Panel II Of A Hearing Of The Defense Subcommittee Of The Senate Appropriations Committee

Statement

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SEN. INOUYE: I'd like to welcome back Rear Admiral Christine Bruzek-Kohler, director of the Navy Nurse Corps, also Major General Patricia Horoho, Chief of the Army Nurse Corps, and Major General Kimberly Siniscalchi, chief of the Air Force Nurse Corps.

There are many things I would like to say at this point, but it's been my pleasure to work with all of you for many years. I'd like to extend my congratulations to Admiral Bruzek-Kohler, who has been selected to serve as the first nurse corps officer ever to be in command of our Navy Medicine West and Navy Medical Center of San Diego, along with a continued role as corps chief of the Navy Nurse Corps.

I look forward to listening to your testimony, so may I call upon the admiral first.

ADM. BRUZEK-KOHLER: Am I on? Well, good morning, Chairman Inouye, ranking member Cochran, and distinguished members of the subcommittee. As the 21st director of the Navy Nurse Corps, I am honored to offer my testimony to you and your esteemed colleagues. My written statement has been submitted for the record, and today I would like to highlight some of the remarkable work being accomplished by Navy nurses.

The role of Navy nursing is unquestioned in today's Navy. We are at the forefront of all operations, and are accepted as mission- essential within Navy medicine in support of the Navy Marine Corps. Under my leadership, we have developed a model of professional military nursing, the essence of nursing relevance and practice in the nurse corps today.

Built upon a solid foundation of clinical skills, Navy nursing encompasses clinical specialization via advanced education and certification, operational readiness, and leadership development. When combined, these yield clinical nursing leaders and future executives for Navy medicine, who are business savvy, operationally experienced, and clinically adept. These nurses can and will impressively lead our people and organization into the future.

As Navy nurses, we are renowned for our steadfast commitment to our patients and respected for our impressive ability to collaborate with a host of other health care disciplines. We are integral in the provision of superb care to America's fighting forces, their families, and the retired community.

While we are a corps of many specialties, I have identified eight which are the critical wartime mission-essential specialties: medical- surgical, psychiatric mental health, critical care, perioperative, emergency trauma, maternal-child, certified registered nurse, anesthetist, and nurse practitioners.

Of all of these, medical-surgical nursing is the bedrock of our practice. For this reason, it is my expectation that all nurses in the Navy Nurse Corps maintain their clinical relevance in medical- surgical nursing, particularly if they function in purely administrative roles. Our total Navy nursing workforce is composed of over 5,500 active, reserve, and federal civilian nurses. Our active- component manning is at 96 percent. For the third consecutive year, I am proud to share with you that the Navy Nurse Corps has made its active-duty direction accession goal. And as we heard from my surgeon general, for the first time in over five years, Navy Nurse Corps gains have outpaced our losses.

In speaking with nurse corps officers, I found that their engagement in local recruiting initiatives from elementary schools to colleges, opportunities to provide nursing support via disaster relief and humanitarian assistance missions, and pursuit of advanced education via our duty under instruction program have all contributed to their decision to stay Navy.

While recruiting to the active component remains robust, manning in the reserves is of concern to me and my reserve component's deputy director, Rear Admiral Suzia DeLay (ph) who is here with us today. Despite meeting 107 percent of the recruiting goal in 2008, deficits from shortfalls in the three previous years have lead to challenges in filling junior officer billets. To that end, reserve component recruiting initiatives will be targeted toward these vacancies.

Last year, we saw the release of a new retention initiative, the Registered Nurse Incentive Specialty Pay. Uniquely designed to incentivize military nurses to remain at the bedside providing direct patient care, we targeted RNISP eligibility towards our critical wartime undermanned specialties with inventories of less than 90 percent. This year we were able to expand that RNISP to include psychiatric mental health nurses and nurse practitioners, women's health nurse practitioners, and certified nurse midwives. In the future, I look forward to being able to offer an incentive such as this to all of my nurses practicing within their specialties.

In addition, targeted recruiting efforts for both active and reserve assets will be focused not only on the acquisition of medical surgical nurses, but also on fortifying high off-tempo communities of critical care and perioperative nurses and family nurse practitioners.

