Navy Nurse Corps… Outstanding Care…. Anytime, Anywhere. LCDR Denise M Navy Nurse Corps… Outstanding Care…. Anytime, Anywhere! LCDR Denise M. Gechas, NC, USN Specialty Leader, Community/Public Health AAACN Conference 16 April 2008

Navy Nursing We are a Nation at War… and the true mission of the Navy Nurse Corps both today and in 1908 when we were first established by Congress, has remained unchanged; caring for our warriors as they go into harm’s way. We mend the wounds of war; wounds, both visible and invisible. The practice of Nursing has changed over the last 100 years with research and technology, but the basic tenets of the profession are unchanged and timeless. We have grown from the original “sacred twenty” as the first few Navy Nurses were called to a force with over 4100 active and reserve nurses. In every conflict since 1908, Navy Nurses have been there. From World War I to the present War on Terrorism, our nurses have been at the forefront of providing the finest care to our troops. In addition to supporting our troops at war, Navy Nurses have also served our country around the world in times of natural disaster. Thanks to the generations of Navy Nurses who moved us forward through other wars, we have a solid foundation in which to meet the challenge of tomorrow. 1908 - 2008

Presentation Objectives: At the end of this presentation the participant will be able to: List and describe Navy Medicine and Navy Nursing’s priorities Discuss current and projected Navy Nurse Corps manning and demographics Review current 1940 subspecialty code practice issues Discuss methods to increase promotion potential

Navy Surgeon General’s Priorities: Maintain a fully ready force by recruiting and retaining outstanding healthcare personnel Excellence in clinical care, graduate education and research, the foundation stones of Navy Medicine Responsive and compassionate care to all our beneficiaries, focusing on the health of our service members and their families while providing VADM Robinson, the 36th Surgeon General, has outlined his priorities for Navy Medicine: His intentions include: Future Force-Readiness, Recruiting and Retention, Graduate Health Education, Medical Research, Prevention/Wellness, Casualty Care, Patient and Family Centered Care, Quality Care/Customer Service, VA Integration and Internal and External Communications of which can be summarized by these three main points. One of his top priorities is recruitment and retention. We are asking Navy Nurses from our MTFs and Operational Health Support Units (OHSUs) to support our recruiting efforts by representing Navy Nursing at national and local conferences, presenting in local schools, universities, and partnering with Navy Recruiting Districts acting as Navy Nurse Corps Ambassadors to applicants considering Navy Nursing. As a pillar priority, graduate education and research are the foundation of Navy Medicine. Our SG is a strong supporter of our TriService Nursing Research Program and understands its importance to our professional development as we add to the body of scientific knowledge caring for our wounded and the impact on families. Nursing is essential to the health care team. Nursing researchers are essential to our nursing practice. Since Feb 2007, the Military Health System has come under fire regarding care to our warriors and their families. Though clinical quality was not in question, the public has underscored the importance of caring and communicating to our patients and families in a timely, compassionate manner. Nursing is leading the way in the effort as it is the heart of our practice. 4

FY 08 Nurse Corps Strategic Priorities Leadership Competencies identified for senior & mid-level leaders; Gap analysis completed for leadership training. Creation of a new and fluid leadership continuum, and implement recommendations of this team. Force Shaping Recruiting & Retention Force Shaping. Focus will be on wartime relevance of maintaining adequate numbers in each specialty. Understand migration patterns and values of Active Duty, Reserves and Civilian Nurses as it relates to retention. Education Policies and Programs DUINS Utilization Policy for APN and CNS dual degree, Mentorship programs for students in NC Pipeline programs (MECP, NCP, ROTC, STA-21) Readiness & Clinical Proficiency Clinical skills sustainment for operational assignments; Tri-Service competencies; Pilot Competency assessment and orientation/ skill assessment. Standardize competency-based orientation among RC. Productivity Pursuing selection and funding for commercially available products to streamline workload capture and scheduling across health care and the three Services. Communication Communication to the Deckplate - Overhaul of NC Website, VTCs with new accessions, Newsletter, NC News, Semiannual VTCs, Bimonthly meetings with Regional SNEs, Semiannual VTC with DNS & Admiral by Region In FY 06 – 07, significant work was done in these six areas. I liken it to poured a foundation and we have framed the house. This year, however, it is time to finish the building and implement these six priorities. In FY 08, the priority is to execute.

