Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

UFDC Membership

Aggregations:
Digital Military Collection

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The education mi ssion of the army medical department January March 2014 Perspectives 1 MG Steve Jones; COL Mustapha Debboun; Richard Burton What is the Value of Graduate Education? An Economic Analysis of 7 Army Medical Department Graduate Programs LTC Lee W. Bewley; Kevin D. Broom, PhD; LTC Mark Bonica Incorporation of Learning Styles into the Graduate Program in Nutrition Curriculum 14 MAJ Renee E. Cole; LTC Reva L Rogers; Maj Heidi L. Clark, USAF; LTC (Ret) Lori D. Sigrist An Active Learning Approach to Blooms Taxonomy: 2 Games, 2 Classrooms, 2 Methods 21 MAJ Fred K. Weigel; LTC Mark Bonica Impact of an Innovative Clinical Inte rnship Model in the US Army-Baylor 30 Doctoral Program in Physical Therapy COL Josef H. Moore; CPT Kathleen T. Glenesk; CPT David K. Hulsizer; et al The Army Social Work Internship Program: Training Todays Uniformed Social Worker 35 COL (Ret) Reginald W. Howard US Army Veterinary Corps First Year Graduate Veterinary Education Program 39 COL Erik H. Torring; LTC Wendy Mey Achieving Army Nursing Evidence-Based Practice Competencies 42 Through a Civilian-Milita ry Nurse Partnership LTC Leilani A. Siaki; Debra D. Mark, Ph D, RN; COL Denise L. Hopkins-Chadwick Infusing Evidence-Based Instructional Strategies to Prepare 52 Todays Military Practical Nurses for Tomorrows Practice Richard A. Neilson, MHA, RN; COL Denise L. Hopkins-Chadwick The Effects of Using a Human Patient Simulator Compared to a CD-ROM in 59 Teaching Critical Thinking and Performance Don Johnson, PhD, RN; Sabine Johnson, MS Raising the Educational Standard for Army Nursing Faculty 65 COL Bruce A. Schoneboom; COL Denise L. Hopkins-Chadwick Legal Education for Army Medical Department Leaders and Soldiers 68 MAJ Joseph B. Topinka Innovating to Integrate the Intangibles into the Learning Air Force 77 Capt Benjamin T. Hazen, USAF; MAJ Fred K. Weigel, USA; Maj Robert E. Overstreet, USAF To Change or Not to Change a Multiple Choice Answer 86 Don Johnson, PhD, RN; Susan Anderson, MSN, RN; Sabine Johnson, MS Pediatric Surgery and Medicine for Hostile Environments 89 A New Volume in the Borden Institute Textbooks of Military Medicine Series CAPT (Ret) Bradley Poss, USN Abstracts and Winning Poster Presented at the Graduate School 3rd Annual Research Day, 91 Academy of Health Sciences, US Army Medical Department Center & School

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January – March 2014 The Army Medical Depa rtment Center & Sc hool PB 8-14-1/2/3 Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspx A Professional Publication of the AMEDD Community The Army Medical Department Journal [ISSN 1524-0436] is published quarterly for The Surgeon General by the AMEDD Journal Office, USAMEDDC&S, AHS CDD, 3599 Winfield Scott RD STE B0204, JB SA Fort Sam Houston, TX 78234-4669. Articles published in The Army Medical Department Journal are listed and indexed in MEDLINE, the National Library of Medicine’s premier bibliographic database of life sciences and biomedical information. As such, the Journal’ s articles are readily accessible to researchers and scholars throughout the global scientific and academic communities. CORRESPONDENCE: Manuscripts, photographs, official unit requests to receive copies, and unit address changes or deletions should be sent to the Journal via email to usarmy.jbsa.medcom-ameddcs.list.amedd-journal, or by regular mail to the above address. Telephone: (210) 221-6301, DSN 471-6301 DISCLAIMER: The AMEDD Journal presents clinical and nonclinical professional information to expand kn owledge of domestic & international military medical issues and technolo gical advances; promote collaborative partnerships among Services, components, Corps, and specialties; convey clinical and health service support information; and provide a peer-reviewed, high quality, print medium to encourage dialog ue concerning healthcare initiatives. Appearance or use of a commercial product name in an article published in the AMEDD Journal does not imply endorsement by the US Government. Views expressed are those of the author(s) and do not necessarily reflect official policies or positions of the De partment of the Army, Department of the Navy, Department of the Air Force, Department of Defense, nor any other agency of the US Government. The content does not change or supersede information in other US Army Publications. The AMEDD Journal reserves the right to edit all material submitted for publication (see inside back cover). CONTENT: Content of this publication is not copyright protected. Reprinted material must contain acknowledgement to the original author(s) and the AMEDD Journal OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical Department units and organiza tions, other US military medical organizations, and members of the worldwide professional medical community. LTG Patricia D. Horoho The Surgeon General Commander, US Army Medical Command MG Steve Jones Commanding General US Army Medical Department Center & School Administrative Assistant to the Secretary of the Army GERALD B. O’KEEFE 1325501 By Order of the Secretary of the Army: Official: Raymond T. Odierno General, United States Army Chief of Staff DISTRIBUTION: Special

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January March 2014 1PerspectivesCOMMANDERS INTRODUCTIONMG Steve Jones We live in a much more competitive security environment. This means that we have to learn faster and better than our future adversaries.General Martin E. DempseyThe Joint Publication Capstone Concept for Joint Operations: Joint Force 2020 describes a future:likely to be more unpredictable, complex, and potentially dangerous than today. The accelerating rates of change present in so many aspects of this future security environment will require greater speed in the planning and conduct of military operations. Once in a ght, adversary capabilities and tactics will also shift more quickly.1(p3)To prepare the Army to win decisively in this environment, the Chief of Staff published ve strategic priorities for the future: Adaptive Army Leaders for a Complex World A Globally Responsive and Regionally Engaged Army A Scalable and Ready Modern Army Soldiers Committed to Our Army Profession The Premier All-Volunteer Army We can only achieve these priorities through effective education that teaches principals, concepts, facts, and Army Values. The Army requires agile, adaptive leaders with critical analytical skills, problem solving abilities, intellectual curiosity, and intellectual discipline. These leaders will exercise Mission Command, a leadership style de ned as the exercise of authority and direction by the commander using mission orders to enable disciplined initiative within the commanders intent. Unexpected threats and opportunities during military operations require responsibility and decision-making at the point of action. Agile leaders and subordinates who are comfortable with uncertainty can adapt to meet the challenges of the mission at hand. In taking action they remain within the commanders intent, integrating their efforts with the rest of the force. They exercise disciplined initiative in support of the overall objective because they understand they are part of a larger force. This approach requires much more from commanders; they must clearly understand, visualize, describe, direct, lead and assess operations. The Army Mission Command Strategy FY13-19 ,2 Army Leader Development Strategy 2013 ,3 and The Army Training Strategy4 describe how the Army will develop these leaders though a rigorous program that includes education, training and experience. Future leaders will better understand the social, cultural, political, and physical environment of the regions in which they operatethe human terrain. Armed with this knowledge they will be far more relevant to the Joint Force Commander. The time to gain this in-depth knowledge is prior to an operation, not when troops are already engaged on the ground. Operational forces will be regionally aligned to speci c geographic regions to allow this learning prior to deployment. The institutional Army Medical Department (AMEDD) has in-depth knowledge of the unique medical aspects of the different geographic regions of the world that affect operations. It must reorganize now to more effectively employ that information in support of regionally aligned forces. Future military operations will unfold over hours and days rather than weeks and months. To adapt, the Army will transform to become a leaner and faster force. It will employ new war ghting concepts including expeditionary maneuver and integrated distributed operations where small, highly capable units operate across a large area. The Armys Campaign of Learning 20135 looks at Americas Next First Battles to help guide the transition. The Campaign uses studies, science and technology, seminars, wargames, experiments, and live exercises to identify possible new challenges, and capabilities the Army should develop to meet these challenges. The AMEDD participates in the Campaign because it must transform as well. It must provide the Combatant Commander with tailorable, expeditionary and sustained medical capabilities that can operate in complex and austere environments. Creative thinking and a thorough understanding of requirements are the foundation for development of new doctrine, organizations, equipment, and processes. As the AMEDD adapts, these changes will be implemented through education and training. The professionalism of the US Army is the basis of its success. Professionalism earned it the trust of the American people and created an environment of dignity and

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2 http://www.cs.amedd.army.mil/amedd_journal.aspxEDITORS P ERS PE CTIV EHealthcare is a profession within which learning must never stop, whether from experience and licensing mandates, or with additional formal education which complements that experience and equips the healthcare professional with additional knowledge, skills, and ca pabilities. There has always been competition among healthcare institutions for those practitioners who seek such additional education and training because they are necessary for any organization to maintain a high level of capabilities and performance. To that end, many insti own and assure a foundation of extended professional expertise continues to be available. Military medicine is no different. Indeed, a reservoir of comprehensive pro fessional medical knowledge and experience is absolute ly vital to military readiness and operational success. However, the costs of programs that provide graduate education must always be viewed from the perspective of the value gained by the organization, whether military or civilian, especially in the current economic environ ment. LTC Lee Bewley and his coauthors have examined the Army Medical Department (AMEDD) graduate pro grams to determine whether any economic value added to Army Medicine can be assessed, and, if so, does it justify the investment in those programs. Their article describes their approach to an economic value analysis, how they applied their concept to evaluating each of the article is a well organized, clearly presented treatment of a vitally important aspect of AMEDDs efforts to ensure that Americas Warriors continue to receive the only the Perhaps no organization or institution is as dependent on cation as the military. Further, the nature of the military dictates the almost continual delivery of training and PER SPECTIVE S respect where all can reach their full potential. The Cen ter for the Army Profession and Ethic has implemented an education and training program for Soldiers and Army acteristics of the Army Profession: trust, military exper tise, honorable service, esprit de corps, and stewardship. They have developed doctrine, educational materials, case studies, virtual simulators, and Training Support Packages in support of the Army Profession Campaign. To maintain the Premier All-Volunteer Army, we must maintain the resilience of our Soldiers, Families, and Ci vilians. The Armys Comprehensive Soldier and Fam ily Fitness Program, and the AMEDDs Performance Triad build, maintain, and strengthen resilience through education. By following a thoughtful strategy and rig orous program, a Soldier can build the strength, speed, endurance, and agility required to succeed on todays Civilians, and Family members can develop their cogni tive and psychological abilities. The Army Learning Concept for 20156 supports each of the strategies, campaigns and programs above. It de scribes learning as a deliberate, continuous and progres sive process that extends from the time Soldiers are ac cessed until the time they retire. It notes the responsibil ity for developing Soldiers and Army Civilians is shared among the institutional schoolhouse, the organizations to which individuals are assigned, and to the individuals themselves. It is a learner-centric model that provides relevant, tailored, and engaging learning that is not lo cation dependant but delivered at the point of need. It recognizes that most Soldiers have grown up in a digital world, are adept at using technology, and require feed back and support from peers and mentors. It also un derstands the requirement to challenge seasoned Army professionals with repeated deployments who bring a wealth of experience to the learning system. After twelve years of war, the US Army and its Medi cal Department are undergoing a major transformation The centerpiece of this transformation is education. Ed ucation is the foundation for developing effective lead ers, an understanding of new requirements, the creative thinking required to adapt to new challenges, advancing the Army Profession, and maintaining the resilience of the Soldiers, Army Civilians, and Families that are the strength of the Army. The Army Medical Departments emphasis on education allowed us to achieve survival will lead to a successful transformation to meet the new 1. http://www.defenseinnovationmarketplace.mil/ resources/J V2020_ C apstone.pdf2. http://usacac.army.mil/cac2/ R epository/Army_Mis sion_ C ommand_ S trategy_dtd_12June%202013. pdf3. http://usacac.army.mil/cac2/cal/AL DS .asp4. U S Army C hief of S taff Memorandum dtd O ctober 15, 2012. S ubject: Army T raining S trategy (A TS ).5. http://www.army.mil/standto/archive/issue. php?issue=2012-09-216. http://www-tradoc.army.mil/tpubs/pams/tp525-82.pdf

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January March 2014 3 instruction throughout its structure, from the nonstop basic training cycles of large numbers of new accessions through the various levels of career courses that prepare service members for responsibilities incumbent with ad vancing rank. As a result, for many years the US military has been recognized as a leader in the incorporation of leading edge concepts and innovations in the design of courseware and delivery of training targeting many lev els of subject matter and student/trainee aptitude. Those responsible for the education and training of military personnel constantly explore techniques and approaches from across the spectrum of thinking and experience design and deliver the necessary training. This issue of the AMEDD Journal presents 8 articles which are excel lent examples of this ongoing effort within the AMEDD, discussing approaches from formal, advanced graduate level education to workplace experiential training. One area of research in formal education involves the manner in which information is conveyed to the student, taking in consideration a students learning style, rather than the traditional lecture style with curriculum cre ated primarily from the teachers perspective. Learning style is, in essence, how a student learns, based on envi ronment, presentation, interaction, and other factors. In their article, MAJ Renee Cole and her team of coauthors describe how the existing curriculum of the Graduate Program in Nutrition at the AMEDD Center and School (AMEDDC&S) was evaluated to assign categories to researchers examining similar student populations and possible to incorporate a variety of learning modes to support student learning style preferences. Their article is a clearly presented, detailed presentation of a care fully planned and conducted review of a curriculum and its results, and the integration of changes and the result ing changes in student outcomes. It is another example of the initiative and high level of expertise among those charged with ensuring Army medical education remains at the forefront of academic excellence. In a similar vein, MAJ Fred Weigel and LTC Mark Bon ica discuss another technique for the delivery of educa tional material in an effort to improve learning outcomes. They adopted an Active Learning approach in the design of the curriculum for a course at the Army-Baylor Grad uate Program in Health and Business Administration, incorporating the well-respected concept of 3 learning domains (cognitive, affective, and psychomotor) gener ally known as Blooms Taxonomy of Learning. This was done by incorporating game play into the coursework, actively engaging students across the learning domains in the application of the subject matter of the course. Their article is an excellent presentation of this approach to learning, as they introduce the concepts of Blooms taxonomy and explain how they were used to design and integrate the lessons and games to be a synergistic whole. Furthermore, they developed 2 games to address different subject matter, each of which used a distinct approach in its incorporation into the lesson design. The article clearly describes the foundation for and develop ment of the concept, the application, and the evaluation of outcomes. The high level of sophistication, expertise, and dedication to excellence among those involved in the education of our military healthcare professionals is once again obvious in the content of this article. The Graduate School at the AMEDDC&S is comprised of a number of graduate programs, most of which con fer professional degrees in clinical practice specialties. The degree is only one of the requirements to obtain a professional license to practice the respective specialty. eral requirements, typically involving a period of super vised practice and completion of an examination. The supervised practice is accomplished in various ways, one of which is a collaborative internship program that is dependent on the availability of a supporting clinical environment. Medical activities must always consider ternship program before a formal agreement of support can be reached. As COL Josef Moore and his coauthors point out, collaborative internship models have not been the norm for physical therapy clinical practice programs. They have contributed an article examining those as pects of the collaborative internship arrangements that the Army-Baylor University Doctoral Program in Physi cal Therapy established with 3 military academic medi cal centers and a private physical therapy practice. The study described in their article was carefully planned to ensure that the data organization provided detailed com parative information. Those comparisons are illustrated across a number of charts which support the information presented in the text. This article is a well organized, easily understood presentation of yet another proactive approach by Army medical education to maximize the skills and capabilities of military medical professionals. In 2008, the AMEDDC&S Graduate School established another program to address an increasing demand for its own licensed clinical social workers. Similar to the cial worker licensure requirements involved an extensive

