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Establishing a collaborative trauma training program with a community trauma center for military nurses
ORIGINAL ARTICLES
Establishing a Collaborative Trauma Training Program with a Community Trauma Center for Military Nurses Karen J. McNamara (CDR), RN, BSN, MEd, Christine Schulman, RN, MS, CCRN, Dennis Jepsen (CDR), RN, MSN, CEN, FNP, and Janet E. Cuffley (LT), RN, BS, CEN A mission of the Navy Nurse Corps is to deploy medical support for military forces on short notice. Navy nurses must possess a working knowledge of trauma management, but meeting this clinical experience is a challenge. Peacetime military hospitals do not routinely care for severely injured patients. This article describes how the Navy established a partnership with a Level 1 Trauma Center, the role and expectations for both Navy and civilian nurses, and an evaluation of the experience. (Int J Trauma Nurs 2001;7:49-56.)
ilitary nurses may, at a moment’s notice, be deployed worldwide to care for the trauma patient. A primary goal of the Navy Nurse Corps is emergency preparedness and provision of trauma care during armed forces deployments. During peacetime, the daily routine consists of providing health care to all
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Karen J. McNamara (CDR), RN, BSN, MEd, is the head of staff education and training for Naval Hospital Bremerton, Washington. Christine Schulman, RN, MS, CCRN, is a trauma and surgery clinical nurse specialist for Harborview Medical Center in Seattle, Washington. Dennis Jepsen (CDR), RN, MSN, CEN, FNP, is a division officer in the emergency department of Naval Hospital Bremerton, Washington. Janet E. Cuffley (LT), RN, BS, CEN, is a staff nurse in the emergency department of Naval Hospital Bremerton, Washington. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. Reprint requests: Karen J. McNamara (CDR), RN, BSN, MEd, Naval Hospital Bremerton, HP01 Boone Rd, Code 018, Bremerton, WA 98312. Copyright © 2001 by the Emergency Nurses Association. 1075-4210/2001/$35.00 + 0 65/1/115642 doi:10.1067/mtn.2001.115642 APRIL-JUNE 2001
The Navy is challenged to provide multiple clinical opportunities for personnel to enable them to maintain readiness to respond to critically injured patients. Department of Defense personnel and their beneficiaries. The Navy is challenged to provide multiple clinical opportunities for personnel to enable them to maintain readiness to respond to critically injured patients in time of war, natural disaster, or humanitarian need. Naval Hospital Bremerton (NHB) in Washington state is a fully accredited, medium-sized, community-based acute care and obstetrical hospital, with 5 branch clinics and a Naval Fleet Hospital training facility. The hospital is an integral part of TRICARE Region 11, who, in partnership with Foundation Health Federal Services, administers care to 65,500 military families in the Pacific Northwest. The 101-bed hospital provides a wide range of medical services throughout the emergency, critical care, acute care, and outpatient care continuum. The medical care provided in Navy treatment
INTERNATIONAL JOURNAL OF TRAUMA NURSING/McNamara et al 49
facilities meets and frequently exceeds community standards. The military health care team demonstrates exceptional competence and expertise in the care of routine medical and surgical patients. Despite their proven ability to provide comprehensive medical care in a peacetime setting, military treatment facilities manage a limited volume of trauma patients. This does not provide enough practical experience to prepare physicians or nurses for their expected medical roles during emergent military deployments.1-5 In an effort to facilitate training that would prepare Navy nurses for their roles in the care and management of battlefield injuries, a relationship between NHB and Harborview Medical Center (HMC), a local trauma facility, was established. The purpose of this article is to describe the development and benefits of a partnership in trauma nursing education between the 2 institutions. THEORETICAL FRAMEWORK FOR NAVY NURSING OPERATIONAL COMPETENCIES A goal of the Navy Nurse Corps’ strategic plan states that nurses will be prepared to deploy worldwide and provide clinically competent nursing care for any type of patient. In an effort to further define the intent of this goal, a work group comprised of experts in multiple clinical specialties was formed in 1999. The work group defined clinical skills and
The goal of the partnership between NHB and HMC was to facilitate transition of the Navy nurse from the “competent” to the “proficient” level of practice. abilities (competencies) that were the minimum required to successfully prepare nurses for emergency deployment. The competencies served as guidelines for assessing the achievement of sets of skills needed for military preparedness. The Navy bases nursing competency levels on the work of Patricia Benner.1 Benner describes these 5 levels of skill acquisition in nursing: novice, advanced beginner, competent, proficient, and expert. The Navy Nurse Corps competencies were developed for the “competent” practitioner. Benner states that competence is present when the 50
nurse begins to see his or her actions in terms of long-range goals or plans; plans dictate which attributes are to be considered most important and which can be ignored. For the competent nurse, a plan establishes perspective and is based on considerable conscious, abstract, and analytical contemplation of a problem. The competent nurse lacks the speed and flexibility of the proficient nurse but has a feeling of mastery and the ability to manage the many contingencies of clinical nursing. The goal of the partnership between NHB and HMC was to facilitate transition of the Navy nurse from the “competent” to the “proficient” level of practice in the specialty of trauma care. It would be unrealistic to assume that a nurse would become proficient in the time allotted for the individual rotations. Therefore, the focus of this program was to pair the Navy nurse with a proficient trauma nurse clinician who practiced in a fast-paced trauma center. The clinician helped the NHB nurse to navigate the learning process and learn patient management in a busy and often