Individual Readiness
Air Force Reserve nurses: Developing a self-assessment of
individual deployment readiness for Air Force Reserve nurses.
Since September 11, 2001, military nursing has focused on supporting the war on terrorism, primarily providing nursing support for operation Enduring Freedom and Iraqi Freedom. In 2006, at a hearing before a Senate defense subcommittee hearing on medical programs, Major General Melissa A. Rank, assistant Air Force surgeon general, nursing service stated that active duty, Guard and Reserve nurse corps officers have served around the world providing robust nursing support to over 202 missions and operations treating 1.47 million patients.
Nurses from all components of the Air Force have been deployed for OIF/OEF as members of expeditionary medical support units (EMEDS), aeromedical evacuation (AE), and contingency aeromedical staging facilities (CASF). These nurses have treated more than 33,500 casualties, with AE teams having flown over 3,200 medical missions. Air Force Reserve (AFR) nurses have played significant roles in these deployments as over 850 Reserve medical/surgical, critical care, emergency and flight nurses have been mobilized for these deployments.
After the first Persian Gulf War, the Air Force Medical Service implemented major organizational changes including new training platforms and developing new concepts for providing nursing care during a wartime environment. The new concept of expeditionary medical support, introduced by Lieutenant General Carlton Jr., former AF surgeons general, is the guiding framework that Reserve nurses are now working under during current deployments. These new paradigms of training and providing nursing care during conflicts requires continual research to determine if the current readiness training platforms are effective and valid to prepare Reserve nurses for the current wartime contingencies. The purpose of this research was to evaluate readiness skill levels of AFR nurses who are preparing for deployment within the Expeditionary Medical System (EMS).
Conceptual Framework
Von Clausewitz wrote “the theory of war occupies itself with the use of the prepared means [of war] for the object of war.” and advised that military planners need to clearly understand their readiness capabilities in order to achieve strategic and operational objectives. Nursing research has provided data on the evaluation and development of a conceptual definition for nursing readiness. Although there may be no concrete definition of readiness, its key component is individual deployment preparedness.
Even when readiness is defined as a process, not an outcome, the ability to evaluate and determine a level of readiness in an individual is a difficult task. Several researchers concluded that the broad definition of readiness requires the physical, mental, financial and legal preparedness for deployment. Individual readiness has been defined as “a dynamic concept with dimensions at the individual, group, and system levels, which together influence one’s ability to prepare to accomplish the mission.” Clinical readiness is defined as the ability of AFR nurses to provide nursing care for patients with trauma, disease or injury, be able to triage and regulate casualties for staging and evacuation under contingency environments.
Concept of Self-Assessment
Self-perception of a knowledge deficiency is important in order for an individual to actually seek out education. This type of methodology is frequently utilized for evaluating knowledge in many research studies. Specifically, Alspach Bridges identified significantly lower levels of performance in AF nurses determined by actual testing compared with the nurse’s self-assessment of their skill level [Readiness Skills Verification program for Aeromedical Evacuation Nurses, 2002]. Another paper [by T.L. Dremsa, B. Resnick, R.F. Braun, L.R. Derogatis, M. McEntee, M. Turner, and C. Reineck] found self-assessment an important concept because self-perceptions influence an individual’s state of stress resistance. Therefore, stressful events are appraised as challenges and the nurse thus gains a sense of confidence and mission accomplishment. A more stress-resistant perspective enables the military to accomplish mastery of skills amid complex demands of military deployments. This concept has been holding true since World War II. The research questions included: (1) What are the characteristics of the AFR nurses’ readiness skill levels?, (2) Is there a relationship in positive self-identified readiness skills in AFR nurse and deployment experience?, and (3) Is there a relationship in positive self-identified readiness skills in AFR nurses with their civilian nursing position?
