1
Introduction and Background

In 1992, Congress authorized funds to support targeted research by military nurses through a new program—the TriService Nursing Research Program (TSNR Program, S.R. 102-154). In 1995, the program's advisory group (the TriService Nursing Research Group, TSNR Group), acting through the program administrator, asked the Institute of Medicine (IOM) to convene an expert committee to review the TSNR Program and supporting literature; to make recommendations for program management, areas for future research funding, and allocation of resources to program functions; and to identify short- and long-term objectives. In requesting this Institute of Medicine study, the TSNR Group seeks more formal mechanisms for assessing the state of the science that undergirds military nursing, for sustaining the research effort necessary to improve that science, and for actively translating these results into military nursing practice.

This military nursing initiative fosters acceptance of responsibility for rapid translation of fundamental research findings into clinical applications and for directing a reasonable portion of Department of Defense (DOD) investment toward military and peace operations; humanitarian assistance; and the urgent problems stemming from preventable illnesses, violence, and substance abuse.

Overview

Scope of Military Nursing

Nurses have a major responsibility for the provision of health care. In DOD, the responsibility is enormous. Military nurses confront a daunting range of



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--> 1 Introduction and Background In 1992, Congress authorized funds to support targeted research by military nurses through a new program—the TriService Nursing Research Program (TSNR Program, S.R. 102-154). In 1995, the program's advisory group (the TriService Nursing Research Group, TSNR Group), acting through the program administrator, asked the Institute of Medicine (IOM) to convene an expert committee to review the TSNR Program and supporting literature; to make recommendations for program management, areas for future research funding, and allocation of resources to program functions; and to identify short- and long-term objectives. In requesting this Institute of Medicine study, the TSNR Group seeks more formal mechanisms for assessing the state of the science that undergirds military nursing, for sustaining the research effort necessary to improve that science, and for actively translating these results into military nursing practice. This military nursing initiative fosters acceptance of responsibility for rapid translation of fundamental research findings into clinical applications and for directing a reasonable portion of Department of Defense (DOD) investment toward military and peace operations; humanitarian assistance; and the urgent problems stemming from preventable illnesses, violence, and substance abuse. Overview Scope of Military Nursing Nurses have a major responsibility for the provision of health care. In DOD, the responsibility is enormous. Military nurses confront a daunting range of

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--> health problems in ambulatory clinics, community hospitals, medical centers, hospital ships, field hospitals, ships, aircraft, and other settings. They are part of a health care system that incurs annually more than $15.4 billion in expenses to provide care for approximately 1.5 million active-duty military personnel and 5 million retired military personnel, family members, and other eligible beneficiaries.1 Service members and their beneficiaries are a diverse group culturally and ethnically. For example, 22 percent of all enlisted active-duty service members are black, 7 percent are Hispanic, and 5 percent are from other racial-ethnic groups. Thirty-one percent of all active-duty forces are nonwhite (Defense Manpower Data Center, 1995). Military nurses are responsible for controlling costs while providing state-of-the-art care ranging from the treatment of combat casualties to chronic illness and from health promotion and preventive care to maternity and gerontologic nursing for the vast range of beneficiaries. A majority of active-duty service members are young: 13 percent are age 20 years or younger, 50 percent are ages 21 to 30, and 30 percent are ages 31 to 40 (Randy T. Smith, Defense Manpower Data Center, Personal communication, 1996). Military nurses include all nurses in the Army, Navy, and Air Force, regardless of whether they are in the active or reserve component.2 Members of the selected reserve and guard components generally serve 2 days each month plus an additional 14 days per year. Reserve and guard members can be called to active duty on very short notice and assigned anywhere in the world during both peacetime and wartime operations. Army The 4,100 active-duty Army Nurse Corps officers provide nursing care in both inpatient and outpatient arenas to approximately 524,000 active-duty service members and to beneficiaries of all ages. Over 14,000 nurses serve in the reserve component. They serve in field, evacuation, and mobile facilities, as well as in the many fixed facilities in the continental United States and abroad. During Operation Desert Shield/Desert Storm, 2,265 Army Nurse Corps officers were deployed to Southwest Asia. In Somalia, Army nurses served in a humanitarian mission executed under hostile conditions. During this mission, Army Medical Department personnel cared for the largest single-day volume of combat casualties since the Vietnam War (Feller and Moore, 1995). 1   Nearly 2 million additional individuals are eligible to use the DOD health care system. 2   In the Army and Air Force, the reserve component includes the Selected Reserves and the National Guard.