unpredictable work environment. This training enhanced the NHB nurse’s speed, flexibility, and skill mastery in management of the multiple trauma victim. Proficient practitioners use conscious and deliberate planning to achieve efficiency and organization. It was immediately apparent that the trauma center nurse preceptor (mentor) played a crucial role in helping the Navy nurse to move from the “competent” to the “proficient” level. The preceptor challenged the Navy nurse to practice decision making during real-life clinical experiences. The liaison between the Naval and community hospitals was a realistic approach to fostering this level of nursing practice. HMC is a Level 1 Trauma Center for the Pacific Northwest, serving Washington, Alaska, Montana, and Idaho. It is a part of the University of Washington and provides trauma care and continuing education projects to trauma facilities throughout the region. HMC is a 360-bed hospital that admits approximately 4900 trauma patients per year. PLANNING A COLLABORATIVE TRAUMA TRAINING PROGRAM In 1999, NHB developed a partnership for rotation of physicians to HMC to enable exposure to and experience with trauma patients. Because this was such a positive learning experience, the staff education and training officer at NHB explored expansion of the program to include nurses. The key issues that needed to be addressed were licensure,
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Table 1. Clinical activity guidelines* Skills to be performed during clinical experiences:† Inserting IV catheters Venipuncture and arterial puncture for obtaining blood gas samples, drawing of blood from arterial pressure monitoring lines Changing of IV bags and hanging crystalloid IVs for maintenance or resuscitation fluids Working with rapid volume infuser Administering medications and narcotics (as determined by preceptor and individual scenario) Log rolling and maintenance of cervical spine precautions Managing the airway with a bag-valve-mask device Endotracheal suctioning Inserting urethral urinary catheter and gastric tubes Assisting with insertion of PA catheters, monitoring of PA catheters Performing PA measurements and cardiac output Assisting with insertion of chest tubes, and care of chest tubes Dressing changes Other nursing skills as directed by, and under the direct supervision of, the preceptor Skills not to be performed:‡ Transfusions or checking of blood products Documenting in the CIS Retrieving medications from computerized distribution system IV, Intravenous; PA, pulmonary artery; CIS, computerized information system. *In the ED, the NHB nurse may document vital signs, fluid intake and output, and nursing procedures on the trauma flow sheet. In the ICU, documentation of these skills in the patient record will be performed by the HMC nurse. †These skills have been cleared by both institutions; all NHB nurses are licensed to perform these tasks at HMC under the supervision of their preceptor. Every effort should be made to create opportunities for them to practice these skills as often as possible. ‡It is expected that although these activities cannot be performed by the NHB nurse, the NHB nurse should have active discussions with his or her preceptor about the content, indications, assessments, and contraindications as appropriate.
affiliation agreement, skills competencies, employee health and safety, and prerequisite education. 1. Licensure: HMC typically limits visiting professionals to an observational role because of licensure and institutional competency standards. However, the NHB request was different in that the goal was to provide actual “hands on” experience for their nurses. The United States does not have national licensure; each state is responsible for regulating its own nursing practice. The Washington State Board of Nursing ruled that in accordance with the Revised Code of Washington,6 military nurses can practice anywhere while “in the line of duty,” or in a training program attached with their line of duty. The Navy nurse’s individual license covered his or her professional practice under these conditions, and he or she was cleared to deliver hands-on patient care at HMC. 2. Affiliation agreement: A legal agreement between the 2 facilities that addressed confidentiality, safety, and liability concerns was required. In this situation, the affiliation agreement was between the federal government and HMC. A draft document was reviewed by the APRIL-JUNE 2001
University of Washington Attorney General’s Office. The final version was signed by medical directors of both institutions. 3. Skills competencies: Educators from NHB and HMC together developed a list of skills to be practiced during the Navy nurses’ clinical rotation. After reviewing common procedures from both institutions, the educators determined that the standards of nursing practice were comparable. Most basic nursing skills were permitted for the rotation, with a focus on emergency and critical care trauma-related procedures and activities (Table 1). The primary objective was for nurses to practice traumarelated skills rather than learn institution-specific guidelines such as charting, medication administration, or blood transfusion standards. Both facilities agreed that institution-specific activities had a potential for error and liability and would not be performed by NHB nurses during their clinical experiences. 4. Employee health and safety: Just before the visit, NHB nursing personnel submitted documentation of current immunizations against tetanus, diphtheria, measles, mumps,
INTERNATIONAL JOURNAL OF TRAUMA NURSING/McNamara et al 51
Figure 1. Trauma Clinical Experience Log
rubella, varicella, and hepatitis, along with a current tuberculosis test. NHB personnel were provided with hospital directions, location of the clinical areas, a life safety brief, HMC contact numbers, area maps, assigned shift times, lodging, and parking. 5. Preliminary education: Each NHB nurse reviewed an HMC procedure packet and cervical spine immobilization video before doing any rotations. A Practice Agreement document was signed stating that NHB nurses had reviewed the procedures and agreed to practice them in accordance with HMC standards. Failure to practice under these expectations or 52
