visits FY 72

x^4 = Total Births FY 72.

This equation means that if values of the indicated variables are substituted on the right-hand side, the equation will give an estimate of the

number of professional nurses, y = (ANC + DAC-RN), in a MEDDAC.

An inpression of how well the above relationship fits can be obtained

from Figure 4-1 which plots the actual ("Observed") values of y against

the calculated ("Fitted") estimates obtained by substituting the values

of the variables for each MEDDAC in the above equation. Most of the values

are seen to lie close to a straight line. They would all actually lie on

a line if the fit were perfect, i.e., if each calculated estimate were

equal to the actual number of (ANC + DAC-RN) nurses. In the present case,

4-12

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4-13
the fit is remarkably good, being calculated as .957 on a scale from 0 to 1

2 (and denoted by the symbol R in the Figure) . A detailed exposition of

this measure of fit is given in Annex II- 3.

When the number of explanatory variables was increased from three

to ten, the goodness of fit increased slightly to .986. Tliis shows that

it need not be necessary to have many variables in order to obtain a

reasonably good fit.

4.4.2 One Variable

It also seemed worthwhile to look at the other end of the scale,

where only one independent variable was fitted to the same dependent

variable y as above. This indicates how good a variable is as a predictor

of the actual number of professional nurses (ANC + DAC-RN) in the MEDDAC.

Of the various variables tried one at a time, it was instructive to make

four fits to see how closely each of the three that are combined in the

three- variable fitted equation above, and, in addition, the remaining

variable in the MCCU definition, namely Admissions, can fit the observed

staff variable y when used separately. These are also shown in Annex II-3,

and one of these is illustrated here, namely that for Bed Occupied Days

(BOD) . The relationship is as follows

(ANC + DAC-RN) = 20.721 + .9248x10"-^ (BOD). (2)

The plot of actual vs. conputed y is shown in Figure 4-2, where the

goodness of fit is calculated as .939. For the other variables. Visits,

Births, and Admissions, these fits were .718, .231, and .597, respectively.

Thus, of all one-variable indicators. Bed Occupied Days is by far the most

accurate predictor of total staff requirements.

4-14
o o o o o o O »• CO fV4 O O orM X r*- •« o s (*< 9- M ^ :> ^ J 1

4-15
4.4.3 The MCCU Variable

The standard definition of the MCCU variable is given by

MCCU = Bed Occi:5)ied Days + 10 (Admissions) + 10 CBirths) +0.3 (Visits),

where all quantities relate to the same time interval (yearly total)

A one-variable fit gives

(ANC + DAC-RN) = .2035 + .3219x10"-^ (MCCU)

The corresponding plot is Figure 4-3 with goodness of fit .884.

If we now substitute in (4) the expression for the MCCU given in Equation

(3) , we obtain

(ANC + DAC-RN) = .2035 + .3219x10"^ (BOD) + 3.219x10'-^ (Admissions)

+ 3,219x10"-^ (Births) + .09657x10'-^ (Visits).

This may be regarded as equivalent to fitting the staff variable

tANC + DAC-RN) to the four independent variables, Bed Occupied Days,

Admissions, Births, Visits, subject to the restraint that the coefficients

of these variables be in the ratio 1 : 10 : 10 : 0.3, as indicated in

Equation (4)

The question of interest then is how good a fit can be obtained

with the same variables if the restraint is removed, i.e., what will be

the ratios of the coefficients corresponding to a better fit than that

which is obtained by use of the current definition of the MCCU?

The result of the unrestrained fitting is (plotted in Figure 4-4)

(ANC + DAC-RN) = 12.138 + .8464x10""^ (BOD) + .7389x10""^ (Visits)

- .2776x10"^ (Admissions) + .8903x10"^ (Births)

4-16
e a 0 B B 0 « 9 s 9 I B s »

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4-17
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4-18
with goodness of fit .968. Equation (6) may also be written as

(ANC + DAC-RN) = 12.138 + .8464xl0'"^ [Bed Occupied Days

- 3.28 (Admissions) + 10.51 (Births)

+ 0.087 (Visits)].

The bracketed expression gives a linear combination of the same variables

as in the MCCU, which, if treated in the same manner as the currently

defined MCCU, gives a superior fit to the staff variable (ANC + DAC-RN)

.

A discussion of the occurrence of a negative sign in a regression is given

in Annex II-3 but its interpretation in an MCCU-type combination would

require further work.

4.5 Data Analysis

This section analyzes the data matrix Table 4-1 from two points of

view: relationships between values for the individual hospitals, and

aggregates for geographical groups of hospitals.

4.5.1 Analysis of M3S Data

The nursing requirements of medical department activities are in

large part specified in terms of the number of nurses required in nine

MOS categories:

Using the NBS survey, data were collected from hospitals on the

numbers and types of duty MDS's currently required in each of the hospitals.

4-19

MPS Category Nurse Title

3449

3448

3430

3431

3437

3442

3443

3445

3446

general duty

medical surgical

administrator

Army Health Service

neuropsychiatric

pediatrics

operating room

anesthetist

obstetrics
The requirements are specified in terms of Am^ Nurse Corps MDS's and

duty positions occupied by DAC RN's. The two have been combined

to establish the total requirements of FY 1972.

It was of interest to the study to examine the hospital needs in

specific military occupational specialties (listed above) , to conpare

these needs with the primary NDS's reported by the nurses in the 1972

survey, and to consider projection into the future using the NBS Army

Nurse Corps Simulation Model. Such information for each of the nine

military occupational specialties currently on duty, and presumably

representing needs of the hospitals, is depicted in Table 4-2 and in

Figure 4-5 for NDS 3442. Charts for all nine MDS's appear in Annex II-9.

In Figure 4-5, the first of the six bars represents the number of duty

MDS's reported by the hospital. These are presumed to be the requirements.

The second bar represents 21 nurse officers not in hospitals but at other

stations such as training, research, etc. These officers have the specified

primary NDS's and, therefore, could satisfy MEDDAC requirements, but are

currently assigned elsewhere. Presumably these other assignments are

essential tasks requiring the specified ^DS's. The third bar represents

171 Department of the Army civilian (DAC) nurses whose job description is

identical with the officers duty MOS. The fourth bar then displays the

total nurse requirements of 378 for FY 72 (snapshot) as the sum of the

first three bars. How many of the MB 3442 nurse requirements are available

during FY 72 from the ANC Force Structure? How many would be expected to

be available in 1977? These are questions that may be answered by making

reasonable assunptions concerning transfer, recruitment, and attrition

as is done in the NBS simulation model.

4-20
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4-21
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4-77
The model referred to in Section 5 was operated under two specified

policies: policy 25-5, a 251 decrease in strength (to 1281 officers) over

a 5-year period and policy 0-5, no decrease over the same period. This

value was used in estimating the number of ^DS's available to the MEDDAC

from the force structure. The number of ^DS 3442 officers available under

this specific policy, not requiring special recruitment or training, is

99 as shown in Table 4-2 and in the fifth bar of Figure 4-5. Obviously,

this number of officers is insufficient to meet the requirements if they

would remain at the current level (378, fourth bar). .

.

The data resulting from simulation are depicted and summarized in

Figure 4-6. As sho\\TL in this figure there should be considerable concern

for the apparent shortage in the following I^DS areas : 3446 (obstetrics)

,

3443 (operating room) , 3445 (anesthetist) , 3442 (pediatrics) , and 3437

(neuropsychiatry). Consider Table 4-2: 161 obstetric military nurses,

supplemented by 293 civilian nurses (and 16 on duty elsewhere) , lead to

a total requirement of 470 nurses. However, currently there are only 144

available. Obviously, the 144 would decrease by a minijnum of 10 to 30

percent over the next five years. Unless specific plans are made to

increase the number of obstetric military nurses to meet the requirements

for the future, the only way in which the Army will be able to operate

these hospitals successfully, assuming the current load, ivlll be to hire

additional civilian registered nurses.

An examination of ^DS 3446 (obstetrics) and ^DS 3442 (pediatrics)

in Figure 4-6 indicates the need for looking ahead and training nurses

for the requirements of these two specialties. Approximately 470 nurses

4-23
O

O lO

O lO o

0> >- 10 <^ to

—

to If) ^ rO OJ ~

4-24
are presently on duty having assignments conparable to MDS 3446, but only

161 are in the Army Nurse Corps. Looking at ANCFSM's projection, and

replacing only certain nurses lost through attrition, it becomes evident

that a reduction o£ appro:Kimately 30 percent of obstetric military nurses

will diminish the number 161 to some number closer to 115. The discrepancy

between the needed number (approximately 167) , and 115 indicates the

advisability for planning and future training. Figure 4-6 summarizes two

of the bar charts for each of the MOS's. For exanple, the number of nurses

in MOS 3430, is represented by the first two bars of this figure, and the

number in MOS 3431 is indicated by a second pair. In all cases, for each

of the pairs, there would be shortages (under 25-5 policy), and in some

cases, rather severe shortages (see MOS 3437, the neuropsychiatric nurse,

MOS 3442, the pediatrics nurse, and MOS 3430, the administrator nurse).

