Outside a dining room in the Longworth House Office Building on Capitol Hill, I asked Congresswoman Karen Bass of California how nursing prepared her for service in Congress. Her response was quick: “Good bedside manner.” But she has had only three terms to hone those skills to propose, advocate, or deliver legislation that impacts the field of her choosing. Not so for Congresswoman Eddie Bernice Johnson of Texas. She is an accomplished nurse, administrator, and legislator covering 23 years in Congress and 60 years as a nurse. I recently visited with them both and gained a fresh perspective on their experiences as nurses in Congress, as well as a candid reflection on the issues currently afflicting our country.
Congresswoman Johnson set her mind on becoming a nurse as a teenager, but in 1952 no nursing program in Texas would accept her, so she applied and was admitted to St. Mary’s College in Notre Dame, Indiana, graduating in 1955. She holds the BS degree in nursing from Texas Christian University, and in 1976, she was awarded the MPA degree from Southern Methodist University. Ten years into her nursing career at Veterans Affairs (VA), she was appointed chief psychiatric nurse at the VA Hospital in Dallas. In 1977, she was appointed regional director of the U.S. Department of Health, Education, and Welfare.
Before her election to Congress, Johnson served as a member of the Texas State House of Representatives from 1972-1977 and a member of the Texas State Senate from 1986-1992. She was elected as a Democrat in 1992 to the 103rd Congress and is in her 12th term representing the 30th Congressional District. In December 2010, she was elected as the first African American and first female ranking member of the House Committee on Science, Space, and Technology, a standing committee of the U.S. House of Representatives. Additionally, she was the first African American female to serve as chairwoman of the Subcommittee on Water Resources and Environment during the 110th and 111th sessions of Congress. Her name is attached to several pieces of legislation. Her office in the Rayburn House Office Building impresses visitors who can clearly see what seniority provides.
The author (left) sharing a copy of Minority Nurse with Congresswoman Eddie Bernice Johnson
James Daniels: Mrs. Johnson, your accomplishments are impressive and even astonishing. Your firsts set you apart as a genuine trailblazer. You are the first woman ever elected to represent Dallas in the U.S. Congress. You are the very first chief psychiatric nurse of Dallas; first African American elected to the Texas House of Representatives from Dallas; first woman in Texas history to lead a major committee of the Texas House of Representatives; first African American appointed regional director of U.S. Department of Health, Education, and Welfare; and the first female African American elected from the Dallas area as a Texas senator since Reconstruction. Your crowning accomplishment, however, is as the first nurse elected to the United States House of Representatives.
Congresswoman Johnson: And I hope I won’t be the last!
Daniels: You are clearly regarded as a pioneer because of all the firsts you have accomplished. What does this mean to you? How do you handle that?
Johnson: I never think about it until someone brings it up. I don’t see it as extraordinary. I see it as opportunities that appeared, and I took advantage of them and was fortunate enough to get elected. It has not been easy because I was the first. As a matter of fact, it has probably been more difficult because of that.
Daniels: What motivated you to enter politics coming from a stellar career in nursing?
Johnson: When I was first approached about running for office, I thought it was a joke. All of the women I spent most of my volunteer time working with were mostly white at that time. The judge that gave Lyndon Johnson the oath of office, Sarah T. Hughes, was the one who pushed it, and along with others, encouraged me. It was the white community that persuaded Stanley Marcus [Chairman of Neiman Marcus] to give me a job because I was working for the government at that time. My African American community had to be brought along because they thought what I was doing was a man’s job.
Daniels: So, you were a pioneer.
Johnson: I guess so! My campaign was run out of my garage and my dining room. Not until I went into a run-off against my opponent did my African American women bring their support. After I won, everyone became my friend.
Daniels: You could not get into any university in Texas to obtain your nursing degree.
Johnson: There was no nursing degree program in Texas [in 1952] with national recognition that I could attend. This was before the University of Texas opened [its doors to black students]. It was before Baylor or Texas Christian opened, so that’s why I went out of state. The colleges [in Texas] were not integrated at that time.
Daniels: Growing up, did your parents influence you to achieve? What role did your parents play?
Johnson: My parents played a very key role, because education was number one for them. They thought it was very important. My grandmother was a teacher and went to Prairie View College. My father finished high school but did not want to go to college. He wanted to be a businessman. I watched them as examples.
Daniels: You’ve been here since 1993. What do you isolate as high points during your tenure?
Johnson: My high point was my first two years. Bill Clinton was president and we [Democrats] had a majority, and I had a chance to work very closely with the president in an environment where we were in the majority and with others who thought just the way we did. It lasted two years. This is my 23rd year and I’ve been in the majority six of those years. What I’ve learned during that time is to keep focused on my work and set the goals of what I was trying to achieve and just keep my attention on that. I have been able to get monies for research, and monies for transportation projects of all kinds. I always saw this as an opportunity to make things better at home. When I look back over my achievements, it feels pretty good.
Daniels: There are six members of the House of Representatives who are nurses. Do you ever find common ground on any legislative issue?
Johnson: Well, some. Four of us are Democrats. Unless I look on the roster, it is hard to tell who are nurses from the Republican side, primarily because they are governed from the top. Many things that we try to do—if they do not get permission to do it they will disappear on you.
Daniels: Some of your nursing background includes time with the VA. What do you think of the state of affairs in the VA?
Johnson: Most of my nursing career was at the VA. It needs great improvement. I didn’t blame the secretary [of VA]. It is that layer of management right under the secretary who has gotten their buddies in these hospitals, and it is fueled by retaliation if anyone complains. Until that is broken we will never get to solve the problems of the VA. People are so afraid if they report something because there is going to be retaliation. It’s a very bad situation.
Daniels: Do you think the president is on top of it?
Johnson: The president is trying. We appropriate enough money for every veteran to get first-class care. Care is not being given to the veterans as this point.
Daniels: Do you think Hillary Clinton is going to be the Democratic Party’s standard bearer?
Johnson: I don’t know, but if Hillary runs I will support her and will give it all I’ve got to see that she becomes president. I’ve known Hillary before she married Bill Clinton, so I know her very well.
Daniels: What’s the whisper regarding who is the likely Republican candidate?
Johnson: I have not seen too many Republican candidates that I liked—and I never thought I’d say this—the one that I liked, compared to the rest of them, was [George W. Bush] I never ever thought I’d say this. He was fun to work with, easy to talk with, he was accessible. He was more accessible than Obama is. Listen, when he called me and told me he would run for governor [of Texas], I said, “You what?” I asked him, “What made you decide to run for office?” He loved to have fun. He loved people. He still loves people. When he was in office he was a people person. I remember I called him to tell him I needed his support on the Water Resources Development bill I sponsored [in 2007]. I told him it’s to make sure there is no flooding of the Trinity River. I said, “Are you going to move back to Dallas when you leave the White House?” He said, “If I can find a house I can afford.” I said, “I just need your address because I want a trench from the Trinity to your front door so you’ll be the first to know when it floods.” But that’s the kind of relationship we had. We have the same relationship now.
About this time in our conversation, Johnson’s director of communications, Yinka Robinson, signaled that Johnson had another engagement. I thanked her for her time and invited her to take some photos with me. As she did, she leaned towards me and said, “I wish I had time to tell you what it was like to be the only black student at St. Mary’s. Perhaps we could do that at some later time.”
Congresswoman Karen Bass grew up with three brothers in the Venice/Fairfax area of Los Angeles and is the only daughter of DeWitt and Wilhelmina Bass. In 1990, she graduated from California State University, Dominguez Hills, with a BS in health sciences and certification as a licensed vocational nurse. She completed the University of Southern California’s Keck School of Medicine Physician Assistant Program, and for nearly a decade, worked as a physician assistant (PA). She also served as a clinical instructor.
Prior to serving in Congress, Bass made history when the California Assembly elected her to be its 67th Speaker, the first African American woman in U.S. history to serve in this powerful state legislative role. Bass serves on the House Committee on Foreign Affairs where she is the ranking member of the Subcommittee on Africa, Global Health, Global Human Rights, and International Organizations. As a member of the House Judiciary Committee, she is also working to craft sound criminal justice reforms as well as protect intellectual property right infringements that threaten the economic health of the 37th Congressional District she represents.
Bass’s office is in the Cannon House Office Building, but she is on her way to a luncheon with the Congressional Black Caucus and pauses to chat with me.
The author (left) interviewing Congresswoman Karen Bass
Daniels: You are the first PA ever elected to the Congress, and the first African American and woman elected as Speaker of any legislature in the United States. Does that give you a sense of pioneering?
Congresswoman Bass: No, it gives me a sense of enormous responsibility. I am happy to step up to that responsibility, but it definitely is a big responsibility.
Daniels: You leaped past nursing to obtain credentials as a PA. Why did you do that, and what drew you to the role of the PA?
Bass: When I was a nurse, the pathway to be a nurse practitioner was very, very long. I was a licensed vocational nurse. The pathway to be a PA was much more direct. And in those years I had originally started out to be a PA. But the PA profession was very new, [so] you had to be another profession first.
Daniels: Looking at your nursing and PA careers, how do they inform you to be an effective legislator?
Bass: Well, you know bedside manner can apply in a lot of different places. [Uproarious laughter.] And bedside manner in the political context is called diplomacy. As a PA, I worked in the emergency room, and when I was a nurse, I worked in acute care—both life and death areas—and that type of responsibility and pressure make this pressure seem a lot easier. It gives me a level of calmness in the midst of crisis that other people might not share.