- Deputy: Responsible for the day to day operations of the Corps - Deputy: Responsible for the day to day operations of the Corps. - Reserve Affairs: Tracks all programs recruiting, manpower, specialty leaders, policy/practice issues re. to the reserves - Strength Planner: Maintains the command scrubs of SSCs, updates the manpower numbers and maintains the BUMIS database, projects, forecasts & plans for promotion planning and analysis after each promotion cycle. - Education Programs: Dean of the graduate programs (DUINS- drafts training plan for Director, coordinates all DUINS, Periop training, ECCO, EROC, supervised MECP program mgr, - Specialty Leaders: Coordinated under the Career Plans officer. Specialty Leader selected by Director and is SME representative for the SG. - Detailers: Coordinates assignments with Commands and Members. Head Detailer, drafts and coordinateness the slates for CO, XO, DNS/SNE, special details, War College - CNRC, NC Programs: Coordinates all recruiting activities at headqrts of Navy Recruiting. Works closely with Recruitment/retention Liaison officer at BUMED - Recruitment/retention liaison officer: Coordinates and acts as a liaison between MTFs and Recruiters to coordinate 1. Junior and mid grade officers of various specialties to attend National Conferences and assist Recruiters at their booths. 2. To coordinate MTF tours visits and answer questions of potential NC applicants. This position/officer coordinates retention initiatives for the NC office, ie. Special Pay (RN-ISP, CRNA-ISP/MSP). -Community Manager: -Career Planner: Policy and Practice: Regional SNEs:

Navy Nurse Corps MTFs and Clinics Updates Clinical Sustainment Policy 13 Deployment Health Clinics Comprehensive Combat Casualty Care Center, NMC San Diego Mental Health Nursing and Practitioners 28 Military Treatment Facilities 135 Medical Clinics and Branch Clinics Throughout the career continuum, Navy Nurses are responsive, capable, and continually ready to provide the finest care, “Anytime, Anywhere.” Our clinical sustainment policy ensures our nurses are ready to deploy at a moment’s notice and provide superior clinical care from operational deployments in Iraq, Kuwait, Djibouti, Afghanistan and Germany - to humanitarian missions in Southeast Asia, Africa, Central and South America. At military treatment facilities, in the operational theater, on humanitarian missions, or working in a joint environment, Navy Nurses are clinically agile and trained to mission requirements. Working with our sister Services, we continue to define scopes of nursing practice and competencies to promote integration and cross-utilization within the military healthcare system. At our military treatment facilities at home and abroad, Navy Nurses are at the forefront of providing comprehensive mental and physical care to our returning heroes. To fully address their needs, thirteen Deployment Health Clinics have been established across the country. Here, a specialized team of nurses, medical providers and allied health professionals ensure all personnel returning from operational deployments receive timely and thorough medical screenings and follow-up care. For those wounded warriors returning from overseas, Naval Medical Center (NMC) San Diego offers a multidisciplinary program of care via the Comprehensive Combat Casualty Care Center. This service offers a wide range of medical, surgical, behavioral health and rehabilitative care to those wounded in the service of our country. In the Global War on Terror, We are learning everyday of the impact of Combat Operational Stress on service members and their families. Nursing practice is evolving to meet these emerging needs in a variety of settings including behavioral health, case management, and community health nursing. Our mental health nurses and practitioners are working with deployed personnel, families and non-medical military leaders to recognize signs of combat operational stress and destigmatize access and care to our wounded warriors. We recognize the advanced skills of mental health nurse practitioners and for the first time are investing in a doctoral prepared nurse in the mental health clinical field.

Operational & Humanitarian Navy Nurse Corps Operational & Humanitarian 242 (13%) Navy NC currently deployed as of FY ‘07 Assigned to Marine Corps and Navy Operational around the world. Beyond our medical treatment facilities, Navy Nurses continue to serve with pride in a variety of operational and humanitarian theaters. Clearly this is not new news to anyone in the audience today. We are a Nation at war. Our importance and our success has caused our operational leaders to take notice and they want Navy Nurses in more roles than ever. There is the Surge of the Marine Corps (Blue in Support of Green – BISOG) where there will be a requirement for more critical care and ER/trauma nurses to serve in the Fleet Marine Force (FMF). For the first time ever, we have a nurse at Fleet Forces Command, advising nursing care for the entire fleet. For the second year, the requirement from the Army asked the navy to staff Landstuhl Regional Medical Center with over 100 Navy Nurses. The challenge is how do we maintain safe, quality, competent care at home and in forward deployed settings, while balancing the needs of our people. Both for those deployed, and those who provide care at home. Both are vital and demanding. Central to both practice settings, is that we must be vigilant in caring for the caregiver. Compassion fatigue is a real phenomenon, therefore we ask to make caring for each other a priority. Are you contacting, writing those who are deployed and checking in with their families on a regular basis. When folks return, ensure their PDHRA and associated care are done. This is a leadership responsibility.

