Nursing Services in the New Zealand Defence Force: A Review After 100 Years

By Maree Sheard , Annette Huntington and Jean Gilmour In   Issue Volume 24 No.1 .

Abstract
This year marks 100 years since the inception of the Royal New Zealand Nursing Corps. The centenary provides an opportune time to reflect upon the nature of military nursing in New Zealand today. The past century has
seen significant changes in the way in which nursing services are configured as well as to whom care is provided and when. Much of the change has been driven by a political reorientation that has required the New
Zealand Defence Force to become more agile and flexible. In turn military nursing services have needed to adapt to meet the challenges of modern Defence employment contexts.
Nursing in the contemporary military environment is no longer based exclusively on the Territorial workforce as it had been in the early years. Defence nursing is now comprised of a suite of services provided by civilian
and military nurses with military nurses belonging to the Regular Force as well as the Reserves. Unlike their predecessors, uniformed nurses must be prepared to operate across the full continuum of healthcare in a
range of garrison, civilian and deployed settings and caring for diverse population groups. What has not changed in the past 100 years is the need for military nurses to remain highly motivated, physically fit and
competent in their professional practice. As in the past, Defence nurses today and those of the future will be required to carefully balance the tensions between professional nursing responsibilities and the expectations
of their military role.

Introduction
This year marks the centenary of the Royal New Zealand Nursing Corps (RNZNC), the only military nursing service in New Zealand. The centenary has significance not just for those who have been members of the Corps, but for all New Zealand nurses. Over one quarter of the country’s registered nursing workforce served in WWI in a variety of operational theatres and facilities1. At the conclusion of hostilities many of these nurses returned to their prior employment, taking with them their wartime knowledge and experiences and by so doing influenced civilian nursing practice1-4. The flow of knowledge between civilian and military employment contexts continues today. Military nurses in New Zealand are recruited from the registered nursing workforce to work full-time and return to civilian practice post-service while a number of nurses balance civilian employment with ongoing Army Reserve nursing obligations. Nurses are now also routinely employed as civilians in the Defence Force adding depth to the nursing services available in the New Zealand Defence Force (NZDF). This contrasts to early military nursing in the country where for the first thirty years, military nurses served only during times of conflict5.

While the effects of war on civilian nursing in New Zealand has received some recognition, little attention has been paid to how war, or indeed international relations, have shaped the role of the military nurse today. It is timely then in this centennial year to consider the purpose of the RNZNC and the contribution Corps members make to wider Defence outputs. While the Corps remains a discrete entity, the functions of New Zealand’s military nurses now, as in 1915, have stayed closely aligned to those of the Royal New Zealand Army Medical Corps. Collectively members of these two Corps represent the bulk of health service personnel capability in the NZDF. However the changing employment contexts of the NZDF, an increasing understanding of the value of joint health service delivery, and the stability provided by civilian health professionals working alongside military personnel, has seen an evolution in the nature of Army nursing in the contemporary military environment. This article aims to provide insight into that environment.

Health services in the New Zealand Defence Force
In the past the focus of the military health services like the wider Defence Force, has been to prepare for combat. The Government now requires the NZDF to be equipped and trained for peacekeeping and humanitarian assistance as well as for war6 due to global political change and New Zealand’s strategic positioning since the Second World War. The NZDF must also be able to operate alongside New Zealand’s principal defence partners, so considerable emphasis is placed on capability integration in coalition environments7. The ability for the NZDF, as a small military, to achieve desired operational effects across the breadth of possible employment contexts involves significant agility and flexibility. All elements of the NZDF are required to demonstrate these attributes including those that contribute to health service support8.

Transformation of the military’s health services in recent times has been necessary to enable alignment with the Government’s strategic intent9. In addition to acquiring the ability to deliver care in peacekeeping environments and disaster zones, the health services have been required to adapt to changes in treatments due to the nature of injuries that result from mobile warfare and the types of weaponry employed in asymmetric conflict. New Zealand’s commitment to the United Nations and to the country’s obligations as a good international citizen also requires medical personnel to be prepared to provide care to a range of sick and injured people including military personnel from other countries, the very young and the elderly, and enemy prisoners of war7, 10.

In addition to providing a deployable capability, the military health services of the NZDF must also deliver primary health services to enlisted personnel at home. People are critical to enabling the NZDF to meet the country’s defence needs, so the Chief of Defence Force makes clear that it is necessary for Defence personnel to be in optimal health in order that they are able to make the best possible contribution towards mission success8,11. Health personnel play a crucial role in helping others to achieve their physical potential which, in turn, reduces those operational risks associated with lack of fitness or ill health. Primary health care and dental services are therefore freely available as a condition of service12.