Daniels: Now there are six nurses in Congress. Do you ever collaborate or find common ground with those on the other side of the isle?
Bass: Yes, as a matter of fact, Diane Black [Tennessee Republican Representative] and I are working on child welfare issues. We are both co-chairs of the Child Welfare Caucus. We know each other! It might not be nursing issues per se that we are working on, but it certainly is human service issues.
Daniels: I like what you just said about equipping you with good bedside manner. Does that say you use a lot of touchy, feely ways to persuade support for legislation you are advocating?
Daniels: Tell us about your work on behalf of the foster care issue in the country.
Bass: It’s one of those issues that bring Republicans and Democrats together. The basic premise is that for kids who do not have families, who don’t have parents, it becomes the responsibility of government to take care of those kids. And we should take care of those kids as we would take care of our own. Those are the values that underlie the work that I do on child welfare.
Daniels: Do you run up against Republicans who believe this is just another government overreach?
Bass: No, no, I don’t at all. Diane Black is a Republican and she is the co-chair of the committee. This is an area where members of Congress come together because most of the members of Congress are parents. When it comes to juvenile dependency, kids who are without parents, people are a lot more open.
Daniels: About your work on behalf of Africa, do you see a movement towards democracy and the establishment of democratic institutions?
Bass: Absolutely. The big issue in Africa right now from the perspective of minority nurses is the reason why the Ebola crisis happened. The health infrastructure in those particular countries was so weak that it got out of control. In countries like Nigeria, where they had a few cases, they were able to bring it under control. I think one of the biggest issues for the continent of Africa right now is making sure its health infrastructure is strong enough so that when an epidemic happens it is not catastrophic.
Daniels: And your hot button issue that you are pursuing in this Congress?
Bass: My hot button issue regarding Africa is trade. There is a trade agreement that we need to have happen, the African Growth and Opportunity Act. In terms of health care, it is to ensure that our health care reforms stay strong.
Do you know the symptoms of post-traumatic stress disorder [PTSD]? Do you know who is at risk? Are men and women at equal risk of developing it?
If you find yourself struggling to answer these questions, consider checking The PTSD Toolkit for Nurses, www.nurseptsdtoolkit.org, a new interactive resource designed by the University of Pennsylvania School of Nursing.
The American Nurses Foundation (ANF) recently announced the launch of the toolkit to help civilian registered nurses better assess and treat PTSD in veterans and military service members.
An estimated half million veterans and military service members suffer from this mental health condition that is triggered by a traumatic event, such as exposure to combat, violence, natural disasters, terrorism and accidents.
According to the U.S. Department of Veterans Affairs website, experts think PTSD occurs:
In about 11-20 percent of Veterans of the Iraq and Afghanistan wars (Operations Iraqi and Enduring Freedom).
In as many as 10 percent of Gulf War (Desert Storm) Veterans.
In about 30 percent of Vietnam Veterans.
PTSD symptoms include angry outburts, trouble sleeping, and other negative changes in thinking and mood, or changes in emotional reactions.
PTSF can affect anyone, and women are at greater risk. Sometimes symptoms are hard to identify. The website provides an e-learning module to build assessment and intervention skills, so nurses can treat and refer military members and veterans for help. It also includes videos and an interactive game to practice your assessment and referral skills.
Nurses are often the first point of contact when veterans and military personnel seek medical help. PTSD can be treated and cured. This toolkit can help you immediately recognizie symptoms, and intervene to help veterans make a successful transition to civilian life.
Robin Farmer is a freelance journalist with a focus on health, business and eduucation. Visit her at www.RobinFarmerWrites.com.
It’s the experience of a lifetime. After you’ve cleared security to enter Fort Bragg in North Carolina and your vehicle has been searched, you are instantaneously awed by the enormity of this army military post. I am on my way to engage two ranking officers—nurses—in conversation regarding health care in the military. The drive takes you on the four-lane All American Expressway with vehicles whizzing by between 55 and 60 miles per hour. As I slow down to take in this sprawling city, I am reminded that I am no longer in the city of Fayetteville that abuts the post.
But the pièce de résistance was the emotional tremor I felt when the Womack Army Medical Center loomed up at the end of a long entrance way to affirm that this was iconic America. This complex, 1.1-million-square-foot (this is not an error) care facility is not just impressive by its bricks and mortar, but is a care facility providing world-class health care across a compendium of general and specialized medical disciplines to our service men and women, veterans, and the families of those who serve on active military duty. To visually take it all in requires a significant swivel of my head.
The purpose of my visit is to gain some measure of understanding and appreciation of this reputable institution and to tell the story to those who will not have the opportunity I had to visit and see for myself. My host is Lieutenant Colonel Angelo D. Moore, Deputy Chief, Center for Nursing Science and Clinical Inquiry, a native of Queens, New York, and graduate of Goldsboro High School in Goldsboro, North Carolina. Moore holds a PhD from UNC Chapel Hill and was the university’s first African American male awarded a doctorate from the School of Nursing. A scholar, clinician, and practitioner with a passion for attacking health care disparities, Moore knows his way around scholarly journals but is just as comfortable applying a Band-Aid to a 5-year-old with a splinter in his thumb. He leads the effort at Fort Bragg to integrate evidence-based practice (EBP) into all aspects of nursing care.
Moore chose Winston-Salem State University for his undergraduate degree because of the seven-to-one ratio of women to men among the student body—a decision he candidly admits worked out for him because that was where he met his wife, Lee Antoinette, a civilian nurse now on the faculty at Fayetteville Technical Community College. He was posted to Fort Bragg last July from Honolulu, where he had been stationed for six months having initiated and led the EBP process.
For the better part of a day, Moore allowed me to engage him in an in-depth conversation on what happens within the walls of this facility that necessitates a tour by a skilled guide to truly appreciate the delivery of military health care services. I was taken through the “miles” of passageways and corridors, to the service malls and the various departments, as well as the skilled nurses training center to witness the nurses being tested on their competencies on a variety of medical and dispensing procedures; the cafeteria to sample military fare; and, eventually, one of the deputy commanders of the medical center, Colonel Kendra Whyatt, who on this day was in charge.
Too often there is a perception that connects questionable treatment of our military service personnel to the assumption that the health care delivered is similarly questionable. Nothing could be further from the truth. In my conversation with Colonel Whyatt, she very carefully called my attention to the signature difference between a military nurse and a civilian nurse that is invaluable in understanding the dynamism of military health care.
“Military nurses,” Whyatt says, “wear inseparably and simultaneously the role of the soldier and the role of the nurse, and they are expected to provide care for their fellow soldiers and protection for them if necessary, and certainly for themselves at the same level of competence.”
It is this dichotomy—the syringe and the gun—that guides my desire to understand how care is delivered by our nurse soldiers to a military population of 57,000 at Fort Bragg, of which 45,000 are active duty members.
What we know today as Fort Bragg came into effect in September 1922, but its history is attached to a Confederate general, Braxton Bragg, a native of North Carolina. The post occupies 127,000 acres; its population makes it the largest US Army base; and it is the home of the Airborne—the 82nd Airborne Division, referred to as “All-American” because its members represent 48 states. It is also the home of the distinguished Special Operations Force. Among its many amenities are its schools—preschool through high school for nearly 5,000 students, the children of soldiers on active duty.
Womack Army Medical Center opened its doors on March 9, 2000. The center is named for Private First Class Bryant H. Womack, a North Carolina native who was posthumously awarded the Medal of Honor for conspicuous gallantry during the Korean conflict. The center’s mission is succinctly stated: Provide the highest quality care, maximize the medical deployability of the force, ensure the readiness of Womack personnel, and sustain exceptional education and training programs.
The center is 1,020,359 square feet, encompassing six-floor towers and other buildings. It sits on a 163-acre site, has a 153-bed inpatient capacity, and serves the more than 225,000 eligible beneficiaries in the region. It is the largest beneficiary population in the Army.
The building has a state-of-the-art design: The inpatient tower floors have an interstitial space between each floor that allows computers, as well as other technical components, to be repaired without interrupting patient care. The complex is designed to transform many of the administrative areas into service areas providing care if necessary, which would double their inpatient treatment capacity.
Four patient-centered medical homes are located on Fort Bragg, and two community center medical homes are located in the surrounding military community where their beneficiaries live and work. The Womack Army Medical Center was among the first health care providers in the country to seize on the benefits, design, and purpose of the medical home in 2004. The military’s ability to make the medical home work for their patients rests on their enormous electronic records capacity, making it easier for them to implement the benefits from the Electronic Health Records (EHR) system that gives providers worldwide access to comprehensive and timely patient histories. The $1.2 billion medical records system began deployment that year across the entire force and was fully operational by 2007, just as the benefits and necessity of the EHR were dawning on the civilian medical community.
The medical home is best described as a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. It is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the simplest to the most complex medical conditions.