The shortages (e.g., MOS 3446) can easily be visualized from Figure 4-6.

Some question may be raised with regard to the validity of both the

requirements and the future estimated numbers. It is clear that if one

trains enough nurses in each of these specialties there will be no shortages.

The survey data, the models, and the questionnaire results are

intended to be used in a combined (iterative -conjoint) fashion. The

simulation model outputs contain annual MOS configurations of the simulation policies which are conpared with the actual hospital requirements.

The simulation policies should be examined for conpatibility and acceptability using the survey data as a guide. This is an exanple of what is

referred to as a conjoint use of the various management tools mentioned

in this report. The bar charts in Figures 4-5 and 4-6, the summary

4-25
Table 4-2, and the conputer output Table 4-3, are intended to be compared

with specific policies used as inputs to the ANCFSM simulation.

The operation of the model, under reasonable policies and programs,

will reveal future shortages. This is an exairple of how the output of

the Force Structure Model (assuming it to be valid) can be compared with

the output of the data base on hospitals for detection of shortages and

excess. It should be pointed out here that regression fitted equations

for each of the NDS's can be generated by the techniques used to generate

the regression equations of Section 4.4 based on the variables of the

data matrix (Table 4-1).

4.5.2 Graphical Relationships

This subsection deals with the inportant staff variable, total

professional nurses (Army Nurse Corps nurses plus civilian registered

nurses), plotted against three other variables, in which the correlation

coefficient is greater than 0.80 in each case. Some additional figures

with highly correlated variables may be found in Annex 11-10.

It is of interest to plot the dependent variable "number of

professional nurses" as a function of the more inportant independent

t variables. See Figures 4-7, 4-8, and 4-9. In these three graphs, the

average number of nurses is plotted against : the number of beds with

which the hospital is equipped, the average number of beds occupied, and

the number of M.D. 's respectively. As mentioned earlier, the number of

beds staffed and BOD are two inportant variables in the determination and

calculation of nursing requirements.

4-26
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4-27
i I I -» I I I i«tiiitiiri«iitii tti(«trf i> I I I

I I I I I I I I • I I I I I I I I I I I I I

4-28
4 i t > II I « I I I t I I t I

I + I I I I I

4-29
+ I I I I I I I I + • • I I « I III! 4 1 I I I I

I I I I I I I I -f I I I I -f I I I I I I I I I I I I I I I -f I I I I I I

4-30
This basic factor in determining the required number of both

ciA/ilian registered nurse and the ANC officers is somewhat modified by

other factors such as: the number of M.D. 's on the staff, the amount of

on the job training (OJT) , the number of outpatient visits, and the number

of intensely ill, as conpared with the minimally ill patient. These four

factors seem to be relatively secondary in the determination of the nurse

requirements. Stated another way, once the numbers of staffed and occupied

beds are determined, the other factors, i.e., the number of doctors, etc.,

are hi^ly correlated with the number of occupied beds. Consequently, one

can make a reasonably acceptable approximation of the total number of

nurses required simply by counting the number of staffed and occupied beds.

Once having made this basic determination, it is possible to revise the

estimate of nurse requirements Lpward or downward depending upon the

inportance of the other factors.

The inportance of the number of M.D. 's in the hospital in determining number of nurses is of special interest. It must be understood

that a doctor's specialization, e.g., brain surgery, plastic surgery,

psychiatry, etc. , is significant. His particular speciality will have

an iirportant effect upon the requirements of the number of nurses. Figure

4-9 is a plot of the professional nursing staff vs. the number of M.D.'s.

The extremely high correlation between the M.D.'s on the one hand and the

professional nursing staff on the other hand is evident from the correlation

matrix. One way of interpreting the high correlation is to say that the

workload of the nursing staff is in part related to the number of M.D.'s

and becomes an inportant independent variable in computing the nursing

staff requirements.

4-31
An additional set o£ figures appears in Annex 11-10. The reader

will note the high correlation between the staff and selected variables

included in the regression-fitted relationships previously described.

4.5.3 Geographical Distribution

This analysis considers the original data matrix (Table 4-1) variables

aggregated over broad geographical sectors, i.e., total and average values

of the variables related to hospitals in the Continental United States

(CONUS) , Europe, All Other overseas locations, and the global aggregates.

All of these values are presented in Table 4-4, which is the first page

of Annex 11-11 that also indicates the category to which each

variable belongs.

In the data base (see Annex 11-11), one observes that 5,600 professional nurses (2963 ANC + 2637 civilian registered nurses) serving

in 63 hospitals or MEDDAC throughout the world, carried on a wide range

of activities expressed in terms of the numerical values of the variables.

For exanple, these 5,600 nurses: handled approximately one-half million

admissions in FY 72; were involved in delivery of 54,000 births; handled

over 20 million visits; reported over 4 million total bed-occupied days;

and were involved in the delivery of service represented by over 15

million medical care composite units (MCCXJ)

,

The geographical distribution of the enormous workload of these

hospitals may be observed by comparing the columns for the Total CONUS

4-32
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4-33
with that of the rest o£ the world. Very roughly, it appears as if almost

80 percent of the total workload (MCCU FY 72) was carried on in the

Continental United States, somewhat under 20 percent of it was carried on

in Europe, and the remaining 4 percent was carried on in other parts of

the world, including Alaska, Korea, and Southeast Asia.

It is the quantitative expression of these numbers which

constitutes the current nursing workloads. One can express these workloads in terms of the average number of nurses required in hospitals of

various sizes, the number of ICS's required per hospital, and so on. The

workload ultimately must be expressed in terms of the number of professional

nurses necessary to do the job. Since the total nursing force consists

of both civilian and military nurses, there will be tradeoffs in assignments whereby civilian nurses will sometimes be doing military jobs and

military nurses will, on occasion, be required to assume some of the more

traditional civilian nursing jobs.

4.6 Quality of Care

One of the roles of the U. S. Army nurses resides in their contribution to the quality of patient care, and therefore a study of the Amy

Nurse Corps should examine the extent to which the quality of patient

care is affected by the nunt^er of nursing staff.

The difficulty with this statement is that the quality of patient

care is an extremely conplex subject, involving a substantial number of

4-34
variables, in which the role of the nursing staff caraiot be fully determined,

except under the most controlled conditions.

Even the measurement of quality of patient care poses its problems;

how, for exanple, can the numerous indicators of patient care

(e.g., hospital infection rate, conplaint rate, average length of stay,

etc.) be combined into one single conposite index for each hospital?

With such an index it would be possible to compare any two hospitals,

rank-order a list of hospitals, or determine whether overall quality of

patient care was inproving or deteriorating at a given hospital.

The purpose of this section is: (1) to develop a first-cut methodology for the construction of such a conposite index for the overall

quality of care, and (2) to apply this index to the MEDDAC data base and

note the results obtained.

4.6.1 Theory

In previous studies quality of care has been represented by a vector

of several variables or indicators, often including hospital infection

rate, care complaint rate, average stay for special surgeries, etc. The

total number of such variables conprising the quality of care vector is

ordinarily large (nine in this study) , and should supply the user with

substantial information about the quality of care at any given hospital.

This approach, however, has two principal shortcomings: a) direct

conparisons of the overall quality of care between hospitals caraiot be

made—^from which it follows that the list (or any sublist) of hospitals

4-35
cannot be rank-ordered by quality of care, from highest to lowest, and b)

the contribution of each conponent contains other effects which tend to

obscure the true indicator of quality of care.

The solution to this problem resides in the establishment of a

single index which will represent overall composite quality of care.

The coirposite indicator will permit conparisons between (and rank ordering

among) the various hospitals in the survey and can be used to determine

changes in overall quality of care at a given hospital through time. To

show how this is done suppose that v^, ^2'**"^ stand for the n variables

conprising quality of care. The quality of care index is a scalar, related

to these v's, which in its most general form is given by the function:

QOC = f(v^,V2,...,v^). (8)

One of the simplest candidates for (8) is the unweighted, additiA/e

composite given by:

QOC = v^ + V2 + . . . + v^ . (9)

Before (9) can be applied, however, several inportant steps must be carried

out. The first of these is normalization, in which each variable is adjusted

so as to be on a per patient basis ; that is , total infections or total

conplaints must be first divided by admissions to arrive at a per patient

rate. The next step is to introduce standardized (dimensionless) variables,

of the form:

= (v^ - v^) fa^ , (10)

where v-j^ is the mean for the set of hospitals under consideration and

the standard deviation of the first variable, v^. The reason for using

standardized variables, instead of original variables, is to insure that

4-36
no one variable dominates or overpowers the others Cor is, conversely,

"lost" if small in magnitude), due to its particular choice of dimensions.

