Introduction:
Late in 2011, the Royal Australian Air Force (RAAF) deployed a Role One enhanced health facility in support of Exercise Precision Support. The Role One health facility was deployed to the Shoalwater Bay military training area and tasked with providing 24 hour care during the pre-deployment exercise for Australian forces headed to operations overseas. The Precision Support exercise integrates with air operations, large scale logistic movements and austere base establishment elements, to aid in the preparation, training and sustainment of service personnel for operational roles, both in a conflict environment as well as humanitarian aid roles. The Role One provided this medical support with 2 Emergency Nurse Practitioners (ENPs), Registered Nurses (RNs), Medical Assistants (MAs) and Radiographers. The ENPs took on the role of the senior clinicians during this exercise, competently managing all of the health complaints that presented during the exercise period.
This article will discuss and review the role of the Nurse Practitioner (NP) within a Role One, deployed Defence health facility, build on international evidence whilst supporting the utilisation of NPs in the RAAF Health Service and subsequently more widely in the greater Australian Defence Force (ADF). This article will provide some practical evidence enabling health commanders to recognise, deploy and fully utilise NPs, in order to support current and future ADF operations.
Background:
The future of health and its delivery is changing across all sectors, including the military. As the provision of health care evolves globally, so do the influencing factors such as an ageing population, scientific and technological developments, increasing consumer knowledge, awareness and expectations. As a quality provider of health care, the Australian Defence Force will not escape the increasing complexity of health care as well as the opportunities and threats presented by globalisation. The global responsibility of health care provision to those in need, secondary to crises arising from international political unrest and instability, will continue to provide the Royal Australian Air Force with ample opportunity to provide health care in austere and complex environments. Taking onboard these issues, Air Force Health is beginning to embrace the challenges ahead with a well trained and well equipped health care workforce, though there remain further refinements and developments to maintain this force capability. Transformations and reviews in Defence health include the division of garrison from operational health components, the review of deployable hospital systems and the critical analysis of human resource utilisation, and are continually being conducted to optimise Defence’s response to these challenges.
Reviewing changes in health care provider options, distribution and availability, offers a unique opportunity to access options previously not available. This review will inevitably lead to the implementation of new strategies, with a focus on responding to the health needs of the ADF community, while fully utilising the skills and knowledge of experienced, existing Defence Force health care professionals. Within civilian practice new roles are being explored, and innovative models of care, with an emphasis on a collaborative team approach, are being implemented both nationally and internationally. These models are helping to meet emerging health care provision demands and should be equally explored in the military setting to ensure equivalent service provision and professional opportunities. Whilst some work has already begun in the area regarding NPs and Physicians Assistants (PAs) within the Defence Force health workforce, neither path has yet been consolidated nor rolled out across the wider Defence Force.
FLTLT Danny O’Neill Clinical case review
Nurse Practitioners:
The Australian Nursing and Midwifery Council (ANMC) apply the following definition for a Nurse Practitioner:
“A nurse practitioner is a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing profession’s values, knowledge, theories and practice and provides innovative and flexible health care delivery that complements other health care providers. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorised to practise.”[1]
Whilst nurse practitioners may appear a new asset in the ADF, they are well established in the military setting internationally as well as nationally within the civilian sector. NPs are employed across many specialty streams with a small portion of these already employed in Defence, whilst others utilise their extended clinical role for Defence, yet to be recognised, within a reserve capacity. Coalition forces such as the United States, Canada and the United Kingdom, all utilise NPs in the provision of health care,
within the garrison space, in support of exercises as well as on operations. The impact and acceptance of the NP role within civilian and coalition military health care models can be attributed to the robustness of the professional position, flexibility, as well as care coordination functions of the role.
FLTLT Matt Luther Clinical
The professional attributes of a NP that recommend it to a Defence application are those that highlighted the role appropriate to fulfil the need for health care options in rural and remote Australia, late in 1990.[2] Extended practise within an autonomous, yet collaborative model, allows the NP to immerse themselves in varied health care environments, complementing the existing structure, whilst bridging the historical gap between nursing and medicine. NPs have filled a service capability gap and acted as a force multiplier, with significant potential, in the military health model.