outside the direction and supervision of their HMC preceptor could result in termination of the clinical rotation. A copy of this signed statement was kept on file at both institutions. A database collection tool was developed by NHB educators to document skills observed and practiced during the training program and to evaluate the program (Figure 1). The NHB nurses were provided with a portable computer to help document their experiences in a timely manner. The trauma clinical nurse specialist at HMC worked with the NHB training officer, the Emergency Department, and Intensive Care Unit division officers to develop preceptor guidelines
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Table 2. Preceptor guidelines for patient assignments* ED Nurses should be precepted by HMC staff assigned to the trauma resuscitation rooms. They should observe and participate in the care of as many trauma patients as possible. In lieu of an active “trauma day,” the next priority for observation/participation will be in the medicine and cardiac resuscitation rooms. The goal is to expose them to as many high-severity patients as possible, with a priority given to trauma patients. They should accompany patients (along with their preceptor) out of the department for diagnostic procedures such as angiography, computed tomography, and radiography. During “down time” they may observe other activities in the ED, or the preceptor may do some clinical teaching through case studies and “war stories” to focus on key issues related to trauma patient resuscitation. They may follow a patient to the OR, if appropriate. ICU NHB nurses should be assigned to preceptors taking care of any severity of trauma patient, although paired assignments should be avoided. High priority should be given to extremely critical patients and patients undergoing active resuscitation. NHB nurses should actively participate in the admission of trauma patients. NHB nurses should accompany and monitor patients requiring diagnostic procedures. High-severity medicine or neurosurgery patients may be assigned if the census of severe trauma patients is low. Ideally, the NHB nurse would stay with either the same patient or the same preceptors for all 3 days in a given week. They may accompany a patient to the OR, if appropriate. ED, Emergency department; ICU, intensive care unit; OR, operating room. *These are guidelines intended to assist the HMC preceptor with selection of patient assignments and activities that enhance the learning opportunities for the NHB nurses.
(Table 2). It was agreed that the nurse managers at HMC would serve as the first-line resources for preceptors if questions arose. The clinical nurse specialist explained the program and its objectives to the HMC staff, answered questions and concerns, and provided anticipated time lines. Dates, preceptor assignments, and final arrangements were coordinated between the 2 facilities. Each preceptor and participant received a packet that included the guidelines, a list of skills to be practiced, and an orientation activity (ie, short scavenger list) for the NHB nurse to complete on the first day. The scavenger list included basic activities to familiarize the NHB nurse with the HMC unit, such as locker and restroom location, report room, break times, crash cart and other emergency equipment location, and sites of fire alarms. IMPLEMENTING A CLINICAL EXPERIENCE After completing the prerequisite preparation, NHB nurses were assigned to work weekend evening hours. During the first 72-hour rotation of the program, an NHB nurse participated in the care of more than 60 trauma patients, far exceeding the APRIL-JUNE 2001
initial expectations of the program. This program provided experience in receiving 2 or more patients simultaneously. Several patients presented with wounds similar to those seen on the battlefield (ie, gunshot wounds, near amputations, amputations, and multisystem trauma). During the initial clinical experience, 53 patients required spinal precautions.
Several patients presented with wounds similar to those seen on the battlefield. Patients were treated for burns, intracranial hemorrhage, and maxillary and pelvic fractures. There were 5 cases that required major resuscitation. The NHB nurse observed bedside ultrasound and diagnostic peritoneal lavages. Numerous central venous infusion lines were placed, the rapid infusion system was used in the majority of resuscitations, and 2 emergency open-chest thoracotomies were performed. The activities were documented
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Table 3. Comparison of the clinical experiences of Navy nurses in working with trauma patients at HMC and at NHB during peacetime Procedure or treatment (observed, performed, or assisted)
Observed at HMC (frequency)*
Observed at NHB (frequency)†
134 18
10 0
Respiratory Chest tube placement and management Endotracheal intubation Suctioning Thoracotomies (ED)
14 26 11 2
3 0 0 0
Tracheostomy Unspecified airway management Ventilator management
2 34 42
0 0 0
Cardiovascular Blood transfusion Central venous line placement General shock management Pneumatic antishock garment Rapid IV volume infuser Nonspecific fluid resuscitation
7 23 16 1 15 26
1 0 0 0 0 0
Central nervous system Burr hole placement Spinal precautions
5 99
0 0
Gastrointestinal/genitourinary Nasogastric tube Urinary catheter
35 50
0 0
Musculoskeletal Casting and splinting Traction
20 5
0 0
9 8 27 6 12 4
0 0 0 0 3 4 0
8 27 6
1 0 1
11 0 7 7 73
0 0 0 0 0
8 9 136 6
0 1 0 0
Trauma patients cared for Adult Pediatric
Selected injuries Amputation (traumatic) Burns Concussion Fractures Pelvic Skull Maxillary Gunshot wounds Intracranial injuries Stab wounds Selective diagnostics Peritoneal lavage Radiologic studies Angiography Computerized tomography Ultrasound Selected experiences Crisis intervention Death Pain assessment and control Anesthesia regional blocks ED, Emergency department; IV, intravenous. *During 216 hours of clinical time at HMC. †During 18 months at NHB. 54
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Figure 2. As seen through the head of the machine, Lt Janet Cuffley of Naval Hospital Bremerton prepares a patient for a computerized tomography scan at Harborview Medical Center during her trauma rotation in the emergency department. Photograph by J02 Howlett.