The third and equally inportant step is to select the form of the original

variable v-^ for use in (10) for which increasing (or V-^) iiiplies increasing quality of care. That is, all individual quality of care variables

utilized must be conpatible in direction as well as dimension. To

illustrate, the variable "unusual occurrences" should not be directly combined with "hospital infection rate." Instead, unusual occurrences/

admissions should be combined with the normalized hospital infection

rate.

The quality of care index, QOC, in (9) can be regarded, in effect,

as a score in an examination where the questions have equal weight. Should

the user feel that certain conponents must count more heavily than others,

then the differentially weighted conposite:

QOC = a^V^ * a^V^ * . . . * (11)

can be used. As is readily apparent, (11) reduces to (9) when all the a^'s

are unity. One final caveat that must be made is that the set of individual

indicators V^, i=l,2,...,n should be as statistically independent (see

6.3.2, page 6-8) as possible. That is, if the indicators in a certain

subset were highly correlated with each other, their combined effect might

be to dominate the composite index, reducing its sensitivity to variations

in the remaining indicators. If high statistical dependence is known or

suspected among certain indicators they should be combined into subgroups

with the resulting subcomposites used to form the final conposite index.

For example, if it were the case that V-j^, V^, and Vy were highly correlated,

one could replace them with the variable V-j^, formed as indicated below.

4-37
In general, one tries to introduce groiqDings of the form:

n.

1 0

V.' = - 2 V, , Cwhere Sn. = n)

1 n. . T k.' ^ 1 ^

such that the sets {V-j^ } have the highest arrangeable internal correlations,

i

with the resulting subcomposites Vj ' having the lowest a^Tanggj-^fl)® external

correlations among themselves.

In summary, therefore, what the coirposite quality of care indejc (9)

or (11) loses in its ability to detail the spectrum of quality of care at

a given hospital, it makes up for by permitting comparison between, and

rank ordering of, any group or subset of hospitals.

4.6.2 Application

Let us now put theory into practice Figures 4-10 through 4-18 present the normalized form of the following nine quality-of-care indicators

(ordinate) plotted against hospital size (abscissa) and selected for

inclusion in the conposite index:

(1) Hospital infection rate

(2) Average stay, all procedures

(3) Average stay, general surgery

(4) Average stay, appendectomy

(5) Average stay, hernia

(6) Average stay, cholelithiasis

(7) Care complaints , medical

(8) IMusual occurrences

(9) Nursing attitude

The last indicator, nursing attitude, is a variable expressing the fraction

of the nursing staff that believes its hospitals to be below average in

overall patient care; in this sense it is normalized on a per patient

basis. Notice that increases in the magnitude of any of these indicators

4-38

Unnormalized Normalized

V-,

v^
inply unifoniLLy decreasing amounts o£ quality of care, and the set of

indicators therefore satisfies the necessary axiom of direction, as called

for in the definition of conposites.

Let us now regard the figures themselves. The x axis (abscissa)

in all figures is the hospital size (in beds) ; the y axis (ordinate) is

the value of the normalized quality of care indicator (V^) —the number

of standard deviations from the mean assumed by the original unnormalized

variable (v^^) . For convenience the y axis has been labeled "Score" in

Figures 4-10 through 4-18.

In Figure 4-19, where the total conposite quality of care indicator

is presented (based on Equation (9)) we see what the individual indicators

could not really tell us: That overall quality of care is enhanced with

decreasing hospital size . Virtually all hospitals of from 10 to 100 beds

have better than average quality of patient care, and almost all moderate

to large hospitals (from 150 to 1000 beds) are seen to have below average

quality of patient care. This could be a profound result, but must be

verified by substantial additional research. This caveat is made because

\^^at we have labeled as "qnal i tyj3£_jcarelLJ^-C£rLaialy-- nQt,.§^

with tnie quality nf rarPj but i g m^rply a grnrp nn qn^^-ygm who se results

would hopefully correlate well with the abstract and rather subjective

concept we are trying to measure. With this warning in mind we present

Table 4-5 containing the rank-ordered quality of care index starting with

the largest positive value (i.e., "worst") and going to the largest negative

value (i.e., "best") for the 62 U. S. Army hospitals, worldwide.

4-39
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4-40
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4-42
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4-49
Rank-Ordered Composite Quality of Care

Hospital # Beds Q.O.C. Hospital # Beds Q .O.C

800 422 1.1165

1 350 50 .0140

030 1024 1.0684 490 261 .0138

061 525 .8186 390 546 - .0587

550 300 .8178 640 60 - .0628

051 559 .8152 251 186 - .0668

241 535 .8128 210 116 - .0877

020 800 .7835 ! 871 130 - .0939

Oil 980 ' .6374 290 126 - .1309

410 339 . 5855 i 500 110 - .1320

47 0 344 ' .5422 ! 561 132 - .1419

690 485 .5147 520 440 - .1438

810 750 .4815 i

1 720 115 - .1476

820 50 .4653 1 270 75 - .1569

830 350 .4383 360 88 - .1806

260 142 .4235 850 35 - .2031

340 679 . 3821 510 60 - .2235

041 850 . 34 77 710 272 - .2632

450 285 .3284 380 75 - .4095

301 997 .2805 : 440 40 - .4297

320 254 .2416 230 25 - .4934

670 330 .2116 I 730 19 - .5237

680 175 .2046 j 370 40 - . 5387

460 450 .1747 860 15 - .6283

630 125 .1701 i 660 35 - .6350

400 100 .1550 740 20 - .7983

430 378 .0855 610 40 .7993

280 125 .0477 i 480 106 .8328

220 334 .0454 1 530 12 -1 .0101

620 100 .0415 i 052 50 -1 .0679

420 85 .0360 1 521 12 -1 .1223

330 98 .0177

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Table 4-5

4-50
Because of the possibility that the average length of stay for

the various surgical procedures may not be sufficiently statistically

independent, with the same possibility for the two "conplaint" rates,

let us fomrulate an alternative quality of care index utilizing the

procedure outlined earlier. If V^, i = 1,2,..., 9 stands for the nine

separate quality of care indicators, let

q^ = V-j^ (the hospital infection rate)

^2 ^^2 ^3 ^ ^4 ^5 ^ ^6-^'''^ subcomposite of average length

of stay)

q^ = (Vy + Vg)/2 (a subcouposite of tlie two "conplaint" rates)

q^ = Vg (nursing attitude)

and now define the alternative conposite quality of care index as

The use of (12), however, does not change the fundamental conclusion,

as is succinctly illustrated in Figure 4-20. Not only does the trend remain

the same, but the fitted curves in Figures 4-19 and 4-20 are virtually identical

This "stability" of fit supports and strengthens the original conclusion.

This does not coirplete the analysis, however, for one question

that was posed in Section 1.3 was whether quality of care is correlated

with the level of residual nursing staff at the individual hospitals.

By residual nursing staff is meant the difference between the actual

levels and the corresponding staff levels that are predicted by the

"regression" fits in Section 4.4. These residuals were confuted and

normalized for 47 hospitals and appear in Figure 4-21 graphed against the

corresponding quality of care index. As it was the smaller hospitals for

which the residual nursing levels were not calculated (the original list

had 67 hospitals) , most points are seen to lie above the mean QOC axis

(where QOC = 0). 4.51

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4-53
The point to note is that the average level of quality of care,

as measured by the indicators of this study, for those hospitals with

shortages in nursing staff (to the left of the vertical axis) is just

about equal to the average level of quality of care for those hospitals

with overages (to the right of the vertical axis) . This implies that

what this study has taken to be quality of care does not appear to

correlate with the averages or shortages of nurses, as observed, in

the various U. S. Army hospitals. The true extent of the effect of

nursing staff quality (and quantity) upon the quality of patient care

must, of course, be the subject of further research.

4-54
5.0 ANC Force Structure Simulation Model (ANCFSM)

The model was designed and developed by the team members to predict

the characteristics of future ANC force structures and to help answer

questions such as those raised in Section 2.0, namely:

1. Is there an effective way to describe quantitatively the annual

changes in the ANC grade structure?

2. Is it possible to develop a model of the ANC which can generate

specific configurations?

3. How many lieutenants are required for initial entry by

phased year to attain and maintain a specific configuration?

