Decreases in size, capability, clinical volumes, case mixes, and complex care opportunities in military treatment facilities contribute to the atrophy of clinical skills among medical professionals in these facilities.
The COVID-19 pandemic resulted in a 39% decline in admissions to a military critical care unit. The decrease in patient census contributed to skill sustainment challenges.
To identify methods to combat skill atrophy, the CINAHL and PubMed databases were searched using the terms peacetime effect, military-civilian partnership, and skill sustainment. Active-duty critical care nurses stationed at a military treatment facility implemented a military-civilian partnership with a civilian medical facility for clinical skill sustainment.
One year after implementation, 39 critical care nurses had completed 511 shifts, gaining clinical experiences seldom achieved at the military facility. A survey of these nurses demonstrated that 8 of 17 (47%) gained experience treating patients requiring intra-aortic balloon pumps or continuous renal replacement therapy, 6 of 17 (36%) gained experience with patients requiring a ventricular assist device, 12 of 17 (71%) acquired hands-on experience with intracranial pressure monitoring, and 14 of 17 (82%) reported vasoactive intravenous infusion manipulation.
This article highlights the importance of evaluating clinical practice within the military health system, developing military-civilian partnerships, and removing military-civilian partnership barriers for nurses and other health care professionals. Failure to implement military-civilian partnerships may adversely affect the clinical competency of the military nurse force.
Over the years, the military has encountered significant hurdles in maintaining the clinical proficiency of their medical professionals because their primary patient demographic consists of active-duty members and dependents, who are typically young and relatively healthy, with few comorbidities.1 Veterans Affairs and military retiree beneficiaries make up a large proportion of patients in many military treatment facilities; however, their demographics and medical conditions differ from those typically encountered in deployed environments. Additionally, assigned duty locations determine the patient population that medical personnel encounter.2 With the gradual decrease in deployment frequency, varied patient acuity during deployment, and the withdrawal from Afghanistan, military clinicians, especially critical care nurses, have limited opportunities to care for acutely ill patients. Most military treatment facilities do not receive trauma patients and rely solely on their civilian counterparts for this experience. With defense budgetary issues constantly in the spotlight, military treatment facilities are dwindling in size and capabilities. Many are reduced to surgical centers, decreasing complex care opportunities.3 Moreover, military treatment facilities have limited case mixes and low clinical volumes.4
The National Defense Authorization Act of 1996 established a plan for military trauma training in civilian institutions during peacetime.5 Various clinical sustainment platforms have been developed across the country to combat skill degradation. Although these platforms allow military clinicians to practice trauma skills, they do not provide the day-to-day application of skills needed to ensure a competent medical military force.
Partnerships with civilian trauma centers and systems are a less complicated way to mitigate the peacetime effect and help bridge the clinical gap between deployments.
The term peacetime effect refers to the erosion of skills that military medical personnel experience upon return to peacetime conditions.2,6 The peacetime effect has been a problem in military medicine for centuries and continues to recur as new conflicts arise. Although the primary focus of the Military Health System is to provide care for active-duty members and their beneficiaries, the lack of emphasis on training medical personnel in procedures relevant to combat casualties is a missed opportunity.2,6 Maintenance of regular clinical encounters and complexity is necessary to maintain clinical proficiency and readiness.2,3 The Military Health System has a dual mission of delivering beneficiary care while simultaneously requiring operational medicine skills for deployments, but these areas of focus have few similarities.2,4,7,8
Many suggestions for countering the peacetime effect exist. “Flattening the curve” by optimizing clinical experiences in trauma care to avoid skill atrophy among military medical teams is an example.6 One recommendation is for Military Health System facilities to gain designation as regional trauma centers, if appropriate.6,9 This designation provides bidirectional usefulness for military-civilian partnerships (MCPs) in mass casualty events and underserved areas.9 Trauma designation is possible for only a small fraction of Military Health System facilities because the volume of trauma patients would be low and these facilities would directly compete with civilian hospitals in the region.10
Partnerships with civilian trauma centers and systems are a less complicated way to mitigate the peacetime effect and help bridge the clinical gap between deployments. However, they are often underused.11 Military-civilian partnerships are crucial for providing military medical personnel with relevant experience in both combat medicine and general hospital care.2–4,6,7 Although variable, the attributes touted by MCPs include exposure to research, exposure to trauma teams, dedicated critical care time, and patient volume.12,13 However, most of these partnerships are established solely to sustain surgeons’ skills, with few negotiations for the remaining medical force.10 In addition, MCPs offer various ranges of clinical experience, and many studies of MCPs do not demonstrate their effects on patient outcomes, quantifiable skill development, or retention.11
Level I trauma centers are considered the most appropriate facilities for sustaining military combat surgical skills through integrated programs because these centers provide the most robust and expansive trauma care experience.2,11,14 Embedment of surgeons in high-volume and clinically relevant facilities has been recommended for maintaining surgeons’ readiness.15 However, one author suggests that entire medical teams be embedded in a civilian trauma system, stating that trauma care is a team effort and that surgeons are not the only members of the combat casualty care team with a lifesaving role.16 Many of the injuries seen in wartime are unique to military conflict and are more complex than those seen even in level I trauma facilities.3 Trauma skills aside, there is little in the literature pertaining to the maintenance of basic nursing critical care skills within military treatment facilities.