Recognizing the efforts of those who diligently serve our beneficiaries when Navy nurses deploy, we have recently implemented two innovative programs to expand the professional development of our valued federal civilian registered nurses. One of these programs offers training in perioperative nursing, augmenting a high-deploying critical nursing specialty, and providing service continuity to patients at our military treatment facilities.

The graduate program from federal civilian registered nurses provides funding for competitively selected candidates to pursue their master of science degree in nursing, adding to our pool of clinical nurse specialists who help mentor and train our junior nurses and hospital corpsmen.

I remain an ardent supporter of the TriService Nursing Research program, and I'm duly committed to its sustainment. Navy nurses throughout our military treatment facilities are engaged in research endeavors that promote not only the health and wellness of our service members, but that of their families also.

Nurses have always been recognized for their expertise in disease prevention, health promotion, and patient education. The melding of Navy nurses clinical proficiency in the aforementioned areas and their keen operational focus ensure success in Navy deployments and encounters in rural, isolated villages with impoverished communities. My nurses are agile, adaptable, capable, and ready to deploy.

The Navy's newest nurses graduating from the officer development school in Newport, Rhode Island, eagerly inquire how soon they might deploy after reporting to their very first command.

All of my nurses, from ensign to captain, because of their clinical relevance, have the potential opportunity to deploy. Today's deployment environments involve locations in harm's way and include practice settings that require the application of clinical expertise in a myriad of areas. Line-side commanders recognize our nurses' value immediately and champion their assumption of key operational leadership roles previously held by other professional corps and services.

Recently returned from deployment, as the officer in charge of the combined Joint Task Force cooperative medical assistance team in Afghanistan, a Navy pediatric nurse practitioner offered, and I quote, "I would be willing to redeploy to an operational setting and endure separation from my family and even sacrifice my safety because of the overwhelming sense of fulfillment that I received in helping empower the women of Afghanistan. Even the smallest changes that we made to increase their education, economic stability, and improve their health will ultimately make a profound difference in their lives and that of their children."

A Navy nurse deployed as an individual augmentee assumed the role of team leader for an embedded training team in Kabul. She served as a mentor to a senior nursing leader of the Afghan national army, and was instrumental in the development of a variety of educational programs for over 80 military nurses, and 140 health aids. She shared that she and her team empowered these nurses to become not only teachers but leaders, and in doing such, they became role models to others within their organization.

A maturity, sense of personal fulfillment, and confidence of having done something that their peers have not done is readily identifiable among my nurses returning from these unique deployments. From the way they act, talk, and perhaps even the swagger in their walk, one can tell that they have returned with experiences far and too many, accomplished goals unrealized in the past, and matured in a way years could never have provided. Indeed, they are forever changed. However, in order to retain resilient, we are committed to ensuring they have access to all resources via our care of the caregiver program and can continue to live in a healthy manner as members of our corps.

Last year, we celebrated the 100th anniversary of the Navy Nurse Corps. Within the next century, we have identified what we must do to continue to prepare our nurses to deploy in any environment to care for America's heroes. We are not the same nurse corps of our ancestry; we are moving into assignments and unchartered roles that were never held by Navy nurses before. For example, within this coming year, a Navy nurse will become the first nurse assigned to the headquarters of Marine Corps -- are the Marines in for a surprise. (Laughter.)

We are models of interoperability as we function seamlessly in missions beside our sister services on land, sea, and air. Our skillful integration and translation between services is perhaps best exemplified in this last vignette. At the conclusion of one of my nurse's briefs in Afghanistan during a transfer of authority between incoming and outgoing personnel, a colleague turned to her and said, while you might not have learned a lot of Dari while you were here, you can sure speak Army well. Hoo-ah! (Laughter.)

I appreciate the opportunity to share some of these accomplishments of my wonderful nurses, and I look forward to continuing our work together as I lead Navy nursing. Thank you.

SEN. INOUYE: All right. Thank you very much, Admiral.

General Horoho.

GEN. HOROHO: Chairman Inouye, Vice Chairman Cochran, and distinguished members of the committee, it's an honor and truly a privilege to be able to speak before you today on behalf of over 40,000 officers enlisted and civilians of the Army Nurse Corps. It has been your continued unwavering support that has enabled Army nurses as part of the larger Army Medical Department Team to provide the highest quality of care to all those who are entrusted to our care.