In New Zealand, military personnel access specialist and secondary health services through the public system. However the NZDF is required to have plans in place for the management of sick and injured servicemen and women who may require secondary as well as primary care when they are deployed. Depending on the size, nature and location of an operation, a military contingent may deploy with anything from a rudimentary, organic first aid capability through to full primary, medical and surgical services11. This requires the NZDF health services to maintain a health capability that is not only flexible enough to operate within the range of employment contexts but for health personnel as a group to be technically prepared to operate across the continuum of health care7, 9.

The Army employs the largest number of health professionals of the three Services in the NZDF. While the purpose of the health services in the Army is to provide health support to that Service, there is an obligation when it is deemed necessary by command, to extend that support to the wider Defence Force in joint operational environments7. The three primary objectives of health support are to prepare servicemen and women for deployment, to identify and minimise health risk, and to deliver medical care in order to protect the fighting force (Commander of the Joint Operational Health Group, personal communication, May 29, 2015). The majority of those personnel who deliver health support belong, or are attached, to the Royal New Zealand Army Medical Corps. However the Corps that contains the largest number of registered health practitioners is the RNZNC. The Royal New Zealand Army Medical Corps and the RNZNC work in close and complementary association.

Standards of care
The knowledge that militarily competent and experienced medical personnel will respond immediately to health needs, whatever the context, serves as a powerful motivator for soldiers to fight13. The NZDF commits to ensuring that any care that is delivered to service personnel is of a standard commensurate with that provided in the civilian sector. This level of care is required to meet the expectations of NZDF personnel and to limit distracting concerns regarding injury or illness, thereby assisting with the psychological preparation of servicemen and women for deployment. Due to rigorous selection processes and investment in the professional development of health professionals, service personnel, notwithstanding extreme operational circumstances, can be confident that the
care they receive when they are serving overseas is of a similar level to that which they receive in New Zealand.

Consistency in healthcare standards is not only necessary for soldiers’ motivation but it is also a statutory requirement. The NZDF must comply with all New Zealand’s legal and regulatory frameworks whether at home or off-shore14, therefore the health services must also comply with New Zealand laws and regulations. The majority of deployable health personnel in the NZDF are medics who, because they are not regulated under the Health Practitioners’ Competence Assurance Act (2003), must be governed by registered health practitioners. Because nurses form the largest group of military health practitioners, there is an expectation that nurses will create and lead the delivery of quality health care.

Nursing services in the New Zealand Defence Force
Nursing services in the NZDF are tailored specifically to meet the needs of the organisation. Because the NZDF is small by international standards but is required to respond to a broad range of employment contexts, and because standards of health care must be consistent with those in the civilian sector, it is essential that nurses employed by the NZDF possess the technical knowledge, nursing expertise and military skills to operate competently and confidently anywhere they are directed. It is also necessary for NZDF nurses to demonstrate inter-professional collaboration, as collectively the attributes of technical knowledge, practical expertise and crossdisciplinary collaboration optimise flexibility in health service planning and clinical intervention. Nursing personnel are required to operate and take responsibility for nursing care within a variety of specialty areas of practice, to work autonomously, and to possess the understanding and skills to safely direct and delegate nursing care to others. Within the cohort of registered nurses there are two distinct groups; civilian nurses and military nursing officers.

Civilian nurses
Civilian nurses are non-uniformed members of the NZDF who may work for any one of the three Services or for a joint force headquarters element; joint operations being those where the three Armed Services work together. Civilian nurses are not required to maintain a degree of physical or medical fitness above that necessary to perform the functions of nursing, nor to participate in any compulsory military training or activity outside their nursing roles. There are similar numbers of civilian nurses as military nurses with most employed in general practice settings although a very small number of occupational health nurses work for the Royal New Zealand Air Force. The Employment Relations Act (2000) applies to civilian nurses so their conditions of service are bound by the same provisions as those nurses working for civilian organisations. Because NZDF civilian nurses are not attested members of the Armed Forces, they are not subject to the Armed Forces Discipline Act (1971) in the same way as their military colleagues.

The nature of civilian nurse employment in the military is very similar to that of practice nurses working in the wider community. As only regular force military personnel are eligible for domestic primary care through the NZDF, the patients to whom nursing care is provided are predominantly young, fit, healthy and male15. The health status of military personnel is largely good because before entry into the Armed Forces, all applicants must pass a medical assessment that automatically excludes individuals who carry the effects of past injuries or who suffer from ongoing medical conditions16.