The robust nature of nurse practitioner accreditation ensures that the Medical Officers (MOs) collaboratively working with an NP, can rely on a competent, qualified and professional health care provider.[3] NPs add to the capability of a health care service rather than straining it further. The role of the NP is not to cover shortfalls in qualified medical officer positions, the role is to augment traditional medicine, support the provision of holistic health care and broaden the health care option for the consumer.
Whilst the human body remains unchanged, intricacies in the application of health care in a military environment provides many and varied examples of why military health is rapidly being recognised as a specialty area. Austere environments encompass contaminated working conditions, poor lighting, little or no environmental control, limited pharmaceutical options, minimal reserve capacity including a prolonged supply chain, clinician fatigue, as well as limited equipment and consumables. The above list aptly describes the Role One operational environment.
Military health facilities are categorised across a range from one to three, denoting their level of capability according to the assets deployed, with the Role One being the foundation of these facilities. Adding components to this base model will ultimately achieve a Role Three facility, capable of sustaining a significant surgical element including recovery of those surgical patients requiring critical care. A Role One is normally established within a complex of tents, in a remote locality, providing health support for a small deployment of personnel. The services provided from a Role One facility include aviation medicine, primary health care, resuscitation and environmental health.
Similar to other streams of health care providers, nurse practitioners are divided into subspecialties according to their training and expertise. When correlating the skill sets of a civilian NP to those required by a primary clinician in a military health facility, a best fit relationship can be found in an Emergency Nurse Practitioner (ENP). An ENP brings specific skills and experience in the acute care setting, mapping across to the identified health professional requirements of a Role One facility including triage, minor injury and trauma, acute minor illness, health promotion, resuscitation and primary health care.[4,5] Whilst aviation health crosses both the civilian and military spheres, the Role delineated health facility concept is unique to a military setting and specifically takes into account Defence type aviation and its remote locality application. Civilian trained and sustained ENPs can obtain this aviation health specific knowledge through the RAAF’s Aviation Nursing/Medical Officer (AVNO/AVMO) course. The care provided in the military health setting by an AVNO qualified ENP is in collaboration with an AVMO in accordance with the Civil Aviation Safety Regulations 1998 (CASR, 1998) and Defence aviation medicine requirements. This collaboration completes the capability expectations of an Air Force Role One.[6] Further consideration may be placed on this subject, enabling the appropriately trained and qualified nurse practitioner flexibility to operate collaboratively, yet autonomously, in this aviation field in the federal/commonwealth sphere, rather than the civilian sphere, further empowering the capability.
Whilst this observational report describes the integration of emergency nurse practitioners in the deployed Air Force health model owing to the specialties of the NPs in focus, there are other NP specialties that may also be adaptable to the military model. One of the specialties considered should be primary health care. A Primary Health Care NP (PHCNP) has wide extended-care nursing experience in primary care. Whilst not regularly engaging in the management of trauma and resuscitation, these PHCNPs bring another level of care for those with subacute and chronic health issues. PHCNPs provide individuals, families and groups with health care services such as health promotion, disease and injury prevention, acute and chronic disease management and rehabilitation and support.
Exercise Precision Support Role One:
As expected from an extensive operational exercise involving considerable movements of equipment and personnel in a remote environment, the described Air Force Role One within the Shoalwater Bay military training area received significant presentations on a daily basis. The presentations ranged from acute injuries and trauma to minor illness and the ongoing management of chronic conditions/issues. The spectrum of diagnosis included cellulitis, soft tissue injuries and musculoskeletal complaints, upper and lower respiratory tract infections, ophthalmic injuries, abscess, dental trauma, genitourinary as well as gastrointestinal complaints. These presentations were competently managed by the nurse practitioner on duty. The two NPs were permanently on call, providing a wide range of consultative and diagnostic services to the service personnel presenting for treatment during the exercises.
