It’s the experience of a lifetime. After you’ve cleared security to enter Fort Bragg in North Carolina and your vehicle has been searched, you are instantaneously awed by the enormity of this army military post. I am on my way to engage two ranking officers—nurses—in conversation regarding health care in the military. The drive takes you on the four-lane All American Expressway with vehicles whizzing by between 55 and 60 miles per hour. As I slow down to take in this sprawling city, I am reminded that I am no longer in the city of Fayetteville that abuts the post.
But the pièce de résistance was the emotional tremor I felt when the Womack Army Medical Center loomed up at the end of a long entrance way to affirm that this was iconic America. This complex, 1.1-million-square-foot (this is not an error) care facility is not just impressive by its bricks and mortar, but is a care facility providing world-class health care across a compendium of general and specialized medical disciplines to our service men and women, veterans, and the families of those who serve on active military duty. To visually take it all in requires a significant swivel of my head.
The purpose of my visit is to gain some measure of understanding and appreciation of this reputable institution and to tell the story to those who will not have the opportunity I had to visit and see for myself. My host is Lieutenant Colonel Angelo D. Moore, Deputy Chief, Center for Nursing Science and Clinical Inquiry, a native of Queens, New York, and graduate of Goldsboro High School in Goldsboro, North Carolina. Moore holds a PhD from UNC Chapel Hill and was the university’s first African American male awarded a doctorate from the School of Nursing. A scholar, clinician, and practitioner with a passion for attacking health care disparities, Moore knows his way around scholarly journals but is just as comfortable applying a Band-Aid to a 5-year-old with a splinter in his thumb. He leads the effort at Fort Bragg to integrate evidence-based practice (EBP) into all aspects of nursing care.
Moore chose Winston-Salem State University for his undergraduate degree because of the seven-to-one ratio of women to men among the student body—a decision he candidly admits worked out for him because that was where he met his wife, Lee Antoinette, a civilian nurse now on the faculty at Fayetteville Technical Community College. He was posted to Fort Bragg last July from Honolulu, where he had been stationed for six months having initiated and led the EBP process.
For the better part of a day, Moore allowed me to engage him in an in-depth conversation on what happens within the walls of this facility that necessitates a tour by a skilled guide to truly appreciate the delivery of military health care services. I was taken through the “miles” of passageways and corridors, to the service malls and the various departments, as well as the skilled nurses training center to witness the nurses being tested on their competencies on a variety of medical and dispensing procedures; the cafeteria to sample military fare; and, eventually, one of the deputy commanders of the medical center, Colonel Kendra Whyatt, who on this day was in charge.
Too often there is a perception that connects questionable treatment of our military service personnel to the assumption that the health care delivered is similarly questionable. Nothing could be further from the truth. In my conversation with Colonel Whyatt, she very carefully called my attention to the signature difference between a military nurse and a civilian nurse that is invaluable in understanding the dynamism of military health care.
“Military nurses,” Whyatt says, “wear inseparably and simultaneously the role of the soldier and the role of the nurse, and they are expected to provide care for their fellow soldiers and protection for them if necessary, and certainly for themselves at the same level of competence.”
It is this dichotomy—the syringe and the gun—that guides my desire to understand how care is delivered by our nurse soldiers to a military population of 57,000 at Fort Bragg, of which 45,000 are active duty members.
What we know today as Fort Bragg came into effect in September 1922, but its history is attached to a Confederate general, Braxton Bragg, a native of North Carolina. The post occupies 127,000 acres; its population makes it the largest US Army base; and it is the home of the Airborne—the 82nd Airborne Division, referred to as “All-American” because its members represent 48 states. It is also the home of the distinguished Special Operations Force. Among its many amenities are its schools—preschool through high school for nearly 5,000 students, the children of soldiers on active duty.
Womack Army Medical Center opened its doors on March 9, 2000. The center is named for Private First Class Bryant H. Womack, a North Carolina native who was posthumously awarded the Medal of Honor for conspicuous gallantry during the Korean conflict. The center’s mission is succinctly stated: Provide the highest quality care, maximize the medical deployability of the force, ensure the readiness of Womack personnel, and sustain exceptional education and training programs.
The center is 1,020,359 square feet, encompassing six-floor towers and other buildings. It sits on a 163-acre site, has a 153-bed inpatient capacity, and serves the more than 225,000 eligible beneficiaries in the region. It is the largest beneficiary population in the Army.