Army nurses are a corps of seasoned combat veterans that are highly trained, highly skilled, and highly committed. We deploy an average of 400 to 500 Army nurses a year, so we have moved well beyond lessons-learned to lessons-applied.

For example, Army nurses in Iraq in the Iraq theater who fly MEDEVAC with critically wounded patients have developed a set of tactics, techniques, and protocols over the last seven years that we've codified into an intra-theater flight nursing program, a program we'll sustain for the future. Our flight nurses have decreased the incidents of hypothermia for the patients that fly in the back of these MEDEVACs from 20 percent to less than 5 percent.

On my recent trip to Iraq I was absolutely humbled to see the level of care that is provided to not only our service members, but to coalition forces, contractors, and the detainee populations that we served. I was told how at the Ibn Sina Hospital that's in Baghdad, Army nurses moved patients into the hallways away from the glass windows when the hospital was under mortar fire, and covered them with their own bodies so that they were protected. These patients were wounded Iraqis.

Army nurses are partnering with Iraqi nurse leaders to help them begin to rebuild their profession of nursing. The nurses of the 345th reserve component Combat Support Hospital established training programs on the fundamentals of emergency nursing, and subsequently are providing medical diplomacy at the most crucial interface between two nursing cultures.

During this year of the noncommissioned officer, I want to share a story with you about a particular NCO that established an automatic external defibulator program for the entire Iraqi theater. This NCO recognized the need to have emergency cardiac care equipment in theater that provides our soldiers with the same standard that we offer in the United States. He created the theater-wide policy that mandated easy accessibility to AEDs.

This NCO had an opportunity to put into action his own policy when he encountered a sergeant major that was in cardiac arrest. He quickly responded with the AED and saved this sergeant major's life. I'd like to introduce to you Sergeant Major Brurer (ph) who is in the audience today. He is my sergeant major -- could you please stand -- he is my corps sergeant major, and is returning from his second deployment in Iraq. We could not be more proud to have him as part of our team.

Furthermore, I would like to highlight the nurse case management program at Camp Cropper and Camp Bucca detainee camps in Iraq, built and managed by our NCO licensed practical nurse, Army nursing team members. To date, the program has provided specialized wire medicine care for over 1,000 Iraq detainees requiring case management care for diabetes, hypertension, and medical management.

I am proud of the Army nursing team as they shape the face of deployed nursing. We are sustaining best-practice strategies to provide standardized nursing care from the combat zone to an Army medical treatment facility through the warrior transition unit all the way into our VA hospitals. The Army Nurse Corps is undergoing the most massive transformation that I've seen in my 25 years on active duty. We're using the first-ever Army Nurse Corps campaign plan to operationalize a nurse corps that consistently achieves performance excellence, fosters innovation, builds knowledge and capabilities, and ensures organizational credibility and sustainability.

We are piloting an inpatient and an ambulatory nursing care delivery system that uses best practices and evidence-based data to optimize patient outcomes. These pilots are already showing improvements in staff satisfaction, in interdisciplinary communication. We're also incorporating data from the military nursing outcomes database study, as well as evidence-based research from the TriService Nursing Research program, funded studies of which we are extremely grateful for your support into our practice to reduce the incidents of care indicators like patient falls and medication errors.

We are standardizing nursing care delivery systems to decrease patient variance and improve patient outcomes.

For example, nurses at Walter Reed Army Medical Center collaborated with our VA nurse colleagues to develop the first-ever evidence-based nursing transfer note that is electronically exported to a web-based- secure portal (?) allowing staff to bidirectionally exchange critical patient information in real time. This effort significantly optimized Army and VA nurses' ability to tell the patients' story via the electronic medical records.

We are harnessing the power, the pride, and the passion of Army nurses to transform into a corps that by 2012 is leading a culture, a performance innovation and improvement across the entire continuum of care. This is unequaled in the delivery of nursing excellence. We will use the vision to embrace the past, engage the present, and envision the future. On behalf of the entire Army Nurse Corps team serving worldwide, I'd like to thank each of you for your support and unwavering support, and I look forward to continuing to work with you. Thank you.

SEN. INOUYE: Thank you very much, General. And now General Siniscalchi.