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4 http://www.cs.amedd.army.mil/amedd_journal.aspxperiod of formal postgraduation clinical supervision experience, as well as an examination. As COL (Ret) Reginald Howard relates in his article, at the time MSW program was under development, the Armys methods and resources for providing the requisite clinical experi ence to its graduates were not standardized and lacked cant delays in obtaining the necessary clinical experi ence, which was preventing them from gaining their licenses, thus contributing to the continued shortage of licensed practitioners desperately needed by the Army. The article describes how the Army revamped its ap proach to the process by developing and establishing the Army Social Work Internship Program, designed from the ground up to move MSW graduates through a stan dardized internship no matter the medical facility, with minimal administrative disruptions not related to their licensure requirements, and focused on the competen cies necessary to provide services in the military envi ronment. Most important, the program was designed to support timely licensure, to get licensed professionals working among Soldiers and Families as expeditiously as possible. This article presents an excellent example of the coordination and expertise among the multiple pro fessionals involved in identifying the problem, conceiv ing the solution, and making it happen. The Veterinary Corps had a different problem. Their basic skills to provide clinical veterinary medical care. However, the role of veterinarians in the military en vironment demands an additional number of skill sets, most of which cannot be acquired outside of the military, had become a growing problem for effective veterinary support. The shock of lack of preparation was also a dis incentive for the individual to remain in the Army after their initial obligation. In their article, COL Erik Torring and LTC Wendy May describe the Veterinary Corps initiative to address this problem and ensure that new pared for their military responsibilities. In 2009 the Vet erinary Corps developed a program to provide exposure and reinforcement of those skills required to function in the military environment. A formal, standardized in ternship program of curriculum and clinical case train ing has been implemented on 7 military bases around the country. The one-year internship is designed to pro vide training in 3 areas: veterinary public health (food protection, preventive medicine, etc), veterinary clinical medicine (tailored to responsibilities necessary at inde pendent duty locations), and military leadership. When enter this program immediately following completion of is in its fourth year, and all locations are now receiving students. This article provides a great deal of insight into the enormously important and complex responsibilities of the Armys Veterinary Service, and how their profes sionals are well prepared for them. As mentioned in the opening sentence of this Perspec tive, learning must never stop in the healthcare profes sion, and it therefore cannot be solely the province of educational institutions and organizations. LTC Leilani Siaki and her coauthors have contributed an article which clearly illustrates how the ongoing process of pro fessional education can be addressed locally and region ally through initiatives and cooperation, both within or ganizations themselves, but also among different types of agencies and provider types, including government, as a formal approach to clinical practice circa 1992, evidence-based practice (EBP) has become an accepted model among medical specialties to optimize the provi sion of healthcare at the point of delivery. The article describes how the Army Nurse Corps, the Tripler Army Medical Center, the Hawaii State Center for Nursing, and 15 civilian healthcare organizations across Hawaii joined in partnership to share experiences, expertise, and lessons learned in nursing practice across the dif ferent environments. This effort includes work teams formed to identify problems to investigate and identify possible resolutions, an annual educational and practice workshop where teams present their work on problem resolution for discussion among the attendees, and an internship program that focuses on applying the steps of the EBP model to the problem in a series of bimonthly meetings to address progress, garner outside input, and additional education. The statewide initiative was in spired by the Tripler-wide EBP program that had been formalized several years earlier and provided a structur al and procedural model for the State Center of Nursing to adopt and implement. The success of this militarycivilian partnership for nursing practices in Hawaii is among all participants, without regard to the sizes and resources available to the respective partners. The authors argue that such arrangements can be established in the geographic area surrounding almost any military medical facility within the United States. The evidence-based approach is not limited to the op timization of point-of-care practice methods and proto ery. In their article, Richard Neilson and COL Denise Hopkins-Chadwick describe how it was used to develop PER SPECTIVE S

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January March 2014 5 US Army Practical Nurse Course, even as the career path of Army Practical Nurse has itself been evolving. Over a 6-year period, elements and phases of the program of instruction (POI) were examined and the latest thinking in educational concepts and design were researched to see which may be successfully incorporated within the course structure. In this case, researchers looked for evi dence of statistically sound improvements in educational outcomes in situations of similar student demographics, course content, learning environments, etc, in evaluating an instructional techniques potential for use. Five new strategies were incorporated as the POI was redesigned to support the new military occupational specialty des ignation for the Army Practical Nurse, which provides a fessional skills. This article joins others in this issue in demonstrating the professional acumen, dedication, and proactive energy of those charged with the education and training of the best our nation has to offer. Another ongoing element of higher level professional education is the comparative evaluation of different techniques of presenting information and accomplishing learning by the students. In their article, Dr Don Johnson and Sabine Johnson describe a study performed within the US Army Graduate Program of Anesthesia Nursing ferences between use of a human patient simulator and CD-ROM delivered training in the knowledge and skills obtained (and retained) by students. Interestingly, their preliminary research found no indication of any studies that investigated the relative effectiveness of a simulator against CD-ROM teaching strategies in care of trauma patients in terms of critical thinking and performance. The study they designed and conducted is intended to do exactly that within the context of nurse anesthetists training to contend with extensive, severe trauma injupresents a carefully conceived, extensively researched, meticulously designed, and rigorously conducted scien from that data. Studies such as this are invaluable to while considering which choice will best serve the ul For many years, Army Nursing has been recognized for its leadership in setting standards for professional nursing in the United States. Those standards cover the range from the minimum requirements to enter the necessary to both teach and supervise the education of Army Nurses. The article contributed by COL Bruce Schoneboom and COL Denise Hopkins-Chadwick pro vides insight into the superb quality of Army Nursings education and training structure by detailing the high educational standards required of the active duty fac ulty and supervisory positions. The article describes and enumerates the positions which are designated as re quiring a terminal degree, and discusses how the Army builds and retains a cohort of nursing professionals with the necessary academic preparation. The reader cannot but be impressed by the high standards and levels of academic excellence integral to Army Nursings educa tional system, which stands among the best in the world. Over the last several years, MAJ Joseph Topinka has been instrumental in the publication of a number of ar ticles in the AMEDD Journal either authored by him or his JAG Corps colleagues, which have provided a wealth of information concerning the legal concerns, consider ations, requirements, and risks inherent in the delivery and support of military healthcare. In this issue, he caps off that series by offering a plan by which he thinks the AMEDD education structure could better initially pre pare its personnel for contending with those legal aspects during their early careers, and later providing more so phisticated training tailored to higher level responsibili ties. His plan integrates 12 major areas of law into the Joint Medical Skills Institutes Competency Model by illustrating how one or more areas of law are inherent to each competency along with its other knowledge and skills components. He argues that healthcare profession als cannot achieve total skill competency without under standing the legal aspects of their jobs, and a lack of such tions can be both expensive and detrimental to a profes sional career. This article should be of great interest to those charged with planning the education and training requirements for military medical career tracks, from ments of time and training resources. Capt Benjamin Hazen and his colleagues have contrib uted an article which examines concerns facing the pro fessional military education (PME) in the US Air Force. in the residence courses, so those not designated for such schools must obtain their PME education with correspondence versions (also called distance learning) which use different delivery methods. This situation is a product of necessity due to the realities of resource and time constraints, and is obviously not unique to those points in their careers where they are expected to complete PME, for a number of reasons. Capt Hazen et

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6 http://www.cs.amedd.army.mil/amedd_journal.aspx referring to certain aspects of attending residence PME which are not part of the curriculum, but still affect out come from attendance. Some of those intangibles may be only perception rather than reality, but they are still those who do not attend residence PME often feel that they are at a competitive career disadvantage. On the other hand, some of those attending PME are concerned career tracks. There is no record in the literature of a dence PME (pro and con), so the authors designed and conducted such a study to identify the intangibles as the starting point to consider alternative approaches to the allay the majority of the concerns, while still delivering the necessary level of PME to ensure the continuity of a The article describes the concept of a blended approach to all PME, a combination of both correspondence and residence learning experiences. The correspondence as pect could employ the latest in delivery methods (such as mobile technology, game-based learning, online col laboration) over a period of time. Completion of the cor respondence phase of the course would be followed by a considerably shorter residence phase. In theory, a prop erly designed, blended model could provide the same PME experience to the majority of the Air Forces of fully developed, thought-provoking article which should stimulate or reinforce ideas and concepts of military education planners of all the services. All of us have experienced multiple choice examina tions at some point in our academic endeavors. All of us choice of an answer selection about which we are not about it? The question has probably existed as long as there have been multiple choice tests. Researchers have been formally investigating this conundrum since 1929, with consistent results. However, those studies have looked at a relatively small segment of academic disciplines, which did not include anesthesia nursing students. As part of the Army Graduate Program in Anesthesia Nursing process improvement program, it was decided to investigate whether their student popula tions attitudes toward answer changes were consistent with other studies, with the intent to provide informa tion to the students based on the entire body of research before they began multiple choice tests. Dr Don Johnson and colleagues prepared an excellent article clearly de scribing the preparatory research, the careful planning and execution of the study, and details of the results. This is a very interesting and informative article with perhaps surprising results. This article is a fascinating discussion for all of us who have ever anguished over an answer choice, and a must-read for anyone anticipating a multiple choice examination in the future. The AMEDD Journal is pleased to present CAPT (Ret) Bradley Poss review of a recently released revision of a volume of the Borden Institutes Textbook of Military Medicine Series, Pediatric Surgery and Medicine for Hostile Environments As CAPT (Ret) Poss so clearly ex ers in the combat environment of today, where children make up a disproportionate share of victims and have a higher mortality rate than adults. Further, most military healthcare providers assigned to combat areas have lim ited pediatric training and experience. He provides a de tailed, informative overview of the book. The value of this book is clearly evident in his descriptions and opin ions. Based on his review, all military medical providers anticipating deployment, whether combat or to an austere environment, should investigate this book as a resource for helping the smallest and most tragic of casualties. This issue of the AMEDD Journal closes with a collec tion of abstracts and the winning poster presented as part of the 3rd annual US Army Academy of Health Sciences Graduate School Research Day held at the AMEDD Center and School on December 11, 2013. Attendees at the Graduate School Research Day, as well as abstract and poster submissions, represent not only students in the various degree programs of the Graduate School, but also submissions from other military and nonmilitary academic institutions and medical centers. The profes sional collaboration and knowledge sharing afforded by the annual Research Day is another outstanding exam ple of the wide variety and high caliber of academic and research opportunities available throughout a career in military medicine. PER SPECTIVE S

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January March 2014 7STATEMENT OF THE PROBLEM The current social, political, and economic environment exists in a cacophony of competing perspectives of re policy, monetary policy, and interest groups. Our society has experienced the effects of sequestration, continuing resolutions, government furloughs, and debt-ceiling leg islation for nearly half a decade in what seems to be a new normal of federal resource formulation for provid ing services and meeting national obligations. cupy a center of gravity in this national discussion of resource priorities as nearly 20% of economic activity is associated directly with the provision of health services in the United States.1,2 Federal and state obligations in current and future budgets manifest in MEDICARE and MEDICAID programs coupled with provisions in the Affordable Care Act of 2010 yield substantial pub lic obligations for resource allocations to health services that are judged by many prominent analysts of being un sustainable in current form.3-5 The prevailing consensus among the community of health policy thinkers, exem Escape Fire ,6 is that meaningful changes must occur within the healthcare ing healthcare resources in a value-generating manner to meet societal needs. The Army Medical Department Center and School (AMEDDC&S) and associated education and training programs have been directly affected by forward-looking assessments of resource constraints and potential con tractions. In 2011, the AMEDDC&S conducted a multi dimensional analysis of all courses conducted within the Academy of Health Sciences, dubbed the 1 to N List, to begin the process of prioritizing education and train ing requirements and resource utilization on a marginal basis to make adjustments in expanding, contracting, or eliminating programs of instruction as necessary. In 2012, the US Army Medical Command, in conjunc tion with other military medical commands and the emergent Defense Health Agency at the Department of Defense (DoD) level, conducted similar studies fo cused on the costs inherent in the various education and training programs conducted across the military health system. Requests to the graduate programs for informa tion focused solely on the actual incremental costs of conducting graduate education in current and forecasted postures, but did not address other dimensions of con sideration for resource management.* In the future, the DoD, Military Health System, and Army Medical Department (AMEDD) will likely be faced with continuing to meet respective missions with diminishing absolute and relative resources. In order to adjust to these emergent environment and market real ties, a comprehensive review and adjustment of activities, processes, and outcomes matched with corresponding allocations of resources will become essential to ensure organizational viability and maintenance of educational and training programs that generate meaningful value. Contemporary research to evaluate the generation of val ue in graduate education has included studies that com pare starting salaries of graduates.7,8 These studies indi cate substantial variation in outcomes associated with What is the Value of Graduate Education? An Economic Analysis of Army Medical Department Graduate ProgramsLTC Lee W. Bewley, MS, USA Kevin D. Broom, PhD LTC Mark Bonica, MS, USAA B S TRACTCurrent and forward-looking resource constraints within the federal health system and general health market are gen establishes a framework for assessing economic value among graduate health-related programs within the Army Medical tion within each of the programs. Suggestions for future research and policy application are also discussed. *Source: internal AME DD and AME DD C &S documents not readily accessible by the general public.