But there is also the Soldier Centered Medical Home (SCMH). This is a care process with an exclusive and unique focus: the soldier. It includes behavioral health, physical health, and nutrition services; these are significant to soldiers who may be displaying the symptoms of Post-Traumatic Stress Disorder (PTSD). Everyone is screened using a predetermined questionnaire and an initial evaluation that determines whether the soldier is a prime candidate for treatment or follow-up. The Army’s official position is that “80% of all soldier complaints at sick-call are muscular-skeletal,” according to physician Colonel Dallas Homas, the former commander of the Madigan Army Medical Center in Tacoma, Washington, and the originator of the SCMH that became operational in November 2011. The concept grew out of an incident where an exceptional noncommissioned officer lost his knee unnecessarily, according to Homas.
Diagnosis and treatment of PTSD, however, continues to be a contentious issue within the military sector and might have led to Homas’s reassignment from Madigan Army Medical Center. Colonel Ramona Fiorey, a nurse, assumed command of Madigan on August 9, 2013. The Department of Veterans Affairs (VA) has reported that for the last two years PTSD diagnoses are just shy of 30% of the 800,000-plus Iraq and Afghanistan War veterans treated at VA hospitals and clinics.
It is during my conversation with Moore that a picture emerges of how the soldier-nurse threads her way through the system to attain the highest heights of a nursing career. One thing they do have is the role models to motivate them to succeed. You see, the Surgeon General of the US Army is also the Commanding General of the US Army Medical Command. Currently, that person is Lieutenant General Patricia Horoho. She is a nurse. Whyatt, one of Womack’s deputy commanders, is also a nurse. Nurses provide the leadership at the highest level and at base level. This is without precedent, and the profession does take notice.
Horoho has already made significant changes regarding military health care by her emphasis on what she calls, “life space.” She wants providers to address those periods when military personnel are away from a care facility with emphasis on ensuring they are engaged in healthy behavior.
Horoho’s leadership centers around the Army Nurse Corps’ five-point strategy, known as the Patient CaringTouch System or—with the military’s characteristic use of acronyms—PCTS. It has five components: enhanced communication, capability building, evidence-based practices, healthy work environments, and patient advocacy. The PCTS is a patient-centered model for nursing care that was developed to reduce clinical quality variance by adopting a set of internally and externally validated best practices. Additionally, it is an enabler of Army medicine’s culture of trust initiative and the transition from a health care system to a system of health. The plan is elaborately laid out in a campaign document intended to guide the care leadership through 2020, with emphasis on evidence-based decisions, metrics, and best practices that cannot be overemphasized.
As you might expect, the Army takes the issue of leadership very seriously. Army nursing is guided by an Army Nursing Leader Capabilities Map that encompasses a thirty-year journey, and Moore is a good example of how the process has guided his own career. A nurse’s development has three segments, and the progression is tied to seven performance criteria. The three segments are tactical skills, operational and organizational skills, and strategic thinking and execution. The nurse can move along a career path in what is called “duty positions,” beginning as a staff or charge nurse and rising in rank to a section or department chief and then deputy commander for nursing.
During this progression, the Army nurse develops competency in such areas as change and people management, succession planning, and foundation thinking, where he or she is expected to demonstrate unit-level, evidence-based decision making. At this level, “the PhD or the DNP enables and equips a nurse to engage in visionary and strategic thinking,” explains Moore. “After ten years in the military, nurses overwhelmingly have acquired the master’s degree, and this is a distinguishing factor in military nursing culture.”
Lieutenant Colonel Moore (never addressed as “Dr. Moore” but exclusively by his rank, as is the pattern within the military regardless of credentials) actually wanted to be a dentist, but financing that career seemed to be out of reach. He heard about the Army College Fund, so he enlisted in 1989. He was placed in the communications section, but had a strong desire to transfer to the medical field. He was working to complete his associate’s degree at night and heard from a friend about the Army’s Green to Gold program in which, if selected, he could progress over time from an enlistee to an officer. He completed the degree and applied, was accepted, and enrolled in the nursing degree program at Winston-Salem State University, graduating with the BSN in 1995.
As an active duty nurse, Moore’s assignment took him to the Eisenhower Army Medical Center in Georgia as a medical/surgical nurse; later, he chose to be certified as a critical care nurse upon completion of a four-month training program. Moore tells me that this is the normal developmental pattern allowing nurses to be associated with a particular specialty of their choosing.
As a male nurse in the 1990s, Moore was not an oddity because the requirements of war had always allowed the Army to attract males to the military nursing profession. Medics were trained to provide treatment to fellow soldiers on the battlefield, so the transition to formal training to administer generalized or specialized care was natural for many. Today, males’ 30% representation in Army nursing is six times higher than in the civilian nursing population.
“Male nurses,” Moore says, “are usually more prevalent in the areas that are ‘action-packed,’ such as trauma, or the highly technical areas where elaborate technical components are integrated into the patient’s care and in emergency room nursing.”
After several years of praying “Please, Lord, do not let any of my ICU patients die on my shift,” Moore wanted a change out of critical care and chose to work in primary care to reduce the prospect of patients needing critical care in the first place. He applied to the Army’s long-term education and training program and was accepted into the master’s program to become a nurse practitioner.
His next assignment was his appointment in 2007 as a recruiting commander stationed in Brooklyn, New York, with centers in Albany, New York, and New Jersey. Moore and his team of recruiters focused on enticing doctors, dentists, and nurses into the Army as officers by being visible at medical conferences and health forums where these professionals were present. The recruiters championed the experience, benefits, and research engagements that a recent MD graduate, for example, would never get in a hospital or private practice in his or her civilian role. They also targeted students considering careers in the medical profession.
Moore responds to my question regarding minority recruitment within the Army by explaining that there is no program designed to recruit minorities into the health care ranks as a targeted group.
“To the best of my knowledge, we do not look at race in our recruiting efforts,” says Moore. “We make appealing what the Army has to offer and allow the prospect to decide. Because of the culture of the Army, we encourage the prospective recruit to consider carefully the choice of military service.”
There is a well-known, generalized concern, however, about the low minority representation among the officer ranks in the military, which has attracted the attention of the top brass. So it came as no surprise when in March 2011 the Military Leadership Diversity Commission issued a report that included the state of diversity among the leadership ranks of the military.
“The disparity between the numbers of racial and ethnic minorities in the military and their leaders will become starkly obvious without the successful recruitment, promotion, and retention of racial/ethnic minorities among the enlisted force,” the report states. “Without sustained attention, this problem will only become more acute as the … makeup of the United States continues to change.” It’s similar to the state of private sector organizations.
Whether the Army does or does not have a minority recruitment strategy, the fact is that officer and leader representation will not improve unless there is a deliberate pipeline strategy leading from enlistee to officer. However, as I walked the hallways and visited the patient treatment locations at Womack, those at work and those receiving care looked very much like America.
With Moore accompanying me as I toured the facility past the many labs, the enormous back-office function, work stations, administrative functions, physical therapy service areas, and clinical specialties of every description along the long and seemingly interminable walkways, he added to my attempt to grasp the magnitude of what takes place at Womack as a matter of routine, by citing some impressive statistics. While doing so, he emphasized that the active military and the Veterans Healthcare Services are decidedly not affected by the provisions of the Affordable Care Act (ACA).
“There is one provision, however, where we see eye-to-eye with the ACA, and that is in the aspect of prevention as opposed to curative or disease care, because a healthy lifestyle is central to mission readiness,” explains Moore. “The three streams that drive mission readiness within the healthy life space triad are activity, nutrition, and sleep—and we are confident there will be a pay-off down the road.”
In fiscal year 2013, the Womack Army Medical Center had over 12,000 admissions with a 62% average daily bed occupancy rate and average length of stay of 2.6 days, over 3,000 live births, and over one million outpatient appointments. On a daily average, the associated clinics provided over 3,400 outpatient visits, approximately 6,000 outpatient prescriptions, almost 1,000 radiological exams, over 4,000 pathological tests, almost 200 Emergency Department visits, almost 40 surgeries, and at least eight live births. There are two medical residencies (family practice and obstetrics), and 14 other physician or Allied Health educational and training programs. Moore points out that no prosthetic service is provided to the injured soldiers at this facility. He reminds me that the health care staff consists of active duty members, Department of Defense civilians, and contractors who include civilian physicians and nurses. It is easy to identify the civilian medical staff because they are listed on appointment boards by their medical credentials; whereas, the active duty medical staff are listed by their rank, often on the same appointment boards.
Moore guides me along a walkway with photographs of distinguished service members and towards the skilled nursing center where competency tests are taking place. This is a biannual event where nurses are tested and certified to perform certain medical procedures. Womack nurses are required to expose themselves to this process if they are to be allowed to perform certain procedures. It is proctored by senior nurses and other technical staff. My visit to the center as this event was taking place was purely coincidental.
In a room deep inside the complex, nurses were examined on performing catheterizations on a mannequin (part of the infusion therapy procedure) and on their ability to know the difference when it is a pediatric patient compared to an adult; reading and interpreting the ECG tape—a necessary step before referring it to a cardiologist; identifying mental health behavioral issues such as PTSD; and using newly introduced, technologically sophisticated equipment. There are charts and poster boards everywhere. The atmosphere is intensely business-like, presided over by a nurse with the rank of major and dressed in fatigues. Even the test mannequin appears to be aware of the buzz over the event’s significance.
Next, Moore takes me to the pharmacy services mall, which is where the patients have their prescriptions filled. Every aspect of this procedure is very clearly understood as between 25 and 30 patients wait for either a consultation with a pharmacist or watch to see that their prescription is ready. The first served are those requiring immediate and preferential attention: the active duty soldiers. He or she registers as they all do, and the patient’s name lights up on a marquee pallet as an indication that the prescription is ready. The active duty member’s name will supersede all others.
Finally, our walk heads towards the command center where Moore has arranged for me to visit with Colonel Whyatt, Deputy Commander for Nursing and Patient Services, who is acting commander today because Commander Colonel Steven J. Brewster is off the post. This is Whyatt’s first assignment to Fort Bragg. After being cleared to enter the command center, I am seated in what is quite easily comparable to an executive suite in any corporate headquarters. The offices are bright and cheerfully wood-paneled, with each executive officer’s support staff seated within earshot of their work stations. One is dressed in fatigues, as is Colonel Whyatt. She is tall, relaxed, and with a distinctive military bearing that suggests a calm, in-control demeanor. She is a native of Greenwood, Mississippi, and was previously stationed at a military facility in Germany.
With my discussion about minority recruiting still turning over in my mind, I wanted to know her opinion regarding mentoring and coaching. But first she has to be reassured by Moore that I have been cleared to have this conversation with her.
I first want to know what makes for a successful and responsive military health system. “It’s the combination of the military, civilians, and contractors working together,” Whyatt responds.
“What are the two top concerns that occupy your attention?”
Whyatt responds succinctly: “[To stay in mission readiness], I have to recruit staff, retain and train staff, and we are facing challenges in this area; in particular, in the recruiting and retention of staff. Most everyone knows that certain funding is at a standstill.”
“Do you mean the sequester?”
But a majority of hospital executives believe there is a shortage of physicians and nurses in the US, according to a new survey from American Mobile Nurses Healthcare, a staffing company that recently published its 2013 Clinical Workforce Survey. It found that 78% of hospital execs think there is a shortage of physicians; 66% say there is a shortage of nurses; and 50% report there is a shortage of advanced practitioners. The survey also found that the vacancy rate for physicians in hospitals is nearly 18%, compared to 10.7% in 2009, and nearly 17% for nurses, up from only 5.5% in 2009. The vacancy rate also rose for allied professions, from 4.6% in 2009 to 13.3% in 2013. But Womack is currently under a staff freeze, and the civilian workforce is expected to be reduced sometime during 2014.
Colonel Whyatt owes her military career to her mother. At the end of Whyatt’s sophomore year at Prairie View A & M University, her mother strongly suggested that instead of coming home and looking for a summer job, she visit with the ROTC office on campus and see what they could do for her. Whyatt visited the office, enlisted, and went on to complete her undergraduate degree in nursing with a scholarship from the Army. Her career has taken her to three tours of duty to Germany and several Army posts within the US.
“Are you mentoring and coaching any on active duty at this time?” I ask.
“That is an expectation of this position. Yes, I am,” she responds.
According to the U.S. Department of Veterans Affairs (VA), approximately 20% of our nation’s 23.5 million veterans are people of color. Like other racial and ethnic minority populations, minority veterans face a variety of unique health care challenges, ranging from chronic disease disparities and high levels of post-traumatic stress disorder (PTSD) to difficulties in accessing medical treatment.
Testifying before the House Committee on Veterans Affairs in July 2007, Lucretia McClenney, MSN, RN, director of the VA’s Center for Minority Veterans (CMV), noted that “in many instances, any challenges that minority veterans encounter as they seek services from VA are magnified by the adverse conditions in their local communities. These challenges may include [lack of] access to VA medical facilities (especially for American Indians, Alaska Natives, Pacific Islanders and other veterans residing in rural, remote or urban areas), disparities in health care centered on diseases and illnesses that disproportionately affect minorities, homelessness, unemployment, lack of clear understanding of VA claims processing and benefit programs, limited medical research and limited statistical data relating to minority veterans.”
The CMV’s mission is to identify barriers to service and health care access, increase local awareness of minority veteran-related issues and improve minority participation in existing VA benefit programs. As a result, VA medical facilities throughout the country are implementing strategies to provide veterans of color with more accessible, culturally sensitive care. Each VA health care facility has a Minority Veterans Program Coordinator (MVPC) who serves as a liaison and advocate for minority patients. And VA health care professionals are taking the lead in developing innovative solutions for closing the gap of health disparities, from outreach programs designed to increase minority veterans’ use of services to diversity training programs aimed at increasing staff members’ understanding of patients’ cultural needs.
Not surprisingly, nurses are playing key roles in these efforts. Here’s a look at how individual nurses are working to improve health outcomes for minority veterans, one program at a time.
Native American Outreach
Bruce Kafer, MSN, RN, is a member of the Oglala Sioux (Lakota) Tribe that resides on the Pine Ridge Indian Reservation in South Dakota. Adopted as an infant by white parents, he grew up with virtually no knowledge of his tribal culture. After tracking down his birth mother in 2000, he began to learn about his lost Indian heritage from his Tiospaye (Lakota extended family) and tribal elders. Now, as American Indian/Latino Outreach Coordinator at the Louis Stokes Cleveland (Ohio) Department of Veterans Affairs Medical Center, Kafer is drawing on his rediscovered heritage to provide culturally sensitive healing to Indian vets.
The Changing Face of Minority Veterans When you hear the term “minority veteran,” what image comes to mind? First of all, it would probably be a person of color. The person you visualize is also likely to be male, and perhaps even an older man who fought for his country in a historic conflict like World War II or the Vietnam War. But in recent years, the traditional profile of minority veterans has begun to expand and evolve. Patients from other types of underrepresented populations are becoming a growing presence in the VA health care system, bringing with them a whole new set of unique health challenges and needs. While women may not be a group that comes to mind under the “minority” heading, female veterans are definitely a minority within the VA system, says Jacinda Beug, BSN, RN, who works in the Women’s Health Program at the Southern Arizona VA Health Care System in Tucson. The program, along with its outlying clinics, treats about 5,500 women annually, providing primary care, prenatal care, gynecological and obstetrician services. Many of these patients are veterans of Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF). In 2003, says Beug, 6% of America’s 23.5 million veterans were women. Today that figure is 7.4% and is expected to climb to 8.7% by 2013. “We were noticing that [within the overall population of veterans coming back from Iraq and Afghanistan], women had their own specific concerns and needs,” says Norma Hernandez, RN, manager of the medical center’s OEF/OIF Transition Program. These special concerns include mental health issues, post traumatic stress disorder (PTSD) and sexual trauma. The Women’s Health Program focuses on providing gender-specific care, and it has an all-female staff—including doctors, nurses, receptionists, clerks and dietitians—to make the patients feel more comfortable, says Beug. Another new “minority” group to surface within the VA is the young veteran. “[Because of OEF/OIF], many younger veterans are coming into the system. We’re treating age groups ranging from 17 and 18 up to 90,” Beug says. Hernandez agrees that the younger patient population within the VA medical system has become a minority group with its own set of specialized needs. The VA is used to serving older veterans, she explains, and is now having to adapt to these younger vets’ needs and develop different treatment modalities to meet them. This is an example of how the VA is constantly evolving, creating new programs and services as specific needs arise, Hernandez adds. For awhile, the special needs of Vietnam veterans were the catalyst for new programs. But now OEF/OIF is bringing in a new special-needs population of combat veterans. The percentage of OEF/OIF veterans in the VA system right now is less than 5%, says Hernandez, but that figure is misleading. Military personnel serving in OEF/OIF are predominantly reservists and National Guard troops who bounce between two different roles. They are activated, come home, are discharged into the VA system, but then can be reactivated back to active duty. “That creates a variety of issues and concerns we need to keep abreast of,” she says. “Their situation keeps fluctuating. It used to be you did active duty, were discharged and then became a veteran.” The unique combat injuries suffered by OEF/OIF veterans, such as those caused by improvised explosive devices (IEDs), are also creating a whole new set of challenges for VA nurses, says Dianne Lethaby, RN, CRRN, Polytrauma Nurse Case Manager at Southern Arizona VA’s Polytrauma Network Site. The site is one of 21 facilities in the nation designed to provide long-term rehabilitative care to veterans who experience severe injuries, including traumatic brain injury, hearing loss, amputations, fractures, burns and visual impairment. The Tucson Polytrauma Network Site, which treats about 320 veterans from Arizona, Texas and Colorado, operates clinics that give patients access to a medical provider, social worker, speech/language pathologist and psychologist, all in one visit. If time permits, the clinics will try to fit in sessions with physical and occupational therapists. “Essentially, [the younger veterans] want to get back and get on with their lives. They’re young and have families to support,” Lethaby says. “It’s been a challenge getting them into the system.”
Kafer, who works with Native veterans both in Cleveland and in Arizona, is also a PhD student at Case Western Reserve University in Cleveland, where he is conducting research with Indian vets to add to the limited body of knowledge available about this population. Through his research, he has discovered some compelling statistics about Native Americans who have fought for their country. During World War II, for example, 40% of the Cheyenne Nation volunteered service to the U.S. military. During the Vietnam War, 90% of eligible Cheyenne volunteered for duty, with the overwhelming majority serving in combat areas. Yet despite this long-standing history of service, Native Americans have historically underutilized VA services, Kafer says.
“Part of my role,” he adds, “is to help bridge that gap and make services more accessible.” To accomplish this, Kafer does outreach to the American Indian community, participating in powwows and other cultural events, visiting reservations in remote locations and working with Native veterans and elders from a variety of tribes to develop culturally appropriate programs.