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--> Navy The Navy Medical Department provides care for approximately 613,000 active-duty sailors and marines and for 2.6 million retirees and family members of active and retired sailors and marines. Approximately 3,200 active-duty Nurse Corps officers serve in various settings throughout the world, and nearly 2,000 nurses serve in the Selected Reserve. Navy nurses provide care to eligible beneficiaries and lead, teach, and guide those who assist them. In recent years, Navy Nurse Corps officers have served in Southwest Asia aboard hospital ships and Fleet Guantanamo Bay, Cuba, caring for Haitian and Cuban migrants under extremely austere conditions. Air Force Approximately 4,850 active-duty Air Force nurses make up 34 percent of officers in the Air Force Medical Service. They provide care for approximately 408,000 active-duty service members and for their beneficiaries. Over 3,300 nurses serve in the reserve component. Air Force nurses play key roles in the transport of large numbers of patients for long distances. For example, the Air Force moved 8,046 patients during Operation Desert Shield/Desert Storm and 375 patients during the United Nations' mission in Haiti. Transported patients range from the neonate to the aged and encompass those who are mortally wounded to the chronically ill. Air Force nurses also provide care at mobile aeromedical staging facilities located away from the front line, where military aircraft swoop in to load the wounded and off-load ''beans and bullets'' for the fighting troops. Unique Aspects of Military Nursing The functions and processes of military work involve force projection and mission readiness. Force projection is the movement of military forces from the continental United States or a theater in response to the requirements of wartime or peacetime operations. Such movements may involve the mobilization and deployment of forces, return to the United States or home theater, and subsequent demobilization. Peace operations may take several forms (peace building, peacekeeping, or peacemaking), each of which involves health care services delivered by a team that includes nurses. Humanitarian assistance is assistance provided by DOD in the aftermath of natural or man-made disasters. Such assistance is designed to help reduce conditions that present serious threats to life, health, and property. Military support to civil authorities involves the authorized use of military logistical and human resources in disaster assistance and law enforcement.

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--> Mission readiness is the guiding principle of the military health care delivery system. The military nurse is expected to satisfy all criteria (e.g., personal health and fitness, knowledge of mobilization assignment, required training) for readiness for mobilization. The nurse may be working in a large tertiary care facility in the United States one day and be en route to a destination halfway around the world the next. Knowledge and skills must be transferable to a variety of peacetime and wartime scenarios having unique problems that the nurse officer must confront. For example, military nurses might work in North Atlantic Treaty Organization (NATO) settings where equipment may or may not match and expectations of care may differ. As another example, two Air Force nurses and three Air Force medical technician crew members routinely handle 40 to 100 patients on one aircraft, and there is a trend toward carrying sicker patients in the aeromedical evacuation system. Thus, such problems as dehydration and hemorrhage must be managed at high altitudes under difficult working conditions. The physical and psychosocial environment aboard ship presents numerous challenges unique to the Navy. On ships, regardless of their size, the living and working spaces are cramped; mobility, equipment, and supplies are limited; and physical and professional isolation is routine. Dietary constraints, exercise limitations, and exposure to potential hazards may vary depending on the ship. The physical movement of the ship presents unusual challenges that require special care and consideration: bolting of examination tables, beds, and bunks to the floor or ceiling; physical securing of all supplies; and special handling of liquids and breakables. Although relatively few Navy Nurse Corps officers serve at sea full-time, a large portion of the population they serve does. The shipboard environment presents many occupational hazards. Therefore, nurses must be acutely aware of safety issues. Because of the unique constraints and demands of life aboard ship, Navy nurses focus their practice on mental and physical health and wellness. Mission readiness involves the education, supervision, and evaluation of others, especially medical support personnel. Medical technicians learn basic nursing techniques and receive other training based on the mission readiness needs of DOD. Suturing, casting, and intravenous therapy are among the skills taught. Mission readiness involves interdisciplinary coordination; it requires the ability to devise novel but safe approaches to nursing care delivery in austere conditions with potentially large groups of patients. New nurse officers may need to learn about the use of old equipment, how to cope with sand or mud, and other aspects of care not covered in the usual education of nurses. Army nurses need to be able to function in a field setting or high threat environment, which may require the wearing of protective clothing for chemical and biological threats. Air Force nurses need to prepare modular air-transportable hospitals and tented patient staging facilities for patient care, and to configure