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8 http://www.cs.amedd.army.mil/amedd_journal.aspxnumerous confounding factors including backgrounds, attitudes, and varying curriculums. Other studies fo cused on the value-generating effects of graduate pro grams that conduct research. Buxton et al9,10 analyzed more than 30 contemporary academic studies and found support for value generation in both extrinsic (cost sav ings) and intrinsic (knowledge development). Reviews of each of those articles found no consistent framework for assessing economic value generation. A fundamental framework for assessing and develop ing the future organizational composition of services and activities could be a value perspective advocated by Michael Porter and other organizational economists.11-13 The basis of the economic value perspective is that the combination of service and support activities within the organization can be expected to be matched with the ries, and/or stakeholders in a marketplace. Simply put, the value of an organization is based on what resources (budget, revenue, donations, grants, sales, etc) others provide. In an increasingly resource constrained envi ronment, elements within an organization will likely be required to demonstrate what value is generated in abso lute and relative terms in order to survive or potentially thrive as a going concern. The graduate programs of the AMEDD have a long tra dition of quality education matched with deep ranks of distinguished alumni, numerous national awards and recognition, and a tremendous record of research and service.14 Despite this standing, perpetual, recurring analyses of stakeholder perspectives seem to indicate both an incomplete understanding of the operational and resource bases of the various graduate programs and ideas that tremendous systemic cost-savings could be achieved by changing, diminishing, or possibly eliminating some or all of these programs. This article is intended to demonstrate the value of the AMEDDs graduate programs by applying a framework for eco nomic value analysis, enhance the understanding of the evaluating value in graduate education. B ACKGROUN D The AMEDD has conducted graduate education con tinuously since 1951. In that year, a relatively new pro gram of instruction in the Army Medical Field Services School (precursor to the Academy of Health Sciences and AMEDD Center and School), the Hospital Admin istration Course, initiated in 1947, developed and imple tract with Baylor University in order to be able to convey graduate degrees to graduates of the program.14,15 Since then, the Army-Baylor University MHA-MBA program has served the Army, Navy, Air Force, Veterans Health Administration, and Department of Homeland Security, graduating more than 2,400 alumni since 1951 includ service members, commanders, and national healthcare executives, while attaining a national ranking of 11 by US News in 2013 among all accredited healthcare man agement programs.16 graduate program, the Army continued to develop addi Army-Baylor Graduate Program in Physical Therapy was established in 1972 to enable awarding graduate degrees after decades of providing high quality educa than a degree. Similarly, graduate programs in physi cian assistant studies, nursing anesthesia, nutrition care, and social work were developed to meet ongoing human capital development requirements of the AMEDD and other military and federal health systems. versity provides all of the institution services associated with quality graduate education (accreditation to confer degrees, national standing and reputation, resources for research, student/alumni services, support for faculty, and admission/registrar services) and the government provides faculty, students, facilities, and conducts education. The mechanism of the contracting process is that academic institutions that meet government contracting requirements bid to provide services aligned with the pro visions in a one-year contract with 4 renewal periods that renegotiated every 5 years. The government only pays students enrolled in AMEDD graduate programs at cost rate per degree that is substantially discounted from nor Currently, the AMEDDs graduate programs are orga nized within the Graduate School of the Academy of Health Sciences (AHS). The AHS Graduate School con sists of 12 graduate programs and 13 degrees, including a doctoral program conferring a degree in clinical pas programs are conducted both within the AHS at Fort Sam Houston, Texas, and across the Army in hospitalbased programs. Degrees conferred include Doctorate in Physical Therapy, Doctorate in Science, Doctorate in WH A T IS TH E V A LU E OF GR AD U A T E E D UC A TION? AN ECONO MIC AN A LYSIS OF AR M Y MED IC A L DEPA RT ME NT GR AD U A T E PRO G R AM S

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January March 2014 9 Pastoral Care Ministry, Masters in Social Work, Mas ters in Health Administration (MHA), and Masters in ties include Baylor University, Northeastern University, University of Nebraska (Medical Center), Fayetteville State University, and the Erskine Theological Seminary. In addition to the Army-Baylor MHA-MBA Program earning top-tier US News national rankings in 2013, the the University of Nebraska (Medical Center) is ranked 13, the Army-Baylor Doctoral Program in Physical Therapy is ranked 5, and the US Army Graduate Pro ern University is ranked 1 within their respective disci plines among accredited programs.16M ETHODS Michael Porters research in value generation and devel opment of the Value Chain framework for organizational analysis makes a case that the economic value of an or ganization is directly associated with the resources that are drawn to the activity through organizational service delivery and support activities. In practical terms, the value of an organizations products or services is direct ly related to the prices that consumers are willing to pay and the aggregate combination of sales to generate rev 11,12The framework of this economic analysis to assess value costs directly associated with the annual activities of the 6 AHS-based graduate programs providing education to health services. Value will be expressed as the net dif nature and magnitude of the difference between costs Three dimensions of graduate education (teaching, ser vice, and research) provide a basis to assess value gener ated. Each of these dimensions may have both extrinsic costs will be calculated. Meaningful intrinsic or indirect analysis. AMEDDs graduate programs is the value of education received through the teaching provided by faculty and the degrees conferred from that education. The value of education provided by faculty was found by determin ing the market price of the aggregate credit hours within the curriculum of each program. The market price of ed ucation was determined by multiplying the credit hours in each curriculum and the public price per credit hour student starts. The public price per credit hour rate was ing costs of attendance. For example, the Army-Baylor MHA-MBA Program contract provides for 60 MHA an nual student starts (66 hours), and 30 of these students may earn a joint MHA-MBA (87 credit hours). Baylor University graduate tuition costs per credit hour for students that would purchase equivalent graduate educa tion on the open market is $1,357, which yields a value of $6,228,630 annually. Service provided by the graduate programs ranges from service-learning opportunities that faculty pursue, such as short-term deployments, enterprise consulting, or pa tient care, and includes student graduate research proj ects and patient care in training. Other types of graduate program service encompass editorial review boards, accreditation fellowships, institutional review board membership, and external teaching or speaking engage that most value generation, while substantial, is largely intrinsic and cannot be directly included in the initial framework of this analysis. The 2013 AHS Graduate School Scholarly Activity Re port outlined the research value generated by the nearly 100 faculty members serving the AMEDDs graduate school programs. Fiscal Year 2013 research efforts pro viding value included 259 publications, invited presenta tions, or technical papers. Additionally, more than $18.1 million of aggregate grant activity had been generated Costs were determined for each of the AMEDD graduate programs based on the extrinsic contractual costs of Operating costs, including supply, travel, and miscel costs from the most current (Fiscal Year 2013) cost data were used.* The cost analysis conducted by the US Army Medical Command in conjunction with the other military medical services and the Defense Health Agency established the cost per faculty or staff member composite full-time equivalent DoD employee factoring time spent for readiness, training, and/or other required *Source: internal AME DD C &S documents not readily accessible by the general public.

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10 http://www.cs.amedd.army.mil/amedd_journal.aspxactivities that were not directly associated with the mission activities of assignment. Human re source costs were determined by multiplying this rate and the number of faculty, staff, and future faculty in doctoral studies assigned at the graduF IN D ING S A summary economic analysis of the AMEDDs graduate program indicates that substantial net extrinsic value and intrinsic value are generated by these programs individually and in the aggre gate. Table 1 presents the results of net extrinsic value accounting for the market value of educational degrees conferred compared to the ex budgets, and human resources (faculty, staff, and future faculty in doctoral studies). Table 2 provides summary economic value per graduate student by program given each programs annual contractual capacity. Table 3 depicts intrinsic Clearly, the AMEDD graduate programs demon costs. Each of the assessed graduate programs rates a that generate economic value in a range of 3 to 5 times in the AHS Graduate School generate economic ben $39 million to receive, balanced against extrinsic costs of only $11 million to provide this value. uate programs are substantial and support strategic Northeastern University, and the University of Nebras ka provide strategic alliances and access to academic and research resources that enable the AMEDD and the Military Health System to enrich strategic stakeholder networks. Additionally, earning peer-reviewed national rankings provides tremendous standing for Army Medi cine and military services in terms of establishing and furthering a position of high level human capital devel opment. Furthermore, the graduate programs collective network of supporting organizations including each of the US News Top 5 Hospitals in America (Johns Hop kins, Massachusetts General, Mayo Clinic, Cleveland Clinic, and UCLA Hospital) provide a substantial ba sis for collaboration, benchmarking, and best practices exchange. Finally, the value of knowledge and grant activity provided by the graduate programs extends and enhances societal knowledge and healthcare organiza health resources to achieve higher quality healthcare. portfolio of intrinsic costs, including opportunity costs, WH A T IS TH E V A LU E OF GR AD U A T E E D UC A TION? AN ECONO MIC AN A LYSIS OF AR M Y MED IC A L DEPA RT ME NT GR AD U A T E PRO G R AM S T able 1. Summary Economic A nalysis of AME DD G raduate Program Value.Program Extrinsic Extrinsic C osts Economic Value C ost Ratio ArmyB aylor MHA MBA $6,228,630 $2,008,472 $4,220,158 3.10 ArmyB aylor DP T $4,206,700 $1,396,613 $2,810,087 3.01 ArmyB aylor G PN $1,465,560 $1,260,978 $204,582 1.16 N ortheastern U SAG P AN $9,595,300 $2,373,654 $7,221,646 4.04 N ebraska I PA P $16,119,600 $2,999,293 $13,120,307 5.37 A rmyF S U M SW $1,376,160 $1,206,800 $169,360 1.14 A ggregate AH S G raduate School $38,991,950 $11,245,810 $27,746,140 3.47Glossary: MHA M asters in H ealth A dministration MBA M asters in B usiness A dministration DP T Doctorate in Physical T herapy G P N G raduate Program in N utrition U S AG P AN U S A rmy G raduate Program in A nesthesia N ursing I P A P I nterservice Physician A ssistant Program F S U F ayetteville State U niversity M SW M asters in Social Work T able 2. Summary Economic Value per G raduate Student by Program.Program Annual S tudent C ontract C apacity Average Economic Value per Graduate S tudent ArmyB aylor MHA MBA 60 $70,336 ArmyB aylor DP T 25 $112,403 ArmyB aylor G PN 20 $10,229 N ortheastern U SAG P AN 65 $111,102 N ebraska I PA P 240 $54,668 A rmyF S U M SW 40 $4,234 A ggregate AH S G raduate School 450 $61,658 Glossary: MHA M asters in H ealth A dministration MBA M asters in B usiness A dministration DP T Doctorate in Physical T herapy G P N G raduate Program in N utrition U S AG P AN U S A rmy G raduate Program in A nesthesia N ursing I P A P I nterservice Physician A ssistant Program F S U F ayetteville State U niversity M SW M asters in Social Work

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January March 2014 11 which provide insight on alternative uses of resources. Each of the graduate programs receive institutional sup tion technologies, human resources support, as well as general logistic and security support that generate ex penses, but are usually cost allocated among activities as overhead or indirect costs. One prime opportunity cost that the AMEDD and other military health services that provide interservice faculty bear in the operation of graduate education programs is semiexclusive use cost by transferring faculty to practitioner assignments after 3 to 5 years service within a program, or by ad hoc, short-term (3 to 12 months) assignment in deploy ment and then return to the graduate program, which also effectively provides a service-learning opportunity for faculty members. C ON S I D ERATION S FOR F UTURE R E S EARCH Future research in development of a framework to as cost measures, particularly for human resources and overhead costs. By incorporating these costs, education al managers may be able to have even more complete information sets to evaluate tunities to expand value. Po tential problems likely to be encountered in the incorpora tion of these costs are primar ily associated with apportion ment. In the case of assigning precise human resource costs rather than a composite cost factor, portions of time dedi cated exclusively to graduate education versus other activities may likely prove problematic. Similarly, allo cations of overhead costs to operating units often attract questions of validity, de pending upon bases of cost allocations. Other potential opportunities of AMEDD graduate educa tion programs could seek to research and service into ex the Doctoral Program in Physical Therapy is often able to use resources derived from grant activity that en hance the quality of patient care and diminish care de livery costs. Similarly, the Administrative Residents in the MHA-MBA Program often develop graduate man agement research projects that yield substantial costsavings to host organizations that might be included as C ON S I D ERATION S FOR EDUCATIONAL POLICY The AMEDD has developed successful business prac the market standing of nationally-renown education in stitutions to facilitate economic value generation mani fest in the teaching, service, and research of AMEDD ation agreements by the AMEDD and DoD may sup port the continued human capital development required Key requirements to being able to continue generating ation contracts to top-tier educational institutions with substantial market standing marked by the prevailing market tuition rate, investing graduate students to the Program I ntrinsic and O pportunity C osts ArmyB aylor MHA MBAUS News N o. 11. 62-year strategic affiliation top-tier national university. A ffiliation with each of the US News top 5 hospitals. F aculty and future faculty could be diverted to practitioner assignments. U se of facilities and overhead support.ArmyB aylor DP TUS News N o. 5. 42-year strategic affiliation top-tier national university. C ombat Soldier oriented research. F aculty and future faculty could be diverted to practitioner assignments. U se of facilities and overhead support.ArmyB aylor G PNC ombat Soldier oriented research. G raduates prime support A rmy Surgeon G eneral Performance T riad. F aculty and future faculty could be diverted to practitioner assignments. U se of facilities and overhead support.N ortheastern U S AG PANUS News N o. 1. G raduates are filling critical gaps in hospitals and deployable units. F aculty and future faculty could be diverted to practitioner assignments. U se of facilities and overhead support.N ebraska I PA PUS News No. 13. G raduates are filling critical gaps in hospitals and deployable units. F aculty and future faculty could be diverted to practitioner assignments. U se of facilities and overhead support.A rmyF S U M SWG raduates are filling critical gaps in clinics and deployable units. F aculty and future faculty could be diverted to practitioner assignments. U se of facilities and overhead support.A ggregate AH S Graduate School259 annual publications, presentations $18.1 million research grants. 50+ affiliations/ MOU s with national institutions and organizations.Glossary: MHA M asters in H ealth A dministration I P A P I nterservice Physician A ssistant Program MBA M asters in B usiness A dministration F S U F ayetteville State U niversity DP T Doctorate in Physical T herapy M SW M asters in Social Work G P N G raduate Program in N utrition MOU s M emoranda of understanding U S AG P AN U S A rmy G raduate Program in A nesthesia N ursing

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12 http://www.cs.amedd.army.mil/amedd_journal.aspx fullest educational capacity of the programs, and moder include considering the economic value of changing the vanced market standing during the normal contract so licitation, bidding, and evaluation process. Additionally, the Masters in Nutrition Care and Masters in Social Work from other military or federal services in order to attract more students which would yield more economic value and gain economies of scale. Finally, in the case of the Masters in Nutrition Care program, perhaps AMEDD strategic initiatives advocating nutrition care may gener ate additional force structure requirements for dieticians, for example, a dietician assigned to each Army brigade combat team or increased demand for graduate nutrition care education may emerge for other providers such as physicians, dentists, or nurses. SUMMARY This article seeks to establish a framework for evaluat ing the economic value of AMEDD graduate programs and to provide summary analyses of the extrinsic ben that the 6 graduate programs providing graduate educa processes to provide a richer understanding of the eco nomic value of graduate programs. A number of policy considerations including maintaining, expanding, or contracting these graduate programs may be considered R EFERENCE S1. Fuchs F. Who Shall Live? Health, Economics, and Social Choice 2nd ed. Hackensack, NJ: World Sci 2. Santerre RE, Neun SP. Health Economics: Theo ries, Insights, and Industry Studies 6th ed. Mason, 3. Krugman P. Ailing health care. The New York Times Available at: http://www.nytimes.com/2005/04/11/ opinion/11krugman4.html?ref=paulkrugman. Ac cessed October 22, 2013. 4. The Federal Governments Financial Health. sites/default/files/omb/financial/reports/citizens_ guide.pdf. Accessed October 22, 2013. 5. Kaiser Family Foundation. Assessing the effects of the economy on the recent slowdown in health spending [internet]. April 22, 2013. Available at: http://kff.org/health-costs/issue-brief/assessingthe-effects-of-the-economy-on-the-recent-slow down-in-health-spending-2/. Accessed October 22, 2013. 6. Escape Fire: The Fight to Rescue American Healthcare [documentary]. Aisle C Productions & 22, 2013. 7. Pfeffer J, Fong C. The end of business schools? Less success than meets the eye. Acad Manag Learn Educ 8. OBrien J, Drnevich P, Crook T, Armstrong C. Does business school research add economic value for students?. Acad Manag Learn Educ 2010:9(4):638-651. 9. Buxton M, Hanney S, Packwood T, Roberts S, Health and National Service Research and Devel opment. Publ Money Manag October-December 10. Buxton M, Hanney S, Jones T. Estimating the eco nomic value to societies of the impact of health re search: a critical review. Bull World Health Organ 11. Porter ME. Competitive Advantage: Creating and Sustaining Superior Performance New York, NY: 12. Ginter PM, Duncan WJ, Swayne LE. The Strate gic Management of Healthcare Organizations. San 13. Reinhardt U. On the much used (and abused) word value in healthcare. J Health Adm Educ 14. Mangelsdorff D, Finstuen K, Pryor R. US ArmyBaylor University graduate program in health care administration: 50 years of scholarship in action. US Army Med Dep J January-March 2005:5-9. 15. Ginn RVN. The History of the US Army Medical Service Corps Washington, DC: US Army Center history.army.mil/catalog/pubs/30/30-19.html. Ac cessed October 22, 2013. 16. Americas best graduate schools [internet]. US News and World Report 2013. Available at: http:// grad-schools.usnews.rankingsandreviews.com/ best-graduate-schools/top-medical-schools. Ac cessed October 22, 2013.WH A T IS TH E V A LU E OF GR AD U A T E E D UC A TION? AN ECONO MIC AN A LYSIS OF AR M Y MED IC A L DEPA RT ME NT GR AD U A T E PRO G R AM S

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January March 2014 13 A UTHOR SLTC Bewley is the Program Director and Associate Professor in the Army-Baylor MHA-MBA Program, US Army Medical Department Center and School, Fort Sam Houston, Texas. Dr Broom is an Assistant Professor, Saint Louis University Masters in Health Administration Program, St Louis, Missouri. LTC Bonica is the Deputy Program Director and Assistant Professor in the Army-Baylor MHA-MBA Program, US Army Medical Department Center and School, Fort Sam Houston, Texas.