In general primary health care in the NZDF is straightforward. The majority of people presenting to military treatment facilities suffer from infectious diseases, or training or sporting injuries that have occurred as a result of maintaining fitness for operational service. Civilian nurses are heavily involved with health promotion, screening and prevention because it is recognised that there are measures that can be taken to mitigate against the physical risks routinely faced by military personnel in training and who may be living in communal accommodation. Surges in workload do occur from time to time when groups of new recruits enter service en masse or when teams of military personnel are on short notice for operational deployment. On these occasions additional health vetting and vaccinations take place to ensure that personnel who are about to begin a period of intensive training or who are about to be deployed are as medically fit and prepared as possible9. On these occasions it is common for the civilian nursing workforce to be supplemented with military nurses and medics.

Military nursing officers
While the purpose, employment contexts and day to day activities of military nurses are closely aligned to the professions of the Royal New Zealand Army Medical Corps, all uniformed nurses in the NZDF are recruited into the Army’s separate specialist nurse-only RNZNC17. Unlike their WWI predecessors who held honorary rank2, RNZNC members today are commissioned officers, therefore all nurses wishing to join the Army must apply to become officers. Gaining entry into the Army as an officer is a demanding process. Individuals must possess the requisite skills and qualifications to serve in their profession but are also required to demonstrate the leadership competencies exemplified by military officers. Therefore the officer selection element of the process for entering the Army is the same for general and specialist officers, whether candidates are applying for the Regular Force or the Army Reserve.

Once an officer candidate has been deemed to have met the military’s criteria for their profession, a week-long officer selection board must be attended. The nature of the selection board enables assessors to make predictive judgments of an applicant’s suitability to serve as an officer in the Army18, 19. Due to the significant challenges that are presented on officer selection boards, officer candidates must be highly motivated. Only half of military nurse applicants who meet the academic, psychological, experiential and fitness standards to enable attendance at an officer selection board are ultimately successful (NZDF Director of Nursing Services, personal communication, May 13, 2015).

Because nursing officers must demonstrate prior to enlistment that they possess the minimum professional requirements for military service, and because nursing officers are not expected to perform the combat functions of general military officers, it is not necessary for nursing officers to complete the same initial military training as their general officer counterparts. Members of the RNZNC instead attend a specialist officers’ induction course that introduces them to the Army culture and expectations of military leadership. Subsequent courses are made available to nursing officers as they progress through their careers to prepare them for specialised or advanced military nursing roles.

In the past Army nurses were “tri-Service” meaning that the military nursing requirements of both the Air Force and the Navy were met by members of the RNZNC. However in 1991 the Navy made the decision to withdraw from the tri-service arrangement. It was decided there was no requirement for a deployable military nursing capability in the maritime environment. This resulted in the RNZNC positions being reassigned to civilian posts (NZDF Health Information Manager, personal communication, May 14, 2015). Military nursing services in the NZDF are now routinely provided by the Army for land and air operational outputs only.

Today primary care nursing officers complement civilian nurses working in facilities in Army garrisons and on Air Force bases throughout the country. Those nursing officers whose skills lie in specialty areas of practice that are not primary care, maintain their competence by undertaking clinical placements in the civilian sector. As with all military personnel nursing officers, irrespective of their specialisation, are required to be operationally deployable at all times. This involves meeting minimum physical fitness standards as well as being able to demonstrate the ability to perform a range of role-related physical tasks. Passing annual weapons qualifications as permitted by international humanitarian law is also a requisite. Members of the RNZNC must also understand their wider employment context and contribute to generic military outputs. Not all military nurses’ time can therefore be spent in clinical practice. Maintaining deployability and contributing to collective military endeavours is necessary for all personnel in a professional defence force such as New Zealand’s. Because nursing officers are employed specifically for their nursing expertise, balancing the maintenance of military skills and military outputs with those of nursing must be carefully managed.

Selected RNZNC nurses are trained to undertake roles that extend beyond nursing. Optimising the personnel workforce, including those of the health services, is an important feature of the NZDF to ensure the flexibility and adaptability required for the achievement of outputs. The types of roles nursing officers perform that are not exclusive to nursing include commanding health units, health intelligence gathering and analysis, and undertaking
health service and health operational planning. However these non-nursing specific positions do require considerable knowledge of the wider military environment, particularly as it relates to Defence capability and how capability aligns with the strategic purpose of the NZDF. This knowledge can only be gained from extended experience within the  organisation and with careful preparation. Hence all nursing officers are required to begin their military careers in clinical practice building later upon their clinical base with education, operational experience and promotion to higher rank before being considered for these wider roles.