4. How long will it take to achieve a specific configuration?

This aspect of the study was to provide management with a tool to aid

decision-making in the areas of recruitment, training, promotion, retention,

separation, and retirement. To do this, it was necessary to conprehend the

statutes, regulations, policies, and practices which govern the movement

of officers within the Nurse Corps. Further, this movement of nurses had

to be understood in terms of the three different promotion systems which

prevail (the Regular Army or RA System, the Reserve Army or USAR System,

and the Army of the Uhited States or AUS System) and their main features

regarding zones of consideration, rules of selection, pass-over differences

between the conponents of the Army, and the regulations described in Part III

which deal with separation and retirement. As mentioned in Section 2.3,

the precepts and rules governing all transitions of nurses from one status

to another fall into three main groins: (1) statutes and regulations (e.g.,

retirement regulations) ; (2) annual policies made by various policy-making

groins (e.g., zones of consideration for promotions) ; and (3) precedents

set by historical experience (e.g., transfers from USAR to RA or changes in

M3S) . These regulations and practices are incorporated in the simulation model.

5-1
The basic portrayal of the force structure in this vrork is one in which

officers having closely related values of certain characteristics, e.g.,

dates of rank, M3S, years of service, etc., are placed, by definition, in

the same cohort group . The transition rules operate on the cohort groiqjs

rather than on the individual officers. When these rules have been applied

to all cohort groups for a particular simulated year, the resulting new

cohort groips are then ready for processing for the next year. Among the

changes that are provided for, and which may operate on some or all members

of a cohort groi^, are: permanent and/or tenporary promotions, transfer

from the Reserve to the Regular Amy, change of M3S, involuntary

separation, voluntary separation (attrition), and retirement. One can

think of each officer, in any particular year, as located in some particular

"box" (cohort group) . Departure from this box takes place after the model

has essentially asked such questions as "Is this officer ready for promotion?".

Is the officer one who may change his/her MDS or may transfer from the

Reserve to the Regular Army?", "Is the officer one who may undergo attrition?",

etc. The result of positive answers to these questions is, in effect, that

the officer is removed from the current box and placed (for the next year)

in the appropriate new box.

In summary, the model accepts input data concerning year- end- strengths

and promotion policies, i.e., promotion points and promotion probabilities.

It accepts historical or anticipated data concerning attrition and rates

of transfer from Reserve to Regular Amy. Finally, the model utilizes

the current structure of the Corps, where officers are grouped by permanent

and tenporary grade, years in permanent and tenporary grade, service conponent.

5-2
military occupational specialty, years of active federal service, and

years of active federal commissioned service. Passing from [siniulated]

year to year in accordance with the kinds of transitions and transition

rules indicated above, the model produces, as output, a projection of the

Corps structure in terms of the characteristics above, for the number of

years specified. This projection can be shoim in various tabular or

graphical formats.

5.1 Input Data and Output Formats

A single introduction to how the model operates can best be approached

by illustrating the requisite input data and the corresponding outputs

produced by the ANCFSM program. Output from the model is of two general

forms, namely: (a) output which lists the input parameters, i.e., describes

the scenario under which the model was executed, and, (b) output -ivhich

portrays the current and projected force structures. Figure 5-1 illustrates

some of the output generated by the model. Annex II-8 provides additional,

more detailed outputs.

Figure S-IA shows the promotion points, by grade and year, for five

periods, 1973 to 1977, inclusive, for permanent and tenporar>^ promotion in

both the Regular Army and the U. S. Army Reserve. Promotion points define

the zones of consideration for promotion by specif\"ing the number of years

of active federal commissioned ser\dce that an officer must have to be

eligible for promotion. As shoim in the figure, R\ first lieutenants,

for exanple, must have 4 and 5 years AFCS to be promoted to captain in 1973

and 1974 respectively, i.e., for illustrative exanple promotions are being

delayed in future years. The figure also presents the probabilities of

permanent and temporary promotion, by grade, for those in the zones of

5-3
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consideration. For exanple, virtually all (99°^) of the second lieutenants

in the zone of consideration will be promoted, while only 45% of all

lieutenant colonels will be. The constraint of having but one general

officer is acconplished by setting the promotion probability to zero for

all full colonels. Finally, the figure lists the total strength requirements,

by year, for each year to be simulated. All of the data shown in Figure

5-lA are supplied by the user.

Figure 5 -IB depicts the initial status of the ANC by grade and service

component, and by MDS. Total salaries are tabulated for the same categories.

These numbers represent input only, and because no changes have yet been

simulated, all remaining columns in this figure are zero. This same general

format is repeated each year of the simulation, with the changes occurring

during that year tabulated in the appropriate columns.

Figure 5-lC also represents input and is a detailed breakdown of the

initial profile of the Corps by grade, service conponent and years of

Active Federal Service. This type of output is also repeated for each

year of the simulation.

Figure 5 -ID is the analog of Figure 5-lC for the specific category of

obstetric nurse (M3S 3346) . This particular breakdown for an individual

MDS is not a standard model output. It is generated with very minor

program changes at the request of ANC personnel. The program can, of course,

be made to print these profiles for all ^DS's.

Figure 5-lE presents the results of actual simulation by the force

structure model for the first such year requested. The 1972 authorized

year- end- strength was 4124 officers, but is expected to be only 3597 at

year-end 1973. Consequently, there are substantial separations (555),

5-5
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5-9
with addition of only 18 second lieutenants. It can be seen that in this

simulation the great majority of attrition has taJ<:en place at the captain

level, and that the nursing specialty incurring the largest loss is the

medical surgical groi^D, M3S 3448. These data are presented here to

illustrate the model output. No particular significance should be attached

to the actual numbers without thorough understanding of the simulated

scenario.

5.2 ANCFSM Model Structure and Description

This section presents an overview, of the operation of the force

structure model. The full details of its operation as well as computer

generated flow charts of the program are found in Part III. The model

treats each year as one unit of time. Boxes 1-3 have "initializing"

functions. All changes in the force structure, as shown in boxes 4-11 of

Figure 5-2 are modeled as if occurring at the same time in that year. In

Box 12, the model ages the Corps by one year and returns to reconpute changes

in the Corps for the next year. The data processing steps are described

briefly in the following paragraphs.

Mpdel Operations (Box numbers refer to Figure 5-2.)

Box 1: Read the input data proAaded by the user. These data, representing the policies and practices to be simulated, include the following:

number of years to be simulated, promotion points, probabilities of promotion,

year- end- strengths, attrition data as described in Part III, salary schedule,

and a distribution of transfers from USAR to RA.

Box 2: Read data describing the cohort groups in the current (initial)

force structure. These data can be extracted from an Officer Master File

by a separate conputer program described in Part III.

5-10 .
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Figure 5-2

Overview o£ Steps in the

Simulation of AIJCFSM

5-11
J Box 3 : Print the input parameters of the model and display the initial

force structure in tabular form and, if desired, in graphical form.

Box 4: Process involuntary separations and retirement. Officers

are separated for the following reasons : a) USAR with 20 or more years

AFS; b) RA colonels with 30 or more years AFS and 5 or more years in

permanent grade; c) RA lieutenant colonels with 28 or more years AFCS;

d) RA officers below the rank of lieutenant colonel who were passed over

for promotion with 18 or more years of service and were allowed to remain

until they acquired 20 years of service. Separation of these officers

is based on trends found in historical data rather than on regulations

requiring this action at this particular point in their careers.

Box 5: Process tenporary promotions. Determine if an officer is in

a zone of consideration for promotion. If so, the officer is promoted

with a certain probability. Recall that both the zones of

consideration and the promotion probabilities are input parameters.

Officers with less than 18 years of service who are passed over are

assumed to resign.

Box 6: Process permanent promotions. Determine if an officer is in

the zone of consideration for a permanent promotion. If so, the officer

will with the specified probability be promoted. The zones and probabilities

for permanent promotions are also input parameters. Officers below the

rank of lieutenant colonel who are passed over for promotion are assumed

to resign. ;

5-12
Box 7: Determine if an officer is a candidate for attrition. Those

who have recently enlisted or been promoted have not been considered

candidates in most of the smulations executed thus far. (To consider these

officers as candidates for attrition requires only minor program and/or data

modifications.) For those officers who are candidates, attrition

probabilities are calculated using the "relative attrition propensity"

(RAP) relationships described in detail in Part III. Officers subject to

attrition then leave the service with the probability so calculated.

Box 8: Simulate career transitions in the medical occupational

specialties. All officers with MOS 3449 are converted to MDS 3448 after

one year of AFCS. In addition, other MOS's are changed in order to maintain

the distribution of officers by MDS that existed in the initial force

structure as read in Box 2. The logic used in the model for changing MDS

was developed after examining historical records to determine typical patterns

of MDS transitions. The model can be easily modified to direct these

transitions toward other target distributions.

Box 9: Simulate the transfer of nurses from USAR to RA. The

number of officers to be transferred is determined by comparing the RA

strength (before transfers) with the RA strength in the initial force

structure as read in Box 2; the transfers are directed at maintaining

that initial strength. The distribution of transferees by years of

service, which can be obtained by examining historical data, is input to

the model.