Nurse Corps Officer Current Manning Profile Nurse Accession Bonus; HPLRP Accession tool Missed recruiting goals in FY04/05 and increased losses have caused these gaps. HPLRP Retention tool CSRB proposal Retention Issues: FY 2007: DUINS Instruction changed allowing 1st term officers to apply for DUINS. 2008, first year selected 1st term officers for DUINS. We had 102 applications, 73 selects. Out of the DUINS selects 8 application were submitted by NC officer in their first tour; 5 of those were for the CRNA program (not a change in policy for their applications). In those who were considered but not selected (28), 6 officers were in their first tour; 5 of those were for the CRNA program. - HPLRP: 2007: everyone that applied received money. Targeted to officers with 3-10 yrs of service, average debt load 17K and requires 2 year pay back. In HPLRP 2008: average debt load of $27,361 and 42 officers selected Talking points: Overall we have retention issues after 1st and 2nd tour of duty, thus retention efforts should be targeted to these NC cohorts groups. See at year 2-year 5, these gaps represent the numbers of officers we are missing in these ranks and that is because we didn’t make recruiting goal for those four previous years. RN ISP implemented for the first time ever in 2008 for critical wartime specialties <90% (Critical care: 57%, PNP-69%, FNP-76%, Periop-89%). RADM Bruzek-Kohler’s plan is to work to POM for these special pay monies and expand this to other specialties as more $ is available and as the needs and requirements change. Please see the Black horizontal bars and explanation, for HPLRP, CSRB proposal, targeting FY04-FY05 when we didn’t make recruiting goal, and offer it as a retention bonus to keep these officers in at their first decision point….has not yet been approved. RN ISP/ DUINS/ War College Years of Commissioned Service Data as of 30SEP06 Data as of Aug 2007

Nurse Corps Force Structure FY98 - FY08 (Projected) (Data source: Strength Plan and 1-page World Book - inclusive of plan adjusts, file corrections, grade changes, designator changes FY08 Gains Projected/KTD = 260/169 FY08 Losses Projected/KTD = 290/212 2950 is target range Loss of ~280-290 each year. *FY08 Gains Projected at 260; Losses at 290 Source: BUMIS, PERS, 31DEC07

Nurse Corps Force Structure Billet Authorizations vs Inventory Delta demonstrates that we are currently over executing in the number of active duty CAPT and CDRs. We have significant retention issue at the LT rank. Need to look at the billet structure, however, as some of the LT billets may need to be reverted to ENS. Need to increase the number of ENS billets to allow for appropriate accession numbers. Current cap by CNP is 260. OCM driving to increase to 280. We are not certain what grade levels will return with the reversal of the MRR. Need to ensure that we do not create a worse problem at the LT rank. Source: BUMIS, 31DEC07

Nurse Corps Force Structure Losses by Rank FY03 - FY07 Increased retirements in LCDR/LT ranks; especially of prior enlisted personnel. Also demonstrates effects of no continuation policy. Increased losses at LTJG level from previous years related to increased administrative discharges. A decrease in number of CAPT/CDR losses coupled with decreased billet authorizations/OPA for these grades is creating an overage in these ranks. Projecting higher number of losses in controlled grades in FY08-FY10 to create vacancies for promotions. Need for more CAPT and CDRs to choose retirement verses staying until statutory limits. Source: BUMIS, PERS, 31OCT07 (*Includes Plan Adjusts)

Nurse Corps Force Structure by Specialty From http://www.aacn.org/aacn/practice.nsf “Registered Nurse Statistics Fact Sheet” updated 4/2003 Primary Practice Setting: 45% Hospital 17% ICU (11% of our billets are ICU/PACU related) 6.8% Telemetry/Step Down/PCU 7.8% ER (6% of our billets are ER related) 9% Operating Room (8% of our billets are Periop related) 3.2% PACU 35.1% General/specialty unit 6.9% labor/Delivery room *Based on Primary Subspecialty Code *In Trng not included *1900 – Inventory = 802; Billets =812 Source: BUMIS, 31DEC07

Nurse Corps Force Structure by Specialty Phasing out community Phasing out community 2XXX billets are fair shared to the following communities (Total = 45): 3130 MPTA = 2 3150 ETMS = 4 7900 Prof Nursing = 39 1903 Nursing Ed = 1 1940 Public Health = 1 (BUMED 2XXX position, Disaster Preparedness) *Based on Primary Subspecialty Code *In Trng not included Source: BUMIS, 31DEC07 1901 and 1903 communities will become 1900

