Secondary Logo

Journal Logo

Impact of the Clinical Nurse Specialist in the Transformation of Military Healthcare From Bedside to Battlefield

Wanzer, Linda DNP, RN, CNOR, FAAN; Oliver, Jeffrey J. MSN, RN, CCNS, CNOR; Rodriguez, Jose DNP, RN, APRN, CNOR, CCNS; Bradley, David MSN, RN, APRN, CNOR, AGCNS-BC; Taylor, Laura A. PhD, RN, ANEF, FAAN

doi: 10.1097/01.NUR.0000604200.03201.6d

Author Affiliations: Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

The authors report no conflicts of interest.

Correspondence: Laura A. Taylor, PhD, RN, ANEF, FAAN, Daniel K. Inouye Graduate School of Nursing, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda MD 20841 (

As of October 2019, for the first time in our modern military's history, a single agency—the Defense Health Agency (DHA)—will superintend all healthcare within the Navy, Army, and Air Force (Department of Defense). The goal of this congressionally mandated change is to ensure a more adaptable and cohesive healthcare system that will provide 9.5 million sailors, soldiers, airmen, retirees, and their beneficiaries with a reliable, high-quality healthcare experience, no matter where in the world care is delivered.1 The leadership in the DHA has aligned their key priorities closely with the strategies inherent in the Quadruple Aim to standardize performance across the Military Health System (MHS) to increase readiness, better health, improve care, and lower costs, which results in a medically ready force and a prepared medical force.1

During this time of transformation, the military clinical nurse specialists (CNSs) are an invaluable asset to the organization, as they bring the necessary leadership to facilitate the rapid changes for streamlining systems and processes to meet the new directives and priorities within the MHS.2 The CNS critically evaluates DHA/MHS processes and structures and provides input into evidence-based practice opportunities to improve outcomes, promote and enhance care, and advance the business of healthcare across the DHA. They analyze data to justify interventions and consolidate the necessary analytics to improve quality of work, reduce clinical risks, and address financial and educational issues. They promote critical progress toward achieving the goals of the Quadruple Aim and enhance organizational efforts toward becoming high-reliability organizations (HROs).3,4 Such actions are accomplished through the widespread organizational influence of the CNS, whose expertise invaluably affects such varied operational areas as traditional stateside military treatment facilities (MTFs), corporate-level settings such as DHA and the Office of the Surgeon General, and in austere settings such as humanitarian and/or operational missions.

Back to Top | Article Outline


The CNS scope of practice and spheres of influence align with the military priority of access to care and the assurance of a trained and ready medical force. In addition to the 3 spheres of influence in which CNSs traditionally operate—patient, nurse/nursing practice, and organization/system5—a unique fourth sphere of influence, the operational environment, demands military CNSs improve outcomes across multiple operational platforms to further and sustain medical force readiness and the medical preparedness of our Armed Forces. Military CNSs work in collaboration with all members of the healthcare team across various areas, including quality management, patient safety, risk management, infection control, and clinical informatics. The CNS also partners with nurse researchers and specialty leaders to capitalize on evidence-based medicine. The scholarship, leadership, and clinical expertise of the military CNS are integral to the efforts of the DHA/MHS on the journey toward becoming an HRO.

Back to Top | Article Outline


Through the exceptional nursing and military officership education and training, the CNS is uniquely poised to spearhead hundreds of care processes and mechanisms responsible for transforming the nation's healthcare.2,5 The following are some of the most distinguished international and national contributions to healthcare in the past 10 years by our military CNSs.

The largest military CNS project performed to date was the collaboration with the United States Pharmacopeia for medication safety. This interprofessional partnership was the largest known national analysis and the first initiative to examine medication errors across a clinical continuum of care (perioperative community—perioperative holding, ambulatory care unit, operating room, and perianesthesia care unit).6 The faculty and students of The Daniel K. Inouye Graduate School of Nursing lead the analysis and interpretation of 7 years of perioperative medication error data. This report achieved immediate international acclaim, garnering more than 110 million media impressions. The initial impact on safe medication practices resulted in major revisions to the Association of periOperative Registered Nurses medication guidelines with the inclusion of a new section related to pediatric medication safety; the American Society of PeriAnesthesia Nurses developed procedural guidelines for medication safety; The Joint Commission published a sentinel event alert: “Preventing Pediatric Medication Errors”; and the Association for Professionals in Infection Control and Epidemiology published a position paper on “Safe Injection, Infusion, and Medication Vial Practices in Health Care” (2016) in an effort to nationally disseminate key safety information. Data and recommended practices from this project were also included in the RAND Report: “Assessing Patient Safety Practices and Outcomes in the U.S. Health Care System.” This extraordinary work continues to impact interprofessional practice, education, policy development, and research on quality and safety of medication practices across the globe.