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i

I 5-13
Box 10: Simulate the recruitment process. Upon entering Box 10,

all voluntary and involuntary separations have been recorded. The Corps

now consists only of officers who have survived these processes. If

this number is less than the authorized year- end- strength, officers are

assumed to be recruited to fill the vacancies. Although the model input

allows for the specification of recruitment policies, definite future

policies had not yet been established. Pending such establishment, the

model's current version fills 20% of the vacancies by second

lieutenants and 801 of the vacancies by first lieutenants.

Tliis distribution of recruits was based on past data. All recruits in

the model are in the USAR and have MOS 3449. This recruitment policy of

the present model can be easily modified if desired.

Box 11: Update and consolidate the internal computer representation

of the ANC. This process reduces the computer memory requirements for

the model.

Box 12: Advance time by one year. All cohort group attributes

relating to time in service or time in grade are increased by one to

reflect the passage of a year.

5.3 Validation and Initial Results of Simulation

Tlie ANCFSM has been exercised numerous times during its

development. In addition to the usual runs needed to debug the computer

5-14
program, several runs were designed to validate the model logic and the

associated input parameters. Validation of the simulation was approached

by providing the model with force structure descriptions from past years

(1970 and 1971) and exercising it to "predict" force structures up to

and including 1972. The model results were then compared with known data

for this period of time.

Conparison of the predicted results with the "true" data indicated

that the predicted nurse profiles (distribution of officers by rank, years

of service, and service component) did not always agree with those obtained

from the corresponding Officer Master Files. These discrepancies led to

closer examination and comparison of the data extracted from various

reports used as data sources. It was found that corresponding data from

these sources (COPO-11 reports, Officer Master Files, and Separated Officer

Master Files) did not agree. The discrepancies, which were discussed with

ANC personnel, are apparently the result of two factors: acknowledged

inaccuracies in past Officer Master Files, and uncertainty surrounding

the actual dates on which these various sources were prepared. (Although

the sources were dated at fiscal year ends, some may actually have been

generated slightly earlier or later. ) The effort required to attempt

reconciliation of these past data discrepancies was judged to be beyond

the scope of this study. Fortunately, similar discrepancies were not found

in 1972 data and are not expected to occur in the future, since ANC efforts

at improving the accuracy and completeness of these data sources are scheduled.

5-15
It is extremely iniportant that the validation effort be resumed when

1973 force data are available for comparison with predictions for 1973

from simulation runs started with the apparently more accurate 1972 data.

A complete discussion of the validation efforts to date as well as an

illustration of the data discrepancies are found in Part III.

Although it would be premature to attach great significance to model

results prior to the completion of validation, it is anticipated that validity

will indeed be confirmed when the 1973 data are available for comparison.

For this reason, the study team went on to exercise the model several times,

using the initial force structure obtained from the 1972 Officer Master

File. These runs were made with a variety of settings for the input parameters,

and the results have received considerable study. Figure 5-3 is a typical

output from one such run in which the total number of officers in the Nurse

Corps is plotted as a function of years of service. The figure shows that

in the initial year (1972) there were approximately 450 officers with no

experience (recent recruits), 750 officers with one year of experience,

and 400 officers with two years of experience. After simulating three

years, these numbers had changed to 680, 450, and 250 respectively.

Such a profile can be extremely useful in identification and consideration

of questions regarding costs, attrition, retention, and types of nursing

experience. Scrutiny of such a curve produced under a specific policy

can communicate distinct impressions, for management, of the changes that

could occur over a number of years. To illustrate: it was noted that

for a particular policy designated as 25-5 (a 25% decrease in the Corps

over a 5 -year period) a "valley" in the profile curve was introduced in

the early years. As simulation proceeded it was possible to see this

5-16
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5-17
"valley" move across the horizontal axis with time. (In Figure 5-3 this

valley appears in the 1975 profile curve at 2 years of service.) The

movement of the "valley" directed attention to the effects of this policy

in the year 1975 when the number of officers with less than seven years

of service would be greatly reduced. Under the 25-5 policy the profile

of officers in the higher ranks (with more than seven years service) was

relatively unaffected, according to the simulation.

The worldwide questionnaire provided an additional source of data

for comparison with data utilized in the simulation. In particular, the

nurses were asked to give their active federal military service (rounded

to the nearest year). Figure 5-4 compares the responses to this question

for the 3,481 respondents with the profile obtained from the 1972 Officer

Master File. Here again discrepancies were noted for officers with less

than seven years of experience. It should be remembered, however, that

the 1972 Officer Master File was prepared several months before the

questionnaires were distributed. These discrepancies for tlie lessexperienced, more transient officers could be the result of this time

difference.

A study of tabular and graphical outputs and the profiles, and of

their changes in response to specific policy variations, enables a planner

to see and visualize future ANC force structures. The simulation model

is a tool for use in studying the effects of various policies upon the

Nurse Corps. It cannot be overemphasized that the model can and should

be modified to represent any number of policy proposals and variations .

In fact, the real potential of tliis model will not be realized until it

is exercised under the direction and guidance of ANC personnel. If, by

5-18

considering the needs of the MEDDAC and the changes produced by modem

technology, it is possible for OTSG to formulate a preferred configuration,

then use of the model under various policies will show which one best

directs the initial structure to evolve toward that desired one. In this

way, alternative future policies can be examined without the great cost

and delay of real-life experijnentation. The model is flexible, with

parameters that are easy to change, and its use provides insight in a

relatively inexpensive manner.

5-20
6.0 DISCUSSION AND CONCLUSIONS

This section treats potential ANC problems and ways of minimizing

these problems. It discusses the study products, projects results for

possible future uses, and finally presents specific findings and conclusions.

6.1 Future Uses of Models and Data

The interdisciplinary team developed tecliniques and tools for answering

a broad range of questions of possible importance to the United States Amy

Nurse Corps. These include:

• A force structure simulation model

• Analysis of a worldwide ANC questionnaire

• Quantification of the MEDDAC.

Associated with these tools is a large valuable data base on nursing

personnel that has been collected and reduced to computerized, machine

processable form. This data base can be thought of as consisting of three

components

1. A data set derived from an attitudinal survey of nurses'

thoughts, opinions, preferences, and dissatisfactions;

2. A data set derived from an organizational survey of the Nurse

Corps, including distributions by number, nursing military

occupational specialty, experience, and other U. S. Army service

attributes (see Annex II -7 for survey Instruments)

3. A data set (Annex II -6) derived from a medical activities survey

of the Nurse Corps, as characterized by staff and workload,

quality of patient care, and other descriptors of their operating

environment

.

A principal objective of this project was to furnish the Office of

The Surgeon General with sets of data and the means to continue a program

of analysis on questions of importance. A number of possible studies

and analyses emerged during the collaboration between NBS and the Office

of The Surgeon General. These go beyond those planned for the NBS effort.

However, they could be accomplished using the end products of this effort.

Several possibilities are recommended on the following three pages.

6-1
— For specific missions use the model for obtaining answers to the

following questions:

1. Can a specific ANC configuration be developed for near future

specific mission requirements?

2. What actions can be taken to correct variations from such

specific configurations?

3. How many appointments as lieutenants are required for initial

entry by phased year to attain and maintain a specific con- figuration?

4. How long will it take to achieve a specific configuration?

5. What are the described retention, separation, and promotion

points required to achieve, in an orderly progression, a specific configuration?

6. What percent of the nursing corps will be leaving the service,

and when?

7. What specific steps can the OTSG take (in terms of policy

changes) to decrease this attrition and increase retention? — Compare the relative attrition propensities (RAP's) of a sample of

cohort groups to identify groups with relatively high and low RAP's.

Establish the degree of correlation between attrition actually experienced

by each group and the same groups' answers to the worldwide questionnaire

item: how they feel about remaining in the service for a full career.

Follow this analysis with an examination of the factors apparently most

important to the career decisions of cohort groups with different

attrition histories. — The more meaningful of the personnel proposals to which the ANC officers

responded in the worldwide questionnaire should be considered as subjects

for future modifications and development of the force structure model

(ANCFSM) . Additional subroutines could be developed to simulate the

effects of such proposals, and pertinent attitudinal data could be analyzed

in relation to the results. — The MEDDAC Regression Model (MRM) and the hypothesis testing

techniques developed for the project permit the examination of additional

6-2
questions pertaining to the variables already analyzed in the model, and

are also amenable to the addition of new variables to obtain a better

understanding of the MEDDAC environment of nursing services staff. It is

possible to pose and answer such questions as:

1. What is the effect of the size of the hospital on the nurse/

workload relationships?

,2. What is the effect of hospital size and hospital staff on the

quality of patient care?

3. Can composite indicators be developed for determining hospital

nursing staff requirements?

4. Is it possible to identify a workload quantity which correlates

better with nursing requirements than the frequently employed

Medical Care Composite Unit (MCCU)?

5. Is there any significant difference in staff/workload, or quality of care variables between hospital classes such as class sizes or Class I and Class II?