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14 http://www.cs.amedd.army.mil/amedd_journal.aspxRecent research advocates a learner-centric over a more traditional teacher-centric approach to enhance learning in formal education.1-5 Teacher-centric learning, a passive one-way delivery of information from teacher to student, typically relies on the students short-term memorization of course material while the teacher takes full responsibility to facilitate student learning. Con versely, in learner-centric teaching, the responsibility for learning is shifted to the student4 as the instructor serves as a coach to provide education through a variety of learning methods/tools. Several investigators empha size that learning is optimized when students are active ly involved in applying course material, are required to tive efforts that expose them to people with divergent emotional, cultural, and personal experiences to stimulate self-awareness.2-4 These concepts support Knowles original work published in 1970 and still valid today. Knowles states that as individuals mature they become more self-directed, need to understand why information is important, and gradually shift from knowledge gath ering to knowledge application.6A key component in creating an environment that stim ulates learning is the manner in which information is conveyed to students. The concept of learning styles has emerged to elucidate how students learn. A students learning style is dictated by personal characteristics, in cluding a combination of cognitive, affective, and physi ceive and interact with educators and peers.7,8 Although there are several learning style theories, the GrashaRiechman, Kolb/McCarthy, and VARK (visual, audi tory, read/write, kinesthetic) Learning Styles, described in Table 1, appear to be more thoroughly assessed in re search. Each theory presents a different view of how in dividuals learn and drives the methodology for assessing and classifying learning styles. The Grasha-Riechman Learning Style is based upon student response to class activities, while the Kolb/McCarthy and VARK mod els assess students prior to the educational experience to increase awareness and identify study strategies that promote learner success.9The progression from undergraduate to graduate educa tion requires a more complex and thorough understand ing of course material and some students may need to in corporate new or different study habits to facilitate criti cal thinking skills.9 Consequently, institutions use a va riety of surveys based upon learning theories to enhance learner success in a formal education environment. It is hypothesized that students will be more successful if a Incorporation of Learning Styles into the Graduate Program in Nutrition CurriculumMAJ Renee E. Cole, SP USA LTC Reva L. Rogers, SP, USA Maj Heidi L. Clark, BSC, USAF LTC (Ret) Lori D. Sigrist, SP, USA Learning Style Grasha-Riechman Kolb/McCarthy VARKDistinct cognitive, affective, and psychological characteristics of students addressed by each learning style. better

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January March 2014 15survey is used to assess and increase student awareness of individual learning styles and provide strategies to enhance study efforts. The US Military-Baylor University Graduate Program in Nutrition (GPN), established in 2006, is a masters degree and dietetic internship program for US Army plete the program obtain a master of science degree in nutrition and are eligible to take the national Registered Dietitian (RD) exam to earn the RD credential. Over on the national exam; students rank between the 82nd and 94th percentile compared to approximately 3,500 students taking the exam annually. Although the GPN is a premier program for graduate dietetics education and selects high quality students, every year approxi mately 8% (1 in 12) of students fail to meet academic standards to complete the program. Thus in 2009, to im prove student retention with an emphasis on effective learner-centric education, GPN faculty implemented the Saginaw Valley State University (SVSU) 45-item selfassessment learning style to increase student awareness of individual learning styles and provide effective study strategies. The SVSU Learning Style survey is an ex pansion of the VARK Learning Style survey that elabo rates on auditory and visual learners, evaluates students oral and written expressiveness and the preference for individual versus group learning activities.10 The In terservice Physician Assistant Program at the Army Medical Department Center and School successfully used the SVSU learning style survey to assist student transition of learning at the graduate level. A review of the GPN curriculum indicated that the ma jority of information provided to students during Phase 1 was teacher-centric, relying heavily on PowerPoint slides and one-way communication of knowledge from teacher to students. Phase 1 of the GPN consists of 45 credits of didactic coursework over a 9-month period (2 semesters) while Phase 2 is comprised of 1,338 hours of supervised practice to attain 38 competencies over a cil for Education on Nutrition and Dietetics. Since Phase 2 focuses on application and practical experience of the information taught in Phase 1, faculty assessed each Phase 1 didactic course and incorporated a combination of learning style modes to accommodate all learning preferences. The remainder of this paper will discuss the transition to a learner-centric curriculum within Phase 1 of the GPN by incorporating learning style pref This section provides a review of each learning style corporated the learning modalities into the curriculum. Table 2 highlights the 15 Phase 1 didactic courses with the learning styles that were integrated into the curriculum. GPN students complete the SVSU survey before beginning coursework and faculty members review the results with each student to increase student awareness and motivation. The faculty also provides study strate gies for each learning style (Table 3) and fosters student sions throughout Phase 1. Students with a visual learning style prefer to learn lan guage and mathematical skills by sight (reading and writ ing). Activities that support the visual learner include: PowerPoint presentations and posters with a variety of colors, fonts, graphics, bulleted information, and calculations. Self-study material and assigned reading such as journal articles and textbook chapters. Graphics, such as charts, tables diagrams and DVD and Internet videos to support both visual and auditory learners. Online calendar with courses visually represented as color-coded time blocks. Baylor Blackboard, an online application that al lows visual organization of course materials and assignments into folders, and an online grade book. Many GPN courses use visual means to display class materials with concurrent oral presentations. The Vita mins and Minerals course uses diagrammed pathways to Med (MNT), students create a detailed patient-focused handout on dietary intake recommenda tions for disorders impacted by nutritional therapy and develop a poster to convey key information on a selected MNT topic. uses several short video clips on featured sports activities. The auditory learning style students prefer to learn lan ing on the information. The learning mode activities to support the auditory learner include: Listening to lectures Class discussions of course material Small group discussions of case studies THE U NIT E D S TAT E S A RM Y ME DICAL DE PARTME NT JO URNAL

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16 http://www.cs.amedd.army.mil/amedd_journal.aspx DVD and Internet videos to hear the information complemented by visual display Peer teaching of course material Although all GPN courses incorporate auditory learning skills through instructor-taught lectures or facilitated dialogue, discussions among students are critical for the success of auditory learners. The MNT course uses case studies to discuss the nutrition care process for assessing nutrition and lifecycle patient examples and integrates relevant You Tube videos, as well as documentaries such as the HBO production in Producer; 2006) to comprehend issues related to anorex ia. The course uses the American Society of Parenteral and Enteral Nutri tion patient care guidelines as a platform to develop a nutrition support policy, and reinforces end-of-life care and ethical decision-making concepts with case study discussions. The course features a variety of guest speakers, minimal PowerPoint presenta tions, and reliance on group discussion to facilitate as similation of critical course information.Students with a kinesthetic learning style prefer to learn by doing and practicing. The learning mode activities to support the kinesthetic learner include: Hands-on activities Practical exercises/simulations Performing laboratory assessments Creating a video, poster, or other prac tical tool Role playing Game playing Field trips The and courses use a variety of nutrition and phys ical assessment devices, such as: hemocue and glucometer for blood analyses; dual energy x-ray absorptiometry, bioelectri cal impedance analysis, whole-body airdisplacement plethysmography, and skin fold measurements for body composition ity, and endurance testing for physical per formance. guides student development of a GPN marketing and/or nutrition education video. In the Re course, students conduct a research project to include recruiting and enrolling subjects, collecting and analyzing data, and course uses a nutrition jeopardy game, similar to Boctors Nursopar dy.11 The as visiting the military food service prime vendor to understand food vendor warehouse operations and a military dining facility to discuss food service opera tions with personnel. The course such as a Shor-board to measure childrens height in a remote humanitarian mission environment. In the Ad course, teams of students peer-teach several of the main nutrition concepts followed by group discussions.Individual learners prefer to learn in an environment conducive to learning alone, whereas group learners prefer to interact with others to assimilate information. Students may have a preference as individual or group learners, but all GPN students are expected to become tioning successfully in a group environment. As future healthcare team members and effective military leaders, level *Course Title Visual Auditory Kinesthetic O ral and/or Written E xpressive Individual and/or Group I ment Lab I G I I I G I I I* INC O RP O RATI O N OF LE ARNING S T Y L E S INT O T HE G RADUAT E P R O GRAM IN N UTRITI O N C URRICULUM

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January March 2014 17 it is essential that GPN students become adept at inter acting in a group setting. To emphasize this aspect of dietetics, many courses incorporate group activities in addition to individual requirements. Courses such as and require individual learning, whereas primarily relies on group learning. In small groups read and criti cally assess 5 peer-reviewed research manuscripts, com pare and contrast the quality of nutrition-based research, conclusion of the research assessed, and the implica tions for the RD. Many courses employ a combination of individual and group activities. Although re quires each student to individually write a research pro tocol for a masters level research project, students work in groups to discuss and understand the research process. requires individual assessment of the research protocol to be implemented, small teams to conduct several aspects of the study, large group discus sion of statistical methods and analysis, and individual assignments involving creation of a research abstract and partial manuscript. Courses including both individ ual and group work often grade written assignments on individual effort but also grade each students effective ness with group discussions or combined efforts. This ences of others, gaining a broader comprehension and appreciation for the topic. Some courses ask each student group member to rate their teammates on their contributions to the group at ing by classmates is included in the course as a project grade. Since it is unacceptable to allow team members to cover for or carry another student through the course, the expectation of effective group participation is highlighted at the beginning of the course to ensure students understand their role as a team member. Many rate/rank their classmates participation in a formal manner and, although they are hesitant about the pro cess, they understand that as a future supervisor, they nates in an objective manner. Expressiveness focuses on how the information is as similated and disseminated. The oral expressive student is typically a skilled public speaker. The individual uses verbal skills to organize and assimilate knowledge and is effective at expressing knowledge through a discus sion, simulation or practical exercise. This person of ten needs to talk through the process to strengthen their comprehension of the knowledge. The practice-based small group learning (PBSGL) activity is used in some classes to improve oral expressive skills. It is self-direct experiences with peers for more effective knowledge acquisition and critical skill development.12The written expressive learner is typically a skilled writer. The individual uses written skills to organize information into manageable subcategories and is pro Visual Auditory Kinesthetic Study listening Cue Card Use remember

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18 http://www.cs.amedd.army.mil/amedd_journal.aspxby organizing thoughts on paper than expressing verbal ly. Practice oral exams are provided throughout the year in various courses to encourage verbal dissemination of material. This is especially helpful for those students who are written expressive learners. Over the past 3 years, the GPN faculty integrated a vari ety of learning modes to support student learning style preferences. Since initiation of the SVSU learning style survey, the GPN assessed the learning styles of the past 3 classes, and formally started tracking progress over the past 2 classes. Figure 1 outlines the distribution of the students major learning style preferences. Nearly half ous undergraduate studies group experiences than a true learning preference, as students commented anecdotally that undergraduate group projects were not necessarily team oriented and the work was typically completed by the most diligent students. Almost one-third (28%) of students were expressive oral and even fewer (16%) were expressive written, which may be related to de-em phasis of undergraduate curriculum writing opportuni ties due to often large class sizes. Since communication in the oral and written forms are key skills for effective registered dieticians, 67% of courses incorporate both written and oral expressive requirements, and 77% of courses taught primarily by GPN instructors integrating both elements. The results of GPN students were similar to other health care students presented in the research examining the VARK learning style theory. The GPN students were all multimodal learners, similar to that of premed, nursing, and biomedical students (53% to 80%) reported in litera ture.1,7,13-15 Interestingly Hsieh et al16 found a unimodal learning preference (87%) in undergraduate biomedical students and Samarakoon et al15 found the majority (52%) of their College of Medicine postgraduates were unimodal learners.15,16 The GPN students most common learning style was kinesthetic (32%) closely followed by visual language (24%), which was lower than research reported on premed, nursing and biomedical students (53%-69% kines thetic).1,7,9,13,14,16 Although 75% of GPN students were women, research suggests that there are minimal differences in learning preferences between men and women.1,7,13Student age as a factor in learning style pref et al, who found there was no impact.13 The GPN students typically range in age from 23-35 years (mean 26.4 3.3 years). Figure 2 depicts a potential dif ference in learning styles when the past 2 classes were categorized into 23-26 years and 27-32 years. The younger age category appears to be more kinesthetic and less visual; however the student sample size was not large enough to support statistical comparison. Eckle berry-Hunt and Tucciarone suggest that Generation Y (born from 1982 to 2005) students tend to prefer kines thetic learning and desire a close relationship with their educators.17,18 Only one GPN student fell outside of the Generation Y year group. The authors suggest that eduand focus on increasing use of technology by minimiz ing traditional lectures, using multimedia, and using simulations, case studies, and group discussions; men addressing inappropriate behaviors, and role-modeling desired behaviors; providing clear communication with tion and developing priorities; and providing oral and written feedback to build accountability, responsibility and independence.17 The GPN program is dedicated to student mentoring through monthly academic counsel ing sessions, and an open-door policy encourages com munication with faculty when students are faced with challenges requiring immediate attention. Some faculty adopted a unique approach to monthly student counsel ing sessions. Rather than a traditional sit-down, faceto-face session, the student and faculty member spend 20-30 minutes walking while talking; an approach that seems to encourage greater disclosure and particularly engages the kinesthetic learners. To facilitate student growth in critical thinking skills and assimilation of information, it is important that faculty 18,19 As a result, GPN faculty also completed the SVSU Learning Styles survey. INC O RP O RATI O N OF LE ARNING S T Y L E S INT O T HE G RADUAT E P R O GRAM IN N UTRITI O N C URRICULUM

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January March 2014 19 Visual-numerical was the facultys primary major learn secondary major learning style. The faculty is equally divided between preferences for oral versus written ex pressiveness. Learning styles within the faculty were similar, however, the faculty annually reevaluates each course through student and faculty feedback in an effort to continually stimulate learning through a variety of modalities. Incorporation of various learning modalities ensures that coursework remains relevant and challeng ing to students; encourages them to use their strengths and focus on areas for improvement; and prepares them to deal with the various challenges they will face as both For the faculty, implementing various modalities into the curriculum creates an engaging work environment, creative presentation of material. It is also worth noting that there is skepticism within ing learning style assessments to tailor course design. Although it is widely accepted that education should be tailored towards learning styles, Rohrer and Pashler state there is no clear evidence to support learning-style instruction.20 They contend that tailoring is logistically demanding and effective only if all students fall within the same style, therefore, educators should focus on a combination of educational modalities that best pres through a literature review, only 13 were noteworthy, and none have been adequately validated.19 He supports that faculty must show how the course material is clini cally relevant to the student in order to truly stimulate learning. The GPN staff agrees that course content must demonstrate clinical relevance. However, student aware ness of learning styles may also help them understand their patient population, especially in an outpatient nutrition setting, and adapt their education and counseling effective communication with peers and subordinates throughout their military and professional career. The US Military-Baylor University Graduate Program in Nutrition transitioned from a teacher-centric to a learner-centric educational environment in 2009. The Saginaw Valley State University learning style survey was administered to students to assist them in their transition to graduate level education, which requires a collaborative, self-directed approach to knowledge assimilation and application. It is unknown if this pro gram improvement impacted student success in their didactic coursework and dietetic internship. The GPN has many unanswered questions about predictors of suc cess and will continue with annual program assessment and revision. A retrospective study identifying potential predictors of student success, including learning style

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20 http://www.cs.amedd.army.mil/amedd_journal.aspx modality effectiveness, may add valuable information in the quest to meet and maintain educational goals and registered dietitians. 1. Breckler J, Joun D, Ngo H. Learning styles of phys iology students interested in the health professions. Adv Physiol Educ 2009;33(1):30-36. 2. ible learning for adult learners in professional con texts: an activity-focused course design. Interact Learn Environ 2011;19(4):381-393. 3. Hyland T. Mindfulness, adult learning and thera peutic education: integrating the cognitive and af fective domains of learning. Int J Lifelong Educ 2010;29(5):517-532. 4. Saulnier B, Landry J, Wagner T. From teaching to learning: learner-centered teaching and assessment in information systems education. J Inform Syst Educ 2008;19(2):169-174. 5. Schiller SZ. Practicing learner-centered teaching: pedagogical design and assessment of a second life project. J Inform Syst Educ 2009;20(3):369-381. 6. Knowles MS, Holton EF III. The Adult Learner: man Resource Development 7th ed. Burlington, MA: Butterworth-Heinemann; 2011. 7. Alkhasawneh IM, Mrayyan MT, Docherty C, Alashram S, Yousef HY. Problem-based learning (PBL): assessing students learning preferences us ing VARK. Nurse Educ Today 2008;28(5):572-579. 8. Kumar P, Kumar A, Smart K. Assessing the impact of instructional methods and information technol ogy on students learning styles. Issues Informing Sci Inf Technol 2004;1:533-544. 9. Murray C. Use of learning styles to enhance gradu ate education. 2011;40(4):67-71. 10. Learning styles survey: student learning style sur vey [internet]. StudyGuide.org. Available at: http:// www.studyguide.org/learning_styles.htm. Accessed April 8, 2013. 11. Boctor L. Active-learning strategies: the use of a game to reinforce learning in nursing education. A case study. Nurse Educ Pract 2012;13(2):96-100. 12. Zaher E, Ratnapalan S. Practice-based small group learning programs: systematic review. Physician 2012;58(6):637-642. 13. James S, DAmore A, Thomas T. Learning pref students: utilising VARK. Nurse Educ Today 2011;31(4):417-423. 14. dents. Nurse Educ Today 2009;29(1):24-32. 15. Samarakoon L, Fernando T, Rodrigo C, Rajapak se S. Learning styles and approaches to learning among medical undergraduates and postgraduates. 2013;13(1):42-47. 16. Hsieh C, Mache M, Knudson D. Does student learning style affect performance on different for mats of biomechanics examinations?. Sports Bio mech 2012;11(1):108-119. 17. Eckleberry-Hunt J, Tucciarone J. The challenges and opportunities of teaching generation Y. J Grad Med Educ 2011;3(4):458-461. 18. Fuentealba C. The role of assessment in the student learning process. J Vet Med Educ 2011;38(2):157-162. 19. Hughes S. The Emperors New Clothes revisited: learning styles in medical education. Educ Prim 2012;23(2):79-81. 20. Rohrer D, Pashler H. Learning styles: wheres the evidence?. Med Educ 2012;46(7):634-635. MAJ Cole is Director, US Military Dietetic Internship Consortium and Assistant Dean for Research, Academy of Health Sciences, AMEDD Center and School, Fort Sam Houston, Texas. LTC Rogers is Chief, Nutrition Care Division, William F. Beaumont Army Medical Center, Fort Bliss, Texas. Maj Clark is a Lecturer/Instructor, US Military-Baylor Graduate Program in Nutrition, AMEDD Center and School, Fort Sam Houston, Texas. When this article was written, LTC (Ret) Sigrist was Program Director, US Military-Baylor University Graduate Program in Nutrition, AMEDD Center and School, Fort Sam Houston, Texas.INC O RP O RATI O N OF LE ARNING S T Y L E S INT O T HE G RADUAT E P R O GRAM IN N UTRITI O N C URRICULUM

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January March 2014 21Learning is not a spectator sport. Chickering and Gamson1The traditional approach of teaching, with instructors standing at a podium in front of the class before the students, imparting the wisdom of the collective years of their education and experience, may not be the best method for all students to learn and retain material. Cog nitive research supports that this derisively labeled sage on the stage lecturing approach to teaching does not work well for all students.1,2 Some students learn better through varied pedagogical practices: [the literature] suggests that students must do more than just listen: they must read, write, discuss, or be engaged in solving problems. To be actively involved, students must engage in such higher-order thinking tasks as analysis, synthe sis, and evaluation.2 It follows then, that instructors in terested in engaging their students at a more thoughtful level should consider expanding their repertoires of educational methods beyond a death by PowerPoint ap proach to lecturing. In addition to students increased longing for captivating educational environments, the competitive environment at universities places pressure on faculty to excel at teaching.3What methods can we employ to engage our students better? How do we extend our reach beyond the lec tern? How do we engage students across the domains of Blooms Taxonomy? An answer may lie in an Active Learning approach to address the domains of Blooms Taxonomy. In this article, we put this discussion on a tive Learning and the 3 domains of Blooms Taxonomy: cognitive, affective, and psychomotor.4 We synthesize the role of Blooms Taxonomy and Active Learning in developing 2 games: Trade or Raid, and Vote, Negotiate, and Retaliate (Method section). We developed one game, Trade or Raid, to be played over multiple class sessions and the other, Vote, Negotiate, and Retaliate, to be played during a single class session at a fast pace. In the Com ment section, we provide a thorough comparison of the multiple versus single session games, elaborating on the Active Learning advantages and disadvantages through the lens of Blooms Taxonomy. In the Future Directions section, we focus on continuous improvement and rec ommend study avenues in the realm of Active Learning across the Bloom domains. BACKGROUND one of the seminal Active Learning manuscripts: Ac tive Learning is any instructional activities involving students in doing things and thinking about what they are doing.2 As mentioned, the Blooms Taxonomy do mains are cognitive, affective, and psychomotor. In as thinking/head, meaning it involves activities that stimulate the mind. The affective domain can be thought emotions. Activities stimulating students physically fall in the psychomotor domain and can be described as doing/hands. In their discussion of developing affective methods to improve training for Airmen, Tharp et al recommend further research into affective learning to address questions regarding its use in and impact on Air Force education and training.5 We feel the call from Tharp et al can be even broader. Their call for further investiga tion into affective learning can generalize beyond the An Active Learning Approach to Blooms Taxonomy: 2 Games, 2 Classrooms, 2 MethodsMAJ Fred K. Weigel, MS, USA LTC Mark Bonica, MS, USAAB STRACT with a deep understanding of the material the instructors share. One challenge lies in how to provide the mate rial with a meaningful and engaging method that maximizes student understanding and synthesis. By follow ing a simple strategy involving Active Learning across the 3 primary domains of Blooms Taxonomy (cognitive, affective, and psychomotor), instructors can dramatically improve the quality of the lesson and help students retain and understand the information. By applying our strategy, instructors can engage their students at a

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22 http://www.cs.amedd.army.mil/amedd_journal.aspxneeds of the Air Force, and likewise, should expand to include the other 2 domains of Blooms taxonomy: the cognitive domain and the physical domain. Tharp and his colleagues ask how cognitive and affective-design methods [can] be combined to create a more effective overall curriculum-development process.5 We suggest that the solution may be found in a strategy of Active Learning that targets all 3 learning domains of Blooms Taxonomy. BLOOMS T AXONOMY In developing principles to classify outcomes in educa tion, Bloom and his colleagues generated their classi as Blooms Taxonomy of Learning. In the cognitive do main, thinking/head, the emphasis is on remembering or reproducing something which has presumably been learned, as well as objectives which involve the solv ing of some intellective task for which the individual has to determine the essential problem and then reor der given material or combine it with ideas, methods, or procedures previously learned.4 Much effort has been focused on the cognitive domain in the past 2 decades.6 Although a detailed discussion is beyond the scope of this article, it is worth mentioning that the cognitive do main is further subdivided into 6 detailed levels: knowl edge, comprehension, application, analysis, synthesis, and evaluation.7,8 many consider learning as it relates to the cognitive do main. In contrast, the affective domain, feeling/heart, is focused on objectives which emphasize a feeling tone, an emotion, or a degree of acceptance or rejection.4 In this domain, the objective is to tune the teaching approach toward the learners emotions, or to use the feeling/heart terminology: to touch the learners heart to impact his or her learning. For a detailed discussion of the 5 subdivisions of the affective domain (receiving, responding, valuing, organization, and characterization by a value or value complex), refer to Bloom et al.4 A detailed discussion of the levels of the affective domain is beyond the scope of our study. In addressing outcomes focused on objectives which emphasize some muscular or motor skill, some manipulation of material and objects, or some act which requires a neuromuscular coordination, Bloom et al4 developed the psychomotor domain. Despite that few objectives in the literature focus on the psychomotor domain, it is im portant to consider the value of the psychomotor domain in healthcare education. For example, clinicians provide hands-on or manual care treatments; we should develop methods to tend to health education students. In their research, Bloom et al4 determined that most learning objectives fell into the cognitive domain, fol lowed by the affective, and the fewest learning objec tives fell into the psychomotor domain. In their vision, they hoped to develop a theory of learning that would cross all spectrums of education from those of the sim plest learning to those of the most complex. It follows that if we approach the learner from more than one do main of the taxonomy, we should achieve stronger atten tion, comprehension, and retention. A CTIVE L EARNING As previously mentioned, Bonwell and Eison2 provide tivities involving students in doing things and think ing about what they are doing. Active learning can be looked at in contrast to the traditional classroom in which the instructor does most of the talking, moving, and doing, while the students sit and observe passive ly.9 Two assumptions on which Active Learning is built, become apparent; learning is by nature an active en deavor and different students learn differently.9 Active learning can be achieved through a variety of education al activities that focus on engaging students and rely less on instructor activity. These instructional activities can be problem-solving exercises, informal small groups, simulations, case studies, role playing, and other activi ties, all of which require students to apply what they are learning9 (emphasis in the original). Active learning may involve using structured exercises, challenging discussions, team products, and peer critiques.1How then, do we incorporate Active Learning in our classrooms? We suggest the systematic approach to Active Learning that Auster and Wylie offer with 4 teaching dimensions: context setting, class prepara tion, class delivery, and continuous improvement.3 We set the context by developing a foundation of the skills needed to understand the games through traditional lecture methods, class discussions, and reading assign ments. For our multiple session game, Trade or Raid, we introduce the game in its simplest form at the end of the roeconomic concepts even before they receive a formal lecture on the topic. Thus, the Active Learning context is initiated in advance or concurrently, depending on the few class sessions with a foundation of health policy lectures. This leads to class preparation. For each of the 2 games, we developed instructions, gathered necessary materials, and designed the games to inspire the students to apply AN A CT IVE LE A RNIN G APPRO AC H T O B L OO M S T A XONO M Y: 2 G AMES, 2 C LA SSROO M S, 2 ME T HODS

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January March 2014 23 the material developed in the foun dation. Class delivery was different for each game. For our multisession game, Trade or Raid, the delivery was done in many short stages. At the beginning of the game, when the students had minimal founda tion in economics, the instructions were simple with few variables. As the students gained more understanding of macroeco nomic theory over the semester, we integrated more factors into the game. The challenge with the one ses sion approach of Vote, Negotiate, and Retaliate was that we had to make the information thorough, yet concise enough to be consumed in one class period. We discuss our approach to Auster and Wylies fourth dimension, continuous improvement, in detail in the future direc tions section. M ETHOD: 2 G AMES, 2 C LASSROOMS, 2 M ETHODS How do instructors engage students across the domains of Blooms Taxonomy? To engage our students at the Army-Baylor Graduate Program in Health and Business Administration (part of the Academy of Health Science Graduate School in the Army Medical Department Center and School), we created 2 games. Trade or Raid is played in multiple sessions over the entire semester, building and evolving based on the material taught in the macroeconomics lectures. Vote, Negotiate, and Re policy class session and requires quick thinking, strat egy, and action.G ame 1. T he M acroeconomics G ame: T rade or R aidTrade or Raid is an interactive economics game de signed to familiarize the students with the fundamentals of macroeconomics, development, and political econo my. In Trade or Raid, we adopt an iterative approach to the game over multiple class sessions, with rule changes additional material the students learn in the macroeco nomics lectures. The initial session of Trade or Raid is played early in the semester and is designed to require only a minimal foundation in macroeconomics. By the end of the semester, Trade or Raid rule changes increase the complexity of the game to a degree that integrates a more thorough knowledge of macroeconomic concepts, principles, and theories. Trade or Raid Game Play ExplainedEach round of Trade or Raid may take from 10-15 min utes. Typically, we may play one round at the end of a class. In this game, we organize students into 3 teams, each representing a notional sovereign country. In actual play, each team chooses its own name to create a sense of be longing. For clarity in this article, we use Team 1, Team 2, and Team 3. During the game, the teams work independently to try to develop their respective nations economies. To do so, each nation begins with a set of poker chips that represent the nations capital stockthe productive capacity of the nation. The instructor provides the teams with the chips as shown in Table 1. Each round is broken down into a series of phases. The blue and one red, Team 1 receives 3 blue chips and one red chip at the beginning of each round. During the sec ond phase, consumption, each team decides how much of their production they will consume. When the team consumes production, they turn in chips representing production to the instructor and receive gold coins that represent social utility (gold coins are not tradable; they represent the cumulative happiness of the residents of the Teams country). Following consumption, the teams can trade any remaining production with other teams. For example, Team 1 could trade excess blue chips with Team 3 for white chips, with the intent of consuming nal phase, investment, teams can use any remaining chips to buy additional productive capacity. Additional productive capacity is priced differently for each team. Team 1 can buy additional blue chips for one chip each; additional red capacity for 3 chips each; and cannot buy white capacity. Team 2s costs are reversed, and Team 3 must pay 3 chips for any additional capacity, regardless of color. If the team chooses to invest, the productive capacity is greater in the next round, yielding more pro duction for all future rounds, representing a wealthier country. In subsequent rounds of the game, we intro duce other economic principles to increase complexity, such as capital depreciation, taxation, infrastructure investment, etc, coinciding with lessons taught in class lectures. While the game seems stacked against Team 3 based phase. Now during the trade or raid phase, teams may either make a peaceful offer of trade with one of the other teams, or they may raid one of the other teams. Raiding consists of one of the team members from the raiding team taking as much (usually all) of the target teams production as they like. Under these rules, the target team has no defense. Order now becomes critical, T able 1. T he distribution of chips among the teams at the beginning of the T rade or R aid game play. T he chips represent the productive capacity of each nation (team) in play.Team Blue Chips R ed Chips White Chips 1 3 1 0 2 1 3 0 3 0 0 4