Military CNSs are instrumental in conducting staff-assisted visits across MTFs around the world in preparing for Joint Commission surveys. As consultants, the CNS impacts every area of care (eg, specialty clinics, family practice clinics, mother baby units, intensive care units, emergency rooms, and dental facilities). They have driven evidence-based organizational practice change, including directing Enhanced Recovery After Surgery programs that reduced length of stay by 1 day for gynecological patients; designing and evaluating the use of essential oils for postoperative recovery which resulted in statistically significant decreases in pain, anxiety, and nausea; establishing registered nurse–operated hypertension clinics that demonstrated a reduction in blood pressure and increased attendance at follow-up appointments; exploring best practices with newborn injections while ensuring skin-to-skin contact between mother and baby which decreased newborn duration of crying; facilitating changes to align high-level disinfection and sterility assurance practices to regulatory and national standard setting bodies and recommended practice guidelines across numerous MTFs which resulted in positive patient outcomes, compliance with standards, and successful Joint Commission accreditation.

Currently, CNSs are leading a multicenter effort on postpartum hemorrhage to standardize care across 10 US Air Force MTFs and the DHA CNS Subcommittee is actively reviewing the perinatal training requirements in the recently released DHA protocol (April 2019). On an annual basis, the Uniformed Services University AG-CNS Program, along with industry partners, hosts a 4-day evidence-based “Excellence in High Level Disinfection (HLD)/Sterilization Quality Assurance Program” norming global improvements in patient safety in endoscope reprocessing and sterility assurance across the Department of Defense/DHA Enterprise. On the readiness front, Military CNSs are also consulting as subject matter experts on the development of an Operational Planning Guideline to increase trauma readiness for intensive care and emergency department nurses supporting intraoperative damage control on the battlefield.

Back to Top | Article Outline


The military CNS is a dynamic, multifaceted expert clinician/independent practitioner, consultant, leader, educator, and evidence-based scholar. Clinical nurse specialists across the MHS must possess the expertise to navigate its complexity, offer clinical expertise and consultation, and assume active leadership roles in transitioning organizations into HROs. Today's military CNSs not only actively lead multidisciplinary teams for systems change and prepare healthcare units to operate across humanitarian or austere/downrange-deployment environments, but also find themselves in an exciting position of transforming a once siloed organization into an integrated system of readiness and health. Because the CNS is uniquely prepared and able to manage quality across the continuum, to analyze healthcare systems and processes, to optimize patient outcomes, and to guide change in support of HROs in healthcare; the military CNSs are a valuable asset to the DHA leadership as they navigate the future transitions of healthcare within the MHS.


Back to Top | Article Outline


1. Department of Defense (2018). The Defense Health Agency 2017 Stakeholder Report.
2. Horner S. (2016). Allowing clinical nurse specialists to practice to the extent of their education and training will improve access to care for our veterans. Accessed October 5, 2019.
3. Chassin MR, Loeb JM. High-reliability health care: getting there from here. Milbank Q. 2013;91(3):459–490.
4. Spruit M, Lytras M. Applied data science in patient-centric healthcare: adaptive analytic systems for empowering physicians and patients. Telemat Inform. 2018;25:643–653.
5. National Association of Clinical Nurse Specialists. Statement on Clinical Nurse Specialist Practice and Education. 2nd ed. Harrisburg, PA: NACNS; 2004. Accessed October 5, 2019.
6. Hicks RW, Becker SC, Cousins DD. MEDMARX® Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005. Rockville, MD: USP Center for the Advancement of Patient Safety; 2006.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved