Rear Admiral Niemyer was interviewed by Group Editor Marty Kauchak. The interview addressed a wide range of learning technology and related training topics in the admiral’s expansive portfolio.  

Rear Adm. Elizabeth S. Niemyer. Image Credit: U.S. Navy.
Rear Adm. Elizabeth S. Niemyer. Image Credit: U.S. Navy.

MEdSim:  Provide some examples of how simulation, simulators and other technology support your nurses’ continuum of learning for individual and team skills.     

Rear Admiral Niemyer:  As key members of multidisciplinary treatment teams, Navy nurses are essential to the provision of outstanding care and optimal patient outcomes for beneficiaries and wounded warriors here at home serving in various clinical and leadership roles within our military treatment facilities (MTFs) and ambulatory care clinics.  The clinical expertise and leadership of Navy nurses ensures a fit and ready fighting force vital to the success of Navy and Marine Corps operational missions at sea and on the ground.  Navy nurses are key players in Humanitarian Assistance/Disaster Relief efforts, medical stability operations and deployment of hospital ships and large-deck amphibious vessels around the world. The Navy Nurse Corps recognizes its people as our most vital asset and we are committed to maintaining a force of highly-skilled and adaptable nurses ready to meet these diverse challenges. From newly graduated novice nurses to extremely experienced advanced practice nurses, medical simulation technology provides a realistic training forum to develop, refine and sustain critical thinking ability, hands-on procedural skills and effective team communication techniques in a safe and controlled environment conducive to continued learning and professional growth.

Medical simulation technology is currently being utilized within our MTFs and training sites as an adjunct for beginning and advanced resuscitation courses such as Basic and Advanced Cardiac Life Support (BLS, ACLS), Pediatric Advanced Life Support (PALS), Pediatric Emergency Assessment, Recognition and Stabilization (PEARS), Neonatal Resuscitation Program (NRP), S.T.A.B.L.E. for neonates, Advanced Life Support for Obstetrics (ALSO) and Trauma Nurse Core Course (TNCC), and Operational Emergency Response Training. Medical simulation technology is also being added to the clinical orientation process for new nurses, physicians and Hospital Corpsmen providing additional training and markedly enhancing the clinical expertise gained from direct patient care at the bedside.  Nurses working in high-risk, high-acuity clinical environments such as emergency/trauma, critical care, pediatrics and obstetrics have readily recognized medical simulation technology as essential to adequate preparation and effective response for emergent patient situations conducting frequent training evolutions and impromptu drills utilizing high-fidelity simulators such as the Mobile Obstetrical Emergency Simulator (MOES), SIM Man, SIM Baby and MATT Man.  We also utilize simulation technology to train to specific tasks such as placement of intravenous catheters and central lines, as well as, virtual trainers.

And most importantly, the value in having the various types of medical simulation technology available and utilized for preparing and training our nurses (in conjunction with all members of our health care team) for the most arduous and challenging assignments in support of our frontline operational forces on the battlefield cannot be emphasized enough. Training our nurses and health care personnel for operational missions has become one of the major focuses in utilizing medical simulation technology.   Numerous patient scenarios and simulation training modules have been developed to provide a realistic replication of  the types of traumatic injuries sustained on the battlefield to familiarize and prepare our nurses and health care personnel for rapid identification and treatment of these life-threatening, traumatic injuries prior to their deployment into the chaotic and stressful battlefield (pre-hospitalization) and trauma care environment.

Overall, the training capability and continued learning forum afforded to nurses and all members of our health care team through medical simulation technology has become absolutely vital to developing and sustaining the clinical acumen and team communication skills necessary to ensure optimal patient safety and the delivery of the highest quality care to those entrusted to us.

MEdSim:  As a follow-up, tell us about the returns on investment and other benefits your community expects from learning technologies.