in a Trauma Clinical Experience Log and were used to analyze the program’s effectiveness. The preceptors encouraged questions and willingly shared information. As a consequence of changing assignments and rotating schedules, many nurses were used in the preceptor role. The variety of preceptors provided an excellent opportunity to work with nurses with different skill levels. Expertise ranged from nurses relatively new to trauma care to highly accomplished and seasoned certified emergency nurses. All preceptors were extremely adept in the teaching role and enthusiastically accepted the challenge of assisting the military nurses. The NHB nurses were encouraged to do hands-on assessments and interventions (Figure 2). The preceptors and other emergency department staff encouraged learning, maintained legal standards, and ensured that treatment remained at optimal levels. EVALUATION OF PROGRAM 1. Pilot test program with an experienced nurse: The first NHB military nurse who participated in the program was an emergency department nurse who functioned well within the daily APRIL-JUNE 2001
hectic environment of the HMC emergency department. An experienced nurse could use her clinical background to anticipate skills and activities, and give feedback to the NHB and HMC staff. The feedback was used to modify the original skills and activity list and to expand levels of involvement by the NHB staff. In addition, the HMC staff had the opportunity to work with a skilled nurse who complemented their efforts. 2. Evaluation of program: The initial evaluation was done in 2 phases, once during the first nurse’s rotation and the second after she had completed all clinical time. After the first week of the first rotation, the NHB education director and emergency department nurse manager met with the NHB nurse to review the experience. There were several minor changes that were made to enhance the overall trauma experience, including (1) changing the clinical hours to 1:00 PM–1:00 AM because of the higher severity and volume of trauma patients in the later evening hours; (2) allowing the NHB nurses to administer select medications (eg, tetanus toxoid, morphine); and (3) encouraging the NHB
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nurses to participate in care by documenting vital signs, assessing pain, and helping with patient transports. NHB nurses continued to function under direct preceptor observation. The second phase of evaluation was done after the first NHB nurse completed her rotation. It was noted that the clinical documentation and discussion between initial and subsequent participants were overwhelmingly positive. NHB participants received training and trauma experience in 6 12-hour shifts that exceeded trauma-related opportunities found in 1 year at NHB. The trauma skills that were practiced directly enhanced NHB operational and emergency readiness requirements. Navy
NHB participants received training and trauma experience in 6 12-hour shifts that exceeded trauma-related opportunities found in 1 year at NHB. nurses immediately applied many standards of care learned during their rotation at HMC to their own work setting. Other NHB nursing staff were given continuing education about the clinical information learned during the trauma rotation. All participants agreed that there was value in having military and civilian colleagues working side by side, exchanging clinical expertise and professional perspectives. There was excellent support from the HMC and NHB administration for this clinical program, and both facilities committed to further development of the program. NHB nurses were given the autonomy to follow a patient from admission to the operating room or to remain in the emergency department to manage multiple trauma influx. By the second week of the experience, NHB nurses were able to monitor and manage multiple trauma patients and make
56
appropriate assessments with minimal supervision, successfully moving toward a “proficient” performance level. As the program continued, each NHB nurse had experienced more trauma case management in 6 12-hour shifts at HMC than they would in a full year at NHB (Table 3). HMC has also benefitted with the extra manpower provided by NHB nurses during times of high patient census and severity in the emergency department. An unanticipated benefit for NHB was the significant interest by civilian HMC staff in learning about military medicine and nursing, a potential recruitment benefit for the Navy Nurse Corps. CONCLUSION The combined efforts of the supportive chain of command and the regional Level 1 Trauma Center clearly provided an excellent training experience. Partnership between military and civilian colleagues was an ideal way to prepare military nurses for treating battlefield injuries, as there is no good substitute for hands-on experience. The objective of providing increased trauma patient exposure and subsequent clinical interventions was clearly accomplished, and the Navy nurse moved closer to the “proficient” level. Both HMC and NHB plan to continue this program, and will analyze data for program success, modification, and potential expansion. REFERENCES 1. Benner P. The Dreyfus Model of Skill Acquistions applied to nursing. In: Evans N, Lewis E, deProsse J, editors. From novice to expert, excellence and power in clinical nursing practice. Menlo Park (CA): Addison-Wesley; 1984. p. 13-38. 2. Stewart TS. Smart training: the US Army’s pilot project for combat trauma surgical training. Semin Perioper Nurs 2000;9(1):11-6. 3. Knuth TE. The peacetime trauma experience of US Army surgeons: another call for collaborative training in civilian trauma centers. Mil Med 1996;161:137-42. 4. Knuth TE, Wilson A, Oswald SG. Military training at civilian trauma centers: the first year’s experience with the Regional Trauma Network. Mil Med 1998;163:608-14. 5. Drury T, Zacharias S. Integrating nursing education into a trauma outreach program. Int J Trauma Nurs 1997;3(3):83-7. 6. Wash Rev Code 18 § 79.240.