GEN. SINISCALCHI: Mr. Chairman and Mr. Vice Chairman, and distinguished members of the committee, it is an honor to come before you today to represent the United States Air Force Nurse Corps. I am proud to serve alongside Brigadier General Catherine Lutz, Air National Guard; Colonel Anne Manley, Air Force Reserves; and Chief Master Sergeant Joseph Potts, Aerospace Medical Service Career Field Manager. Together we represent a robust total nursing force, supporting our Air Force chief of staff's top priorities.

I would like to thank you for your continued support of our Air Force Nurse Corps. Thank you for providing the funding for our accession bonuses, health professions loan repayment and scholarship programs, and our first-ever incentive special pay program. We anticipate the incentive special pay program will positively impact our retention. Last year, 55 percent of our nurses who separated had less than 20 years of military service. And 61 percent of those were our young lieutenants and captains. We are diligently working with our Air Force personnelist (ph) and our surgeon general to address and correct this issue.

Although the incentive special pay will help retain our nurses, retention may further extend timing and reduce promotion opportunity until we correct our grade structure. Our enlisted medical technician, in partnering with A-1, secured funds for their critically manned specialties. Our independent duty medical technicians are heavily tasked with deployments and manned at only 72 percent. I along with Chief Potts am eager to see this initiative's impact.

Through your sustained support of our TriService Nursing Research program, we recently published the "Battlefield and Disaster Nursing Pocket Guide." This guide is utilized throughout our deployed locations. We continue to conduct state-of-the-art research and validate evidence-based practice. Colonel Margaret McNeal, a Ph.D. Air Force Nurse, is in Iraq as a member of the new deployed Combat Casualty Care Research team exploring advancements in medical therapies for our wounded warriors.

The key to successful peacetime and wartime nursing operations is a robust nursing force, a force with the right numbers, right experience, and the right skills. Recruiting experienced nurses continues to be a significant challenge. Although we reach 93 percent of our accession goals, 56 percent were novice nurses, validating the importance of our nurse transition program. And I'm pleased to inform you that our first civilian program at the University Hospital in Cincinnati graduated their first class on December 12th.

Our enlisted nurse commissioning program grows Air Force nurses from our highly skilled enlisted force. We had our first two graduates this year, and we'll have 19 next year. Air Force nursing is an essential operational capability. In 2008, our total nursing force represented 34 percent of all deployments within our medical service. Our medics deployed to 44 locations in 16 countries. Our total nursing force is a well-trained, highly skilled, and committed to saving lives.

We are called to a mission of caring for America's sons and daughters, and here are a few examples. Captain James Stuart (sp), a nurse anesthetist, deployed to Joint Base Balad, received a message from his friend and coworker, Captain James Johnson, informing him that his son, Army Staff Sergeant Curtis Johnson, had been wounded and was in route to Balad. Captain Stuart met Curtis on arrival and recalls, "He arrived stable so we placed a call to his dad so they could talk before we started surgery. Curtis' spirits were high, and I was amazed at how well he was taking the loss of both his lower legs. Following surgery, Curtis was aromatically evacuated to Brooke Army Medical Center and is now undergoing rehabilitation at the Center for the Intrepid.

The Commemorative Air Force recognized Captain Bryce Sandersway (ph) with the Dolly Vincent Flight Nurse Award for aromatical evacuation support to 651 sick and injured warriors, including two canine military working dogs injured by IEDs.

As the trauma nurse coordinator at Joint Base Balad, Captain Zarsie Mornimur (ph) recalls her most precious memory: "We simultaneously received five casualties from an IED blast. When the emergency department settled down, the hospital held a ceremony for the soldier we could not save. Two of his wounded comrades requested that their litters be placed so they could salute their fallen comrade and friend.

In the midst of death and heartache, there are stories of hope and joy. This past October, our staff delivered the first Afghan baby born at Craig Joint Theater Hospital, Bagram. The mother sustained massive injuries as a result of an explosion. But with the help of the Air Force medical team, she delivered a healthy baby girl. According to Technical Sergeant Jeremiah Dias (ph), we had 15 minutes to come up with something. We used a warming blanket and made a little tent with coat hangers, and an egg crate mattress. The newborn's presence was a ray of light.