There are about 562 federally recognized Indian tribes in this country and 365 state-recognized tribes, each with their own unique cultural traditions and, in many cases, their own indigenous languages. Therefore, VA nurses who work with Native veterans often find themselves treating a patient population that is not homogeneous but highly diverse—a concept Kafer calls “diversity within diversity.” Still, he says, while culture and language may differ from tribe to tribe, there are some basic beliefs about health, illness, healing and spirituality that are common to all Native people.
“In traditional Native American culture, health and healing begin first in the spirit, then the mind, then in the body,” he explains. “In the Western model of health care, it’s an opposite paradigm—health and disease begin first in the body, then in the mind, last in the spirit.”
Kafer won an award from the Society of American Indian Government Employees (SAIGE) for a VA diversity training video he helped produce, called “Native America: Diversity Within Diversity.” Created as part of the VA’s R.E.A.C.H. for Diversity program, the video has been distributed to all VA medical centers nationwide to increase employees’ understanding of the unique challenges Indian veterans face.
“Native America resonates with me and my history,” Kafer says. “I’m in a unique position to contribute to improving health care for Native American veterans because I understand about bureaucracy, government and the various phenomena that can impact tribal access to health care.”
Kafer is also involved in another innovative diversity training project, the Gathering of Healers program at the Southern Arizona VA Health Care System in Tucson. The program brings the facility’s staff together with Native veterans and elders to learn more about American Indian culture and how to provide culturally competent care.
“Staff come back from the Gathering of Healers and are more aware of the special needs of this [population],” says Yvonne Garcia, BSN, RN, the facility’s American Indian Nursing Case Manager. “They learn to treat people with cultural humility. They want to know more about them instead of making assumptions.”
Garcia, who is part Mandan Indian, also works with the Indian Health Service to complement services delivered to Native veterans.
Researching Health Disparities
Carol Baldwin, PhD, RN, CHTP, CT, AHN-BC, associate professor and director of the Office of International Health, Scientific and Educational Affairs at Arizona State University College of Nursing and Healthcare Innovation in Phoenix, is a nurse researcher who has focused some of her recent work on studying chronic disease disparities in Mexican American veterans, a population about whom very little health information is available. She led one study which found that, compared to non-Hispanic white veterans, Mexican American veterans were significantly more likely to have diagnosed type 2 diabetes and that having a high body mass index (BMI) put them at greater risk of developing the disease.
More recently, Baldwin published a study in the September 2007 issue of the Journal of Nursing Scholarship that compared homocysteine levels and other stroke risk factors between Mexican American and Caucasian male veterans. High homocysteine levels in the blood have been associated with increased risk of cardiovascular diseases, such as coronary heart disease and stroke.
Baldwin conducted her research in Tucson at the Southern Arizona VA Health Care System’s Minority Vascular Center. She found that Mexican Americans have higher homocysteine levels regardless of whether they scored a high or low risk for stroke. She also determined that the Framingham Stroke Profile, a commonly used stroke risk assessment tool, was derived for a predominantly Caucasian population and does not necessarily provide relevant stroke risk factors for people of other races and ethnicities.
Baldwin says her findings suggest that Mexican American veterans, like other minority populations, face barriers to stroke prevention and therapy, including lower income and education, as well as dietary, genetic and environmental factors.
There has also been very little research conducted on the health care needs of Puerto Rican veterans, says Constance Uphold, PhD, ARNP-BC, FAAN, a research health scientist with the Rehabilitation Outcomes Research Center at the North Florida/South Georgia Veterans Health System in Gainesville. Her current work focuses primarily on the health challenges experienced by Puerto Rico veterans returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF).
In one study, Uphold—who has a master’s degree in transcultural nursing and a doctoral degree in family health nursing—examined mental health issues affecting Hispanic veterans and their caregivers and families. She documented stressors from each group’s perspective, as well as successful coping models. Based on her findings, Uphold and her colleagues developed 12 culturally competent fact sheets for veterans, family members and clinicians. These educational materials are tailored to Puerto Rican veterans, complete with colors and symbols from the Puerto Rican flag. She’s now working to secure funding to reproduce and disseminate the fact sheets.
This past February, Uphold became a co-investigator of a grant that will research stroke interventions and family caregiving for Hispanic veterans, as well as how to disseminate stroke prevention information to this population. The Spanish-language information will be posted on MyHealtheVet.com, an interactive Web site that encourages veterans to take charge of their own health.
Promoting Health Literacy
Teaching minority veterans with chronic diseases how to self-manage their conditions is also a priority for Jawel Lemons, RN, MS, FNP-C, associate director of Patient Nursing Services at the Charlie Norwood VA Medical Center in Augusta, Georgia. Lemons remembers watching her own father struggle with his health. The man who raised her had a third-grade education and couldn’t read the directions printed on his medicine bottles.
“I thought, ‘If he wasn’t living with me, what would he do?’” she says. “That’s when I came up with the idea for the labels.”
The “labels” in question were part of a highly successful health literacy program Lemons created and implemented at the Dallas VA Medical Center in Texas before transferring to her current position in Augusta last year. As a cardiology nurse practitioner in the medical center’s congestive heart failure clinic, she often received referrals from primary care providers for patients who appeared to be noncompliant with their medications. Assessing the situation, Lemons discovered that the real reason why the veterans weren’t taking their medicine was that they had low literacy levels and couldn’t understand the instructions printed on their prescription labels.
So she designed a protocol for teaching her low-literacy patients how to take their medications correctly, using pictures instead of words. She found colorful, easy-to-understand computer clip art symbols, copied them onto adhesive labels and stuck them on the patients’ medicine bottles. For example, a rooster pictured with a sunrise symbolized a morning medication, while a bed indicated a nighttime medication. Lemons also transferred the same symbols to the patients’ pill boxes. As a result, the patients’ health improved dramatically.
VA Travel Nurse Corps
Her current goal is to establish special needs clinics across the VA system, with physician consults on site and nurses who are trained to make sure medications are properly labeled. She also hopes the concept of using picture labels will catch on with pharmacies.
Another way Lemons is empowering minority veterans to take control of their health is by providing them with culturally relevant dietary guidelines. “A lot of our [patient education] information is geared toward the average [majority] American, but there’s not much on the different cultures,” she notes.
Suggested menus for a low-salt diet, for example, are usually designed with Caucasian patients in mind and don’t always address the foods that African American or Hispanic patients may include in their regular diets. Lemons provides her patients with the general list of approved foods, but she also offers additional food lists that take into account a patient’s particular culture.
This is another example of how minority patients can be labeled as “noncompliant” when the real problem is that they simply could not overcome cultural barriers to their care, Lemons emphasizes. “If they don’t understand how to eat and take their medicine, they’re not in control of their ailment,” she says. “It really impacts the cost of health care when you have people who end up in the hospital over and over because they just don’t understand what they’re supposed to do.”
One of the Department of Veterans Affairs’ newest initiatives for increasing minority veterans’ access to culturally sensitive nursing care is the VA Travel Nurse Corps (TNC). Designed for RNs who prefer the flexibility and adventure of travel nursing, this program will establish an internal pool of nurses who can be available for temporary, short-term assignments at VA medical centers throughout the country. The TNC deployed its first nurse in December 2007.
Jacqueline E. Jackson, RN, MS, MBA, director of the TNC, says the new program is actively recruiting nurses from culturally diverse backgrounds. “[Minority] VA nurses bring not only cultural competence but respect and acceptance to the many culturally diverse patients under VA care,” she explains. “Nurses in the VA Travel Nurse Corps have an opportunity to travel the country working with a diverse VA patient population and a diverse VA workforce.”
For more information about the VA Travel Nurse Corps, visit www.travelnurse.va.gov.
Who Are Today’s Veterans?
Estimated U.S. Veterans Population: 23,532,000
Number of Total Enrollees in VA Health Care System (FY 2006): 7,900,000
Veteran Population by Race:
White Non-Hispanic 80%
Black Non-Hispanic 11%
Veteran Population by Gender:
Percentage of Veteran Population Age 65 or Older: 39%
Source: Department of Veterans Affairs, October 25, 2007
For Native American nurses, many of their stories have been lost to the past. Scholars have generally paid scant attention to the lives and deeds of rural minority women, and few articles have been written about the early education of Native American nurses and their contributions to health care. The people of the Catawba Indian Nation use storytelling to keep their culture and the memory of their heroes alive. Consider this one such story, one such hero.
The Sage Memorial Hospital School of Nursing, known simply as “Sage Memorial,” operated from 1930–1953. It was the only nursing school ever opened for the sole purpose of educating Native American women as nurses.1 One of these nurses was Viola Elizabeth Garcia, a graduate of the Class of 1943.2 Viola’s life illuminates the struggles for education common among the women who attended Sage Memorial. Her contributions and experiences as a World War II nurse demonstrate the hardships encountered and outstanding contributions made by many of her fellow alumna.
By law and custom, most nursing schools were segregated by race before the passing of the Civil Rights laws of the 1960s. From the 1880s through the 1960s, most schools of nursing were comprised of either all white or all African American student bodies, leaving few opportunities for Native Americans, Asian Americans, or Hispanic Americans to obtain a nursing education.