Human Subjects
After Institutional Review Board approval from Office of Research Conduct at The City University of New York was granted, a packet with an introductory letter explaining the purpose of the research was sent to all possible participants. Each potential participant was asked to answer demographic questions and assess their readiness skills using the Readiness Estimate and Deployment Index Revised for Air Force Reserve Nurses (READI-R-AFRN) instrument. A return of the completed survey was considered consent to participate in the study.
READI-R-AFRN
Adapted for the AF, the Readiness Estimate and Deployment Index Revised for Air Force Nurses (READI-R-AFN) instrument is based on Readiness Estimate and Deployment Index (READI). The READI instrument evaluates self-reported individual medical readiness based on six dimensions: (1) clinical nursing competency, (2) operational competency, (3) soldier/survival skills, (4) personal, physical and psychosocial stress, (5) leadership and administrative support, and (6) group integration and identification.
Using these six dimensions, the READI instrument was developed and tested to evaluate individual medical readiness by the self-reporting of Reserve and active-duty Army nurses with a wide array of time in service, military deployment experience, nursing specialties and geographic assignment for active duty.
Subsequently, the READI tool was modified for active duty AF nurses to assess their readiness for deployments and to pinpoint specific areas where further deployment preparation was needed. Tool modifications were consistent with AF terminology and requirements determined by experts in the field of AF medical readiness. Not too long after, a shortened version for rapid administration for active duty AF nurses was developed.
The READI-R-AFN questionnaire, using 40 questions, was used in this study. Twenty AFR nurses with and without deployment experience reviewed this questionnaire to determine its appropriateness with the Reserve nursing environment. In addition, Reserve nurses at Head- quarters Air Force Reserve Command (HQ AFRC) and the research team reviewed the tool to evaluate its appropriateness for Reserve nursing readiness. This process was used to ensure that appropriate responses would be elicited from the study participants. Modifications were limited to replacing the phrase “AF” with “AFR.” Since only semantic modification of to the tool was made (face validity), no extensive psychometric testing was deemed necessary. The instruments took approximately 15 to 30 minutes to complete.
Demographic data collected on each subject included age, gender, years of nursing experience, and time in the AF and the AFR. Nursing education level, civilian job title, Reserve job title, type of unit (e.g., air evacuation squad (AES), aeromedical staging squadron (ASTS), etc.) was also collected. It was considered extremely important to collect specific civilian employment and education data in order to determine individual readiness within these categories. In addition, if the participant was deployed, time deployed and job title information while deployed was also collected.
Sample
A random sampling technique was used to achieve a representative sample of the Reserve nurse population. HQ AFRC reported a total Reserve nursing population of approximately 1,500 nurses and a power analysis determined that a sample size of approximately 306 participants would need to be recruited for this study in order to reach a pre-designated confidence level of 95 percent with a margin of error of 5 percent The final sample size collected for this study was 405.
In order to assess the individual readiness of AFR nurses, this study surveyed previously deployed and non-deployed nurses. Using a random number generator, every ninth unit was chosen out of the total 92 Reserve units to create the sample population.
Recruitment
Packets were mailed to each identified Reserve nurse through a list generated at HQ AFRC. A postage paid return envelope for the completed surveys was provided to each participant to return the surveys by mail. McMahon et al. compared e-mail, fax and postal survey results and determined that utilization of multiple methods of requesting survey completion increased return rates by 14 percent. A second mailing was completed for those subjects who did not initially return the survey. An e-mail survey was sent to identify potential participants as a third way of soliciting participation. Using these varied methods provided a 45 percent return rate.
Data Analysis
Survey data were coded and entered into statistical packages for the social sciences (SPSS) 13 and analyzed after all data was checked for accuracy of entry and missing data.
Descriptive statistics were used to summarize all demographic data. Independent-samples t-tests were conducted to analyze the six domains versus deployment including a total score. Independent-samples t-tests were conducted to analyze the six domains versus Air Force Specialty Codes (AFSC) including a total score. One-way between-groups analyses of variances were conducted to explore the six domains and a total score versus unit types. Finally, one-way between-groups analyses of variances were conducted to explore the six domains versus civilian specialty.