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Establishing a Collaborative Trauma Training Program with a Community Trauma Center for Military Nurses Karen J. McNamara (CDR), RN, BSN, MEd, Christine Schulman, RN, MS, CCRN, Dennis Jepsen (CDR), RN, MSN, CEN, FNP, and Janet E. Cuffley (LT), RN, BS, CEN A mission of the Navy Nurse Corps is to deploy medical support for military forces on short notice. Navy nurses must possess a working knowledge of trauma management, but meeting this clinical experience is a challenge. Peacetime military hospitals do not routinely care for severely injured patients. This article describes how the Navy established a partnership with a Level 1 Trauma Center, the role and expectations for both Navy and civilian nurses, and an evaluation of the experience. (Int J Trauma Nurs 2001;7:49-56.)
ilitary nurses may, at a moment’s notice, be deployed worldwide to care for the trauma patient. A primary goal of the Navy Nurse Corps is emergency preparedness and provision of trauma care during armed forces deployments. During peacetime, the daily routine consists of providing health care to all
M
Karen J. McNamara (CDR), RN, BSN, MEd, is the head of staff education and training for Naval Hospital Bremerton, Washington. Christine Schulman, RN, MS, CCRN, is a trauma and surgery clinical nurse specialist for Harborview Medical Center in Seattle, Washington. Dennis Jepsen (CDR), RN, MSN, CEN, FNP, is a division officer in the emergency department of Naval Hospital Bremerton, Washington. Janet E. Cuffley (LT), RN, BS, CEN, is a staff nurse in the emergency department of Naval Hospital Bremerton, Washington. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. Reprint requests: Karen J. McNamara (CDR), RN, BSN, MEd, Naval Hospital Bremerton, HP01 Boone Rd, Code 018, Bremerton, WA 98312. Copyright © 2001 by the Emergency Nurses Association. 1075-4210/2001/$35.00 + 0 65/1/115642 doi:10.1067/mtn.2001.115642 APRIL-JUNE 2001
The Navy is challenged to provide multiple clinical opportunities for personnel to enable them to maintain readiness to respond to critically injured patients. Department of Defense personnel and their beneficiaries. The Navy is challenged to provide multiple clinical opportunities for personnel to enable them to maintain readiness to respond to critically injured patients in time of war, natural disaster, or humanitarian need. Naval Hospital Bremerton (NHB) in Washington state is a fully accredited, medium-sized, community-based acute care and obstetrical hospital, with 5 branch clinics and a Naval Fleet Hospital training facility. The hospital is an integral part of TRICARE Region 11, who, in partnership with Foundation Health Federal Services, administers care to 65,500 military families in the Pacific Northwest. The 101-bed hospital provides a wide range of medical services throughout the emergency, critical care, acute care, and outpatient care continuum. The medical care provided in Navy treatment
INTERNATIONAL JOURNAL OF TRAUMA NURSING/McNamara et al 49
facilities meets and frequently exceeds community standards. The military health care team demonstrates exceptional competence and expertise in the care of routine medical and surgical patients. Despite their proven ability to provide comprehensive medical care in a peacetime setting, military treatment facilities manage a limited volume of trauma patients. This does not provide enough practical experience to prepare physicians or nurses for their expected medical roles during emergent military deployments.1-5 In an effort to facilitate training that would prepare Navy nurses for their roles in the care and management of battlefield injuries, a relationship between NHB and Harborview Medical Center (HMC), a local trauma facility, was established. The purpose of this article is to describe the development and benefits of a partnership in trauma nursing education between the 2 institutions. THEORETICAL FRAMEWORK FOR NAVY NURSING OPERATIONAL COMPETENCIES A goal of the Navy Nurse Corps’ strategic plan states that nurses will be prepared to deploy worldwide and provide clinically competent nursing care for any type of patient. In an effort to further define the intent of this goal, a work group comprised of experts in multiple clinical specialties was formed in 1999. The work group defined clinical skills and
The goal of the partnership between NHB and HMC was to facilitate transition of the Navy nurse from the “competent” to the “proficient” level of practice. abilities (competencies) that were the minimum required to successfully prepare nurses for emergency deployment. The competencies served as guidelines for assessing the achievement of sets of skills needed for military preparedness. The Navy bases nursing competency levels on the work of Patricia Benner.1 Benner describes these 5 levels of skill acquisition in nursing: novice, advanced beginner, competent, proficient, and expert. The Navy Nurse Corps competencies were developed for the “competent” practitioner. Benner states that competence is present when the 50
nurse begins to see his or her actions in terms of long-range goals or plans; plans dictate which attributes are to be considered most important and which can be ignored. For the competent nurse, a plan establishes perspective and is based on considerable conscious, abstract, and analytical contemplation of a problem. The competent nurse lacks the speed and flexibility of the proficient nurse but has a feeling of mastery and the ability to manage the many contingencies of clinical nursing. The goal of the partnership between NHB and HMC was to facilitate transition of the Navy nurse from the “competent” to the “proficient” level of practice in the specialty of trauma care. It would be unrealistic to assume that a nurse would become proficient in the time allotted for the individual rotations. Therefore, the focus of this program was to pair the Navy nurse with a proficient trauma nurse clinician who practiced in a fast-paced trauma center. The clinician helped the NHB nurse to navigate the learning process and learn patient management in a busy and often unpredictable work environment. This training enhanced the NHB nurse’s speed, flexibility, and skill mastery in management