The building has a state-of-the-art design: The inpatient tower floors have an interstitial space between each floor that allows computers, as well as other technical components, to be repaired without interrupting patient care. The complex is designed to transform many of the administrative areas into service areas providing care if necessary, which would double their inpatient treatment capacity.
Four patient-centered medical homes are located on Fort Bragg, and two community center medical homes are located in the surrounding military community where their beneficiaries live and work. The Womack Army Medical Center was among the first health care providers in the country to seize on the benefits, design, and purpose of the medical home in 2004. The military’s ability to make the medical home work for their patients rests on their enormous electronic records capacity, making it easier for them to implement the benefits from the Electronic Health Records (EHR) system that gives providers worldwide access to comprehensive and timely patient histories. The $1.2 billion medical records system began deployment that year across the entire force and was fully operational by 2007, just as the benefits and necessity of the EHR were dawning on the civilian medical community.
The medical home is best described as a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. It is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the simplest to the most complex medical conditions.
But there is also the Soldier Centered Medical Home (SCMH). This is a care process with an exclusive and unique focus: the soldier. It includes behavioral health, physical health, and nutrition services; these are significant to soldiers who may be displaying the symptoms of Post-Traumatic Stress Disorder (PTSD). Everyone is screened using a predetermined questionnaire and an initial evaluation that determines whether the soldier is a prime candidate for treatment or follow-up. The Army’s official position is that “80% of all soldier complaints at sick-call are muscular-skeletal,” according to physician Colonel Dallas Homas, the former commander of the Madigan Army Medical Center in Tacoma, Washington, and the originator of the SCMH that became operational in November 2011. The concept grew out of an incident where an exceptional noncommissioned officer lost his knee unnecessarily, according to Homas.
Diagnosis and treatment of PTSD, however, continues to be a contentious issue within the military sector and might have led to Homas’s reassignment from Madigan Army Medical Center. Colonel Ramona Fiorey, a nurse, assumed command of Madigan on August 9, 2013. The Department of Veterans Affairs (VA) has reported that for the last two years PTSD diagnoses are just shy of 30% of the 800,000-plus Iraq and Afghanistan War veterans treated at VA hospitals and clinics.
It is during my conversation with Moore that a picture emerges of how the soldier-nurse threads her way through the system to attain the highest heights of a nursing career. One thing they do have is the role models to motivate them to succeed. You see, the Surgeon General of the US Army is also the Commanding General of the US Army Medical Command. Currently, that person is Lieutenant General Patricia Horoho. She is a nurse. Whyatt, one of Womack’s deputy commanders, is also a nurse. Nurses provide the leadership at the highest level and at base level. This is without precedent, and the profession does take notice.
Horoho has already made significant changes regarding military health care by her emphasis on what she calls, “life space.” She wants providers to address those periods when military personnel are away from a care facility with emphasis on ensuring they are engaged in healthy behavior.
Horoho’s leadership centers around the Army Nurse Corps’ five-point strategy, known as the Patient CaringTouch System or—with the military’s characteristic use of acronyms—PCTS. It has five components: enhanced communication, capability building, evidence-based practices, healthy work environments, and patient advocacy. The PCTS is a patient-centered model for nursing care that was developed to reduce clinical quality variance by adopting a set of internally and externally validated best practices. Additionally, it is an enabler of Army medicine’s culture of trust initiative and the transition from a health care system to a system of health. The plan is elaborately laid out in a campaign document intended to guide the care leadership through 2020, with emphasis on evidence-based decisions, metrics, and best practices that cannot be overemphasized.
As you might expect, the Army takes the issue of leadership very seriously. Army nursing is guided by an Army Nursing Leader Capabilities Map that encompasses a thirty-year journey, and Moore is a good example of how the process has guided his own career. A nurse’s development has three segments, and the progression is tied to seven performance criteria. The three segments are tactical skills, operational and organizational skills, and strategic thinking and execution. The nurse can move along a career path in what is called “duty positions,” beginning as a staff or charge nurse and rising in rank to a section or department chief and then deputy commander for nursing.
During this progression, the Army nurse develops competency in such areas as change and people management, succession planning, and foundation thinking, where he or she is expected to demonstrate unit-level, evidence-based decision making. At this level, “the PhD or the DNP enables and equips a nurse to engage in visionary and strategic thinking,” explains Moore. “After ten years in the military, nurses overwhelmingly have acquired the master’s degree, and this is a distinguishing factor in military nursing culture.”