Research Questions
To answer research question 1, what are the characteristics of the AFR nurses’ readiness levels, a series of independent-samples t-test were conducted on the total six domains (clinical nursing competence, operational competency, soldier/survival skills, personal/psychosocial/physical readiness, leadership and administrative support, group integration and identification) scores. In all domains except leadership and administrative support, flight nurses (46F) perceived themselves as more competent than counterparts in the clinical nurse (46N) category. When comparing unit types versus the total READI-R-AFRN, in all domains except leadership and administrative support and group integration and identification, Reserve nurses from the AES units perceived themselves as more competent than their counterparts from other units. When looking at deployment effects on READI-R-AFRN, Reserve nurses who were deployed during the last three years perceived themselves as significantly more competent in all domains as compared to those Reserve nurses who were not deployed during the last three years.
Total Readiness Scores by Civilian Specialty
To answer research question 2b, is there a relationship in readiness skills in AFR nurses and their civilian nursing position, a series of one-way between-groups analysis of variance were conducted on the total and domains scores. In two domains, critical care nurses perceived themselves as more competent than their counterparts (clinical nurses, educators and administrators) on the clinical competency domain and for the total readiness score.
A Discriminate Tool
It is mandatory that AFR nurses participate in specific initial and sustained training efforts to meet all their medical readiness requirements for their specific AFSC and deployment positions. All training must be frequently evaluated to assure that the training is valid for current requirements and that the nurses are meeting the level of required competency after receiving that training.
Data collected from the surveys in this research provides information and guidance for training and preparing future Reserve nurses during employments including developing competencies to meet training needs. Self identified readiness training needs identified were different by type of unit the nurses were assigned. For example, AES nurses rated leadership competencies lower than other units, medical squadron (MDS) nurses rated operational and soldier survival competencies lower than other units, while ASTS nurse rated clinical competencies lower than other units. Although not statistically significant, it is important to understand that 7 percent of ASTS nurses stated they need training in clinical competencies, while only 3 percent of MDS nurses and .5 percent of AES nurses reported needing training in clinical competencies. Data validates the need for Reserve nurses to be at the critical care level as a significant difference identified between critical care nurse and clinical nurse. This data is corroborated by flight nurses (46F) who rated themselves as feeling more competent in clinical competency than clinical nurses (46N).
The research team determined that READI-R-AFRN was a discriminate tool as the participants were able to assess their needs as “trained,” “moderately trained,” or “needs training” based on a scale of 1 to 5 using those terms. Resulting data identified different areas of readiness training that may need emphasis for the different types of units. Then use of self-assessments can be useful tool for Reserve leadership as demonstrated by the wide range of “needs training” and “moderately trained” scores found. Military nurses have and should continue to utilize self-assessment tools to identify educational needs in individual nursing readiness competencies in order to be better prepared to manage and respond to current deployment requirements.
This study identified four primary issues: (1) nurse’s self-assessed readiness levels validates current training as meeting their needs as seen by total scores at trained or moderately trained, (2) data analysis identified different areas of readiness training that may need emphasis for each unit, (3) study data validates the need for Reserve nurses to be at the critical care level as a significant difference identified between critical care nurses and clinical nurses, and (4) self-assessments can be a useful tool for Reserve leadership as demonstrated by the wide range of need training and moderately trained scores for each of the study volunteers. The findings of this research should be used to provide the best possible recommendations for improvement in the deployment training for AF Reserve nurses. Currently, a small number of active duty and Reserve nursing staff train with civilian medical centers to enhance their learning of specific war skills and to maintain those critical care competencies. Acuity levels at AF hospitals compared to civilian hospitals are significantly lower, therefore, one may hypothesize that Reserve nurses actively working in their clinical specialty should maintain a higher competency level in certain areas of war skill competencies. The results of this study should provide information for senior nursing leadership to use in validating training and possible focuses of their training plans. Since OEF/OIF, self-identified needs of the Reserve nurses were clearly identified and appropriate interventions will need to be developed. ♦