Mr. Chairman and distinguished members of the committee, thank you for allowing me to share today just a few of the many achievements of Air Force nursing. As our Air Force Medical Service celebrates its 60th anniversary, we recognize we stand on the soldiers of giants. I commit to you we will continue to meet every challenge with professionalism, pride and patriotism that have served as the foundation for our success.

Our warriors and their families deserve the best possible care we can provide. It is the nurses' touch, compassion, and care that often wills a patient to recovery or softens the transition from life to death. There has never been a better time to be a member of this great Air Force nursing team. So on behalf of the men and women of Nursing Services, thank you for your tremendous advocacy and continued support.

SEN. INOUYE: On behalf of the committee, I thank all of you, but I'll give a few questions. There's no secret that there's a national nursing shortage, but somehow you gals have done a good job -- the Air Force has met 93 percent of its goal; Army and Navy have exceeded their goals. What's the secret?

GEN. HOROHO: Chairman, I think the secret is a couple of things: the support that we've received from Congress with the different incentive specialty pay bonuses that has had an overwhelming success with our nurses choosing to remain on active duty. The other is working very collaboratively with the Army Medical Recruiting Brigade. We stood up a brigade in 2007 that focused on recruiting nurses, and the entire Army medical team. And so the first time last year since 2001, they actually exceeded the mission by 147 percent for recruitment of nurses on active duty.

So having that specialized -- there were also bonuses that were given to the recruiters to be able to target special critical categories. We've also been very, very proactive with telling the Army Nurse Corps story and having our nurses engaged in helping with the recruiting effort.

ADM. BRUZEK-KOHLER: Mr. Chairman, there's no doubt that the support we've received from you for our -- in accession bonus increases, and in particular our loan-repayment program, has made a tremendous difference in the numbers of direct accessions, particularly in light of the economic situation for many of our new students. They come with extremely high student loans, more than I would have anticipated. In fact, I remember meeting a lieutenant in Bahrain who had not yet heard about the program -- a new graduate with over $60,000 worth of school loans. So that has made a major, major difference in their lives.

We've expanded our opportunities with our recruiters to use our own nurses in geographic areas, particularly nurses who are going to many of our professional organizations, both in terms of clinical skills, but also in terms of some of our diversity issues. And selling our story, telling our story as well, that has really made a difference in bringing some of the diversity that we've not been able to get in the past. So we will continue to use all of those opportunities to bring in our direction accessions.

We also have a huge pipeline, as we've heard from our sister service in the Air Force, with our medical enlisted programs, and using our corpsmen and other enlisted rating applicants to come into the nurse corps has really been our life's blood really for keeping our corps at a level of being able to provide the kinds of care we provide. And we will continue to support those programs as well as our ROTC programs and our candidate programs. So, again, we thank you for that support for all of those.

GEN. SINISCALCHI: Senator Inouye, thank you. And I would like to reiterate my nursing colleagues for our Air Force accessions. I can attribute our success has been with recruiting novice nurses, the nurses who are completing their bachelorette degrees and are coming into the Air Force as novice, with less than six-months' experience.

Our loan repayment program -- the increase that we received has been very successful. We were able to increase our (quotas ?) from 76 to 102. And the increase in our health professions loan repayment (quotas ?) had a significant impact on our ability to recruit more novice nurses. The accession bonus has also been a very successful recruiting tool, and we appreciate the increased funds that we receive in accession bonuses this year.

And we are finding that with the 30,000 in the accession bonus and up to 40,000 in the loan repayment combination is very helpful to those students who have large loan repayments. So I would like to thank you again for your support with those programs.

We've taken several initiatives to continue success with recruiting. Dr. Casscells and Dr. Hinshaw from USU had organized a conference for academic partnerships addressing military nursing shortages. And that occurred this past weekend. And we had the opportunity to meet with nursing deans and faculty across the country. And our objective was building collaborative relationships among military nursing services with the schools of nursing to foster additional educational opportunities and begin a campaign to educate the faculty from these schools so as they are mentoring and advising their students, they can help direct them toward military nursing as a potential career option.

SEN. INOUYE: Do you believe that we have enough nurse initiatives -- critical care nurses, OR nurses -- these specialists?

ADM. BRUZEK-KOHLER: Those are our critical areas right now that we are looking at in terms of retention as well as accessing. We do not have enough; they are undermanned at about anywhere from 60 to 70 percent. We think anything below 90 percent is critical, and we have to pay attention to them.