The Board of National Missions of the Presbyterian Church was unique in its efforts to address this inequality. In 1901, the National Presbyterian Church opened the Ganado Mission on Navajo Nation land, in the northeast quadrant of Arizona, near the New Mexico, Colorado, and Utah borders, in the community of Ganado.
After a church and school were successfully operating at the Mission, the home missionaries turned their attention to health care.3 In 1929, Dr. Clarence Salsbury and his wife, Nurse Cora Salsbury, took over the mission work at Ganado. One of their first priorities was expanding the antiquated 12-bed hospital into a modern facility of 150 beds, an operating suite, a delivery suite, and a laboratory. This new hospital was named Sage Memorial Hospital after one of its largest benefactors and was accredited by the American College of Surgeons.
In order to staff the hospital with nurses, as well as to provide skilled employment opportunities for Native American women, the Salsburys opened Sage Memorial Hospital School of Nursing in 1930.4
The school opened while naysayers proclaimed no Native American woman would ever be up to the academic task of completing a Nightingale-based nursing education program. They also claimed these women, given their culture, would not be willing to interact with the sick or dying. Sage Memorial graduates proved these assumptions wrong.
Dr. Salsbury felt training Native American nurses was crucial. “They would be able to understand the patients as no white personnel ever could,” he said.1 Sage Memorial started small, with an entering class of two Navajo women: Adele Slivers and Ruth Henderson. They both graduated three years later and passed the Arizona State Board of Nursing Examinations. Their graduation exercises in 1933 were a festive event with scripture readings, vocal duets, a piano solo, and a pinning ceremony. Dignitaries including the Arizona governor, an Arizona State Board of Nursing member, and one of the chief Navajo medicine men praised the graduates and the school during the proceedings.3
As word and reputation of the school expanded among minority communities, the student body increased in number and diversity. By 1943, students from 28 tribes, including the Navajo, Kiowa, and Catawba; students who identified as Eskimo, Hawaiian, Spanish American, Cuban, and Mexican; and one Japanese student from a relocation camp were either enrolled or graduates of Sage Memorial.6 By all accounts, this unique experiment in multicultural education was a success.
In the 1930s and 1940s, such training and cultural exchange among Native Americans and other minority women was not found anywhere else in the United States. The nurses developed a camaraderie and commitment to their work that consistently earned them the highest marks on state licensing exams. The students lived in interracial cooperation while learning the nursing arts and sciences. The school’s stellar reputation drew the attention of white applicants—who were denied consideration because they had access to many other schools of nursing.1
Viola Elizabeth Garcia
Viola Elizabeth Garcia was born on April 12, 1919, in Sanford, Colorado, a poor, rural Mormon community home to approximately half the members of the Catawba Nation. Viola’s family was financially impoverished, but rich in family and culture. The older brothers, George and Labon, left school after completing the fourth and fifth grade to help their ailing father support the large family. Viola’s father was ill for much of her young life and died when Viola was only 11 years old, leaving behind 10 children for his wife to support.
Viola completed the ninth grade in Sanford, but due to the Great Depression, the public high school was closed. For the next three years, Viola tried desperately to complete her high school education by repeatedly applying for admission to the Bureau of Indian Affairs Haskell Boarding School in Lawrence, Kansas. Finally, she was admitted at 18 years old and completed her high school diploma in 1940 at the age of 21. Viola’s classes focused on cooking skills, sewing, home care, and arts. As graduation neared, she was offered full-time employment as a cook’s assistant on the Apache reservation in New Mexico, but Viola was determined to continue her education.2
With the guidance of the staff at Haskell Boarding School, Viola applied to several nursing programs but was only admitted to Sage Memorial. One such rejection stated that she was too old at 21 years of age to begin the nursing program. There was also a concern, as World War II loomed and U.S.-Japan relations became strained, that her Native American features would appear Japanese and frighten patients.6
The head mistress of Haskell wrote in a reference letter about Viola, “Whatever Viola decides to do, she does.” Several months after Viola enrolled at Sage Memorial, Dr. Salsbury personally wrote the Haskell headmistress asking if she had any other students like Viola, and if so, to please send them to his school.6
Studying at Sage Memorial
Applicants to Sage Memorial had to be unmarried high school graduates between 18–30 years of age. Their applications had to be accompanied by a health certificate, as well as four character references, with one being their pastor. Tuition was $100 for the first year with additional fees of $1 for laboratory courses, $0.50 for library use, and $3.50 for health fees. The hospital provided room, board, and laundry services. In addition to their course work, students tended the hospital floors eight hours a day, six days a week. However, students had time to relax outside of their rigorous classroom and clinical schedules, enjoying picnics, parties, movies, and glee club, as well as mandatory gym class and chapel.4
Although Viola was accepted to Sage Memorial, she was not sure that she could afford the tuition, fees, and living expenses. As the months progressed, Dr. Salsbury procured the funds to pay for all her education expenses except for personal items she needed to bring with her.6 According the 1940 catalog, all students had to supply for themselves the following: a bag for soiled clothing, rubbers or galoshes, toiletries, two fountain pens (one for red ink and one for blue), a watch with a second hand, an alarm clock, two standard-size loose-leaf notebooks, a napkin ring, and coat hangers.4 Viola’s eldest brother, George, gave her an entire month’s wages so she could buy the required watch with the second hand sweep. With her determination and supplies in tow, Viola began her three-year long education at Sage Memorial.6
Over the next three years, Viola and her fellow students not only studied the nursing curriculum but also spent many clinical hours on the hospital floors. They made and rolled their own patient bandages and folded disposable patient trash bags and slippers out of newspapers. Third-year students were expected to help teach the lower-level nursing students. Viola not only learned the nursing skills that she would use throughout her life, but she developed a deep devotion and admiration for the Navajo people. She even taught herself to speak Dine, the Navajo language.6
A nurse in practice
Though Viola grew up in the rural, remote, and poor town of Sanford, she was surprised to learn that her new community at Ganado was even more so. Patients were brought to the hospital on horseback and buckboard wagons, and sometimes by rattling old vehicles over rutted and narrow dirt roads. Many roads were so rough and rocky that they were impassable in wet and winter weather. The nursing students were expected to go on home visits with the nursing staff to the homes of the Navajo people, traditional dwellings known as hogans.7 They made these visits in buckboard wagons. Viola would write back to her mentor at Haskell Board School that these hogans were “loving and cozy homes.”6
Viola viewed success as the ability to provide for herself, and she felt her education was essential to achieving that level of self-reliance. Viola studied hard and was the 1943 class valedictorian. She was awarded a set of surgical instruments for her academic success.
In 1943 Viola took her Arizona nursing boards and returned home to Colorado to await the results. She had been worried because she did not have an additional $75 to retake the nursing board examination if she failed. One day a letter arrived addressed to Viola Garcia, R.N., and she knew she had passed. In fact, Viola received the highest test score in the entire state of Arizona. Viola’s academic and nursing success, however, was common among the students who graduated from Sage Memorial.
World War II
Not long after graduating from nursing school, Viola found herself working in Denver, Colorado, when President Roosevelt delivered an ominous speech. While the war efforts in Europe were drawing to a close, battles were still raging in the Pacific, and there might be a need to draft nurses into the military. Viola was told that if she volunteered for military service, she could select her location of duties. In January 1944, she enlisted in the United States Army Nurse Corps, requesting no surgical duties or overseas assignments. Within weeks of her enlistment, she was assigned to Camp Carson (now, Fort Carson, Colorado Springs, Colorado) in the surgical suite where she assisted with amputations from the war-wounded returning from the bitter winter campaign in Europe under General Patton. There were endless mounds of amputated ears, fingers, toes, hands, feet, arms, and legs that filled the air with putrid smells. Viola approached her supervisor and informed her of what she had requested: “No surgery and no overseas duties.” She was promptly informed, “Honey, you are in the Army now.”6
Step Back in Time The curriculum at Sage Memorial Hospital was based on the National League for Nursing Education criteria, accredited by the Arizona Board of Nursing Examiners. But what was nursing school in Viola Garcia’s day really like? Around 1940, courses required for graduation at Sage Memorial included: First-Year Courses: Basic sciences, professional adjustments, nursing arts of bandaging, massage and personal hygiene, nutrition, cookery, pharmacology and therapeutics, aseptic techniques, and nursing care of conditions involving respiratory, circulatory, gastro-intestinal, endocrine, and muscular-skeletal systems Second-Year Courses: Medical-surgical nursing; nursing conditions of the eye, ear, and reproductive tract; and communicable diseases such as tuberculosis, gonorrhea, syphilis, obstetrics, diet therapy, and social problems in nursing Third-Year Courses: Psychiatric, pediatric, emergency, and public health nursing, along with another course in professional adjustment
Within a few months, First Lt. Viola Garcia shipped out from Camp Carson to Los Angeles, where she, along with 600 other nurses, embarked on the largest U.S. Army Hospital Ship at the time, the USAHSMarigold, with an unknown destination. After two weeks, the ship arrived in Hawaii, and 300 of the 600 nurses disembarked, but Viola’s group remained on board. After leaving Hawaii, ship’s public address system announced their destination: Tokyo, still a heavy battle area as the war in the Pacific raged on. “My heart just dropped, I was so frightened,” Viola recalled. The U.S. military was fighting Japanese troops on many Pacific Islands and an invasion of the Japanese mainland was thought to be imminent. The costs in human life for both sides would be high.6
The ship was under the command of General Douglas McArthur, who over saw the military operations in the Pacific. The 300 nurses in Viola’s grouping were to be part of the U.S. invasion actions in Japan. Military leaders expected heavy casualties among those nurses during the invasion operations; the 300 nurses left behind in Hawaii would be their replacements.