RN: Clinical excellence in the provision of holistic and compassionate patient and family centered care is the cornerstone of Navy nursing. The benefits of medical simulation training are evident in all facets of Navy nursing and the roles in which they serve. The expected return on investment and benefits of learning technologies within the Navy Nurse Corps is high. Over the past several years, emphasis on preventive health care and wellness promotion coupled with the increased medical capability to provide surgical and procedural interventions as an outpatient has resulted in decreased volume and length of stay for inpatients within our MTFs. Additionally, we have felt the additional challenges of growing and sustaining clinical experts in support of our fighting forces for a nation at war for the past decade. Navy nurses must be clinically proficient and ready to meet the challenges of the diverse assignments they are given anytime, anywhere while setting the standard for excellence not only as outstanding clinicians, but as patient advocates, mentors and leaders in the provision of compassionate and holistic care even in the most austere conditions. Although there is no substitute for direct patient care at the bedside, medical simulation technologies offer an extremely desirable method for further enhancing the clinical knowledge, skill and expertise gained through the provision of hands-on care at the bedside. The implementation of medical simulation technology has increased confidence, knowledge, skill, and effectiveness of communication for nurses to be at “the top of their game” and stay there,  providing state of the art nursing care no matter what environment they are working in . I would like to share just a few of the significant accomplishments of Navy nurses serving in unique roles and environments throughout Navy Medicine to bring some real-life perspective to what I feel is the return on investment and benefit of medical simulation technology.

Navy nurses are respected health care professionals involved in all levels of professional nursing organizations, the advancement of nursing practice and sustainment of clinical excellence. Central to the provision of outstanding care are those nurses providing direct patient care at the bedside within our MTFs, as well as, our ambulatory care clinics stateside and overseas.  Nurses new to the Navy face many unique challenges from learning the intricacies of patient care and becoming competent in the application of newly acquired knowledge, skills and abilities to integrating into the navy culture as a commissioned officer. Medical simulation technology provides an avenue for novice nurses to develop and enhance their competence, confidence, and comfort in the care of patients in a myriad of clinical settings such as medical-surgical, pediatrics, obstetrics, critical care, and emergency/trauma. It also facilitates the sustainment of clinical knowledge and skills of experienced nurses. This strong clinical foundation is pivotal to continued learning and the development of advanced knowledge and skills required of our more autonomous and arduous assignments.

In addition to the more traditional role of nurses, Navy nurses also provide a vital portion of the medical care provided in the operational arena. Navy nurses provide medical support to civil-military operations and health-related activities such as the Combined Joint Task Force Team-Horn of Africa in Djibouti, Africa, long-standing humanitarian deploying our hospital ships such as CONTINUING PROMISE and PACIFIC PARTNERSHIP, disaster relief efforts such, and routine maritime operations aboard aircraft carriers and amphibious vessels caring for our Sailors and Marines. They are also integral members of diverse units and teams throughout Afghanistan as members of Shock Trauma Platoons and Forward Resuscitative Surgical Systems assigned to Marine Corps and Medical Battalions, Expeditionary Forces and Logistic Groups supporting the immediate pre-, intra-, and post- operative phases of care for traumatically injured patients. These nurses are providing life saving trauma care on the battlefield immediately following injury. They are also trained and qualified to provide en-route care and medical support in rotary wing airframes during the transport of our war injured to higher levels of care.  Following initial life-saving stabilization on the battlefield, critically injured patients are transported to comprehensive medical facilities such as the Role 3 Multinational Medical Unit in Kandahar, Afghanistan. The clinical expertise and technical skills gained through experience and simulated training have ensured nurses capability to effectively function in a chaotic, high-complexity, high stress environment often inundated with several casualties simultaneously. The casualties treated at this facility commonly suffer injury severities scoring twice as high as the average patient seen in a Level 1 trauma center in the United States. Navy nurses are making a tremendous contribution to the unprecedented survival rate of our war casualties of greater than 95 percent.  It is extremely probable that the majority of these experienced emergency/trauma and critical care nurses filling these assignments benefited from medical simulation technology as an integral piece of their deployment preparation and training. The return on investment is self-evident.

MEdSim: What is the U.S. Navy Bureau of Medicine and Surgery's funding for learning technologies contained in the president's FY 2013 defense budget request? 

RN: While there is not a specific line item on BUMED's budget for learning technologies, Navy Medicine has $92.8M programmed in the FY13 budget for the overall education and training of the patient population and workforce through various learning venues.