Skills demonstrated in the field by the NPs included bedside ultrasound, incision and drainage of abscesses, radiological interpretation, management of skin infections and minor injuries and trauma, including dental emergences. Whilst the Air Force does not currently recognise the national authority of NPs to order radiological diagnostic images, the NPs and co-located radiographers integrated well in a collegial and professionally beneficial environment. Whilst testing the application of newly certified deployable equipment, the radiographers were comfortable with the range of tests theoretically requested by the NPs when presented with acute injuries at the Role One. These requests were recommended and confirmed appropriate with medical colleagues via telemedicine prior to commencement, in order to comply with current arrangements.
The four week exercise demonstrated that an appropriate NP is capable of managing a wide array of primary care and emergency cases in an austere environment. This capability enabled the dependant service members to remain in location, effective towards the exercise goals and mission ready.
During the airfield readiness mass casualty simulation exercise, the nurse practitioners again demonstrated their skill and knowledge in such situations by appropriately triaging and managing all simulated case presentations to the Role One facility. The NPs wsere split up during the exercise to provide a medical incident site commander and receiving clinician, providing direct care whilst supervising the care provided by the nurses and medical assistants, further demonstrating the flexibility and capacity of this professional extended nursing role. Further to this, the combat support element in location showed strong support and confidence in the services provided by the NP led Role One health team. The NPs also took the opportunity during low tempo periods during the exercise, to provide continuing professional education to their colleagues and health promotion advice to all personnel on site.
Exercise Talisman Sabre, conducted prior to the Precision Support exercise, held in the same location, also provided an opportunity for NPs to demonstrate their suitability for the military clinician role. During this exercise, one of the NPs from the described Precision Support exercise was again the lead clinician within a Role One facility. The NP was highly regarded when working intermittently with United States Defence Force health professionals transiting through the area during the exercise. The NP treated complex lacerations, fractures, acute respiratory distress, spinal injuries and dislocations, as well as the day to day health requirements of the multinational Defence members on exercise. Some of the above critical injuries and acute illnesses required evacuation from the deployed exercise environment to both military and civilian high level health care facilities. These evacuations were achieved successfully within a collaborative framework, where the NP packaged and dispatched the patients on rotary and fixed wing platforms as well as road assets within both the Air Force aeromedical evacuation system as well as the civilian system embedded in the region.
Participation in significant operational exercises, such as Talisman Sabre and Precision Support, further enhances the ENPs specific military training, helping to bridge the gap between peacetime and wartime practice as described by Yackel et al. in their 2006 study on nurse practitioners in the deployed setting. [7] Contrasting this US experience, the creation of an Australian military NP model will allow for the allocation of appropriate specialty NPs to be tasked with the provision of combat support. As suggested, a civilian sustained ENP would have the smallest gap to bridge whilst transferring to this unique operational environment. Many US military NPs hold family health specialities, thus role conflict may ensue. The US experience as described by Yackel et al. may be replicated in Australia if alternate speciality NPs, such as PHCNPs, are predominant in the workforce make up.