of the multiple trauma victim. Proficient practitioners use conscious and deliberate planning to achieve efficiency and organization. It was immediately apparent that the trauma center nurse preceptor (mentor) played a crucial role in helping the Navy nurse to move from the “competent” to the “proficient” level. The preceptor challenged the Navy nurse to practice decision making during real-life clinical experiences. The liaison between the Naval and community hospitals was a realistic approach to fostering this level of nursing practice. HMC is a Level 1 Trauma Center for the Pacific Northwest, serving Washington, Alaska, Montana, and Idaho. It is a part of the University of Washington and provides trauma care and continuing education projects to trauma facilities throughout the region. HMC is a 360-bed hospital that admits approximately 4900 trauma patients per year. PLANNING A COLLABORATIVE TRAUMA TRAINING PROGRAM In 1999, NHB developed a partnership for rotation of physicians to HMC to enable exposure to and experience with trauma patients. Because this was such a positive learning experience, the staff education and training officer at NHB explored expansion of the program to include nurses. The key issues that needed to be addressed were licensure,
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VOLUME 7, NUMBER 2
Table 1. Clinical activity guidelines* Skills to be performed during clinical experiences:† Inserting IV catheters Venipuncture and arterial puncture for obtaining blood gas samples, drawing of blood from arterial pressure monitoring lines Changing of IV bags and hanging crystalloid IVs for maintenance or resuscitation fluids Working with rapid volume infuser Administering medications and narcotics (as determined by preceptor and individual scenario) Log rolling and maintenance of cervical spine precautions Managing the airway with a bag-valve-mask device Endotracheal suctioning Inserting urethral urinary catheter and gastric tubes Assisting with insertion of PA catheters, monitoring of PA catheters Performing PA measurements and cardiac output Assisting with insertion of chest tubes, and care of chest tubes Dressing changes Other nursing skills as directed by, and under the direct supervision of, the preceptor Skills not to be performed:‡ Transfusions or checking of blood products Documenting in the CIS Retrieving medications from computerized distribution system IV, Intravenous; PA, pulmonary artery; CIS, computerized information system. *In the ED, the NHB nurse may document vital signs, fluid intake and output, and nursing procedures on the trauma flow sheet. In the ICU, documentation of these skills in the patient record will be performed by the HMC nurse. †These skills have been cleared by both institutions; all NHB nurses are licensed to perform these tasks at HMC under the supervision of their preceptor. Every effort should be made to create opportunities for them to practice these skills as often as possible. ‡It is expected that although these activities cannot be performed by the NHB nurse, the NHB nurse should have active discussions with his or her preceptor about the content, indications, assessments, and contraindications as appropriate.
affiliation agreement, skills competencies, employee health and safety, and prerequisite education. 1. Licensure: HMC typically limits visiting professionals to an observational role because of licensure and institutional competency standards. However, the NHB request was different in that the goal was to provide actual “hands on” experience for their nurses. The United States does not have national licensure; each state is responsible for regulating its own nursing practice. The Washington State Board of Nursing ruled that in accordance with the Revised Code of Washington,6 military nurses can practice anywhere while “in the line of duty,” or in a training program attached with their line of duty. The Navy nurse’s individual license covered his or her professional practice under these conditions, and he or she was cleared to deliver hands-on patient care at HMC. 2. Affiliation agreement: A legal agreement between the 2 facilities that addressed confidentiality, safety, and liability concerns was required. In this situation, the affiliation agreement was between the federal government and HMC. A draft document was reviewed by the APRIL-JUNE 2001
University of Washington Attorney General’s Office. The final version was signed by medical directors of both institutions. 3. Skills competencies: Educators from NHB and HMC together developed a list of skills to be practiced during the Navy nurses’ clinical rotation. After reviewing common procedures from both institutions, the educators determined that the standards of nursing practice were comparable. Most basic nursing skills were permitted for the rotation, with a focus on emergency and critical care trauma-related procedures and activities (Table 1). The primary objective was for nurses to practice traumarelated skills rather than learn institution-specific guidelines such as charting, medication administration, or blood transfusion standards. Both facilities agreed that institution-specific activities had a potential for error and liability and would not be performed by NHB nurses during their clinical experiences. 4. Employee health and safety: Just before the visit, NHB nursing personnel submitted documentation of current immunizations against tetanus, diphtheria, measles, mumps,
INTERNATIONAL JOURNAL OF TRAUMA NURSING/McNamara et al 51
Figure 1. Trauma Clinical Experience Log
rubella, varicella, and hepatitis, along with a current tuberculosis test. NHB personnel were provided with hospital directions, location of the clinical areas, a life safety brief, HMC contact numbers, area maps, assigned shift times, lodging, and parking. 5. Preliminary education: Each NHB nurse reviewed an HMC procedure packet and cervical spine immobilization video before doing any rotations. A Practice Agreement document was signed stating that NHB nurses had reviewed the procedures and agreed to practice them in accordance with HMC standards. Failure to practice under these expectations or 52