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24 http://www.cs.amedd.army.mil/amedd_journal.aspxand gives Team 3 a powerful advantage. Since Team 3 always goes last, if Team 1 or Team 2 raid anyone, Team 3 can simply come through last and take all of the booty for itself. With the introduction of raiding, the game changes dramatically and provides an opportunity to discuss the impact of geography on economics. Table 2 demonstrates that the teams did eventually choose to specialize and engage in some level of trade. Looking at the red/blue/white columns for each team, one can see that each team ultimately only maintained productive capacity in its respective specialty. The problem to be solved now for the 3 teams is how to take advantage of peaceful trade opportunities and increase investment so that production for all can in crease. Gaining control over violence is a necessary condition for economic growth and is the central theme of the book Violence and Social Orders ,10 which is read rive at the book, they have viscerally experienced and actively participated in the problem of violence and its utility-reducing effects for weeks as they have struggled to deal with game theoretic issues such as the inability to commit to promises. In Table 2, we illustrate the Teams results over mul tiple rounds and sessions of Trade or Raid (due to space constraints, only 2 teams are listed). Note the minimal amounts of investment that occur. An optimal strategy would be to invest heavily throughout the game to gen erate more production. The problem for Teams 1 and 2 is that if they save production with the goal of invest ing, it may be stolen from them during the trade or raid phase of each round. In the game documented in Table 2, Team 1 invests a total of only 10 chips, Team 2 a total of 15 chips, and Team 3 (not shown) a total of 33 chips, far less than optimal. This pattern has been consistent over ry about development and violence (as modeled by Lee son11 violence, teams gain a deeper understanding as to why many parts of the world seem consigned to povertyG ame 2. T he Health Policy G ame: V ote, N egotiate, and R etaliateWe played Vote, Negotiate, and Retaliate in a single ses the students foundation of health policy-making in the previous 4 lecture sessions. In this game, students are assigned roles as legislators or stakeholders, and their task is to pass a national health policy bill that best supports their respective constituents. Vote, Negoti ate, and Retaliate integrates the health policy course work from earlier in the semester to provide an Active Learning scenario of a health policy-making process in a democratic republic society. Drawing from previ ous class sessions, we expect students will recognize aspects of several frameworks, such as agenda-setting from the Stages Heuristic12 or Longests Framework,12,13 and actors and context factors from Walt and Gilsons Policy Triangle.12,14 Likewise, the national health poli cies that students propose during the game include as pects of both public interest theory and economic theory of government interventions. Before starting the game, we remind the students that they may generate policy items that run the gamut of government roles, including expenditures, taxation, and regulation.Vote, Negotiate, and Retaliate Game Play ExplainedThe overall objective for all players is to diligently pro mote their groups ideologies to best support their con stituents desires. The students are separated into either one of 2 legislator groups or one of several stakeholder groups. The number of stakeholder groups is based on the number of students in the class, but at least 5 or 6 groups are necessary to generate enough complexity. To understand the game play for Vote, Negotiate, and mote to a political partys policy proposal. Students may generate positive promotion items: policy courses of ac the American Hospital Association stakeholder group designs a policy item increasing Medicare/Medicaid reimbursement rates by 10%, thus increasing revenue to hospitals. Alternately, students may create negative prevent disadvantage to the owning group. For instance, the American Hospital Association designs an item, al beit an unrealistic one, that makes the development of provider-owned medical facilities illegal, thus blocking competition. In addition to the overall objective listed above, each legislator group has as its objective passing their politi cal partys national health policy proposal. Passing oc curs when one legislator party collects more chips than the other by the end of the voting period and remains in good standing with constituents for reelection. In other words, the legislators want to pass their proposal, but they do not want to do so at the expense of their constit uency. Therefore, the challenge for the legislator parties is to try to balance as many stakeholder groups desires as possible. While the legislator groups attempt to pass their propos als, each of the stakeholder groups have as their objective AN A CT IVE LE A RNIN G APPRO AC H T O B L OO M S T A XONO M Y: 2 G AMES, 2 C LA SSROO M S, 2 ME T HODS

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January March 2014 25 to have more of their policy items on the National Health Policy Proposal that passes than any other stakeholder group. So, the stakeholder group has to decide which legislator party (or both) to support by contributing chips. For example, the American Association of Retired Per sons (AARP) stakeholder group may want to have the following policy items included in the national health on prescription drug pricing, restrictions on what hospi tals are allowed to charge seniors for hospital stays, and other policy items. The AARP stakeholder group offers one of the legislator groups any number of poker chips constituents in an attempt to have the legislator group place the AARP policy items on the bill. Considering that the stakeholder groups in the game include groups T able 2. T rade or R aid S coring by E ach R ound of a 13R ound G ame C onducted O ver an E ntire S emester.R ound Team 1 Team 2Production Consumption I nvestment I nventory Govt S pending NX G DP GoldProductive CapacityProduction Consumption I nvestment inventory Govt S pending NX G DP GoldProductive CapacityRed Blue White Red Blue White1 4 2 0 2 0 0 4 3 1 3 0 4 0 0 4 0 0 4 0 3 1 0 2 4 2 1 1 0 0 4 3 1 4 0 4 0 3 1 0 0 4 0 6 1 0 3 5 8 0 -3 0 0 5 12 1 4 0 7 6 6 -5 0 0 7 9 6 3 0 4 5 2 3 0 0 0 5 3 2 4 0 9 6 0 0 0 3 9 9 6 3 0 5 6 6 0 0 0 0 6 8 2 4 0 9 7 0 0 0 2 9 8 6 3 0 6 6 5 0 0 0 1 6 7 1 4 0 9 6 3 0 0 0 9 9 6 3 0 7 5 2 0 0 3 0 5 3 0 4 0 9 8 0 0 1 0 9 12 6 2 0 8 4 3 0 0 1 0 4 3 0 4 0 8 4 3 0 1 0 8 6 6 2 0 9 4 1 0 0 3 0 4 1 0 4 0 8 4 0 0 1 3 8 4 6 2 0 10 4 0 4 0 0 0 4 0 0 8 0 8 2 0 4 2 0 8 3 6 1 0 11 8 0 0 0 0 8 8 0 0 8 0 7 10 0 -4 1 0 7 15 6 0 0 12 8 4 2 4 4 -6 8 4 0 10 0 6 0 0 0 0 6 6 0 6 0 0 13 10 8 0 -4 6 0 10 12 6 6 0 0 0 0 6 6 Final Totals 73 43 10 0 17 3 73 59 94 59 15 0 6 14 94 81D escription of G ame Play A ctivity and R esulting S coring The table captures the decisions and outcomes of each student teams actions. duction is 4. Team 1 consumed 2 units of production and saved 2 units as inventory for the following round. Total gross domestic product ( GDP ) roeconomics, where production and consumption have to be equal. Round 2: Team 1 produced 4 again, but this time consumed two units, invested one unit, and saved one unit. The gold earned was 3, representing the 3 for 2 reward the team earned by consuming a mixed pair of chips ( 1 red, 1 blue ) This demonstrates a second principle of economics, that we prefer to consume a variety of goods, rather than just one type. The one unit of investment appears in the increased quantity of blue productive capacity, where the blue capacity went from 3 in round 1 to 4 in round 2. Round 3: As a result of the investment in round 2, Team 1 now produces 5 units, 4 blue and 1 red. In round 3, Team 1 consumed all of their production from round 3 ( 5 units ) plus the 3 units they had been holding in inventory, which results in inventory being measured as 3. Again, this represents changes in inventory, a key measure for Keynesian macroeconomic theory. Round 6: Team 1 has a net export ( NX ) value of 1, which means they exported 1 more unit of goods than they imported. Since the game operates in a real ( rather than money based ) economy, a positive NX tells us that Team 1 was raided in this round, and that 1 of their chips was taken. Losses to raiding are treated as exports. sometimes violent world.

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26 http://www.cs.amedd.army.mil/amedd_journal.aspxwith incompatible goals, such as the American Hospi tal Association and PhRMA (the trade association for the pharmaceutical industry), it quickly becomes clear holder groups creates a layer of complexity and requires all the players to strategize. Additional complexity en sues from the right of the stakeholders to reclaim their chips at any time. Thus, if the legislator group adds or removes a policy item that offends a stakeholder group, the stakeholder group can take back their chips to keep or give to the other legislative body. Note: due to space constraints, detailed instructions for Vote, Negotiate, and Retaliate are not included here. However, that infor mation is available upon request from the authors. C OMMENTC omparison of the M ultiple and S ingle S ession G amesEach game had its advantages and disadvantages; some affected both games. For instance, we designed both games to relate to the concepts and theories of the cor responding coursework and from the inception of each game, we focused on stimulating learning across the 3 domains of Blooms Taxonomy. Although playing the games took longer than if we had only presented lec tures about the topics, we expect the games left a stron ger impression of the concepts on the students. Individually, each game had its advantages and disadvantages as well. For example, playing Trade or Raid, most students developed a better understanding of the game as they played multiple sessions. Correspondingly, their knowl edge of the macroeconomic theories behind the game grew as the students related the game to the coursework and lectures that continued over the class sessions. On the other hand, some students found the game a little confusing initially and did not devote their full attention to subsequent game sessions. Because class sizes were normally 25 to 30 students, it was possible for some students to participate in a limited capacity. However, there was evidence, such as the following students comments, indicating that most students were engaged in the game and associated it to the corresponding concepts:The game mimicked reality. As new concepts were brought into the reading and lectures, the rules of the game were changed so that those lessons would be par ticularly pertinent.Trade or Raid incorporated concepts of consumption, production, investment, and trade. The game illustrated the concept of absolute and relative advantage clearly. Whereas Trade or Raid required 10-15 minutes in mul tiple class sessions over the course of the entire semester, students played Vote, Negotiate, and Retaliate in a single class session, thus minimizing the class interruptions and time required for the game. Like Trade or Raid, Vote, Negotiate, and Retaliate is a complex game, but it has the added challenge of a frenzied pace of game play. Said pace may have led to the students relating fewer con cepts and theory to the game than they did with Trade or Raid. However, we believe the aha moment for some students came after the game session ended as they con templated the events of the game. This is evidenced in one players suggestions for improving the game:I would recommendensuring a clear split between spe cial interest groups that are likely to support republican and democratic sides. To add a real complexity to it, it would be a good idea to give different special interest tual political interests. If this were done I think it would encourage a little more interorganizational collaboration encouraged to collaborate with one another on different causes/policies.Active L earning Advantages and Disadvantages T hrough the L ens of Blooms T axonomyAs we observed the students in-class actions and evaluated their feedback, we determined the Active Learn ing approach was successful in impacting the students across the cognitive, affective, and physical domains. By employing game play, we engaged the students de sire to win. Their desire translated into actions and be haviors affecting learning. Cognitive DomainIn Trade or Raid, we added increasing complexity to the game over the course of the semester. The increas ing complexity encouraged the students to keep their focus and wits sharp if they wanted to have a chance at winning. Their passion for winning engaged the students at the cognitive (thinking/head) level. By adding intricacies over the course of the game, aspects previ For example, in the beginning of the game, Team 3 felt they were at a disadvantage because they only had one production capability. However, when raiding was in troduced, they discovered they had a critical advantage. Similarly, when depreciation was introduced, efforts at diversifying the production base became rapidly inef fective, and so teams were required to change strategies throughout the course of the game. On the other hand, Vote, Negotiate, and Retaliate is a single session game, so we were limited to the extent we could increase the level of complexity. We were, however, able to create a few complexities. We told the students that the instructor may change aspects of the AN A CT IVE LE A RNIN G APPRO AC H T O B L OO M S T A XONO M Y: 2 G AMES, 2 C LA SSROO M S, 2 ME T HODS

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January March 2014 27 economic or political environment, or any other exter nality. For example, 5 minutes before the vote (ie, chips) tally, we told the legislator stakeholder groups to re duce the number of policy items on their national health policy proposal to a level substantially lower than what they had on the board. By doing so, legislators had to re evaluate each policy item to determine which provided the most stakeholder support. Stakeholders had to de termine which of their policy items were being cut and what actions they should take in retaliation (for example, demand the return of their chips).Affective DomainThe passion elicited by the competition in each game affected the students at the affective level. To be ac cepted in the Army-Baylor Graduate Program in Health and Business Administration, students must compete against their peers for a limited number of slots in each cohort. Most of the students are very competitive and have a strong desire to succeed. By placing the students in a de facto competition, a game, we target the students desire to win and focus on impacting the students learn ing by getting them emotionally attached to winning. In Trade or Raid, the competition is on a game session by game session basis; each time the students play, they step through the phases of consuming, trading and raid ing, and investing. To come out ahead, the students have to integrate what they have learned from the macroeco nomics lectures, readings, and exercises. Dealing with intergroup behavior, problems of trust, negotiations, and broken promises, coupled with the inherent unfairness of the rules (order of play, absolute advantages) triggered surprisingly powerful affective responses to the game:It was certainly an emotional experience. Some members of losing nations resented perceived slights from richer nations that extended far beyond the game. Building alle giances and watching them be successful (at the expense of others) was the most memorable part of the game. Trade or Raid brought out the worst in people. Everyone wanted the gold coins and did whatever they could in the hypothetical situation to gain them. There were many tense moments when the personalities of leaders, even within the classroom, clashed.In contrast, we developed Vote, Negotiate, and Retaliate with a compressed timeline to simulate an impulse buy experience. Students want to win; to do so they have to think and act quickly and strategically to have the most items on the passing bill (stakeholders) or to gain the most chips to have their bill pass (legislators). With an impulse buy, consumers are placed in situations in which they perceive they must buy items immediately or lose the opportunity to make the purchase in the future. In like manner, in our game, the stakeholders have to make immediate decisions on how many chips to offer for each policy item they want on the legislator groups bill. The legislators have to decide which policy items will garner the most chips. The impact to the students affective domain can be recognized in how loud and frenzied the negotiations get, particularly as the time remaining in the game begins to dwindle.Physical DomainEach game had a similar but different impact on the students physical domain. Both Trade or Raid and Vote, Negotiate, and Retaliate required students to get involved physically, but in slightly different ways. In Trade or Raid, the students used poker chips to signify their production capability and they collected/dispensed the chips in each phase of the game. As the game pro gressed, the students had more objects to work with, including toy soldiers, different color poker chips, and gold coins. They moved around the room when they armies were introduced. Their handling of the different objects exceeds the impact of solely reading information on a page or screen and makes the information more memorable. As one student commented:It places these lessons in a context that we can see and touch as opposed to viewing them in abstract through lectures (emphasis added).The design of Vote, Negotiate, and Retaliate puts the leg islator groups at separate dry erase boards in the room. Although the legislators do not have to remain at the boards and can pursue the stakeholder groups, generally, the stakeholders approach the legislator groups. Imagine a separate mission to winwhatever win means to the attention of his or her target person. The ensuing chaos ensures a lot of physical movement and involve Exchange on a volatile day may come to mind. FUTURE D IRECTIONS The direction we take our 2 games depends on what we have learned during the process of developing and em ploying the games in the classrooms. Changes we make are based on continuous improvement, an integral part of the Active Learning approach.T he R ole of C ontinuous L earning in the Active L earning ProcessWe previously discussed 3 of the 4 dimensions to the Ac tive Learning teaching approach: context setting, class preparation, and class delivery.3 While each of those as