Lieutenant Colonel Moore (never addressed as “Dr. Moore” but exclusively by his rank, as is the pattern within the military regardless of credentials) actually wanted to be a dentist, but financing that career seemed to be out of reach. He heard about the Army College Fund, so he enlisted in 1989. He was placed in the communications section, but had a strong desire to transfer to the medical field. He was working to complete his associate’s degree at night and heard from a friend about the Army’s Green to Gold program in which, if selected, he could progress over time from an enlistee to an officer. He completed the degree and applied, was accepted, and enrolled in the nursing degree program at Winston-Salem State University, graduating with the BSN in 1995.
As an active duty nurse, Moore’s assignment took him to the Eisenhower Army Medical Center in Georgia as a medical/surgical nurse; later, he chose to be certified as a critical care nurse upon completion of a four-month training program. Moore tells me that this is the normal developmental pattern allowing nurses to be associated with a particular specialty of their choosing.
As a male nurse in the 1990s, Moore was not an oddity because the requirements of war had always allowed the Army to attract males to the military nursing profession. Medics were trained to provide treatment to fellow soldiers on the battlefield, so the transition to formal training to administer generalized or specialized care was natural for many. Today, males’ 30% representation in Army nursing is six times higher than in the civilian nursing population.
“Male nurses,” Moore says, “are usually more prevalent in the areas that are ‘action-packed,’ such as trauma, or the highly technical areas where elaborate technical components are integrated into the patient’s care and in emergency room nursing.”
After several years of praying “Please, Lord, do not let any of my ICU patients die on my shift,” Moore wanted a change out of critical care and chose to work in primary care to reduce the prospect of patients needing critical care in the first place. He applied to the Army’s long-term education and training program and was accepted into the master’s program to become a nurse practitioner.
His next assignment was his appointment in 2007 as a recruiting commander stationed in Brooklyn, New York, with centers in Albany, New York, and New Jersey. Moore and his team of recruiters focused on enticing doctors, dentists, and nurses into the Army as officers by being visible at medical conferences and health forums where these professionals were present. The recruiters championed the experience, benefits, and research engagements that a recent MD graduate, for example, would never get in a hospital or private practice in his or her civilian role. They also targeted students considering careers in the medical profession.
Moore responds to my question regarding minority recruitment within the Army by explaining that there is no program designed to recruit minorities into the health care ranks as a targeted group.
“To the best of my knowledge, we do not look at race in our recruiting efforts,” says Moore. “We make appealing what the Army has to offer and allow the prospect to decide. Because of the culture of the Army, we encourage the prospective recruit to consider carefully the choice of military service.”
There is a well-known, generalized concern, however, about the low minority representation among the officer ranks in the military, which has attracted the attention of the top brass. So it came as no surprise when in March 2011 the Military Leadership Diversity Commission issued a report that included the state of diversity among the leadership ranks of the military.
“The disparity between the numbers of racial and ethnic minorities in the military and their leaders will become starkly obvious without the successful recruitment, promotion, and retention of racial/ethnic minorities among the enlisted force,” the report states. “Without sustained attention, this problem will only become more acute as the … makeup of the United States continues to change.” It’s similar to the state of private sector organizations.
Whether the Army does or does not have a minority recruitment strategy, the fact is that officer and leader representation will not improve unless there is a deliberate pipeline strategy leading from enlistee to officer. However, as I walked the hallways and visited the patient treatment locations at Womack, those at work and those receiving care looked very much like America.
With Moore accompanying me as I toured the facility past the many labs, the enormous back-office function, work stations, administrative functions, physical therapy service areas, and clinical specialties of every description along the long and seemingly interminable walkways, he added to my attempt to grasp the magnitude of what takes place at Womack as a matter of routine, by citing some impressive statistics. While doing so, he emphasized that the active military and the Veterans Healthcare Services are decidedly not affected by the provisions of the Affordable Care Act (ACA).
“There is one provision, however, where we see eye-to-eye with the ACA, and that is in the aspect of prevention as opposed to curative or disease care, because a healthy lifestyle is central to mission readiness,” explains Moore. “The three streams that drive mission readiness within the healthy life space triad are activity, nutrition, and sleep—and we are confident there will be a pay-off down the road.”
In fiscal year 2013, the Womack Army Medical Center had over 12,000 admissions with a 62% average daily bed occupancy rate and average length of stay of 2.6 days, over 3,000 live births, and over one million outpatient appointments. On a daily average, the associated clinics provided over 3,400 outpatient visits, approximately 6,000 outpatient prescriptions, almost 1,000 radiological exams, over 4,000 pathological tests, almost 200 Emergency Department visits, almost 40 surgeries, and at least eight live births. There are two medical residencies (family practice and obstetrics), and 14 other physician or Allied Health educational and training programs. Moore points out that no prosthetic service is provided to the injured soldiers at this facility. He reminds me that the health care staff consists of active duty members, Department of Defense civilians, and contractors who include civilian physicians and nurses. It is easy to identify the civilian medical staff because they are listed on appointment boards by their medical credentials; whereas, the active duty medical staff are listed by their rank, often on the same appointment boards.
Moore guides me along a walkway with photographs of distinguished service members and towards the skilled nursing center where competency tests are taking place. This is a biannual event where nurses are tested and certified to perform certain medical procedures. Womack nurses are required to expose themselves to this process if they are to be allowed to perform certain procedures. It is proctored by senior nurses and other technical staff. My visit to the center as this event was taking place was purely coincidental.
In a room deep inside the complex, nurses were examined on performing catheterizations on a mannequin (part of the infusion therapy procedure) and on their ability to know the difference when it is a pediatric patient compared to an adult; reading and interpreting the ECG tape—a necessary step before referring it to a cardiologist; identifying mental health behavioral issues such as PTSD; and using newly introduced, technologically sophisticated equipment. There are charts and poster boards everywhere. The atmosphere is intensely business-like, presided over by a nurse with the rank of major and dressed in fatigues. Even the test mannequin appears to be aware of the buzz over the event’s significance.
Next, Moore takes me to the pharmacy services mall, which is where the patients have their prescriptions filled. Every aspect of this procedure is very clearly understood as between 25 and 30 patients wait for either a consultation with a pharmacist or watch to see that their prescription is ready. The first served are those requiring immediate and preferential attention: the active duty soldiers. He or she registers as they all do, and the patient’s name lights up on a marquee pallet as an indication that the prescription is ready. The active duty member’s name will supersede all others.
Finally, our walk heads towards the command center where Moore has arranged for me to visit with Colonel Whyatt, Deputy Commander for Nursing and Patient Services, who is acting commander today because Commander Colonel Steven J. Brewster is off the post. This is Whyatt’s first assignment to Fort Bragg. After being cleared to enter the command center, I am seated in what is quite easily comparable to an executive suite in any corporate headquarters. The offices are bright and cheerfully wood-paneled, with each executive officer’s support staff seated within earshot of their work stations. One is dressed in fatigues, as is Colonel Whyatt. She is tall, relaxed, and with a distinctive military bearing that suggests a calm, in-control demeanor. She is a native of Greenwood, Mississippi, and was previously stationed at a military facility in Germany.
With my discussion about minority recruiting still turning over in my mind, I wanted to know her opinion regarding mentoring and coaching. But first she has to be reassured by Moore that I have been cleared to have this conversation with her.
I first want to know what makes for a successful and responsive military health system. “It’s the combination of the military, civilians, and contractors working together,” Whyatt responds.
“What are the two top concerns that occupy your attention?”
Whyatt responds succinctly: “[To stay in mission readiness], I have to recruit staff, retain and train staff, and we are facing challenges in this area; in particular, in the recruiting and retention of staff. Most everyone knows that certain funding is at a standstill.”
“Do you mean the sequester?”
But a majority of hospital executives believe there is a shortage of physicians and nurses in the US, according to a new survey from American Mobile Nurses Healthcare, a staffing company that recently published its 2013 Clinical Workforce Survey. It found that 78% of hospital execs think there is a shortage of physicians; 66% say there is a shortage of nurses; and 50% report there is a shortage of advanced practitioners. The survey also found that the vacancy rate for physicians in hospitals is nearly 18%, compared to 10.7% in 2009, and nearly 17% for nurses, up from only 5.5% in 2009. The vacancy rate also rose for allied professions, from 4.6% in 2009 to 13.3% in 2013. But Womack is currently under a staff freeze, and the civilian workforce is expected to be reduced sometime during 2014.
Colonel Whyatt owes her military career to her mother. At the end of Whyatt’s sophomore year at Prairie View A & M University, her mother strongly suggested that instead of coming home and looking for a summer job, she visit with the ROTC office on campus and see what they could do for her. Whyatt visited the office, enlisted, and went on to complete her undergraduate degree in nursing with a scholarship from the Army. Her career has taken her to three tours of duty to Germany and several Army posts within the US.
“Are you mentoring and coaching any on active duty at this time?” I ask.
“That is an expectation of this position. Yes, I am,” she responds.
“And is LTC Moore one of your mentees?”
“Absolutely, he is my newest.”
James Z. Daniels is a consultant and writer who lives in Durham, North Carolina.