Operational service
Operational service for RNZNC personnel in the past thirty years has seen nursing officers deploy as part of the United Nations Protection Force in Bosnia, undertake peacekeeping with the United Nations in Somalia and deploy to the Gulf War of 1991. Nursing officers also formed part of the New Zealand military medical response to East Timor as well as Bougainville and have responded with New Zealand medical teams to humanitarian disasters in the South West Pacific and Indonesia. More recently nurses from the Corps have deployed to Afghanistan as members of the New Zealand Provincial Reconstruction Team. Nursing officers continue to contribute to the commitments of the NZDF by helping the Government build capacity in the South Pacific20-23.

Until 1945 military nurses in New Zealand served full-time in the Army only during times of war. The intention for the RNZNC following WWII was for the maintenance of a skeleton staff of Regular Force nursing officers upon which an operational nursing capability could be rapidly built should another major multinational conflict occur. However, the changing nature of global relations and the types of engagements with which the NZDF have been involved since WWII have not seen the realisation of New Zealand’s post-war fears. The country’s international political interests have evolved. Realist ideology and the singular importance of the sovereign state that once dominated New Zealand’s outlook is now less apparent with successive governments prioritising diplomacy and working with multinational agencies such as the United Nations to reduce the potential for armed conflict. This contrasts with how in the past alliances were utilised to maintain perceived balances of power however, for the NZDF, the ability to operate effectively in coalition environments remains important7,24-26.

New Zealand’s political priorities lie close to home; priorities that are reflected in New Zealand’s Defence Policy Framework which, while still affording primacy to the defence of New Zealand, actively support
peacekeeping as a means of furthering New Zealand’s interests27. What this has meant for the NZDF and therefore for the RNZNC, is the need for small but multi-skilled configurations of staff who are capable of responding to the most serious of threats, but who are also effective in environments where political stabilisation and conflict resolution are required. So while the original purpose for the existence of fulltime RNZNC nursing officers is of less significance now, the retention of a Regular Force nursing service in addition to the Army Reserve, remains important to the NZDF to ensure that the organisation has the flexibility and quality in its health services for contemporary military employment contexts.

Summary
Today both military and civilian nurses are represented in the NZDF with all military nurses being commissioned into the RNZNC. Nurses work across a range of specialty areas of practice monitoring and promoting the wellbeing of military personnel. This includes primary care for both uniformed and civilian nurses, and emergency, medical and perioperative nursing specialties for military nurses. They work collaboratively with members of the wider healthcare team, undertake health surveillance, provide health education and deliver nursing care to sick and injured servicemen and women at home and on operations, wherever that may be. Like their colleagues in the Royal New Zealand Army Medical Corps, RNZNC officers may be required to care for members of other military forces, for civilians and for enemy prisoners of war. Army nurses must therefore be physically equipped and mentally prepared for the uncertainty, physical rigors and professional challenges that life in military service brings. In return members of the RNZNC enjoy similar professional fulfilment that other military personnel experience from service in the NZDF.

This centenary year of the RNZNC provides an opportune time to reflect upon the nature of military nursing in the NZDF today. Unlike the nurses of WWI, current members of the Corps may be seconded to the Royal New Zealand Air Force and serve not only during periods of conflict but also during peacetime. RNZNC nurses may serve full time in the Regular Force or part-time in the Army Reserve. The suite of military and civilian nursing capability ensures the Defence Force possesses the flexibility in its nursing services necessary for contemporary military employment contexts.

Members of the RNZNC are a select group of highly motivated health professionals who are prepared to provide care to sick and injured people in a whole variety of environments across the globe. The work is complex and dynamic; complexity and change being features of the work of the first New Zealand Army nurses. Military nurses of the past and present have balanced the tensions between professional nursing responsibilities and role expectations in the multifaceted Defence system. However, indications are that as new global threats arise and the world becomes an increasingly interconnected and complex place, finding ways to maintain this balance may become a significant challenge for military nurses in the future. For 100 years RNZNC nurses have needed to be highly motivated, physically fit and competent in their professional practice in order to operate safely and effectively. Possessing these same qualities will go some way to ensuring that New Zealand military nurses of the next era are as well-prepared for the unknown as their predecessors have been in the past.

Acknowledgements

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