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28 http://www.cs.amedd.army.mil/amedd_journal.aspxto implement is that of continuous improvement. Con tinuous improvement requires taking the time to evaluate the work that has been done, make adjustments as necessary, and implement the changes the next time the games are employed. Although for Vote, Negotiate, and sion, we were able to consider changes for Trade or Raid over the course of the semester. Student feedback is an integral part of the continuous improvement process.3 We gathered feedback about the learning experience from our students for each of the games. A few of the student comments and the impact of the comments on the games are included in the fol lowing paragraphs.Regarding Vote, Negotiate, and RetaliateThe preponderance of the students feedback for Vote, Negotiate, and Retaliate called for extending the game; as one student clearly stated:I think the game should be extended to either an entire class period or too [ sic ] 2 class periods. Essentially, it would have been nice to have a little more time with my special interest group to discuss our policy and initiative ideas. Some of this could have also been resolved if we knew our groups ahead of time and you could assign the that would get the creative juices rolling. game, time and pedagogical strategy. Several students suggested that we provide them more time; some sug gested playing the game over more than one session, but most suggested providing time before game day to prepare their policy items and plan of attack. The pedagogical strategy weakness lies in the compressed timeline designed to stress the negotiating process and incite emotionshence, impacting the affective do mainso we want to be careful in increasing game play time. We intentionally withheld information until the day of the game in to make the game more challenging. However, doing so limited time available to determine policy items based on what they had learned in previous lecture sessions. For future renditions, we will provide students lead time and enough information for them to predetermine policy items. Another suggestion would be to weight the power of the stakeholders by dividing the tokens out proportionate 11 tokens.In our initial iteration of the game, we provided each stakeholder group the same number of tokens (11). In reality, health policy stakeholder groups have different health policy bills than does the People for the Ethical Treatment of Animals. In the future, we will distribute weightings of each of the stakeholder groups.I also think that many of the groups that normally sup port the Democratic Partys policies were not included in the game (minority groups, poor, women, etc) and I think it would be interesting to include these groups.It was too easy to talk with the congress and it actually didnt cost much money. Im not sure how we could do that. I just know that you have to contribute a lot of money to gain the favor or vote of a legislator. Concluding the discussion about Vote, Negotiate, and Retaliate with the 2 students comments above, we pro vide the seemingly unrelated comments to illustrate how the sheer volume of feedback can stir our ideas for im proving the games. In the case of the above comments, we derived an idea to add additional player positions in the game. We will add individual voters of various so cial economic status and ethnicities. These voters will have a designated time period in the game during which they will have the legislators full attention and can con front the legislators on any policy items. Doing so will challenge the legislators to remove or add policy items to their bills to satisfy their voting constituents.Regarding Trade or RaidThe feedback differed for Trade or Raid, due in large year we played Vote, Negotiate, and Retaliate, Trade or Raid is in its third year. We have done much of the im iterations. We make minor tweaks to the game as the game progresses over the semester, gauging the students interest and needs. Despite the maturity of the back is integral to the continuous improvement process. Of the 2 games, Trade or Raid is the more intricate and complex. That complexity was not lost on the students, as expressed in these students comments: The game objectives and the process were unclear in the beginning. Better explain the rules and potential stratagies [sic]. I felt like we were operating in the dark for much of the game. game play and rules. AN A CT IVE LE A RNIN G APPRO AC H T O B L OO M S T A XONO M Y: 2 G AMES, 2 C LA SSROO M S, 2 ME T HODS

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January March 2014 29 As with Vote, Negotiate, and Retaliate, time was an is sue for some students. However, the time issue took a different form with Trade or Raid, as show in the fol lowing comments:The game play was too spread out. Each turn was too far removed from the last. dents can know when to expect to play and be prepared.Both comments indicate the need for more structure in the timing of the game. In the future, we will provide ule with students. C ONCLUSIONS AND FUTURE R ESEARCH Our foray into gaming as a strategy to involve Active Learning across the cognitive, affective, and psycho motor domains of Blooms Taxonomy has provided us with dramatic improvements in engaging the students and their information retention. We have shared what we gained from our experience in this article. We pro vided a clear explanation of Active Learning and the 3 domains of Blooms Taxonomy.4 In the explanations of our games, we integrated the role of Blooms Taxonomy and Active Learning to provide an understanding of the relationship between them. We focused the discussion of the advantages and disad vantages of each game through the lens of Blooms Tax onomy to provide a clear understanding of how Active Learning impacts each of the learning domains. Prac titioners can develop teaching games using our model as a template to maximize the impact of their games. Researchers can build on our model through an experi mental or quasi-experimental study focused on empiri cally evaluating the affect of the games on each of the domains. Although the challenge of providing material in a meaningful and engaging way to maximize student synthesis exists, the quality of lessons and the students retention of the information can be dramatically im proved by following a simple strategy of Active Learn ing across the primary domains of Blooms Taxonomy. R EF ERENCES1. Chickering AW, Gamson ZF. Seven principles for good practice in undergraduate education. AAHE Bull 1987;39(7):3-7. Available at: http:// www.uis.edu/liberalstudies/wp-content/uploads/ sites/39/2013/03/sevenprinciples.pdf. Accessed September 30, 2013. 2. Bonwell CC, Eison JA. Active learning: creating excitement in the classroom. ERIC Dig [internet]. Washington, DC: ERIC Clearinghouse on High ed.gov/fulltext/ED340272.pdf. Accessed Septem ber 30, 2013. 3. Auster ER, Wylie KK. creating active learning in the classroom: a systematic approach. J Manag Educ 2006;30(2):333-353. 4. Bloom B, Krathwohl D, Masia B, eds. Taxonomy Educational Goals-Handbook II-Affective Domain 5. Tharp D, Gould A, Potter R. Leveraging affective learning for developing future Airmen. US Army Med Dep J Oct-Dec 2010:25-38. 6. Hamilton S. Assessment Based Instruction. US Army Med Dep J Oct-Dec 2010:63-64. 7. Bloom B, Engelhart M, Furst E, Hill W, Krathwohl D, eds. Taxonomy of Educational Objectives: The Cognitive Domain Company, Inc; 1956. 8. Krathwohl DR. A revision of Blooms taxonomy: an overview. Theory Into Practice 2002;41(4):212-218. 9. Meyers C, Jones TB. Promoting Active Learning. Strategies for the College Classroom San Fran cisco, CA: Jossey-Bass; 1993. 10. North DC, Wallis JJ, Weingast BR. Violence and Social Orders: A Conceptual Framework for Inter preting Recorded Human History Cambridge University Press; 2009. 11. Leeson PT. Trading with bandits. J Law Econ 2007;50(2):303-321. 12. Sabatier PA. eories of the Policy Process 2nd ed. Boulder, CO: Westview Press; 2007. 13. Longest BB. Health Policymaking in the United States 5th ed. Chicago, IL: Health Administration Press; 2010. 14. Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson L. Doing health policy analy challenges. Health Policy Plan 2008;23(5):308-317.A UTHORSMAJ Weigl and LTC Bonica are Assistant Professors, Army-Baylor University Graduate Program in Health and Business Administration, JBSA Fort Sam Houston, Texas.

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30 http://www.cs.amedd.army.mil/amedd_journal.aspxIn the past several years, physical therapy education has been characterized by positive reforms including the transition to a doctoral level education and the emergence of evidence-based practice as part of standard curricula. However, the clinical education system has been largely unaffected by these changes and remains a highly frag cient 1:1 student to instructor format which leads to very disjointed, noncollaborative learning.1 Regardless of the quality of didactic education, the variability across clini cal education sites is profound, evidenced by the lack of systems to credential clinical education to ensure quality and consistency of training.2-4 Furthermore, the current physical therapy clinical education system leans heavily on a barter arrangement dependent on the altruism of clinical practices and the potential to recruit and hire the students they educate upon graduation. The perceived Impact of an Innovative Clinical Internship Model in the US Army-Baylor Doctoral Program in Physical Therapy COL Josef H. Moore, SP, USA CPT Chelsea Wrenn, SP, USA CPT Kathleen T. Glenesk SP, USA CAPT Todd Sander, MSC, USN CPT David K. Hulsizer, SP, USA MAJ Dan Fisher, SP, USA Capt Brittany E. McCright, BSC, USAF Lt Col John D. Childs, BSC, USAFABSTRACTStudy Design: Retrospective case-control.Background and Purpose: Physical therapy education has been characterized by positive reform including the tran sition to doctoral level education and the emergence of evidence-based practice as a standard part of the curricula. However, clinical education remains largely unaffected by these advancements and continues as a highly fragment ternship model in the US Army-Baylor University Doctoral Program in Physical Therapy in which interns train in Case Description: The Army-Baylor program culminates in a 12-month clinical internship conducted at 4 loca base during the period from 2006-2010. A separate analysis was conducted for each site with descriptive statistics Outcomes: engaged mentorship, individual attention, and quality instruction.Comment: sites, this model facilitates a highly collaborative and peer learning environment in which the intern class supports, challenges, and holds one another accountable to a more standardized and higher level of practice. Each site contrib utes 1-2 clinical faculty who no longer engage their own patient schedule but rather are able to serve in a full time ments in collaboration with the clinical faculty. Finally, the collaborative internship model supports the mission investment into their clinical education.

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January March 2014 31 periences for their students.2-4Although the physical therapy interns labor is essential ly free, the short duration and physical therapy interns limited skill set in a 6-8 week clinical rotation diminish es their potential to become a productive, revenue gen when interns spend an inordinate amount of time learn ing administrative systems, documentation standards, billing procedures, etc, only to have the student move indirect costs for clinical practices to provide clinical education under the current model are steep, yet often go unnoticed or written off as goodwill. The medical model of clinical education has long proven receiving a high quality standardized training program delivered under the auspices of a credentialed graduate medical education system that adheres to rigorous ac creditation and quality standards. Residents also train in a collaborative learning model as a member of a resident class or group compared to the 1:1 model historically used in the physical therapy profession. Recent evidence from the literature and anecdotal evidence have chal lenged the traditional model and suggested that there tion model in which students are formed into cohorts of lar to the medical model of residency education. With the emergence of the collaborative model, Ladyshew esky et al showed that both the traditional and collabora tive model learning methods reduce clinical instructors normal levels of productivity. levels of productivity as patient care time versus other nonincome generating activities. The volume of care provided by students, however, compensated for this re duction in productivity. a collaborative clinical education model on a practices productivity metrics. Therefore, the purpose of this ternship model in which physical therapy interns train in groups rather than 1:1 on productivity metrics such as We hypothesize that there will be increased productivity time periods without interns. METHODS AND MATERIALSSubjectsParticipants in the study were interns from the ArmyBaylor Doctoral Program in Physical Therapy, Class of ProceduresWe selected a retrospective case-control design using tary Health System Management and Reporting Tool runs from October 2006 through September 2010. We were primarily interested in variables that represented Data AnalysisWe performed a separate analysis with descriptive sta tistics for each internship site. The raw dependent vari units bined into ratios for standardization. To assess produc 1. Months during which no interns were present. 2009-May 2010). ning of the internship when interns received instruction in administrative functions and at the end of internship itary transition. 8 9THE UNIT E D S TAT E S AR M Y ME DICA L DE PA R TMEN T JO U RN A L

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32 http://www.cs.amedd.army.mil/amedd_journal.aspxRESULTS Since data are only available by month, the partial months at the beginning and the end of the intern rotations were excluded. These months were July 2007, March 2008, July 2008, April 2009, July 2009, and August 2010. In addition to the partial months excluded when analyzing the full period, additional months were excluded when analyzing the optimal period where it is hypothesized the interns were not functioning ef ciently due to development learning early in the internship, and for periods of inand outprocessing. Since interns were not present at each internship site for every time period, each site has a different number of months in each condition, with WHMC having the nearest to equal distribution and DAMC having the least equal distribution. Therefore, only WHMC was assessed under all 3 conditions, BAMC was assessed under conditions 2 and 3, and DAMC was assessed only under condition 3. Productivity at all 3 internship sites for both RVU/encounter (Figures 1, 2, and 3) and encounter/FTE ratios (Figures 4, 5, and 6) revealed little variation during periods with and without interns. Ef ciency (RVU/FTE/ day) also produced little variation (Figures 7, 8, and 9) regardless of the presence of interns. COMMENT Our results indicate that the presence of interns did not result in an increase in productivity and ef ciency at the internship sites. However, the results support the notion that a clinic can provide clinical education without a decline in productivity and ef ciency. Similar to a previous nding, it appears that interns compensate for the time a clinical instructor spends away from direct patient care with interns present.10 Without question, a decrease in productivity and/or ef ciency would bring into question the long term viability and sustainability of the collaborative internship model. We noted several potentially confounding factors that must be considered. There are study limitations with a retrospective analysis, such as the inability to control for confounding factors. For example, there was variability in the reporting of FTEs at the 3 sites. Second, the patient referral volume also differed during the observed conditions at all 3 sites. Those 2 conditions resulted in a lack of ability to differentiate data. We also found that we are unable to generalize our ndings because of differences in how input data are recorded within and between facilities. Despite the robust nature of the M2 database, it does not account for patients sent to civilian hospitals or clinics. Nor does it account for how patients accessed the internships sites or individual provider and intern productivity and ef ciency. Given the retrospective nature of the study design, we also cannot be certain that any of the observed results are necessarily attributable to the presence or absence of interns. The American Physical Therapy Association and the Commission on Accreditation in Physical Therapy Figure 1. Productivity at WHMC indi cated by the RVU/encounter ratio under all 3 conditions. Figure 3. Productivity at DAMC indicated by the RVU/encounter ratio under condition 3. Figure 2. Productivity at BAMC indicated by the RVU/encounter ratio under conditions 2 and 3. IMPACT OF AN INNOVATIVE CLINICAL INTERNSHIP MODEL IN THE US ARMY-BAYLOR DOCTORAL PROGRAM IN PHYSICAL THERAPY

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January March 2014 33 Education have little leverage or ability to lead necessary reform in physical therapy clinical education. Academic programs are in a negative incentive situation when it comes to reform. Currently, physical therapy students pay tuition to their academic insti tution while completing clinical internships or rotations, creating a veritable cash cow for the academic program, not the direct provider of the clinical education. However, those students have very few responsibilities during the clinical internships or rotations classroom didactic environment. If reform is to occur in the area of physical therapy clinical education, this change will likely be mediated by the private sector in the form model that results in a net earnings increase for the clin ical site in the form of longer term internship clinical spective implications of clinical education models on for outside referrals, patient outcomes, and access to care. This study suggests that internship sites can maintain livering clinical education and mentorship to multiple interns at one time. As one looks into the future, it is realistic to envision the current model of PT clinical education moving even closer to the medical model. R EF ERENCES1. Lopopolo RB. Financial model to determine the ef fect of clinical education programs on physical ther apy departments. Phys Ther 2. Dillon LS, Tomaka JW, Chriss CE, Gutierrez CP, riences on clinician productivity. J Allied Health comparison of productivity and learning out come in individual and cooperative physical therapy clinical education models. Phys Ther 4. DeClute J, Ladyshewsky R. Enhancing clinical competence using a collaborative clinical educa tion model. Phys Ther Delunas LR, Rooda LA. A new model for the clini cal instruction of undergraduate nursing students. Nurs Educ Perspect 6. laborative model of clinical education in physical and occupational therapy at the Mayo Clinic. J Al lied Health