I will say our nurse anesthetists actually are very healthy. They aren't really one of the groups that we are focused on this year. Our perioperative nurses, our OR nurses, our critical care nurses, and our nurse practitioners are below that critical 90 percent at this point in time. So we're doing a couple of things. We are looking at when we are recruiting to recruit to those specialties, which means we will bring in a more seasoned, more experienced clinical nurse at a more senior rank.

We don't anticipate nor do we know at this point whether these nurses would want to continue on a full naval career or at least be with us during a very critical time in our history while this war is still going on.

For retention, again, the loan repayment program, the RNISP has been absolutely the most positive actions we could have taken to entice our more senior nurses, particularly those who are at the point of either the 10-year park where they either make the decision to leave now or they continue on for 20 years. Or for some who have come in from the enlisted ranks, who at the 10-year officer mark now have 20 years and can in fact retire, those incentives have actually been positive in making the decision for them to stay in the Navy. And also the opportunities to deploy have been remarkable incentives for our people to stay in the Navy.

SEN. INOUYE: General Horoho.

GEN. HOROHO: Mr. Chairman, both the emergency nurse specialty as well as the ICU specialties are two of our highest deployers as we support two theaters of operation. So we have been working very aggressively to expand our critical skill sets by helping them with deployment skills and training. We have increased the number of seats to be able to train more. We've also started to target the population at the rank of major because I'm at 50-percent strength at that middle-grade leadership, and we're trying to force more clinical expertise back at the bedside.

So there's a pilot project that's ongoing that gives us the authority to be able to recruit individuals to come on active duty for a two-year obligation. So what we are doing is working very closely with recruiting command and accessions command to be able to target that clinical expertise and bring them on active duty for a two-year obligation to help us bridge that critical short fall that we have.

SEN. INOUYE: General Siniscalchi.

GEN. SINISCALCHI: Sir, direct recruitment of our nurse specialties continues to be a challenge. We've come up with programs, very successful programs, to help us with retention and to help us develop those skill sets that we need ourselves. The biggest impact on retention has been the incentive specialty pay program. We just started this program in January and so far over 76 percent who decided to participate in the program accepted the four-year active-duty service commitment. So that will have a significant impact on our ability to retain those critical areas.

We've developed fellowships that are a year-long in critical care emergency training and trauma training that helps us to grow nurses in those critical areas. We continue to select nurses annually to attend USU for advance academic training in critical areas. We've increased our family nurse practitioner (quotas ?) from five to 20 this year. We have an operating room cross training course at Wilford Hall, and a neonatal intensive care course at Wilford Hall which is helping us to meet those critical specialties.

Our future plan for this year is to build a mental health nursing course at Travis Air Force Base. We've had difficulty recruiting mental health nurses, as you know, they are very critical in the care of our wounded warriors. So we are hoping to see this program come to fruition this year. We are building master clinician opportunities at the colonel ranks so that we can have senior leaders in anesthesia, in the operating room, in emergency rooms, and in critical care areas that can help grow and mentor those nurses in those critical specialties.

SEN. INOUYE: Thank you very much. Vice Chairman.

SENATOR THAD COCHRAN (R-MS): Mr. Chairman, thank you. I am concerned that the challenges in view of the war and the constant separation from families and friends may have a very serious consequence in terms of the success of recruiting. And I was sitting here thinking about what could we do as a committee to be helpful to you in increasing the likelihood that your goals were met and that retention rates are high and what you need. Would additional funding of specific programs targeted to recruiting and retention be in order, or do you have enough money to do what you need to do?

ADM. BRUZEK-KOHLER: Well, I'll begin by saying that the support that you have given us to this point in time has shown dramatic improvements in the numbers of accessions, direct accessions and the retention numbers. They have shown that they are successful in, one, in enticing people to join the Navy as well as retaining them for a full commitment to a full career in the Navy. So I thank you for those, and certainly we would appreciate to be able to continue to offer those incentives, both as accession bonuses as well as our loan repayment program, which as I mentioned has been an amazing support to our new students, our new graduates, and our retention bonus to enable our nurses who see that there is competition as a civilian nurse give them the opportunity to want to continue to serve their country.