MEdSim: You are also monitoring advancements in virtual reality treatment to help treat traumatic brain injury and post traumatic stress disorder in the services' wounded warriors. What are some of the recent advancements in this field that have gained your attention?

RN: Yes, virtual reality in the treatment of PTSD continues to be utilized clinically and to be studied in research programs. Results indicate that it has similar efficacy when compared to Evidence Based Treatments (EBT) such as Prolonged Exposure or Cognitive Processing Therapy. The emerging research is examining the different aspects of EBTs across different symptom presentations. The ultimate goal is to match particular EBTs to particular symptom presentations.  That is, we are theorizing that more fear-based symptom presentation of PTSD may respond best to exposure therapy.

The vast majority of TBI patients recover without a need for long-term care or intervention. However, those that do require continued care often need uniquely tailored treatment plans that capitalize on a variety of modalities available. With this in mind, through ongoing research, enhanced training, and implementation of state-of-the-art tools, Navy Medicine and the Department of Defense (DoD) continue to advance virtual reality (VR) technology and the availability of virtual reality treatment for service members. Navy Medicine strives to offer VR technology as a treatment modality for Wounded Warriors when appropriate.

Throughout the DoD, there are several Computer Assisted Rehabilitation Environment (CAREN) systems in use (Naval Health Research Center, National Intrepid Center of Excellence, Military Amputee Treatment Center, and Center for the Intrepid). The CAREN uses virtual reality environments, such as a war-fighting experience, to aid in the assessment and rehabilitation of Wounded Warriors, including those with TBI and amputation. The CAREN has an eight-foot tall, 180- or 360-degree screen whose images are synchronized with movement of a central platform and input from the user. At the Naval Health Research Center (NHRC), they are currently using the CAREN to investigate head stabilization in TBI and amputee populations.

MEdSim: As another follow-up, provide some suggestions to allow the professionals in this field to more effectively meet the needs of the wounded warriors.

RN: Mental Health providers are passionate about helping our warriors and they are doing excellent work in their therapy rooms. Unfortunately, sometimes the overall system can be fragmented. Initiatives such as the Psychological Health Pathways (PHP) are being deployed to provide more comprehensive standardized care. PHP is a best practice psychological health treatment and care management system. Its goals are to improve continuity and collaboration between and across disciplines and clinics, improve access to evidence-based treatments, and provide a comprehensive Web-based registry and patient-tracking tool.

MEdSim:  What are some of the new learning technologies the Navy nursing community may see delivered during the next 12 months?

RN: As new technologies are developed and available, the Department of Navy Medicine will continue to support implementation of these technologies into the professional development and clinical sustainment of our health care personnel. The potential is unlimited as we continue to explore options for incorporating newly developed technologies into the development and clinical sustainment of Navy nurses.  Nurses, in particular, have to learn very early on to effectively address a huge variety of requests, demands, questions and problems that arise in the care of unique patient populations experiencing a myriad of conditions. The ability to provide training that addresses each and every possible patient scenario that might arise can become extremely costly and create scheduling and staffing challenges. The availability of virtual training and “serious gaming” providing real-time, 3-D modules or online training scenarios that are accessible to nurses and healthcare professionals any time could become a very viable option in meeting the professional development needs of an extremely versatile and mobile Navy Nurse Corps.

In the meantime, our current efforts will continue to focus on maximizing the utilization of existing technology to its fullest capability. Currently there are efforts underway to incorporate the various medical simulation modalities to create “hybrid” types of simulation training using both high fidelity simulation which provides a complex and comprehensive patient scenario and task training simulation to focus on specific procedural skills (“tasks”) that may be vital to the treatment of the patient in that particular scenario (i.e. blood draws, intravenous catheter insertion, etc.). Nurse clinical experts and educators will continue to collaborate on the utilization and development of Web-based training in conjunction and follow-on curriculums using medical simulation that targets the development and sustainment of core competencies specific to each nursing practice specialty, as well as, those unique to our operational roles on the battlefield and within the fleet.