The logistics of MCPs involve obstacles surrounding licensure, credentialing, privileging portability, and certification, limiting the use of MCPs to their full potential.5,17 Working through challenges at the local, state, and federal levels regarding policies, regulations, and affiliation agreements requires administrative expertise.9 Moreover, high levels of commitment and sustainment are required to maintain these agreements. Although civilian facilities benefit from having military medical clinicians on-site, these personnel can be recalled at any moment, leading to sudden disruptions in civilian facility schedules or planned procedures and potentially causing cancellations or delays in care.9 The ability to fulfill medical obligations to service members and beneficiaries is also a concern.9 With these challenges in mind, active-duty critical care nurses in the intensive care unit (ICU) at our military treatment facility used an MCP with a civilian medical facility to provide an opportunity to mitigate skill atrophy.
Local Problem
The ICU at our military treatment facility is not immune to skill atrophy. Formerly the site of a modest cardiothoracic surgery program, the ICU has been designated as a combined intermediate and critical care unit. Even with the cardiothoracic surgery program, critical care patient admissions accounted only for roughly 30% of total admissions, with the remaining 70% being patients receiving intermediate care, medical-surgical care, or postanesthesia recovery care. This trend continued after the dissolution of the cardiothoracic surgery program in 2020 and the waning of the COVID-19 pandemic (Figure 1). The pandemic resulted in a 39% decline in ICU admissions, contributing to further skill sustainment challenges because the facility’s patient census has not returned to the prepandemic level. With the onset of the pandemic, hospital operations decreased because of staff deployments to civilian hospitals across the country for Federal Emergency Management Agency assistance. Patients were required to seek care at other local health care organizations, significantly impacting the daily hospital census. The clinical educator team sought solutions to prevent the atrophy of critical care skills at our military treatment facility, ultimately exploring MCP opportunities.
Methods
Literature Review
We conducted a literature review to identify strategies to combat the skill degradation witnessed at our military treatment facility. Several search strategies produced a paucity of results applicable to the critical care nurse population. We searched CINAHL and PubMed databases using the terms military-civilian partnership and skill sustainment for articles published in the last 10 years, from January 2013 through June 2023. We excluded articles that addressed soft skills and comparisons of injury patterns among military and civilian facilities. Figure 2 shows the search strategy for the study selection in this article. The literature concerning skill sustainment primarily describes the maintenance of trauma readiness skills for surgeons.7,11–13,15,17–20 However, a scarcity of results were directly applicable to the critical care nurse population.
Intervention
Using an MCP was necessary to ensure that active-duty critical care nurses had the opportunity to treat patients with high-acuity conditions. Our military treatment facility used a training affiliation agreement with a civilian medical facility to facilitate training that could not be readily accomplished within the military treatment facility. Historically, military nurses were sent to the civilian medical facility for cardiothoracic surgery training and a 2-week annual rotation to obtain 72 hours of training in a trauma care setting, the annual minimum required by the Air Force for the Comprehensive Medical Readiness Program.
The nursing aspect of the MCP started with the selection of a civilian medical facility unit that would provide expansive opportunities for patient care experiences. The unit chosen had a patient population with needs ranging from standard critical care to high-risk, low-volume skills such as intra-aortic balloon pump (IABP) treatment, ventricular assist device (Impella, Abiomed) management, or continuous renal replacement therapy (CRRT). Furthermore, the nurse manager of the unit had significant experience in both the civilian and military sectors, which was essential during the development, implementation, and sustainment of the MCP.
In November 2021, implementation of the MCP began with a military critical care nurse rotating to the civilian medical facility for 1 month, completing three 12-hour shifts per week. After completing onboarding requirements, the military nurse was provided a facility badge, read-only electronic medical record capabilities, and access to the medication dispensing machine. This model was mirrored after nursing student preceptorships at the facility.