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--> and equip aircraft for transporting patients in the air. Navy nurses may be in camouflage uniforms in the field with marines or in a fleet hospital caring for patients in a facility constructed of tents and containers. Deployment places heavy demands on nurses and other personnel for health screening, immunization, and other preventive measures, prior to the departure of military personnel from their home station. While deployed, military nurses have major responsibilities related to the prevention of disease and non-battle injuries—monitoring and mitigating environmental threats to themselves, and to others, and promoting occupational health. Military nurses are at the vanguard in the use of deployable technology (Craigmiles, 1995; Mun, 1995; Sheridan et al., 1995). Military nurses who are not deployed may have major changes in responsibilities that result from the deployment of others. Military nurses contribute to the credo to "conserve the fighting strength" and aid the preparedness and mission readiness of service members. They do this in three major ways: (1) by planning and delivering health care services to return ill or injured service members to their units or to stabilize and remove them from the field of operations as soon as possible; (2) by applying preventive and therapeutic interventions and evaluating health outcomes of military personnel, their beneficiaries, and others requiring humanitarian assistance or disaster relief in the context of worldwide military operations; and (3) by addressing environmental and occupational health hazards that may be encountered by service members, their beneficiaries, and others. Environmental challenges to the provision of health care may include any of the following: primitive conditions with regard to sanitation, equipment, and supplies; exposure to temperature and humidity extremes, and to wind; food and water deprivation; hostile conditions; a changing battle line, with the need for rapid movement of facilities; "shipboard" or "in-flight" conditions with corresponding unique problems; dependence on host nation support facilities; providing care to culturally diverse populations with different beliefs about and responses to health care; and lack of privacy, leisure time, and professional or social supports. Health concerns that have been raised for active-duty service members include infectious diseases commonly found in the United States (Bray et al., 1992; Cross and Hyams, 1990; Stout et al., 1994);

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--> stress fractures and overuse injuries related to high physical fitness expectations during basic or specialized training (Friedl et al., 1992; Garcia et al., 1987; Giladi et al., 1986; Jones et al., 1993; Pester and Smith, 1992; Woodruff et al., 1994); spousal and child abuse (McNelis and Awalt, 1986); cigarette smoking (Bray et al., 1992); heavy use of alcohol (Bray et al., 1992); and risky weight management practices to meet mandated weight requirements (IOM, 1995; McNulty, 1994). Since racial and ethnic differences in health status (DHHS, 1991; Nickens, 1995) and mortality (Sorlie et al., 1995) have been well documented, and a high proportion of service members and their beneficiaries are nonwhite, the military nurse must be prepared to plan and provide appropriate care for all. Smoak and coworkers (1994) provide an example of differences in health status that may be seen among recruits: in a sample of over 900 recruits, about 40 percent of whom were female, seropositivity rates for Helicobacter pylori were 44 percent for blacks, 38 percent for Hispanics, and 14 percent for whites. The military nurse may have to be prepared to care for individuals with such relatively unique health problems as the following (IOM, 1995): stress associated with or caused by separation, isolation, combat, or close quarters; exposure to chemical weapons and other toxic chemicals; exposure to radiation, electromagnetic fields, or hyperbaria; conditions resulting from prolonged exposure to unfavorable environmental conditions (heat, cold, moisture, dryness, wind, noise); battle injuries; posttraumatic stress symptoms and disorders; infectious diseases not ordinarily encountered in the United States; heavy exposure to fuels, lubricants, exhaust, insecticides, pesticides, and dust; and injuries incurred during training exercises or troop movements. Moreover, military nurses have responsibilities for maintaining patient care standards; supporting functioning of the installation or community; safety; and unit cohesion, morale, and discipline. In meeting these responsibilities, they assume practice, management, and leadership roles.