Nurse Corps Force Structure FY04 - FY07 Projected FY03 FY04 FY05 FY06 Ending Inventory 3108 3036 2934 2828 Recruiting Directs 67/68 41/88 46/84 77/92 (Accessions/goal) The Nurse Corps’ inventory and billets have steadily declined in the past few years. Losses have exceeded gains in seven of the last ten years The annual recruiting goal has not been met for the past four years. 2007 was the first year that recruiting goal was met and so far we are on track to make recruiting goal for 2008. Why have the last 2 yrs been successful? NAB (Nurse Accession Bonus for 2008: -3 yr: 20K and 4 yr: 30K) HPLRP: Health Professions Loan Repayment Program: for 2008: $38, 3000. Can be added to the 3 yr NAB for a total commitment of 5 yrs. Nurse Corps Force Structure at EOY FY05 - End inventory = 2,934 164 under NC Billet Authorizations (BA) (including 2XXX share), 175 under NC Officer Program Authority (OPA) 31 Dec 2005 – 206 under end strength Total gains = 193 (including plan adjusts); 57 under Accession Goal of 250 Total number of accessions capped at 250; request to increase to 270 denied by CNP The Bureau of Personnel has reduced accession requirements despite the continuing manning downward trend. Top accession sources: MECP, NCP, DA (NAB), then NROTC Academic failures and other reasons in student accession programs have created steady growth reliance upon DAs Actual Inventory Source - BUMIS, PERS Billet Source - TFMMS extract 30 SEP of Applicable Year.

Nurse Corps Force Structure by Education From http://www.aacn.org/aacn/practice.nsf “Registered Nurse Statistics Fact Sheet” updated 4/2003 Highest Nursing Education: 27.2% Diploma 31.7% Associate Degree 28.8% Baccalaureate 6.5% Master’s 0.6% Doctoral (Nursing/Related) *Based on highest level of education Source: BUMIS, 31DEC07

Nurse Corps Force Structure by Gender From http://www.dol.gov/wb/factsheets/Qf-nursing-05.htm, Quick Facts on Registered Nurses Female 92.3% Male 7.7% Source: BUMIS, 31DEC07

Nurse Corps Force Structure Grade Distribution by Gender Source: BUMIS, 31DEC07

Nurse Corps Force Structure by Race/Ethnicity From http://www.dol.gov/wb/factsheets/Qf-nursing-05.htm, Quick Facts on Registered Nurses According to Bureau of Labor Statistics (BLS), in 2005: 79.3% White 10% African/American 6.4% Asian/Pacific Islanders 4.3% Hispanic Compared to total employment figures in 2003, Black/African Amer and Hispanics were underrepresented as registered nurses. Source: BUMIS, 31DEC07 Hispanic = 5.8%

High Demand Specialties Specialty BA Inventory % Manned # Loss Rate Professional Nursing 868 924 107% 44 6% Operating Room 281 250 89% 23 9% Critical Care 333 188 57% 25 13% Anesthetist 140 137 98% 14 8% Family Nurse Practitioner 68 54 79% 4 Losses exceeded gains for 7 of last 10 years – most losses from LT Cannot continue LTs Direct accessions difficult due to National nursing shortage Loss of CRNAs – highly remunerative specialty in civilian sector Will continue to monitor loss rates post RN-ISP

Nurse Corps Officer Incentives FY 08 New Initiatives: Accession Bonus rate: $20K/3 yrs; $30K/4 yrs May accept $20K/3yr and up to $38,300 in HPLRP = 5 yr Continue Health Profession Loan Repayment (HPLRP) as accession (20 slots) and retention incentive (Board to be held 1st Qtr 08 and 26 Slots) Continue Nurse Anesthetist Incentive Special Pay (ISP) Critical Skills Retention Bonus (CSRB) proposed for FY04 & 05 for nurses at first decision point RN ISP implementation, focus on clinical practice, for critically manned wartime specialties <90% Tiered bonus: 5K/1 yr; 10K/2 yr; 15K/3yr; 20K/4yr. Requires working in specialty full-time, certification, and SG approved Course or MS. Requires active mentoring and long range career planning. Critical Care, Perioperative, FNP, PNP Nurse Anesthetist Incentive Special Pay (FY05 first year for multi-year option) $6,000/yr - training obligation $20,000/yr - one year contract $25,000/yr - two year contract $35,000/yr - three year contract $40,000/yr - four year contract