These are examples of questions that can probably be analyzed via the

MEDDAC Regression Model and related hypothesis testing technique referenced

in Section 4.3 and Annex II-3. — Analyze in more detail the MEDDAC data on nursing staff to ascertain

patterns relevant to implementation of personnel policies that pertain to

such attributes and qualifications as race, sex, age, and professional

training, as well as duty positions and work areas, and the use of nursing

personnel in nonnursing duty positions. — Conduct an analysis of the daily activities of ANC officers, using

the activity data developed for this project's data base. The analysis

should include both the activity data under general categories, as

furnished by all ANC officers who completed the worldwide questionnaire,

and also the more detailed data in Section C of the Survey of Nursing

Personnel.

6-3
— The foundation laid for the development of an index of professional

orientation could be pursued further. Two elements of such an effort could

be an in-depth analysis of the rank-ordered questions on professional and

self-image variables summarized in Table 3-1, the results of which could

be analyzed in relation to attitudinal questions covering various dimensions

of professionalism, bureaucratic functions, organizational behavior, and

individual profile characteristics. — One important aspect of professional orientation among Army nurses is

the relationships among three variable clusters: nursing skills, broader

professional qualifications, and professional status. The data are

available from this project to obtain a better understanding of the

professional perceptions and motivations of MC officers. — Conduct an analysis of ANC responses to the questions: "What do

you think is one of the biggest problems in the Army Nurse Corps?" and

"What do you think should be done about it?" — Finally, it is now possible to answer the following questions by

interrogating the attitudinal component of the Nurse Corps data base with

the computer programs of this study:

1. What attitudinal factors hamper or enhance retention and career

management of nurses in the Army?

2. Can ANC officer reactions to current and contemplated policy

statements and proposals be identified?

3. How do the military career expectations of ANC officers vary by

grade and educational experience?

4. Can the vital factors of job satisfaction be identified and

projected for educational attainments?

5. How many ANC officers are interested in entering nurse clinician

specialties? How many are interested in courses that would

qualify them for critical MOS's?

6. IVliat professional values are most important to nurses, and do ANC

officers associate these values with Army nursing?

7. What reason do Army nurses give for entering the ANC? For

choosing to remain for a full career?

6-4
8. l\'hat do members of the Corps feel are the ANC's biggest problems?

How are these perceptions related to such factors as grade,

component, ^DS, sex, marital status, and dependency responsibilities?

Tliese questions are in large part ansivered in Section 3 of this report.

The force structure and regression models, in combination with the three

sets of data, and the readily available associated statistical programs,

constitute an array of techniques for examining ANC policy questions. Not

only can aggregate needs and effects be projected, but the likely response

of groups of individuals, with a specific attribute profile can also be

made available. This array of instruments makes possible the interactive

use of planning models, the professional judgments of the Corps, and the

attitudinal analysis in simulating, for planning purposes, the future ANC

configurations.

6. 2 The ANC Force Structure Simulation Model

The development of the Force Structure Model revealed the possibility

of testing a range of management policies relating to promotion points,

recruitment, service component transfers, i^OS training effects upon transfers,

incentive contracts, and other grade and career factors. It was found

that the MOS patterns projected by the ANC Force Structure Model are not

extremely sensitive to relatively small year-end strength reductions,

although these patterns are sensitive to larger year- end reductions in

force. This dependence of the future ^DS pattern, and other characteristics

of the ANC structure, upon year-end strength policy, training plans, and

other factors may now be investigated.

6,2.1 Model Projections of Future Staffs Under Current Policy

A class of findings concerning the number and distribution of nursing

personnel, by specialty, that may be available in future years, has been
projected utilizing the Army Nurse Corps Force Structure Model. These

potential distributions were obtained under (i) the current year-end

plans for the Army Nurse Corps, and (ii) one alternative plan. Under

the current policy, a 5-year simulation projection showed, for example,

that a deficit of approximately 360 obstetric nurses may be incurred unless

positive steps are taken during that interval of time. A potential deficit

of some 280 pediatric nurses may similarly be incurred. Assuming current

policy, under the present system only 2,900 ANC nurses will be available for

the projected 3,327 nurse officers potentially required in 1977.

6.2.2 Model Variables, Corps Profile, and Policy Testing

The simulation model exhibits certain items of interest in preliminary

testing. The characteristic shape of the graph of the number of officers

versus years of service (the area under the curve of Figure 5-4 represents

the total Corps size) is sensitive to input parameters related to recruitment, retention (incentive) policies, and promotion policies. For the

promotion policy assumed, the graph (referred to as the profile) is seen to

drop quite rapidly, from a level of 600 nurses with 1-2 years of experience,

to about 100 with about 7 years of experience, attenuating slowly thereafter for nurses with up to 30 years service in the Corps. This effect

shows quite clearly that tliis specific policy results in the training

of nurses who subsequently find employment outside the Corps. It is now

possible to develop and test special promotion policies in which the

profile curve (i) starts lower, and (ii) does not decrease quickly, but

instead, decreases more slowly. Under such special policies there will

be higher retention accompanied by lower recruitment and separation costs.

6-6
6.3 The MEDDAC

Tlie MEDDAC survey requested information on staff, workload, quality

of patient care, and other variables. The issues discussed center around

potential WS shortages and the approach to the quality of patient care.

6.3.1 Hospital Requirements

Hospital requirements, as presented by tabulation of the duty MOS's

enumerated in the survey, are being currently met by a mixture of military

and civilian registered nurses. This mixture varies for specific NDS's,

from almost 100% military nurses, to certain ^DS's in which the military

nurses number less than 50% of the total professional nurses. Comparison

of tlie number of Army Nurse Corps members currently available with the

specific MEDDAC tabulations indicates possible future shortages in

pediatrics, obstetrics and neuropsychiatry. The data gathered from the

hospitals in terms of duty M3S, when compared with the MDS projections of

the model of Section 5, seemed to offer management the opportunity for

projecting, planning, and training.

The findings relating to fitted equations for the number of nurses

as dependent variables with other variables need comment. The success in

obtaining fitted equations suggests the possibility of calculating the

proportion of specific MOS staffs from appropriate MEDDAC variables. The

results also suggest possible use of calculated values in a range of plans

including requirements for future hospitals. The second suggestion is

based on findings that it is possible to accurately compute the total

nun±)er of professional nurses required by any one of the 67 Class I and

Class II hospitals.

6-7
6.3.2 Quality of Patient Care

The quality of patient care studies in the literature must be

interpreted with a great deal of caution. This "caveat',' although mentioned

earlier, is now discussed in greater detail in the light of findings in the

report. It was found that the quality- of-care indicators of the study are

not particularly sensitive to minor perturbations in the staff-to-patient

ratio. That is, minor shortages or overages in nursing staff, as observed

in the survey, did not correlate to any appreciable extent with the study

indicators of quality of patient care. Wliat this suggests is that the

variable nursing staff is a robust (sensitive) function of workload

requirements, but a weak (insensitive) function of the indicators of quality

of care when such staff levels are in the vicinity of the expected levels.

However there seems to be little question of the finding that the

composite quality- of- care indicator reveals somewhat better quality of

patient care in the smaller hospitals as compared with the very large

hospitals. It may tentatively be concluded that the quality of patient

care, based on currently available data, is not correlated with current

operating shortages or surpluses in professional nursing staff.

6.4 The Worldwide Questionnaire

The analysis of the worldwide questionnaire revealed the principal

issues associated with Artny nurses' decisions to leave or remain in the

service.

6.4.1 Retention—Staying or Leaving

Over 70% of all the younger nurses (20-24 age group) indicate

that they will or may leave the service on completion of their initial

obligation. The highest retention rate, by an overwhelming margin, is

6-8
among RN's who enter tlie service through direct appointment from civilian

status. Those nurses with hospital diplomas are among the next highest

group to stay in service. However, young male nurses, once they obtain

an ANC commission, are more inclined to remain in the service than young

female officers,

6.4.2 Minimizing the Major Dissatisfactions of ANC Officers

The principal approaches that might minimize the major dissatisfactions of ANC officers and lower the attrition rate are supported by

the data developed for this study. However, they are addressed in broad

concept only in this report, and the analysis is limited to general

categories. The officers, in addition to giving their responses to

specific proposals and attitude questions , also provided their opinions on

what they regarded as the biggest problems of the Army Nurse Corps, and

what should be done about them.

Among the most important issues that have emerged in this study is

the elimination of the traditional inequities of the military faced by the

female officer. The problem is exacerbated for the predominantly female

nursing profession in relation to other AMEDD, particularly the

physicians of the Medical Corps. Recent and remaining inequities strike

at status and self-esteem, and their removal would go far toward reducing

general dissatisfactions. That is, inequities tend to cause a kind of

dissatisfaction that spills over into other areas, and remedies can have a

corresponding multiplier effect. One avenue that touches both selfesteem and economic pressures, for example, is professional pay.