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--> Military Nursing Research Nursing research investigates the many factors known to affect human health for the purpose of developing clinical interventions and activities that can be carried out by nurses. Military nursing research addresses many areas: the unique military environmental settings in which care is provided; mission readiness and deployment of military personnel; and improving nursing structure (delivery systems) and processes to enhance clinical outcomes, health status, and quality of life of diverse military personnel, their beneficiaries, and populations receiving care during humanitarian, peacetime, and wartime missions. The overriding purposes of military nursing research are to expand military nurses' knowledge and to improve their capacity to provide appropriate and high-quality nursing care for the armed forces. Thus, findings from military nursing research do not benefit only the military; in many cases, they benefit the civilian sector as well. Military nursing delivers care within social conditions established to accomplish the goals of the military—conditions that may have either positive or negative effects on the health of service members and their beneficiaries. Thus, the focus of military nursing research is to understand those conditions and learn how to prevent, modify, or minimize negative health effects and to optimize positive effects. Broadly speaking, military nursing research is concerned with patterns of illness, stress, and injury; the occupational and environmental hazards that affect the health and readiness of service members and their families; and intervention studies to learn how to improve outcomes or to deliver high-quality care in a cost-effective manner. Modest investment in military nursing research has already yielded valuable results and expanded the foundation for further study. History of Military Nursing Research Army The Army Nurse Corps initiated nursing research in the military and has been a major contributor to the evolution of both military and civilian nursing research. The establishment of a Department of Nursing at Walter Reed Army Institute of Research and its Nursing Research Department in 1957 provided formal recognition and opportunities for growth of military nursing research. Maj. Harriet Werley, the first Chief Nurse of the Nursing Research Department, fostered the development of a program designed to concentrate on clinical nursing research in addition to fostering participation in the collaborative studies of other disciplines (Stevenson, 1987). Recognizing the value of expert advice to a young program and lacking appropriate resource persons within the military, Major Werley secured consultation services from R. Louise

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--> McManus—a civilian—one of the few doctorally prepared nurses at that time (Kalisch, 1977; Sarnecky, 1993; Werley, 1962). Among the areas on which the research program concentrated were skin care (Verhonick, 1961a–c), oral hygiene (Ginsberg, 1961; Ginsberg and Yoder, 1964), the mechanics of vomiting (McCarthy, 1964), body temperature measurements (Nichols, 1968, 1972a, b; Nichols and Glor, 1968a, b; Nichols and Kucha, 1972; Nichols and Verhonick, 1967, 1968; and others), and circadian rhythms (Felton, 1970, 1973). Since 1968, the Army has designated the position of nursing research consultant to the Army Surgeon General to serve as the primary adviser to the chief of the Army Nurse Corps and the Army surgeon general on matters pertaining to nursing research. In 1976, the Nursing Research Advisory Board was established to advise and assist the chief of the Army Nurse Corps to establish research priorities and monitor research initiatives throughout the Army Medical Department (Kennedy, 1994). In 1981, the Army Nurse Corps held the first Phyllis J. Verhonick Nursing Research Symposium as a mechanism to disseminate findings from nursing research and to advance the knowledge of research (Kennedy, 1994). Named after a leader in both the military and the civilian nursing communities, this conference continues to be held biennially. The 1996 conference has been opened to the Navy and Air Force. Since the 1980s, the Army Nurse Corps has decentralized its nursing research structure and implemented a regional approach. The nursing research consultant coordinates the regional nursing research coordinators on a daily basis, with the Nursing Research Advisory Board providing periodic global oversight (see Chapter 3 for further information). The Army Nurse Corps has long recognized the importance of education to research and, during 8 of the 9 years between 1961 and 1969, offered a 40-week course: "Military Nursing Practice and Research" (Kennedy, 1994). This course was used to train a cadre of 28 junior researchers (minimum requirement was a baccalaureate degree). Since the 1960s, the Army Nurse Corps has provided graduate education in civilian education programs for selected promising nurse researchers. Navy Kalisch (1977) examined the history of nursing research in the Navy, primarily by review of unpublished master's theses. The range of research topics was broad, covering various aspects of the organization and administration of nursing service, and nursing practice (from procedures for administering medication through public health nurse assessment of preschool