Nurse Corps 1940 Stats Nurse Corps: Inventory: 2774 Training: 149 Billets: 2942 Manning: 94.3% Public/Community Health: Inventory: 20 Training: 4 Billets: 42 Manning: 38.1% **Billets authorized may not be correct; current billets based upon historical need for Ambulatory Nurses. If BA is decreased, then manning will improve. Current billet structure reflects remaining 1940 coded billets aligned for Ambulatory Care Nursing. Ambulatory Care nursing is no longer a specialty that is tracked, but an area of practice. An AQD currently exists to delineate Ambulatory Care experience (to qualify must have at least 1 year of outpatient nursing experience). This AQD is currently held by 460 personnel, and is not meaningful. The past SL was working to change this AQD so that only those personnel with 2 years of outpatient experience AND certification through AAACN would be eligible to carry the code. This would give the NC a better visibility of individuals who have competency and experience in ambulatory nursing for better detailing to free-standing outpatient clinics, and especially in order to serve as a Senior Nurse/OIC at one of these clinics. Data source: BUMIS ao 29FEB08 NAVMED MPT&E

Community Status – Active Component Billet Authorizations to Inventory Strength Billet structure has been downsized in accordance with the changes to the 1940 community. Emerging Public Health role undefined for actual number of requirement. Knowing the requirement will give us a true picture of manning. Cannot say that this community is currently undermanned, unless we know for certain the requirement of this community. *Does not include # in training or training billets; FY08 is as of 29FEB08 Data Source: BUMIS, 30JUN06

Public/Community Health Subspecialty 1940 BA 42* Inventory 20 38.1% Total Inventory = 20 (4 are in DUINS currently); entry into this specialty is only through Masters preparation or certification, or if we recruit a RN with these qualifications. Data source: BUMIS ao 29FEB08

Community Health Needs During San Diego Wildfires

Director Branch Clinics Role at Emergency Operations Center Initial exposure of DBC to the EOC function Facilitated communication between branch clinics, base EOC’s and NMCSD EOC Provided direct report to NMCSD Commander Collaborated with the Director of Public health to educate community regarding “after-fire clean-up”

Community Health Needs BMC staff served as medical representative to base EOC 4,000 evacuees Housed in tent cities at NAB and BOQ Housed military members, retirees, families, pets Provided on-site medical care 24/7 Provided flu shots Monitored air quality and provided masks Coordinate with Marine Corps recruit training impact of air quality Assisted Preventive Medicine staff to ensure proper sanitation at evacuation

Transition from Ambulatory Care to Public Health Operational Relevance: OIF/OEF & Humanitarian Utilization in MTF Mission: Public Health Directorate HEDIS measures Health Promotion Emergency/Disaster Response Team Pandemic Influenza

Career & Promotion Planning Emphasis on Clinical Expertise (translate to outcomes) Leadership & Mission Accomplishment Diversity of Assignments/Commands Stretch yourself, don’t stay in your professional “comfort zone” Expand your leadership ability and influence Leadership position, # led, $ budget, scope & command impact Interdisciplinary involvement and leadership Large commands allow large competitive comparison groups

Nurse Corps Typical Career Path ~100% ~100% ~80% ~70% ~50% ~12% (2007) O-1 O-2 O-3 O-4 O-5 O-6 CO/CO Equiv Staff Nurse Staff Nurse/Division Officer/Instructor/Duty Under Instruction/ Advanced Practice Staff Nurse/Div Off/Instructor/ Duty Under Instruction/Dept Head/Advanced Practice/ Research/HQ Staff Dept Head/Advanced Practice/HQ Staff / OIC/Research/Senior Nurse Executive Clinical Proficiency, Admin. Acumen, and Leadership throughout the career continuum CO Exec. Med. /SNE APN/ HQ Staff/Research 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 The Nurse Corps officer career path consists of four primary career tracks: Clinical, Administration, Education, Research Operational (2% of Nurse Corps billets are operational) Within each of these tracks, Nurse Corps officers have the opportunity to assume positions of increased responsibility as rank increases. The positions represented in the slide at each rank level are a representation of potential positions that can be held by a Nurse Corp officer in the various career tracks. It is not an inclusive list of all possible positions. Nurse Corps officers in all career tracks may screen for Executive Medicine (CO/XO) positions once selected for the rank of Captain. Nurse Corps officers are expected to maintain clinical skills in nursing practice throughout the career continuum. I ask each of you to continue your diligent efforts in mentoring our junior nurses in their achievement of goals that maintain recruitment initiatives, retention efforts, clinical proficiency, operational readiness, and above all leadership. Our junior officers are our future and based on the passion and competence I see daily, our future looks bright indeed. We exist because we are mission essential. They needed us then; they need us now. We can be proud of what we have done and should be inspired by what we have left to do in the next 100 years. I thank you for the opportunity to speak to you today. Years of Commissioned Service Clinical Proficiency & Leadership Career Tracks Clinical Administration Education Research Operational 6