Under international rules of combat, hospital ships were not to be attacked at sea, and thus were to be lit up at night and clearly marked with a red cross. Not long out at sea, the Japanese attacked one such marked ship, and the Marigold was immediately ordered to go into complete darkness. As the lights were put out, those in surgery raced to cover the windows of surgeries in progress. A frightening silence fell upon the crew as the Marigold steamed along in darkness on its way across the Pacific.
The Marigold stopped in the Philippines, and the nurses were allowed to disembark for a few days before the ship went to Japan. While docked there, however, the United States dropped the atomic bombs on Japan, and World War II was brought to a close. Yet, the Marigold continued on to Tokyo, but this time with a different mission. The USAHSMarigold was the first U.S. ship to enter Yokahoma Bay after the Japanese ended the war, and it was in Tokyo Bay where General McArthur accepted the formal surrender of the Japanese on the USS Missouri. That day the sea was filled with ships and the air was filled with flyover planes celebrating the end of the Second World War.
Rebuilding in Tokyo
Over the next eight months, Viola was stationed in Tokyo at the 42nd General Hospital. She treated survivors of the Bataan Death Camp and Corregidor Island (a military stronghold in the Philippines). The hospital had five surgical rooms that had been stripped of all equipment by the Japanese at the end of the war. They were filled with soot and rubble. Several Army nurses ranking higher than Viola were assigned the task of restoring these rooms to their full function. According to Viola, none of the higher-ranking nurses could deal with such an overwhelming task; each time, Viola was asked to “fill in.” After a third nurse was left in tears at the monumental task, Viola was asked to take on the responsibilities as acting head surgical nurse.6
Viola walked into surgical suites devoid of the equipment necessary for performing operations—no surgical tables, no IV stands, no surgical tools. She remembered entering the rooms: “I just wanted to cry too and said to myself, ‘Oh Lordy, what am I going to do?'” But Viola went on to do what she had always done—she rolled up her sleeves and got to work. Viola called in her military crew and ordered them to wash and scrub all the rooms from top to bottom. When that was done, she began looking for equipment for her surgical rooms, including salvaging items from the hospital ship.6 She even taught herself to speak Japanese, just as she learned to speak Dine as a nursing student.
First Lt. Garcia’s work in Tokyo was supported by her own ethic of care, as well as the training she received at Sage Memorial Hospital School of Nursing. From those days following the war until her death in 2004, Viola continued caring for others, marrying Herbert Schneider, another member of the U.S. Army, and raising three daughters. Her legacy, one of determination and pride, compassion and grace, lives on.
Salsbury, C.G., & Hughes, P. (1969) The Salsbury Story. Tucson: The University of Arizona Press. 152–153.
People of Catawba official website, “Life of Viola Schneider.” Cynthia Walsh. http://www.catawba-people.com/viola_schneider_eulogy.htm. (Accessed 2011).
Trennart, R. (2003). “Sage Memorial Hospital and the Nation’s First All-Indian School of Nursing.” The Journal of Arizona History, vol. 44, 353.
Prospectus of School of Nursing, (Ganado, Arizona: Sage Memorial Hospital, n.d), 1-11; Presbyterian Historical Society, Philadelphia, Pennsylvania: Ganado Mission Records.
“Excerpts from Statement re: School of Nursing, Sage Memorial Hospital, Ganado, Arizona sent in on January 3, 1939.” Document from Ganado Mission Records, Presbyterian Historical Society; Philadelphia, Pennsylvania.
Viola Garcia, personal comm. with author.
Salsbury, C.G. (1932). “Medical Work in Navajoland.” The American Journal of Nursing, 32(4), 415.
We often say nurses are on the “front lines” of health care, meaning they work closely with patients and become intimately acquainted with the issues those patients face. And while hospitals can seem a lot like trenches sometimes, they are a far cry from the military operations taking place worlds away.
Here, two military nurses share their stories, from the stress of coordinating care in a combat zone to dealing with prejudice and personal growth, all while caring for the men and women serving in the U.S. armed forces.
Joseph D. Hacinas, R.N., M.S.N., C.N.S., P.H.N.
Lieutenant Commander, United States Navy Nurse Corps Last year, 2011, marked my 10th year as a nurse. Those years have been marked by personal and professional accomplishments. However, this was not always the case. In fact, my nursing career was almost never a career to begin with.
After graduating with honors, I had a great sense of pride and confidence. Perhaps I had too much self-confidence. As a result, I failed miserably with my nursing board exam. Worse, I blamed everything and anything but myself. Having failed this exam almost cost me my job and the opportunity to become a commissioned officer in the U.S. Navy. My mentality relied heavily on the fact that I was going to be a nurse. I intended to be an outstanding nurse, just like the hundreds of outstanding nurses of Asian/Filipino descent who came before me.
Yet, I assumed I could pass the nursing board exam without really studying or working for it. Well, lesson learned. An expensive lesson, I should add. Had I not eventually passed my nursing board exam, I would have been looking at an employer recoupment of about $20,000. Ouch! The good news is that I was able to overcome this barrier just in time.
I began my career in a military nursing at the Naval Medical Center in San Diego, and my goals were simple: learn as much as possible and don’t make mistakes with potentially dire consequences (e.g., a medication error). Not so different from civilian nursing, really!
I remember that rookie year vividly. Looking back, I am still not sure how I was able to succeed in such a demanding work environment. I was assigned as a staff nurse at a 28-bed medical-surgical unit. By far, we were the busiest nursing unit in our 250-bed facility. Every day was non-stop action. It felt like my heart rate increased by at least 10 beats per minute every time I set foot in the unit. It seemed like we never slowed down—and the tempo was dizzying. I would typically have six patients with an assistant. For any given shift, my duties would consist of AM care, vitals, assessment, medications, and procedures. I also had to coordinate MRI visits, CT consults, and X-ray availability while calling for discharge medications in pharmacy. No matter how physically and mentally prepared I tried to be, it was hard to maintain a sense of control. There were times that I was so stressed I literally made myself sick. Basic nursing skills such as prioritization of patients and critical-thinking skills were learned on the go. I wouldn’t exactly call it chaos. But it was close.
Yet, as crazy as it may sound, I actually did not mind it one bit. It’s the truth. One of the reasons was that I had great mentors around me. I used to look around our nursing unit and realized my nursing colleagues were more than willing to help, no matter what. Perhaps it was our sense of teamwork. Or it could have been our dedication to military nursing and our patients. Whatever it was, it didn’t take me long to realize that I had made the right career move. Unlike my civilian nursing colleagues, I have had the unique opportunity to care for patients who have served and are serving this great nation. It is a feeling like no other. To come in on a daily basis and know that I am part of something meaningful is incredible. This couldn’t have been more evident than after the events of September 11, 2001.
I was actually on my way to work when I heard of the terrorist attacks. Not knowing much at the time, I just remember thinking that my nursing skills were about to become a commodity, whether I was ready or not. It was a fearful and uncertain time for everyone, almost surreal to think that such an attack was even humanly possible. I just remember hearing from my supervisors, “Be ready.” There was a good chance most of us were bound for deployment overseas. Soldiers, marines, sailors, and airmen were counting on us to provide the best patient care possible under all circumstances. As it turns out, I was actually one of the nurses that ended up staying behind during the early stages of the war. Nevertheless, it was professionally fulfilling. It provided a great way for me to contribute. For the next few years, I found myself in various nursing assignments, from California to Japan. I have been blessed to grow professionally and gain a better perspective of my overall purpose as a military nurse.
Like some people find their niche in a nursing specialty like pediatrics or oncology, I have found that being a military nurse has its own advantages. I work with an outstanding team. From physicians to social workers, it is a rewarding experience to collaborate and gain a sense of unity. This is especially important as nurses and the rest of the health care team are tasked to care for patients with complex disease processes. More importantly, my service to active-duty patients and beneficiaries truly defines who I am as a nurse. Whether I am teaching a dependent spouse about healthier eating habits or holding a patient’s hand and praying with him before a major surgery, I am there to give it my all. Because, chances are, they would do the same for me. And that alone is what matters most. In a sense, we are more than just a family. We are united as one.
Of course, to say my military nursing career has been nothing but great experiences wouldn’t be entirely accurate. I can recall one incident when caring for a retired military member. He rang his call bell for assistance. When I walked in to his room, he said, “I’m sorry, but I had asked for a nurse.” I politely answered that I would be the one taking care of him for the night. He quickly replied, “No, no, no. I asked for a nurse—the one who has blonde hair, blue eyes, and wears a nice skirt.” Obviously, I could have reacted in a negative manner. Rather, I chose to remain calm and respectfully informed him that not all nurses are females with blonde hair. Somewhat perplexed, the patient quickly changed the topic and turned his attention to the television. I did not feel anger towards that particular patient; all I could think of was trying to find ways to help him understand the evolving nature of nursing, which now consists of men as well as Asian/Filipino nurses like me.
As troubling as that patient’s reaction seemed at first, I truly felt he came to realize that male nurses were more than able and capable of caring for patients like him. Though he never said so directly, I just had a feeling. And if nothing else, I know my serving as his nurse was a concrete example that contradicted his former world-view.