We do exit interviews of all of the nurses that leave the service. And I will tell you that deployments is generally not the reason why they leave the Navy. Usually it's family issues, dual career families wanting to get stable in a community. We also find as we are doing recruiting, particularly at schools of nursing throughout the country, that deployments are not a reason not to join the Navy, that in particular with our ability to provide humanitarian assistance and that type of service to other countries, that again is very enticing to a nurse who really wants to feel like they are fulfilling what the purpose of being a nurse is in the first place.

So at this point, I would just say, thank you for what you've done for us up to this juncture, and we would certainly be thankful for that continued support.

SEN. COCHRAN: General Horoho.

GEN. HOROHO: Yes, sir. I would echo and say continued support of the programs that we do have in place because when we have looked at our nurses, 97 percent of those that are eligible to take those loan repayment programs or the bonuses have accepted them. And so I think it does show that they are positive incentives to helping individuals remain on active duty.

The other incentive is that there is tremendous pride with our nurses that deploy. And most of them that come back have echoed that they found great self-worth to be able to know that they were helping to enhance the health care of those service members that are supporting our freedoms as well as helping with the nation-building.

One of the things that has truly impacted I think retention is that we have changed our policy for deploying nurses from 12 months down to a six-month rotation. That in itself has helped to help with the time to decrease the time away from their family members. So when we look at it, it's the financial incentive programs as well as those support programs that we have in place.

We did a survey across the entire Army Nurse Corps so that I could have a baseline understanding of kind of the health of the corps. And out of that survey we found two areas that we're going to focus on. One of them is looking at the redefinition of our head nurse role of wanting to make sure that that role is having the ability to impact patient care, and it's really focused on outcome- based, as well as leader development. So we've got a team that has set up to look at best practices across our entire Army Medical Department as well as looking at what is being done within our civilian health sector, and then we're going to redesign that leader development role.

And we're also looking at the entire leader development training program that we have in place, because when you look at young nurses during the exit survey -- and we do exit surveys on everybody who's leaving -- a majority of it is because of family reasons, either starting families or an elderly parent and needing to be home. And so two things that we're doing: We're looking at and partnering with the Army to see how is it that we can have a program in place to help nurses take NE (?) and be able to still meet their family needs as well as their military obligation.

And then we're also looking at how do we ensure that we've got our nurses best prepared for the deployment. So we're redoing -- this past year we had 186 lieutenants that were assigned to each one of our medical centers for a year-long clinical immersed program to help them get their clinical skills solidified, as well as their critical thinking skills prior to deployment. So I think those were the major things that came out of the organizational survey.

SEN. COCHRAN: Thank you. General Siniscalchi.

GEN. SINISCALCHI: Sir, I would add, in addition to your support for our nurse accession bonuses and the health repayment -- the health professions loan repayment program, it's more than just the financial incentives that incentivize our nurses. The opportunities for advanced education, the opportunities for increased leadership roles and leadership training has a significant impact on retention.

The support of the health professions scholarship program has been critical. That program, the funding for that program has allowed us to take nurses who already have bachelorette degrees, and put them in programs -- civilian nurses, sponsor their education -- put them in programs for anesthesia training, to become family nurse practitioners, women's health practitioners, and that allows them the opportunity to have advanced education paid for by us and then come on active duty and serve in those critical areas. So I would -- I would submit that continued support of the health profession scholarship program is a big incentive.

And we do continue to look at opportunities, to partner with civilian programs so our nurses can have increased opportunities for advanced education and leadership training.

SEN. COCHRAN: Thank you very much.

SEN. INOUYE: Senator Murray.

SENATOR PATTY MURRAY (D-WA): Thank you very much, Mr. Chairman. I apologize for having to step out; I missed your testimony. But I wanted to personally thank all of you and everyone you oversee for the tremendous work that they do. And General Horoho, it's good to see you here. I appreciate everything you've done out at Madigan Army Medical Center, and appreciate your leadership, as well as both of you.

Time is getting late, so let me just ask one question. I'll submit the other ones for your answers later. But General Horoho, as you know, the Army's deployment schedule and adequate care of both the soldiers and their families is very important to me. We've had the chance to talk about that. And I wanted just to ask you how you are planning to continue to take care of children and families of servicemen.