Inequities based on marital status, dependents, and unequal burdens

of responsibility are a "gut" issue of a different order; they are more

6-9
pragmatic and do not touch so intensely on self-image. Their rectification would ease the ordinary burdens of the individual officer witli heavy

responsibilities to family and dependents.

A second "gut" issue of great importance is the financial squeeze

faced by officers who, for reasons having to do with local housing and

living costs, find the burden of supporting and housing their families

particularly difficult. Adjustments to local costs and provisions for

more adequate housing for military families are important to this group.

:^ A third major issue has to do with the frustration faced by both

younger and older nurses as the popular "generation gap" intersects the

push for greater professionalism and professional status for nurses

among the health professions on the one hand, and the traditional hierarachical system of military rank and authority on the other. The issue

is joined in the question of whether nursing questions are decided on the

basis of rank or of professional competence. Neither the problem nor its

amelioration is simple. However, the introduction of a more

professional frame of reference and a lessening of hierarchical control,

particularly an extension of tlie range and kind of professional judgments

left to the individual member of the profession in his work, might reduce

this area of dissatisfaction.

6.4.3 Nursing and Army-Wide Officer Selection for Promotion

The Omnibus Act of 1967 authorized, for the first time, a general

officer for the position of chief nurse, and this precedent potentially

increased the number of higher ranking officers. However, tv\ro additional

factors now enter into the apparently new opportunities for higher ranking female officers. These two factors are the practices of selection,

6-10
promotion, and authorization of officers on the basis of (a) Army-wide

consideration and (b) non-nursing officer qualifications criteria. ANC

officers will not be selected for promotion relative to their peer group;

they will be selected relative to all other officers in the zone of

consideration. Tliese two factors tend, once again, to reduce the specific

selection and promotion of Army Nurse Corps officers by omitting consideration of specific nursing qualifications and requirements of good nursing

practice.

These factors tend to de-emphasize the utilization of higher

ranking nurses (engaged in "hands-on" nursing) in the treatment of

patients as is the case with physicians in the Army Medical Corps (AMC)

.

If the conceptual limitations on the careers of female nurse officers

in the N-iC are to be removed and the new opportunities of the Omnibus

Act of 1967 fully realized, certain changes in the ANC configuration may

have to be considered. These potential changes relate to the pyramidlike structure of special corps which may have to be broadened at the top

as it is in practice for physicians in the ANC. This pyram.id broadening

is functionally related to six management functions previously mentioned.

However, broadening of the pyramid- like structure with a subsequent

evolution from the supervision/administration role concept to the "handson" assignments in quality nursing care is one which will gradually come

about through appropriate use of the regulatory power of the Secretary

of the Army. This study was aware of the problem and provided the data,

models, and equations which may be useful in such considerations.

The above problem is related to the problem of the appropriate "mix"

of ANC nurses with civilian nurses working in Army hospitals and medical

6-11
department activities. The number and proportion of civilian nurses in

the Army Nurse Corps was increased during the limited war mission in

Southeast Asia. As the military step-down proceeded, there was a decrease

in nursing requirements calling for a change in the "mix" of ANC officers

and Department of the Army registered nurses. It is conceivable that

this military- to- civilian ratio may have a significant bearing upon the

objectives of this study. In particular, it may influence not only the

orderly progression toward a specific configuration, but it may also

exert an influence upon the promotional flow characteristics now regulated by the management policies and practices of recruitment, training,

retention, promotion, separation, and retirement.

6.4.4 Professionalism: Military and Nursing

The two fields of professionalism of the ANC officers, the military

and nursing, emerge from the attitudinal analysis of tlie worldwide question

naire as a complex issue requiring consideration. The problem involves

a conflict between professional nursing and the military bureaucracy, one

based on nursing judgment and expertise, through education and experience,

and the other based on rank and authority. The higher the level of

professional education and orientation a nurse achieves, the more difficult

it becomes to adapt to the military organization, especially when rank

and authority override the nurse's professional judgment.

Professionalism is apparent in the Army nurses' responses to a

variety of questions, and is important to the future of the Corps for

two principal reasons: (1) retention of nurses with a highly professional nursing orientation, and (2) professionalism in the operational

context in which the nurse practices, including military professionalism

of a high order, for those who will provide the Corps with leadership.

6-12
6. 5 Specific Configurations via Education and Training

Education and training constitute a principal avenue for obtaining

the numbers of Army nurses witli the skills and experience needed by the

various medical activities. The aggregate of these numbers and types

provide a given configuration of the Army Nurse Corps for a particular

time frame. Other avenues, besides education and training, may also be

used to achieve a particular configuration. Important among these other

avenues are direct appointments to the Army Nurse Corps and the hiring

of Department of the Army civilian registered nurses.

To the extent that education and training are utilized to help

acliieve a desired AIC configuration and appropriate civilian/military

mix, the educational qualifications and interests of members of the

Corps are of interest at three points. These include tlie qualifications

with which they entered the Corps; current education and training in

which they are participating, if any; and education and training into

which they can be channeled.

Education and training programs can be guided in part by information

available from this study—educational qualifications and interests

from the individual officer questionnaires, needs as reported and projected by the MEDDAC, and projections of the ANC Force Structure Model,

based on current trends or alternative personnel management policies.

The major products can be used conjointly in an interactive, iterative process

for determining the long-term effects of new practices and policies on

the Corps' MOS profile. The procedures are as follows:

• Identify the numbers of ANC officers in each MOS by grade.

• Identify the numbers of DAC RN's in each duty MOS (that is,

what the duty I^DS would be if the position were held by an ANC officer).

6-13
• Project the attrition rate for each MOS and for the programs

through which those with each MOS tend to enter the Corps.

• Identify nurses currently involved in education and training

programs leading toward qualification for each MOS (and, as appropriate, closely related specialties).

• Identify the number of ANC officers who indicate an interest in

work related to qualification for each MOS.

. « Identify Army nurses with past training in each MOS field

(including but not limited to those who hold each MOS as a Secondary MOS (SMOS)). -

« Project the effect of education and training programs for each

. M3S on ANC configuration.

• Plan for education and training programs and for direct appointment

goals with outputs, and in the context of whichever policies one may wish to hold constant (such as the ratio of civilian to

military nurses in a given MOS).

• Determine wlien goals are not achievable within the assumptions given;

these may then be relaxed to examine pertinent changes (again,

for example, altering the civilian/military ratio in order to

obtain the needed number of nurses for a given duty MOS)

An application of the second procedure above to potential shortages

in one MOS is described below. Assuming the requirement for all MEDDAC,

in CONUS and overseas, is 400 pediatric nurses, we find currently there are

only 150 officers in the ANC with the pediatric PMOS (3442) . We further

find that half of these are in the grades of major or above. The other

75 constitute the future leadership of tiie Corps in this MOS and they are

proportionately in short supply. Tlie remaining 250 pediatric nurses are

DAC 1^'s.

Some ANC officers will, perforce, be assigned to duties other than

'hands-on" pediatrics. Therefore, the ratio of civilian to military pediatric nurses will without planning tend to increase over time.

Further, the changes that occur, forcing the MEDDAC to rely on

civilian nurses for certain types of nursing, make a reversal of the

6-14
pattern more difficult. And, as those pediatric nurses now in the ranks

become lieutenant colonels and colonels, the leadership in the NOS group

becomes vanishingly small.

The process of planning, in this case, could be based on these steps:

1. Obtain the pertinent information from the data and analysis;

2. Design a training program to encourage younger nurses to go into

pediatric nursing; and

3. Run the model to see what the results would be over a 5-year

period in terms of building a backlog of 3442's.

If a sufficient number of nurses have indicated an interest in

pediatric nursing, the model should produce projections equal to the need,

assuming that for each nurse who had said in the questionnaire she would like

to enter pediatrics but now will not if given the opportunity, there is

another nurse who gave some other area of nursing as her interest but will

now enter a pediatric nursing course when the opportunity arises. The

model would, of course, consider the grade and component of nurses moving

from one MOS track to another as a result of a change in education and

training while in service.

6.6 Accomplishments, Findings, and Conclusions

The basic results of the study of the Army Nurse Corps can be roughly

grouped into three categories:

• The force structure model

• The worldwide questionnaire

• Tlie MEDDAC—^the operating environment of the MC.

6.6.1 The Force Structure Model

The force structure model has been designed as a planning tool for

evaluating the effect, with respect to time, of various regulations and

policies upon the force structure of the ANC.

6-15
• Relative Attrition Propensities

The design features and operation of the simulation model are discussed in detail in Section 5 of Part I, and in Part III.