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--> children). By 1977, only two nurses had been supported for doctoral study. Formal research endeavors of the Navy Nurse Corps date back to 1982, when Capt. Karen Rieder was assigned as director of the Health Services Research Department at the Naval School of Health Sciences, Bethesda, Maryland (R.Adm. J. M. Engel, Nurse Corps, U.S. Navy, personal communication, 1996). Further work to incorporate nursing research into the Navy Nurse Corps became prominent in 1987, when the Navy conducted a review of billets and identified 11 that called for a doctorally prepared nurse (see Chapter 3). Air Force Kalisch (1977) also traces the history of nursing research in the Air Force, primarily through the review of unpublished mimeographed documents covering research at the School of Aerospace Medicine at Brooks Air Force Base, Texas. Among the research topics reported are the development of equipment for aeromedical evacuation (such as examination lamps, oxygen and humidity apparatus, hand disinfection devices, patient-monitoring and blood pressure measurement, litter lift, and transportable airborne stations). Farrell and Allen (1973) reported physiological and psychological changes experienced by Air Force nurses associated with flying duty on jet and propeller aircraft, and Ford and Lake (1979) studied ways to evaluate patient care in flight. The first doctorates earned by Air Force nurses were awarded in 1967 and 1968 (Kalisch, 1977). The Triservice Nursing Research Program Doctorally prepared nurses from the Army, Navy, and Air Force began meeting informally in 1988 at the Association of Military Surgeons of the United States (AMSUS) convention. In the fall of 1990, representatives from the Army, Navy, and Air Force met to discuss collaborative research among the services. This group formed the Federal Nursing Research Interest Group; its military members later became the TriService Nursing Research Group (TSNR Group). In the spring of 1991, these representatives, along with their respective corps chief or director, met with representatives of the National Center for Nursing Research (NCNR, now the National Institute for Nursing Research) to discuss issues relevant to how the NCNR could assist the military services with developing a coordinated strategy of nursing research activities within the military milieu. The meeting concluded with informal recognition of the TSNR Group by the corps chief and directors, and the commitment of the NCNR to assist and consult with the services on matters relevant to military nursing research. The TSNR Group was made responsible for finding ways to promote

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--> military nursing research both collectively and individually, within and across the services. Authorization and Appropriations The initial appropriation for the TSNR Program under S.R. 102-154 was $1 million for fiscal year (FY) 1992. Subsequent appropriations awarded $2 million for FY 1993 (P.L. 102-396, 1993), $3 million in 1994 (Department of Defense Appropriations Act, 1994, H.R. 3116), and $5 million in FY 1995 (Department of Defense Appropriations Act, 1995, 103rd Congress, H.R. 4650). In FY 1996, $5 million was again appropriated for this program, and most importantly, the FY 1996 Department of Defense Authorization Act contained specific language authorizing the TriService Nursing Research Program as part of the DOD Health Care Program, administered by the TriService Nursing Research Group and established at the Uniformed Services University of the Health Sciences (Chapter 104, title 10, U. S. Code as amended). Relationship with Other DOD Research Programs A $5 million appropriation for the TSNR Program represents a very modest portion of the total funds allocated for research in the DOD budget. The entire FY 1996 DOD appropriation of over $243 billion includes more than $36 billion for Research, Development, Test, and Evaluation (RDT&E), of which $305 million or more3 is allocated for Medical RDT&E. However, the $5 million TSNR Program funds are incorporated in the $10 billion DOD health care appropriation (Public Law 104-61). The TSNR Program dollars are intended to focus entirely on nursing research—an area not addressed by other military research programs. Major areas of research emphasis for DOD Medical RDT&E include medical defense against chemical warfare agents, medical defense against biological warfare agents, combat casualty care, infectious diseases, and military health hazards. Few, if any, doctorally prepared nurse researchers participate as investigators in the DOD Medical RDT&E programs. 3   This does not include Medical Basic Research funds, Navy Medical Technology funds, or medical research supported by the Air Force—none of which are identified separately in budget lines.