GEN. HOROHO: Yes, ma'am. First, I'd like to thank you for your support because we get tremendous support from you and your entire team, and Madigan Army Medical Center being able to meet its mission. Madigan Army Medical Center, the troop strength in Fort Lewis has grown over the years. And so our enrolled population at Madigan has increased from 84,000 to currently we have 106,000 enrolled beneficiaries. And when you add on the health care benefits of that reliant population, which are those reserve soldiers and National Guard that are able to get extended health care, that increases it about 33,000. So we have the third-largest enrolled beneficiary population in the Army, about 133,000. Of that, 20,000 of those are women. So it's a growing population. The increased strength is 20,000 for women and for children.

So what we've done is we have looked at -- we have submitted a proposal of funding for our women's health center that will allow us to consolidate all of those services together to better meet the needs of our women and our children so it's more of a continuum from the infants through the adult parent. And with that, if it's awarded in 2010, then we would look at design and construction beginning and having it completed about 2014. What that would allow us to do is to be able to maximize the efforts. We have a DOD fellowship, the only one in the Army for developmental -- (inaudible) -- as well as maternal-fetal medicine. So we'd have that capability of having the right case mix to be able to help our residents grow and our physicians grow in that specialty.

We also are looking at if that building is built, then we would take that space that it's relieved to further expand our primary care to be able to meet the increased demand that we have from that troop population growth.

SEN. MURRAY: Well, I really appreciate your strong push on that, and want to be supportive in any way I can. It's a great way to move forward I think. And obviously whatever I can do from my end to support that, I really appreciate it.

GEN. HOROHO: Thank you.

SEN. MURRAY: And I just want all of you to know I'm worried about compassion fatigue from all of our nurses. And I know that's a recruiting issue, retention issue.

And we have to look at what we can do, Mr. Chairman, to support them. And, General, you had mentioned several good ways to do that. And I want us to encourage all of us to continue to do that.

I do have several other questions. I know you've been sitting here for a long time, so I submit them for the record, but I do really appreciate the work that all of you do. So thank you so much.

GEN. HOROHO: Thank you, ma'am.

SEN. INOUYE: The nurses are fortunate to have Senator Murray here. (Laughter.)

One of the priority projects I had when I first got on the subcommittee was to make sure that nurses got full recognition for their service. And the one way to do that in the service was by rank. And at that time, I believe I met one nurse who was a colonel. Most of the nurses I knew were captains or lieutenants. I'm happy to see two stars all over the place. But I know that in the Navy you have rear admiral one star, rear admiral up a half two stars. But in the Army and Air Force, there's no billet for one stars. Why is that?

GEN. HOROHO: I'll go first if you don't mind. Sir, one of the things is that we have the surgeon general's full support of leader developing all of our Army Medical Department leaders. And our general officer slots are branching material. And what we do is we work very, very hard as a collective force to be able to ensure that we have the right leadership skill sets, not only the education programs, but the command opportunities, as well as the clinical opportunities to lead at that level. And so we are working very closely to ensure that we have a pool of personnel that will be competitive for general officer at the one-star rank.

GEN. SINISCALCHI: Sir, having gone from colonel directly to two stars, the current construct has worked very well, and I've had tremendous support from my senior leaders. Within the Air Force, we have a limited number of general officer authorizations. And we have elected to allow each of our corps the opportunity to have a star as their pinnacle rank. So if we add a nurse corps one star, we will have to offset it elsewhere. So our current plan is to continue with the current construct and continue to develop our colonel nurses, and select those nurses who have more time and grade and more time and service so that we're selecting our senior colonels as we promote them to the rank of two stars.

SEN. INOUYE: So it would help if we authorized one-star billets with the money that we can provide here. You won't be against that would you? (Laughter.)

GEN. SINISCALCHI: Sir, I would never turn down stars. (Laughter.)

SEN. INOUYE: Well, I thank you ladies very much. I want to thank General Schoomaker, Admiral Robinson, General Roudebush, General Horoho, Admiral Bruzek-Kohler, and General Siniscalchi for your testimony and for your service to our nation. This subcommittee will reconvene on Wednesday, March 25th, at 10:30. At that time we will receive testimony from the guard and reserve. Until then, we'll stand in recess.

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