Certain findings and results are mentioned in the introduction

to the report. It was found that attrition, a necessary subroutine

in the model, required a special approach to minimize simulation

model differences with real world fluctuations. It was determined

that relative attrition propensities (RAP's) defined by a function

of attrition rate are useful and in agreement with recent

historical data over the period of 1968-1972.

• Annual Simulation with "Cohort Groups"

Another result of the modeling work was the representation of

individual nurses by "cohort groups," i.e., groups of nurses

with similar characteristics. The model "applies" each of its

career factors subroutines to all cohort groups for each year

being simulated. Although the model has been exercised numerous

times, and estimates of future shortages and surpluses in nursing

specialties have been observed and reported, time has not

permitted extensive research of the effects of changing parameters

which would operate under contract incentive scenarios.

• Preliminary Trends in Simulations with Specific "Reduction

in Force" Scenarios '.

In preliminary testing runs a scenario of "reduction in force"

for the next several years with low recruitment levels created a small initial decrease in the number of officers with less than

one year of service. It was found that in the model's graphical

outputs, which display the force structure (number of officers

vs. years of service) for each year being simulated, there

appeared a "valley" which "moved" along the horizontal axis

(years of service) as the graphs were viewed in chronological

order. When the initial (1972) profile of these simulation runs was compared with profiles obtained for 1975 the most pronounced

effects of the reduction in force appeared in the 1975 profile for

officers with less than seven years of service. The profile

of officers with more than seven years of service was relatively

unaffected.

• Use of Model in Projection

Output from the model is of two forms, namely tabular and

graphical, for each year being simulated. At present, the

output describes the predicted yearly force structures by rank

and service component, by MOS. With minor changes in the

computer program any combination of cohort group characteristics

can be selected, and the corresponding force structure description

can be output in similar year-by-year form.

6-16
6.6.2 The Worldwide Questionnaire

Tlie analysis of the worldwide questionnaire revealed the principal

issues associated with Army nurses' decisions to leave or remain in

the service.

• Staying or Leaving

Over two- thirds of the younger nurses (20-24 year age group)

indicated a high expectation of leaving the service on completion

of their obligation. The highest retention rate, by an over- whelming margin, is among Rf>J's who enter the service through

direct appointment from civilian status.

• Student Nurse Programs

Army student nurse degree programs reflect the higher mobility

of baccalaureate nurses, who have lower retention rates after

the initial service obligation has been met.

• Policy Proposals

Of the 48 policy proposals on which Army nurses were asked to

give their opinion, the most important issues to the Corps are:

(1) basic pay, allowances, and benefits; (2) nursing professionalism; and (3) inequities based on sex, marital status, and

dependents

.

• Professionalism in the MEDDAC

A dominant issue in attitudinal responses was a conflict between

professional nursing and military bureaucracy in the MEDDAC

environment. The higher the level of professional orientation

of an Army nurse the more difficult it becomes to adapt to the

system of rank, seniority, and authority in a military organization,

especially when that system overrides the nurse's professional

judgment.

The Generation Gap

One major theme that emerges in the attitudinal responses is a "generation gap." Younger nurses tend to agree that there is a conflict between professional competence, and rank and authority

of senior nurses.

• Administration and Facilities

Over half of those who expressed an opinion feel that tlie

Army hospital administration is generally competent, but not

particularly responsive to patients' needs. About the same proportion tend to agree that the Army medical facilities and

equipment are often obsolete.

6-17
Reputation of the ANC

Most nurses agree that the Nurse Corps enjoys a good reputation

and that the quality of patient care is generally good.

• Expanded Nursing Role

The nurses gave strong support to the expanded role of the

nurse and showed an interest in nurse clinician programs.

• Skill and Assignments

About two- thirds of the Corps believe that their assignments

utilize their skills. Most of tlie Corps are satisfied with

their present work assignments and geographic locations,

although a significant proportion indicated they were neither

consulted nor given their preference in their current assignments.

6.6.3 The MEDDAC

The analysis of the MEDDAC data base revealed relationships among

workloads, staff sizes, indicators of tlie quality of patient care, and

other MEDDAC -related variables.

• MPS Mismatches

Data supplied in the survey of over 70 U. S. Army hospitals worldwide indicate a number of mismatches between hospital duty MOS's

and mc primary MOS's. Projections of the ANC force structure

model indicate that this degree of mismatch will widen in the

next few years unless appropriate policies of recruitment,

training, and retention are instituted.

9 Staff Workload Relationships

A range of simple, easy to use fitted relationships between

staff and workload variables in U. S. Army hospitals was derived.

• Staff Indicators

A single indicator of staff requirements is the number of bed

occupied days at a given hospital. An improved weighting of

the four factors used in calculating the Medical Care Composite

Unit resulted in a markedly increased correlation with the

nursing staff.

9 Patient Care and Hospital Size

The overall quality of patient care, as measured by the indicators

of this study, increases, in general, with decreasing hospital

size.

6-18
t Patient Care and Nurses

The observed shortages or surpluses in nurses have little

influence on, or correlation with, the indicators of the

quality of patient care.

niis account started with a description of study goals centered on

nursing personnel attitudes, nursing environment, ANC force structure; and

it concluded with well-defined sets of study findings. The study was

concerned very early with team development and utilization of certain

procedures, metliods, and interrelated concepts. The concepts are interdisciplinary in nature, consisting of elements borrowed from nursing,

behavioral science, survey instrument methodology, statistics, computer

programming, and the simulation modeling characteristic of the field of

operations research.

Tlie study project generated:

• A large, functional, easily accessible computerized data base;

• An analysis of a salient portion of this data base; and

• Quantitative relationships of the MEDDAC—^the nursing environment.

The data of the attitudinal analysis and the numbers derived from the

MEDDAC relationships served both as inputs and outputs of the various

interdisciplinary efforts including the regression and force structure

model

.

In conclusion it is noted that the results of the attitudinal

analysis, the relationships resulting from the MEDDAC statistics, and the

force structure model, simulate for management planners the future

characteristics of the ANC as specified by certain inputs and policies.

It is anticipated that management functions will encompass a wide range

of military as well as civilian manpower planning decisions with respect

to recruitment, training, retention, promotion, separation, and retirement.

6-19
l'.s. dept. of comm. I 1. PUBLICATION OR REPORT NO. 2. Gov't Accession

BIBLIOGRAPHIC DATA |nBSIR 73-285

3. Recipient's Accession No.

4. TITLE AND SUBTITLE

Structure Analysis and Program Planning Study of the

Amiy Nurse Corps (ANC) : Part I

5. Publication Date October 1973

6. Performing Organization Code

7. AUTHOR(S)

John W, Rowen, Ralph B. Swisher, Patsy B. Saunders

8. Performing Organization

NBSIR 73-285

9. PERFORMING ORGANIZATION NAME AND ADDRESS

. NATIONAL BUREAU OF STANDARDS

DEPARTMENT OF COMMERCE

WASHINGTON, D.C. 20234

10. Project/Task/Work Unit No. 4314487

11. Contract/Grant No.

Ltr. Jan. 72

12. Sponsoring Organization Name and Address

Office of The Surgeon General

- Department of the Army

Washington, D.C. 20314

13. Type of Report & Period Covered Final 1/72-10/7 3

14. Sponsoring Agency Code

15. SUPPLEMENTARY NOTES

16. ABSTRACT (A 200-word or less factual summary of most significant information. If document includes a significant

bibliography or literature survey, mention it here.) This report presents the results of a study of the U.S. Army Nurse Corps (ANC)

conducted by the Technical Analysis Division (TAD) of the National Bureau of Standards

(NBS) and sponsored by the Office of The Surgeon General (OTSG) . The study focuses

on nurses' attitudes, working environment, and ANC force structure. It documents the

following study products: A new computer model simulates the ANC force structure under

alternative policies. The study contains analyses of individual and organizational

survey questionnaires distributed to approximately 3500 Army nurses and 70 Am^ hospitals worldwide. The project developed an extensive computerized data base and a quantitative description of the operating environments of the hospitals in terms of staff,

workloads, quality of patient care and other variables. The attitudinal analysis

focuses on issues associated with staying in the ANC and professional interests of

Army Nurses.

17. KEY WORDS (Alphabetical order, separated by semicolons) ActlvitieS I ANC, Army NurSe Cor

pitals; attitudes; attrition; education; force structure; forecasting; man

modeling; nursing staff; personnel; quality of care; simulation; survey; t

ps; Anw hospower; MEDDAC;

raining

18. AVAILABILITY STATEMENT

1 1 UNLIMITED.

[X] FOR OFFICIAL DISTRIBUTION. DO NOT RELEASE

TO NTIS.

19. SECURITY CLASS

(THIS REPORT)

UNCL ASSIFIED

21. NO. OF PAGES

Pt. I - 208

Annex - 416

20. SECURITY CLASS

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UNCLASSIFIED

22. Price

1 itirniuiiui.DC 66244-P7I