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--> Summary This chapter presents an overview of special areas to be considered in an analysis of military nursing research needs. It briefly examines the history of military nursing research and of the new TSNR Program, which is addressing the challenge of improving the scientific knowledge base of military nursing practice. Subsequent chapters in this report describe the methods used by the Institute of Medicine committee to accomplish its task; information about past and current research relevant to military nursing; a description of the TSNR Program and its execution, including program evaluation; and the committee's conclusions and recommendations. References Bray, RM, LA Kroutil, JW Luckey, SA Wheeless, VG Iannacchione, DW Anderson, ME Marsden, and GH Dunteman. 1992. 1992 Worldwide Survey of Substance Abuse and Health Behaviors Among Military Personnel. Research Triangle Park, NC: Research Triangle Institute. Craigmiles, RG. 1995. Telemedicine Strategic Planning and Implementation Issues in the Navy Medical Department. Master's thesis, Naval Postgraduate School, Monterey, CA. Cross, ER, and KC Hyams. 1990. Tuberculin skin testing in U.S. Navy and Marine Corps personnel and recruits, 1980-86. Am. J. Public Health 80(4):435-438. DHHS (U.S. Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS Pub. No. (PHS) 91-50212 Washington, D.C.: Public Health Service. Defense Manpower Data Center. 1995. Distribution of Active Duty Forces by Service, Rank, Sex, and Ethnic Group. Seaside, CA. Farrell, BL, and MF Allen. 1973. Physiologic/psychologic changes reported by USAF female flight nurses during flying duties. Nurs. Res. 22(1):31-36. Feller, CM, and CJ Moore, eds. 1995. Highlights in the History of the Army Nurse Corps. Washington, DC: U.S. Army Center of Military History. Felton, G. 1970. Effect of time cycle change on blood pressure and temperature of young women. Nurs. Res. 19:48-58. Felton, G. 1973. Rhythmic correlates of shift work. Pp. 75-89 in Communicating Nursing Research: Collaboration and Competition, vol. 6, MV Batey, ed. Boulder, CO: Western Interstate Commission for Higher Education. Ford, M, and L Lake. 1979. Establishing an audit system for Air Evac. Aviat. Space Environ. Med. 50:284-289. Friedl, K, J Nuovo, T Patience, and J Dettori. 1992. Factors associated with stress fracture in young Army women: Indications for further research. Mil. Med. 157:334-338. Garcia, J, L Grabhorn, and K Franklin. 1987. Factors associated with stress fractures in military recruits. Mil. Med. 152:45-48.