The common thread
Nursing is an ever-evolving profession. And changes in our health care delivery system will happen, regardless. The past 10 years of nursing have taught me valuable lessons. For one, I have learned to remain humble. I have also learned to not take things personally when it comes to patient comments. Granted, some comments are downright ignorant and hurtful. But, I believe there is a common thread and human decency in everyone. As a military nurse, I am proud to be a part of their lives. In particular, I am proud to know that I have been given ample opportunities to touch lives and care for my patients. I never imagined I would be in the position to make an impact on someone’s life. Personally, those few minutes of comforting patients during the worst of times have turned to a lifetime of personal and professional satisfaction.
Yet, as with any profession, nursing is not for everybody. I have friends and colleagues who left nursing. I think some of the more common reasons for doing so were the stress of the patient workload and the lack of support from nursing leaders. Being a minority nurse, my advice is to truly and honestly evaluate one’s dedication and intention before committing to nursing. Nursing is a great and well-respected profession, but it does come with its challenges. For example, there have been times when I feared for my safety when caring for patients with developmental delays and mental instability. In addition, minority nurses may still encounter racial and ethnic stereotypes.
Once, a patient bluntly asked if all Filipino nurses speak Tagalog among one another in front of non-Filipino patients. Taken aback, I informed her that no, that is not the case. They only speak their native language during their off-duty time. In another instance, when reporting to my new supervisor (who happened to be a minority), she said, “I can already see two things that are against you. You’re an Asian and a male.” In the U.S. Navy Nurse Corps, we value diversity and strongly feel that concept results in a better work environment for all of our valued staff members, regardless of their race or color. Yet, we, as a health care organization, also understand that we are at risk for discrimination. The good news is that we have a solid support structure that enhances equal opportunity for all.
I learned there remains a small group of people in the nursing world who are who they are and believe what they believe, and there’s no changing them. More importantly, I learned the value of self-discipline while serving my patients at the most honorable level. Ignorance and immaturity exist in this world, but we, as minority nurses, have more than the power and ability to achieve the highest levels in long, fulfilling careers. We should not and cannot allow minor setbacks to dictate who we can become as professionals—we are simply too valuable to the profession. I have always seen nursing as a rewarding career, personally and professionally. Joining the nursing ranks seemed like a no-brainer. And, in general, my expectations of camaraderie, mentorship, and professional development have been met.
Who knows what the next 10 years will bring? I may pursue other interests such as golfing and traveling across the globe. I may even find myself teaching at a local university. I am okay with the unknown that lies ahead when it comes to my career as a military nurse. The one thing that I am certain about is that I will continue to strive in providing the best patient care. The ability to make a difference in patients’ lives means a lot to me. And sometimes, that is all you need. Here’s to another 10 years!
Artemus Armas, R.N., M.S.H.S, B.S.N, C.E.N.
Major, United States Air Force, North Carolina
I have been an Air Force nurse since January 2002. Before that I was in the National Guard and Army Reserve for 17 years before I went on active duty. In the Guard I was an Army Infantry officer.
During my fourth deployment, I was at the Camp Bastion Joint Operating Base in the Helmand Province of Afghanistan, the fiercest combat zone in Afghanistan at the time I was there. I was in charge of the Aeromedical Evacuation Liaison Team (AELT) at Camp Bastion Joint Operating Base Hospital. The team consisted of a flight nurse (myself), a medical service corps officer, and two radio technicians. We were primarily responsible for providing fixed-wing aeromedical evacuation for NATO forces and sometimes civilians. The team also helped anyone, including civilians, who may need to be seen by a specialist not stationed at Camp Bastion.
The AELT’s key function is transferring patients, such as those with traumatic amputations or other combat injuries, who need more specialized treatment to a different facility. The hospital relies on the AELT to coordinate the patient’s transfer with a medical aircrew (Aeromedical Evacuation Crew, or AEC), which flies the patient from point A to point B. Once the patient is picked up by the AEC and en route to a higher level of medical care, the AELT advises the staff and hospital awaiting the patient’s arrival.
A secondary mission for AELT is providing emergency medical assistance to local nationals and Afghan National Security Theater hospitals. Camp Bastion is a joint hospital, meaning whichever nation’s military is in charge of the hospital collaborates with the other countries working there. When I was there we had the Danish, British, and U.S. military.
Camp Bastion is a Role 3 hospital. Role hospitals break down as follows: Role 1 hospitals are assigned to areas providing basic or initial care; Role 2 are facilities with some surgical capabilities; Role 3 facilities can support trauma care, surgical procedures, and burn care; and Role 4 is advanced medical center care. As the lead medical person on the AELT, I made sure patients were properly prepared for flight. I also trained coalition force physicians, nurses, and medical technicians regarding approved devices, brands, and materials, including pumps, chest tube drainage systems, and traction devices.
I also taught hospital leadership on how our system works, the process of getting a patient to a higher echelon of care; this education included Army, Navy, and Marines. While at Camp Bastion I authored and implemented new policies on moving patients through the theater hospital systems, called the Patient Movement Requirement (PMR). Fortunately, implementing these procedures cut down patient movements errors by 60%.
The AELT took the lead in teaching hospital personnel how to sanitize patients before entering the hospital. We sanitized over 500 ally and enemy casualties (patients), meaning we removed any guns, ammo, or explosives before injured personnel entered the hospital. This was for security, assuring nothing happened to hospital staff and patients.
Through these initiatives and two published articles, my goal was to educate AE crews as much as possible so they would not stress when they saw unfamiliar medications or procedures, while giving a report for patients being moved by the AECs. I also included a quick reference sheet of drugs used by the coalition facility and its U.S. equivalent. By the end of this deployment, my four-person team had moved 313 patients, including 102 battle injuries.
ICU in the sky
On my second deployment that year, I had a five-day notice to get my bags and go, due to an injured person who was deployed. I went to Southeast Asia, where I was in charge of the Aeromedical Evacuation Operations Team. I managed up to eight Aeromedical Evacuation Crews and two Critical Care Air Transport Teams (CCATT).
CCATT is basically an airborne intensive care unit. The team consists of a physician, nurse, and respiratory technician; they transport the most critical patients with the assistance of the AEC. I needed to make sure the crews were ready to fly 24 hours a day, seven days a week, so we could pick up patients in the Area of Responsibility, which covered seven countries. I planned and coordinated training as needed for the crews, from medical guidelines to how to use specialized communication equipment. Mentoring was also a big part of the job, including how to deal with crewmembers and patients, career planning, and writing military reports.
Another big aspect was scheduling AECs, by following regulations regarding when crews could and could not fly. Crews need enough time to recoup and rest to be able to perform their duties on the plane and provide high-quality patient care. Scheduling can sometimes be hectic, because you have crews both on call and on missions.
I also coordinated over two tons of Patient Movement Items to the AOR, while my team also maintained and managed 73 Portable Therapeutic Liquid Oxygen units (patient oxygen). This optimized five AE units and kept them fully mission capable. While there I functioned as a crewmember when personnel were unable to fly due to injury or illness. I flew three missions as part of an AEC and pulled 120 hours of alert status, resulting in the transfer of 18 coalition casualties to advanced care. During increased operations we relocated 12 Aeromedical Evacuation Crew members and two CCATTs to Bagram, Afghanistan, increasing Operation Enduring Freedom capabilities by 20%. The efforts during that time lead our team to win the Expeditionary Aeromedical Evacuation Squadron “Team of the Month.” While deployed, the team safely evacuated over 400 wounded personnel on 180 sorties.
The most important result of all that I do is making sure patients, whether military or civilian, receive the best, most comprehensive care possible throughout the AE system. You need everything: great patient care, equipment, leadership, management, and more. If you just focus on one, the system will not be optimal. It is crucial to be well-rounded on all aspects of the AE system. I am honored that my commanders have seen qualities in me to give me the opportunity to succeed in the positions where I have been placed. My philosophy is to do what is best for the patient and those who take care of them; everything else will fall in place.
While deployed as an AELT, I lead our team with a program called “Soldiers’ Angels” (www.soldiersangels.org). We would collect items such as books, food, soap, clothes, music, and blankets from people throughout the United States to give to personnel living in austere conditions and patients who needed supplies in the hospital. We ended up distributing over $50,000 in products to over 500 patients, 24 units, and 12 Forward Operating Bases.
Recently, I was honored with two awards: The Air Force Flight Nurse of the Year and Nurse of the Year. When my commander informed me I won, I was shocked. It is an honor just to win one. I had learned my commander had put a Flight Nurse of the Year package in for me when I was deployed to Southeast Asia, but I never expected to win. I gave her my information and didn’t think of it again until I won. It was a shock to both of us when I also won the Nurse of the Year. However, though I say “I” in describing all these events, I truly could not have done it alone. The team makes it happen—I just tried to lead them in the right direction.
Getting the opportunity to be a flight nurse has been the most satisfying job I have had thus far in my nursing career. Being a flight nurse in the Air Force has given me opportunities to be an effective leader and make an immediate difference for those I have taken care of that I would not have had as a nurse in a clinic or hospital. Like the rest of the nation, the Air Force needs more nurses and the AF Flight Nurse community needs even more, as a specialty. I would recommend this life to anyone who likes adventure, leadership opportunities, and enjoys taking care of our wounded warriors.