outside the direction and supervision of their HMC preceptor could result in termination of the clinical rotation. A copy of this signed statement was kept on file at both institutions. A database collection tool was developed by NHB educators to document skills observed and practiced during the training program and to evaluate the program (Figure 1). The NHB nurses were provided with a portable computer to help document their experiences in a timely manner. The trauma clinical nurse specialist at HMC worked with the NHB training officer, the Emergency Department, and Intensive Care Unit division officers to develop preceptor guidelines
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Table 2. Preceptor guidelines for patient assignments* ED Nurses should be precepted by HMC staff assigned to the trauma resuscitation rooms. They should observe and participate in the care of as many trauma patients as possible. In lieu of an active “trauma day,” the next priority for observation/participation will be in the medicine and cardiac resuscitation rooms. The goal is to expose them to as many high-severity patients as possible, with a priority given to trauma patients. They should accompany patients (along with their preceptor) out of the department for diagnostic procedures such as angiography, computed tomography, and radiography. During “down time” they may observe other activities in the ED, or the preceptor may do some clinical teaching through case studies and “war stories” to focus on key issues related to trauma patient resuscitation. They may follow a patient to the OR, if appropriate. ICU NHB nurses should be assigned to preceptors taking care of any severity of trauma patient, although paired assignments should be avoided. High priority should be given to extremely critical patients and patients undergoing active resuscitation. NHB nurses should actively participate in the admission of trauma patients. NHB nurses should accompany and monitor patients requiring diagnostic procedures. High-severity medicine or neurosurgery patients may be assigned if the census of severe trauma patients is low. Ideally, the NHB nurse would stay with either the same patient or the same preceptors for all 3 days in a given week. They may accompany a patient to the OR, if appropriate. ED, Emergency department; ICU, intensive care unit; OR, operating room. *These are guidelines intended to assist the HMC preceptor with selection of patient assignments and activities that enhance the learning opportunities for the NHB nurses.
(Table 2). It was agreed that the nurse managers at HMC would serve as the first-line resources for preceptors if questions arose. The clinical nurse specialist explained the program and its objectives to the HMC staff, answered questions and concerns, and provided anticipated time lines. Dates, preceptor assignments, and final arrangements were coordinated between the 2 facilities. Each preceptor and participant received a packet that included the guidelines, a list of skills to be practiced, and an orientation activity (ie, short scavenger list) for the NHB nurse to complete on the first day. The scavenger list included basic activities to familiarize the NHB nurse with the HMC unit, such as locker and restroom location, report room, break times, crash cart and other emergency equipment location, and sites of fire alarms. IMPLEMENTING A CLINICAL EXPERIENCE After completing the prerequisite preparation, NHB nurses were assigned to work weekend evening hours. During the first 72-hour rotation of the program, an NHB nurse participated in the care of more than 60 trauma patients, far exceeding the APRIL-JUNE 2001
initial expectations of the program. This program provided experience in receiving 2 or more patients simultaneously. Several patients presented with wounds similar to those seen on the battlefield (ie, gunshot wounds, near amputations, amputations, and multisystem trauma). During the initial clinical experience, 53 patients required spinal precautions.
Several patients presented with wounds similar to those seen on the battlefield. Patients were treated for burns, intracranial hemorrhage, and maxillary and pelvic fractures. There were 5 cases that required major resuscitation. The NHB nurse observed bedside ultrasound and diagnostic peritoneal lavages. Numerous central venous infusion lines were placed, the rapid infusion system was used in the majority of resuscitations, and 2 emergency open-chest thoracotomies were performed. The activities were documented
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Table 3. Comparison of the clinical experiences of Navy nurses in working with trauma patients at HMC and at NHB during peacetime Procedure or treatment (observed, performed, or assisted)
Observed at HMC (frequency)*
Observed at NHB (frequency)†
134 18
10 0
Respiratory Chest tube placement and management Endotracheal intubation Suctioning Thoracotomies (ED)
14 26 11 2
3 0 0 0
Tracheostomy Unspecified airway management Ventilator management
2 34 42
0 0 0
Cardiovascular Blood transfusion Central venous line placement General shock management Pneumatic antishock garment Rapid IV volume infuser Nonspecific fluid resuscitation
7 23 16 1 15 26
1 0 0 0 0 0
Central nervous system Burr hole placement Spinal precautions
5 99
0 0
Gastrointestinal/genitourinary Nasogastric tube Urinary catheter
35 50
0 0
Musculoskeletal Casting and splinting Traction
20 5
0 0
9 8 27 6 12 4
0 0 0 0 3 4 0
8 27 6
1 0 1
11 0 7 7 73
0 0 0 0 0
8 9 136 6
0 1 0 0
Trauma patients cared for Adult Pediatric
Selected injuries Amputation (traumatic) Burns Concussion Fractures Pelvic Skull Maxillary Gunshot wounds Intracranial injuries Stab wounds Selective diagnostics Peritoneal lavage Radiologic studies Angiography Computerized tomography Ultrasound Selected experiences Crisis intervention Death Pain assessment and control Anesthesia regional blocks ED, Emergency department; IV, intravenous. *During 216 hours of clinical time at HMC. †During 18 months at NHB. 54
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Figure 2. As seen through the head of the machine, Lt Janet Cuffley of Naval Hospital Bremerton prepares a patient for a computerized tomography scan at Harborview Medical Center during her trauma rotation in the emergency department. Photograph by J02 Howlett.