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--> Giladi, M, C Milgrom, H Kashtan, M Stein, R Chisin, and R Dizian. 1986. Recurrent stress fractures in military recruits. One-year follow-up of 66 recruits. J. Bone Joint Surg. [Br] 68:439-441. Ginsberg, MK. 1961. A study of oral hygiene nursing care. Am. J. Nurs. 61:57-69. Ginsberg, MK, and AR Yoder. 1964. The effectiveness of some traditional methods in oral hygiene nursing care. J. Peridontol. 35:513-518. IOM (Institute of Medicine). 1995. Recommendations for Research on the Health of Military Women. Committee on Defense Women's Health Research. Washington, DC: National Academy Press. Jones, B, M Bovee, J Harris, and D Cowan. 1993. Intrinsic risk factors for exercise-related injuries among male and female Army trainees. Am. J. Sports Med. 21:705-710. Kalisch, PA. 1977. Weavers of scientific patient care: Development of nursing research in the U.S. armed forces. Nurs. Res. 26:253-271. Kennedy, TE. 1994. The evolution of nursing research in the Army Nurse Corps. Mil. Med. 159:680-683. McCarthy, RT. 1964. Vomiting. Nurs. Forum 3:48-59. McNelis, PJ, and SJ Awalt. 1986. Project SAFE: An Armed Forces cooperative initiative for the prevention and treatment of family violence. Eval. Program Plann. 9(3):233-241. McNulty, MA. 1994. Eating Disorders Among Active-duty Female Navy Nurses: Who, When and Why? Dr.P.H. dissertation, University of Hawaii, Honolulu. Mun, SK. 1995. Akamai Network for Diagnosis, Treatment, and Management of Support Telepresence. Contract no. DAMD17-94-V-4015. Washington, DC: Georgetown University. Nichols, GA. 1968. Measurements of oral temperature in children. J. Pediatr. 72:253-255. Nichols, GA. 1972a. Taking adult temperatures: Rectal measurements. Am. J. Nurs. 72:1092-1093. Nichols, GA. 1972b. Time analysis of afebrile and febrile temperature readings. Nurs. Res. 21:463-464. Nichols, GA, and BAK Glor. 1968a. Supportive research roles in Army nursing. Mil. Med. 133:57-62. Nichols, GA, and BAK Glor. 1968b. Temperature taking times in Vietnam. Mil. Med. 133:154-158. Nichols, GA, and DH Kucha. 1972. Taking adult temperatures: Oral measurements. Am. J. Nurs. 72:1090-1093. Nichols, GA, and PJ Verhonick. 1967. Time and temperature. Am. J. Nurs. 67:2304-2306. Nichols, GA, and PJ Verhonick. 1968. Placement times for oral thermometers: A nursing study replication. Nurs. Res. 17:159-161. Nickens, HW. 1995. The role of race/ethnicity and social class in minority health status. Health Serv. Res. 30:151-62. Pester, S, and PC Smith. 1992. Stress fractures in the lower extremities of soldiers in basic training. Orthop. Rev. 21:297-303. Sarnecky, MT. 1993. Inventing nursing research. Nurs. Res. 42:318-319.

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--> Sheridan, TB, J Thompson, J Hu, M Ottensmeyer, and J Ren. 1995. Human Factors in Tele-Inspection and Tele-Surgery. Contract No. DAMD17-94-C-4125. Cambridge, MA: Massachusetts Institute of Technology Smoak, BL, P Kelley, and D Taylor. 1994. Seroprevalence of Helicobacter Pylori infections in U.S. Army Recruits. Am. J. Epidemiol. 139(5):513-19. Sorlie, PD, E Backlund, and JB Keller. 1995. U.S. Mortality by economic, demographic, and social characteristics: The National Longitudinal Mortality Study. Am. J. Public Health 85(7):949-56. Stevenson, JS. 1987. Forging a research discipline. Nurs. Res. 36:60-64. Stout, R, S Mitchell, M Parkinson, R Warner, R Miles, B Franz et al., 1994. Viral hepatitis in the U.S. Air Force, 1980-89: an epidemiological and serological study. Aviat. Space Environ. Med. 65(5 suppl):A66-70. Verhonick, PJ. 1961a. Decubitus ulcer observations, measured objectively. Nurs. Res. 10:211-214. Verhonick, PJ. 1961b. Decubitus ulcer care. Curr. Med. Dig. 28:74-75. Verhonick, PJ. 1961c. A preliminary report of a study of decubitus ulcer care. Am. J. Nurs. 61:68-69. Werley, H. 1962. Promoting the research dimension in the practice of nursing through the establishment and development of a department of nursing in an institute of research. Mil. Med. 127:219-231. Woodruff, S, T Conway, and L Bradway. 1994. The U.S. Navy Healthy Back Program: Effect on back knowledge among recruits. Mil. Med. 159:475-484.

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