Further collaboration ensued with nursing managers from the emergency department and 4 other critical care departments. After careful planning, in April 2022 military nurses started rotating through each department at least twice a month for standard 12-hour shifts. These military nurses were granted only visitor badge access and fewer functions than those with full 1-month rotations, but they were still paired with a staff nurse.
These 2 types of clinical rotation, as described above, have been occurring simultaneously since April 2022. Mission requirements dictated a reduction to 2 shifts per month in the first quarter of 2023 and then 2 shifts per quarter. This decision ensured the minimum intent of capturing the annual Comprehensive Medical Readiness Program requirement. Unfortunately, exhaustion of squadron funds temporarily paused all rotations unless members were willing to pay out of pocket for travel expenses. Priority in scheduling shifts at the civilian medical facility was given to members fulfilling their Comprehensive Medical Readiness Program hours and volunteers willing to pay out of pocket. As the clinical educator team fine-tuned our approach to the shorter rotations, we successfully implemented a more efficient adaptation wherein 2 nurses could individually complete six 12-hour shifts to fulfill the 2-week annual Comprehensive Medical Readiness Program requirement. Although 1-month rotations offer each nurse greater skill exposure, this version of the shorter rotation provided a solution to the staffing challenges at the military treatment facility.
Results
Since inception of the MCP for critical care nurses in November 2021 to January 2023, 39 critical care nurses have completed 511 shifts at the civilian medical facility, obtaining various clinical experiences seldom achieved at the military treatment facility. Upon the first anniversary of the MCP, a comprehensive survey was distributed to the critical care nurses that completed rotations, yielding 17 responses. The findings revealed that 8 of 17 (47%) of the nurses gained clinical experience with patients requiring IABP or CRRT, 6 of 17 (36%) had clinical experience with patients requiring a ventricular assist device, 12 of 19 (71%) acquired hands-on experience with intracranial pressure monitoring, and 14 of 17 (82%) reported vasoactive intravenous infusion manipulation.
In contrast, from 2020 to 2023 our military treatment facility encountered only 2 patients with ventricular assist devices and 3 patients with IABPs, each necessitating an expedited transfer to the civilian medical facility. Analysis of patient care hours for each of these specialized devices revealed 13 hours dedicated to IABP management and 15 hours devoted to ventricular assist device management in the military treatment facility since 2021.
Nurses reported experiences that varied according to the preceptor, patient acuity within the department, and rotation duration. However, the overall consensus was that the rotation positively impacted their clinical practice. Collectively, the nurses accumulated 297 hours of IABP management, 96 hours of ventricular assist device management, and 156 hours of CRRT management in 1 year. Although CRRT use is inconsistent in the military treatment facility, over the same year approximately 387 hours of CRRT management were accomplished because of the development of a robust education and training program. This program was an attempt to keep CRRT capability in the military treatment facility instead of diverting patients requiring CRRT to a civilian hospital. In addition, the civilian medical facility has a dedicated CRRT team that is separate from the preceptors within the units.
Use of an MCP is an ongoing process that must remain flexible because of the dynamics of military treatment facility staffing, cost, nursing skill sustainment, and the military mission.
Discussion
Use of an MCP is an ongoing process that must remain flexible because of the dynamics of military treatment facility staffing, cost, nursing skill sustainment, and the military mission. For this program to be beneficial for both the military and civilian medical facilities, both stakeholders must overcome significant obstacles.
One of the limitations to establishing a resilient relationship with the civilian medical facility was staffing constraints due to the dual missions of staffing the military treatment facility and maintaining deployment medical readiness proficiency, as identified in the literature. In 2022, the average daily full-time equivalent in the ICU at our military treatment facility was 2, meaning the patient census required an average of 2 nurses plus a charge nurse to be working in the unit daily. Nonetheless, nurses were scheduled to support a daily full-time equivalent of 5 plus an on-call nurse. The nursing staff was further constricted by the obligation to augment staffing deficits of multiple other units within the military treatment facility. Although deployments fulfill the global mission, they perpetuate the hospital-wide staffing strain. In 2022, 18 nurses were deployed and another 21 left for various trainings, accounting for 17 300 person hours. Despite staffing challenges, the ICU managed to rotate up to 3 nurses monthly through various critical care units at the civilian medical facility.