Examination of a simulated patient during Naval Medical Center San Diego's (NMCSD) command wide-mass casualty drill. Image Credit:U.S. Navy/ Anastasia Puscian.
Examination of a simulated patient during Naval Medical Center San Diego's (NMCSD) command wide-mass casualty drill. Image Credit:U.S. Navy/ Anastasia Puscian.

MEdSim:  How have your nursing professionals’ lessons learned from supporting 10 years of war in Afghanistan and Iraq influenced the type and scope of learning technologies they require?

RN: As I touched upon previously, Navy nurses provide medical support to our operational forces serving with Marines on the battlefield, forward operating bases and treatment facilities throughout Afghanistan, as well as, aboard Navy ships and amphibious vessels supporting maritime operations, and aboard hospital ships and within medical units providing care during humanitarian and disaster relief missions.  They are also pivotal in the provision of care, treatment, and rehabilitation of our wounded warriors who have returned home. Medical simulation has become an essential and effective component in training and preparing our nurses for arduous assignments in support of our operational forces, as well as, the overall mission of Navy Medicine. Incorporating lessons learned based on wartime experiences  brought back by those who have served in those roles has resulted in the development of numerous training scenarios incorporating medical simulation technology. Some of these include:  Tactical Combat Casualty Care (TCCC), various scenarios incorporating knowledge and skills required in critical care and trauma arenas, en-route nursing care on rotary wing aircraft during patient transport and Operational Emergency Response Training.

Throughout the war, collaboration and resource sharing among all branches of service has continued to expand.  Within the medical departments, this collaboration has resulted in the development of the Joint Theater Trauma System (JTTS) Clinical Practice Guidelines (CPGs). Nurses serving in roles supporting our warriors have become extremely well-versed on these CPGs, not only utilizing them while in theater, but sharing their expertise. Returning nurses work to improve and tailor our pre-deployment training and serve as instructors for medical simulation training providing hands-on, customized education and training based on real-life scenarios incorporating the CPGs nurses will utilize within theater. The nurses who have received pre-deployment training that incorporates medical simulation have provided extremely favorable comments regarding their satisfaction with and effectiveness of this type of training.

MEdSim: Your “help wanted” list: What other advice do you have for the medical training systems community to help it meet your nurses learning needs?

RN: Medical simulation technology has clearly proven itself to be a very effective component to the education, training and ongoing professional development and clinical skills sustainment of today’s health care professionals. Students now entering the field of nursing are very familiar and comfortable with current technology as it is commonly used as an adjunct to clinical experience in their nursing programs.  They also expect to see this technology used to enhance their continued professional growth to improve the quality of care they are able to provide their patients. However, nursing is among the professions with a multi-generational workforce and those with significant experience in the field are attempting to rapidly come to terms with the fast-paced development and implementation of medical technology. It is imperative to seek input from the “end users”, that is, the clinical personnel and educators utilizing the simulation technology. The more realistic and “user-friendly” the technology, the more likely the continued implementation of medical simulation technology will remain an important and viable component for continued learning and clinical skills sustainment.

At the rapid pace simulation technology is developing and being implemented, I also believe that medical simulation technology is here to stay. As medical simulation continues to gain momentum, it will be imperative that we continue to invest the time and training necessary for our personnel to become and remain subject matter experts in curriculum development, as well as, operation of the medical simulators during training evolutions. Medical simulators are no different than any other advanced piece of medical equipment introduced into the work setting.  It requires trained personnel who remain current in the technological advances of medical simulation to effectively operate the simulators. Personnel specifically dedicated to and trained in curriculum development and operation of medical simulators will ensure our healthcare personnel receive the maximum benefit from this state of the art training modality.

MEdSim: Anything else to add?    

RN: In addition to the Navy Nurse Corps’ focus on clinical excellence as its cornerstone, we are also extremely committed to advancing the science of nursing practice through research and evidence-based practice to improve the health of our patients. Medical simulation technology opens up unlimited possibilities to expand nursing’s body of knowledge through research. Currently, there are nursing research proposals being developed and/or submitted for funding specifically geared toward medical simulation technology. We look forward to research outcomes surrounding this important learning modality.