The US Military experience of nurse practitioners:
The United States (US) army has and continues to successfully deploy NPs in the operational environment. During operation Iraqi Freedom eight nurse practitioners were deployed to a Role Three facility of the 28th Combat Support Hospital (CSH). These NPs were recognised by Yackel et al. as providing ‘world class’ primary health care on operations. [7] The deployed NPs successfully treated common illness and injury in the build-up phase and then included the management of combat trauma during combat operations. The advanced knowledge of pathophysiology and pharmacology enabled the NPs to teach critical thinking skills as well as assessing, managing and diagnosing many conditions.[7] Two of the NPs (one Intensive Care NP and one ENP) deployed with the 28th CSH were selected to fulfil a forward deployment. These two NPs continued to provide expert critical assessment and care within a forward operating unit, reinforcing the flexibility of their professional role. The same NPs were further utilised at the Iraqi Tikrit health facility (a 32 bed surgical unit). In this role the NPs led the primary care aspect of the unit redirecting 800 patients per month to their primary care clinic, removing significant pressure off the trauma centre. This demonstrated a measurable effect of the positive impact of NPs within US military organisations, in the roles for which they were educated and trained.[7]
A further US study, by Lewis et al. in 2012, showed NPs effectively provide immediate and lifesaving care during combat operations.[8] The authors of this review also noted that the conflicts in Iraq and Afghanistan have seen an increasing number of nurse practitioner deployments in the combat environment. The study elicited the uniqueness of these conflicts and supported the effective use of NPs in roles not normally associated with military nursing.[8] The study surveyed 50 US Army NPs with deployment experience in order to explore their clinical practice and experience in the combat environment. Over 70% of those surveyed reported seeing more than 11 patients a day with a top three diagnosis spectrum of musculoskeletal/soft tissue (noncombat) damage, spinal pain (mechanical, sciatica), and gastrointestinal complaints.[8] Over 74% reported having a physician available for collaboration, whilst 50% reported the provision of independent emergency care, with 58% of the NPs treating life-threatening injuries.[8] The nurse practitioners in the study reported standard credentialing privileges with most of the care provided falling within the civilian equivalent realm. However, a few reported non-traditional roles such as hospital-admitting privileges in the operational setting.[8] This study adds to the growing body of knowledge on the practice of NPs in the combat environment, demonstrating the professional capability of extended decision making and advanced nursing clinical skills. Nurse pratitioners are battlefield multipliers who bring additional skills and abilities to the combat environment.[8]
Discussion:
This article demonstrates the successes of the NP-led Role One and the international evidence supporting the increased utilisation of nurse practitioners in the Australian Defence Force. The subsequent assumption of NPs being recognised as a significant health resource in the Air Force would lead to their effective use during peacetime and combat/war like operations. The nursing career structure, morale and retention benefits for Air Force and the greater Defence health community would far out-weigh any initial issues associated with implementing these Military Nurse Practitioner (MNP) positions on a tri-service basis. The beneficial impacts NPs have had on the provision of civilian health care have been thoroughly evaluated and whilst the number of NPs in Australia remains small, the work conducted by this group has been proven to have had a positive effect on patient outcomes and health care consumer choice. The US military concluded that the versatility of the NPs assigned to the 28th CSH was clearly demonstrated by their ability to function in the varied critical health care provider roles in which they were immersed.[7] On review, the 28th CSH NPs selected clinical acumen and experience level as important predictors of their ability to transfer their peacetime skill set and perform these critical roles in the combat environment.[7] Due to the wealth of experience and robust accreditation process, Australian NPs should be held in high regard against these self-imposed criteria.
This observational report has discussed some of the benefits of the nurse practitioner in a deployed environment. As we anticipate future requirements of the health sector of the Australian Defence Force, the NP clearly has a role to play in the provision of ADF health care. The implementation of a Military and/or Flight Nurse Practitioner (MNP/FNP) would have a positive measurable effect on the health capability of the Royal Australian Air Force. It is expected that this implementation would realise cost savings (when related to the NPs medical equivalent) as well as productivity benefits derived from the role. From the international experience, it is envisaged that all major stake-holders in Air Force health would support the rapid recognition of existing NPs and the further employment of NPs within the service. An agreed clinical framework could be rapidly transferred from an existing emergency nurse practitioner model, enabling the immediate deployment of these health care professionals according to legislative requirements. Over time this adapted framework could be further refined, as necessary, to ensure a perfect fit for the role NPs may play within the military specialisation. The United States, United Kingdom and Canada are fully utilising NPs in their military, which has proven to be a success for them.[8,12] The next step is to recognise and integrate NPs, as the need for their utilisation is clear, , allowing the Air Force and the wider ADF health system to immediately benefit from these highly trained, experienced mid-level care partitioners.
Disclaimer: The views and comments in this article are those expressed by the authors only and not necessarily the views of the Australian Defence Force.