Another dilemma is cost, which was not discussed in the articles we reviewed because the proximity of most MCP facilities is within travel regulations. However, sending nurses to the local MCP facility required reimbursement for parking and mileage. The travel cost for a 2-week rotation at the civilian medical facility was $318, and a monthlong rotation would be about $636. In comparison, the Air Force solution for maintaining clinical sustainment is to complete a 2-week course at a Center for Sustainment of Trauma and Readiness Skills; these centers have been established at multiple sites across the country.21 The average cost of attending this training, including travel and per diem allowance, is approximately $2300. Completing this 2-week course is not sufficient to prevent skill atrophy. The more cost-effective option is to cultivate clinical currency using the MCP. At the time of this writing, rotating at the MCP is not currently accounted for in the budget of our military treatment facility and is available only to volunteers prepared to pay out of pocket.
To alleviate one of the travel-related financial burdens experienced by the military nurses, the civilian medical facility secured daily parking passes and in June 2023 began distributing them to nurses engaging in rotations. The funds for these passes were procured from an $80 000 MCP grant awarded to the civilian medical facility in fiscal year 2023. Although substantial, the sustainability of this grant is likely limited. The civilian medical facility liaisons have been an invaluable resource for this endeavor, and their appreciation of the importance of this program is palpable. However, despite the collaborative efforts of these civilian liaisons, the extent of their authority is limited.
The ultimate objective of this partnership is to embed active-duty nurses at the civilian medical facility full time with the intent that they act as preceptors for military nurses on rotation. This objective has been met with significant complications, all foreshadowed within the literature. First, the civilian medical facility requires military nurses to acquire a license through the state Board of Registered Nursing to practice independently, a common condition of MCPs. This problem concerns not the ability of a military nurse to obtain a state license but rather the cost for the member. Second, the decision of the Defense Health Agency to use the American Red Cross rather than the American Heart Association for resuscitative life support certification incurs another expense for military members because the civilian medical facility prefers American Heart Association certification. Given the circumstances, the Risk Management Department at the civilian medical facility has been reluctant to sanction a fully privileged active-duty nurse embedment. Therefore, registered nurses rotating through the civilian medical facility will continue to operate as student nurses and forgo embedment opportunities. This endorsement is necessary for the critical care nurses at our military treatment facility to maintain or develop the critical skills required to treat the war-wounded troops of a future conflict.
Conclusions
Since the implementation of a regional MCP, the clinical educator team has consistently arranged for a military critical care nurse to participate in skill sustainment at the civilian medical facility on a monthly basis from November 2021 to the time of publication. The future state is still being determined as the clinical sustainment program evolves. The Defense Health Agency’s transition to being the single governing organization, as opposed to individual military branches self-governing their health system, has left numerous questions concerning how skill sustainment will be addressed. In addition, the perpetual rotation of leaders every 2 years at the group and squadron levels introduces a potential vulnerability to the sustainment program, which relies heavily on consistent support from leaders. Sustaining the MCP necessitates unwavering backing from leaders at all levels to ensure its continuity and effectively meet the needs of military health care professionals.
The ideal platform would be a program similar to the Nellis Air Force Base readiness training program, which involves an active-duty member embedded at a civilian institution. The embedded military member is responsible for acting as a preceptor for other military members who rotate through the civilian facility, allowing for more consistent rotations and providing the opportunity for hands-on experience.
Nurses are retained for reasons other than what they can provide to beneficiaries during peacetime. One suggestion is that the Military Health System and Defense Health Agency further develop MCPs and evaluate and remove barriers to nurses and other health care professionals participating in MCPs at military treatment facilities.4 The Defense Health Agency must evaluate clinical practice within the Military Health System and align that practice with mission readiness. Failure to do so will perpetuate the peacetime effect of skill atrophy and accelerate the loss of a clinically competent nurse force. The historical peacetime effect, the current challenges of low-volume and low-acuity military treatment facilities, and the ability to meet the future needs of the military rely on the ability to leverage MCPs successfully and further integrate military medical personnel.5 Military-civilian partnerships are crucial for ensuring a ready, reliable medical force.
Acknowledgments
The views expressed are those of the authors and do not necessarily reflect the official policy or position of the Department of the Air Force, the Department of Defense, or the US Government.
References
Footnotes
To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected].
Financial Disclosures
None reported.
See also
To learn more about military nursing care, read “Military Medical Role in Civilian Disaster” by Flarity et al in AACN Advanced Critical Care, 2022;33(4):349–359. https://doi.org/10.4037/aacnacc2022595. Available at www.aacnacconline.org.
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