in a Trauma Clinical Experience Log and were used to analyze the program’s effectiveness. The preceptors encouraged questions and willingly shared information. As a consequence of changing assignments and rotating schedules, many nurses were used in the preceptor role. The variety of preceptors provided an excellent opportunity to work with nurses with different skill levels. Expertise ranged from nurses relatively new to trauma care to highly accomplished and seasoned certified emergency nurses. All preceptors were extremely adept in the teaching role and enthusiastically accepted the challenge of assisting the military nurses. The NHB nurses were encouraged to do hands-on assessments and interventions (Figure 2). The preceptors and other emergency department staff encouraged learning, maintained legal standards, and ensured that treatment remained at optimal levels. EVALUATION OF PROGRAM 1. Pilot test program with an experienced nurse: The first NHB military nurse who participated in the program was an emergency department nurse who functioned well within the daily APRIL-JUNE 2001
hectic environment of the HMC emergency department. An experienced nurse could use her clinical background to anticipate skills and activities, and give feedback to the NHB and HMC staff. The feedback was used to modify the original skills and activity list and to expand levels of involvement by the NHB staff. In addition, the HMC staff had the opportunity to work with a skilled nurse who complemented their efforts. 2. Evaluation of program: The initial evaluation was done in 2 phases, once during the first nurse’s rotation and the second after she had completed all clinical time. After the first week of the first rotation, the NHB education director and emergency department nurse manager met with the NHB nurse to review the experience. There were several minor changes that were made to enhance the overall trauma experience, including (1) changing the clinical hours to 1:00 PM–1:00 AM because of the higher severity and volume of trauma patients in the later evening hours; (2) allowing the NHB nurses to administer select medications (eg, tetanus toxoid, morphine); and (3) encouraging the NHB
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nurses to participate in care by documenting vital signs, assessing pain, and helping with patient transports. NHB nurses continued to function under direct preceptor observation. The second phase of evaluation was done after the first NHB nurse completed her rotation. It was noted that the clinical documentation and discussion between initial and subsequent participants were overwhelmingly positive. NHB participants received training and trauma experience in 6 12-hour shifts that exceeded trauma-related opportunities found in 1 year at NHB. The trauma skills that were practiced directly enhanced NHB operational and emergency readiness requirements. Navy
NHB participants received training and trauma experience in 6 12-hour shifts that exceeded trauma-related opportunities found in 1 year at NHB. nurses immediately applied many standards of care learned during their rotation at HMC to their own work setting. Other NHB nursing staff were given continuing education about the clinical information learned during the trauma rotation. All participants agreed that there was value in having military and civilian colleagues working side by side, exchanging clinical expertise and professional perspectives. There was excellent support from the HMC and NHB administration for this clinical program, and both facilities committed to further development of the program. NHB nurses were given the autonomy to follow a patient from admission to the operating room or to remain in the emergency department to manage multiple trauma influx. By the second week of the experience, NHB nurses were able to monitor and manage multiple trauma patients and make
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appropriate assessments with minimal supervision, successfully moving toward a “proficient” performance level. As the program continued, each NHB nurse had experienced more trauma case management in 6 12-hour shifts at HMC than they would in a full year at NHB (Table 3). HMC has also benefitted with the extra manpower provided by NHB nurses during times of high patient census and severity in the emergency department. An unanticipated benefit for NHB was the significant interest by civilian HMC staff in learning about military medicine and nursing, a potential recruitment benefit for the Navy Nurse Corps. CONCLUSION The combined efforts of the supportive chain of command and the regional Level 1 Trauma Center clearly provided an excellent training experience. Partnership between military and civilian colleagues was an ideal way to prepare military nurses for treating battlefield injuries, as there is no good substitute for hands-on experience. The objective of providing increased trauma patient exposure and subsequent clinical interventions was clearly accomplished, and the Navy nurse moved closer to the “proficient” level. Both HMC and NHB plan to continue this program, and will analyze data for program success, modification, and potential expansion. REFERENCES 1. Benner P. The Dreyfus Model of Skill Acquistions applied to nursing. In: Evans N, Lewis E, deProsse J, editors. From novice to expert, excellence and power in clinical nursing practice. Menlo Park (CA): Addison-Wesley; 1984. p. 13-38. 2. Stewart TS. Smart training: the US Army’s pilot project for combat trauma surgical training. Semin Perioper Nurs 2000;9(1):11-6. 3. Knuth TE. The peacetime trauma experience of US Army surgeons: another call for collaborative training in civilian trauma centers. Mil Med 1996;161:137-42. 4. Knuth TE, Wilson A, Oswald SG. Military training at civilian trauma centers: the first year’s experience with the Regional Trauma Network. Mil Med 1998;163:608-14. 5. Drury T, Zacharias S. Integrating nursing education into a trauma outreach program. Int J Trauma Nurs 1997;3(3):83-7. 6. Wash Rev Code 18 § 79.240.
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