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34 http://www.cs.amedd.army.mil/amedd_journal.aspx Triggs Nemshick M, Shepard KF. Physi cal therapy clinical education in a 2:1 student-instructor education model. Phys Ther 8. orandum: Implementing Guidance for the Reports on Use of Funds Pursuant to the American Recovery and Reinvestment 9. National Health Policy Forum. The Ba 10. model. Phys Ther Physical Therapy degree for CPT Glenesk, CPT Hulsizer, CPT McCright, and CPT Wrenn. COL Moore is Dean, Graduate School, Army Medical Department Center and School, and Professor, US ArmyBaylor University Doctoral Program in Physical Therapy, When this study was conducted, CPT Glenesk was a student in the US Army-Baylor University Doctoral Program in Physical Therapy. She is currently a staff PT at Keller Army Point, NY. When this study was conducted, CPT Hulsizer was a student in the US Army-Baylor University Doctoral Program in ACH, Fort Campbell, KY. When this study was conducted, CPT McCright was a student in the US Army-Baylor University Doctoral Program in Physical Therapy. She is currently a staff PT at Wilford Hall When this study was conducted, CPT Wrenn was a student in the US Army-Baylor University Doctoral Program in Physical Therapy. She is currently assigned to the 4th Brigade Combat Team, 82nd Airborne Division, Fort Bragg, NC. CAPT Sander is an Associate Professor, US Army-Baylor University Doctoral Program in Physical Therapy, JBSA Fort MAJ Fisher is Chief, Department of Rehabilitation, Winn ACH, Fort Stewart, GA. Lt Col Childs is an Associate Professor, US Army-Baylor University Doctoral Program in Physical Therapy, JBSA Fort IMPACT OF A N INNOV ATI VE CL INICA L IN T ERN S HIP MO DEL IN T HE US AR M Y-B A YLOR DO CT OR AL PROGR AM I N PHY SICAL THER AP Y

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January March 2014 35Ongoing worldwide operations facing our armed forces today have created extreme emotional challenges for our Soldiers and Families. Data show one-third of the personnel returning from deployment will show signs of depression, anxiety, or posttraumatic stress disorder (PTSD).1 Recruiting and retaining an adequately trained behavioral health force is a serious challenge today, given our deployment cycles in support of an ongoing war. The Army Medical Department (AMEDD) must ensure that the Army is always medically ready to deploy, while maintaining the capability to deliver healthcare to those forces anytime, anywhere, and under any conditions. The AMEDD behavioral health team consists of psychiatrists, psychologists, social workers, psychiatric nurse clinical specialists, and occupational therapists. Social workers represent the largest number of these behavioral professionals. Current Army doctrine assigns behavioral health providers to combat units on operational deployments to enhance mission readiness. Our ability to keep adequate numbers of highly trained behavioral health providers is key to the successful delivery of ready and relevant behavioral health services to Soldiers and Families. Social workers have long been a part of American military history. The rst social workers to support the American military were assigned to the American Red Cross in 1918. During World War I, the American Red Cross demonstrated the value of psychiatric social workers in a demonstration project conducted with the cooperation of the Division of Neurology and Psychiatry in the Of ce of The Army Surgeon General. Red Cross social workers continued to work in Army hospitals following the war and expanded their support to the military during World War II. Over the span of several decades, the role of military social workers grew from a small contingent to a recognized occupational specialty. In June 1945, Army social work became a fully recognized specialty in the Of ce of The Army Surgeon General.2Recruiting, training, and retaining quality social work professionals is vital to the mission of the AMEDD. The process for independent social work licensure begins with an individual obtaining a masters degree from a university accredited by the Council on Social Work Education (CSWE). A uniformed social worker cannot deploy into a combat zone unless he or she is independently licensed. A candidate for independent social work licensure must participate in formal clinical supervision, ranging from 2000 to 4000 hours over a period of 2 to 3 years, depending on individual state requirements. The individual must satisfy the supervision requirement and pass the Association of Social Work Boards independent licensure exam to be recognized as a fully quali ed social worker.3Demand for social workers in this country has increased dramatically. The Department of Labor predicts 25% growth between the years 2010 and 2020.4 While the Bureau of Labor Statistics projects that an additional 100,000 social workers will be needed by 2018, our countrys accredited schools and programs of social work often struggle to recruit and graduate enough students to keep pace with the volume and complexity of social needs in our communities.5The Army has used various methods for recruiting active duty social workers over the years. In 1998, the Army made the licensed independent social worker the standard for social work practice in the Army. This new professional standard increased the complexity of recruiting social workers for service in the active Army. The Army Social Work Internship Program: Training Todays Uniformed Social WorkerCOL (Ret) Reginald W. Howard, MS, USAABSTRACT Uniformed social workers are involved in ensuring the well-being of Soldiers and their Families during peace and war. The Army Medical Department Center and School is charged with the educational development of uniformed social workers. This article focuses on a relatively new approach to preparing social work of cers for their dual role of providing garrison and operational behavioral health services to Soldiers and Families. In the 4 years since implementation, this 2-year training program has become the model for the professional development of new uniformed social work graduates.

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36 http://www.cs.amedd.army.mil/amedd_journal.aspxShortly after the beginning of Operation Iraqi Freedom, the Army began to experience missed recruiting goals for social workers along with an increased demand for behavioral health services. The AMEDD embarked on a plan to focus internally and grow its own. This pro cess to develop from within began with the search for a university that could provide the Master of Social Work (MSW) graduate degree needed to begin the path to in dependent social work licensure. Through a competitive bidding process in 2008, the AMEDD selected and collaborated with Fayetteville State University in North Carolina and began train program at the Academy of Health Sciences, Fort Sam Armys accelerated program eligible for clinical super vision to become independently licensed and fully qual Historical approaches to the process of moving recent social work graduates to independent licensure involved decentralization of the duty to our Army hospitals. The Army commissioned recent MSW graduates and as signed them to Army hospitals for clinical supervision in the Social Work Department. This decentralized ap This process was met with numerous challenges includ ing disruptions to clinical training due to unit exercises, permanent change of station moves, addi tional duties, changes in clinical supervisors, and a lack of attention or focus due to the in formal nature of the process. This traditional decentralized process failed to evolve with the changing forward deployed Army. The wars in Iraq and Afghanistan revealed the need for a more forward presence of behav ioral healthcare on operational deployments in the form of the Brigade Behavioral Health clinical training and supervision lacked the focus needed to meet the Armys new doc trine. This reality necessitated rethinking the training of social workers in the Army.3The Armys ultimate goal is for all social work graduates to achieve independent li censure in 2 years. The senior Army social work leadership called on the AMEDD Cen ter and School (AMEDDC&S) to address what was a clear training need. That request resulted in the development of the Army Social Work Internship Program (SWIP). Today, all graduates of the US Army-Fayetteville State University Master of Social Work Program enter the SWIP immediately after graduation. The SWIP was es tablished with a set of 4 critical goals:1. S tandardize intern training regardless of where the training takes place.To support standardized training for all interns, the AMEDDC&S produced a training manual to stan dardize medical treatment facility SWIP training. 8-member work group formed in January 2009. The work group was comprised of Army uniformed social workers and civilian social workers representing vari in the SWIP. The completed SWIP training manual focused on 31 terminal learning objectives and over 100 enabling learning objectives across 5 military social work practice areas. The practice areas repre sented were Combat Stress Control, Army Substance Abuse, Army Behavioral Health, Family Advocacy, and Social Work Management. The conceptual model is illustrated in the Figure. Military corrections and medical social work are offered as elective experienc es. The SWIP manual called for the use of clinical supervisors in all rotational areas with at least a 4-month rotation for each intern in each area. Plans were made for staff assistance visits to be conducted once every 2 years by a representative of the AMEDDC&S MSW Program to ensure compliance with training standards. THE ARMY SOC IA L WORK IN T ERN S HIP PROGR A M: TR AINING TOD A YS UNIFORMED SOC IA L WORKER T rained and ReadySocial Work Inprocessing and Orientation Preparation for Independent Licensure Examination Outpatient Social Work Social Work and Military Corrections Combat Stress Control Behavioral Health Army Substance Abuse Program Family Advocacy Program Medical Social Work/ Discharge PlanningA conceptual model of the A rmy S ocial Work Internship Program.

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January March 2014 37 2. Minimize administrative disruptions to training.Historically, training and supervision of recent MSW graduates functioned as an informal program not of fore SWIP. This informal status contributed to delays in licensure for many MSW graduates. New MSW graduates are commissioned in the Army Medical Service Corps (MSC). As members of the MSC, so cial workers are required to participate in most addi missions. Time spent working in these additional duties was not countable toward social work licensure, new MSW graduates. The solution to the problem of supervision disruptions was developing and desig nating the SWIP as a 2-year assignment to a formal training program. Shortly after the SWIP manual was developed, AMEDD recognized the SWIP as a formal training program resulting in an Army Medical Com mand operations order calling for its implementation at 9 medical treatment facilities.3. Develop a training program focused on military social work competencies.Social work as a profession has well-established com war on terror, an emergence of special military so cial work competencies was developing within the social work community. The CSWE released a set of educational standards in the form of military practice behaviors which highlight the knowledge and skills clinicians need to effectively serve the military com munity. Understanding military culture, community, programs, and policies are essential in providing ser vices to military populations. Specialized education to prepare social work students and professional so cial workers to aid this population is clearly indicated. The provision of social work services to Soldiers and Families requires specialized training and develop The 2009 SWIP work group considered all of the CSWE prac tice behaviors in its original manual, aligning SWIP with national best practices for social work services to military and veteran populations.4. Focus on timely social work licensure.Timely licensure supports mission readiness. Army policy prohibits providers who are not independently licensed from providing healthcare in a combat zone. The more rapidly our recent MSW graduates can achieve independent social work licensure, the sooner they can deploy in support of combat operations. The older, informal model of supervision resulted in quirement to obtain independent social work licensure. period, this rate has dropped to less than 1% as a result of the close monitoring of supervision hours and an emphasis on licensure preparation by the SWIP Direc tors of Training through the SWIP program.3 Social Work Internship Programs are integral to preparation for the social work independent licensure examination This standardization of training and its corresponding identify a common skill set among its newly licensed social workers. It also allows for measurable standards across all training programs. Since its formal beginning in 2008, 70 uniformed MSW graduates have enrolled on the Army SWIP. The pro gram has shown extreme promise. A brief online survey of SWIP participants from 2010 to 2013 indicated that 75% of the program interns rated the overall supervision they received in the SWIP as above average or outstand pass rate on the Licensed Clinical Social Work exam of 3 The pro gram looks forward to more critical review in the future. CONCLUS I ONS The demand for skilled licensed social workers will con tinue to increase in both the civilian sector and the mili tary. Enrollment in the US Army/Fayetteville State Uni versity MSW Program has increased 50% since 2008, requiring expansion of the SWIP program. In 2012, the SWIP expanded from 9 to 13 sites. In October 2012, a second work group met to update the SWIP training manual. The new manual supports recent changes in the social work licensure examination, places more focus on the role of a social work in a brigade combat team, mandates clinical supervisor training for all SWIP Di rectors of Training, mandates that interns participate in AMEDDC&S evidence-based practice courses for the treatment of PTSD, and includes a requirement for completion of select modules within the Joint Medical Executive Skills Institute distance learning program. The Social Work Internship Program is currently the Ar mys model training program for recent MSW graduates. It supports the new Army Medicine Strategy and 2 of its key imperatives; create capacity and improve stamina. The SWIP creates capacity as a force multiplier which

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38 http://www.cs.amedd.army.mil/amedd_journal.aspxTHE ARMY SOC IA L WORK IN T ERN S HIP PROGR A M: TR AINING TOD A YS UNIFORMED SOC IA L WORKER worker slots. Today, the uniformed social work career years. This increase in Army uniformed social workers has improved mission readiness and the AMEDDs abil ity to meet the increasing challenges of providing care during peace and war. Building capacity is not simply doing more; it is about doing things better.7 The SWIP immerses interns in a training environment best suited for learning about social work to Soldiers and Families. All interns are required to receive training in at least one evidence-based practice for treatment of PTSD. In terns are also allowed an opportunity to participate in electives in emerging treatment areas including telebehavioral health, traumatic brain injury, wounded war rior care, and embedded behavioral health. All training experiences are supervised by military and civilian em ployees who are experts in their areas. The AMEDD as a whole is committed to delivery and transformation of ates in support of this commitment by providing timely, innovative, and evidence-based training for our newly R EF ERENCES1. Hoge CW. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Af ghanistan. JAMA 2. Daley JG. Social Work Practice in the Military New York, NY: Hawthorn Press Inc; 2000. 3. Howard RH. The Army internship program: en hancing mission readiness J Hum Behav Soc Envi ron 4. Bureau of Labor Statistics. Social Workers. Occu pational Outlook Handbook ; 2012-2013 Washing ton, DC: US Department of Labor; 2013. Available at http://www.bls.gov/ooh/community-and-socialservice/social-workers.htm. Accessed May 8, 2013. 5. Social Work Reinvestment Initiative: Social Work 111th Congress; (Nov 17, 2010). Advanced Social Work Practice in Military Social Work Alexandria, VA: Council on Social Work Education; 2010. 7. Horoho PD. Washing ton, DC: US Dept of the Army; 2012. Available at http://www.armymedicine .army.mil/assets/home/ Army_Medicine_2020_Strategy.pdf. Accessed April 23, 2013.A UTHORCOL (Ret) Howard, a Licensed Clinical Social Worker, is a member of the faculty of the US Army-Fayetteville State University Master of Social Work Program at the AMEDDC&S, Fort Sam Houston, Texas. Articles published in the Army Medical Department Journal are indexed in MEDLINE, the National Library of Medicines (NLMs) bibliographic database of life sciences and biomedical information. Inclusion in the MEDLINE database ensures that citations to AMEDD Journal to researchers during searches for relevant information using any of several bibliographic search tools, including the NLMs PubMed service.

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January March 2014 39In 2009, the US Army Veterinary Corps initiated an ef PUR P OSE AND GOALS 1 ing the food supply of Soldiers, Sailors, Airmen, Ma rines, their family members, and military retirees is a key 1 A sur that 52% of respondents pursed some type of postgradu2PRO G RAM CURRI C ULUM US Army Veterinary Corps First Year Graduate Veterinary Education Program

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40 http://www.cs.amedd.army.mil/amedd_journal.aspx for a better understanding of the various programs for imals presented to the veterinary 4 also provides essential training in military installations and in the operational environ lum is designed to help the VCO mature as a leader and PRO G RAM D ESIG N AND L O C ATIONS tivation) and the Veterinary Corps developed a phased viding mentored and hands-on US ARM Y V E T E RIN A R Y COR PS FIR S T Y EA R GR A D UA T E V E T E RIN A R Y ED UCA TION PRO G R A M 5 Location Academic Year 2010-20112011-20122011-20122012-20132012-20132013-20142013-2014

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January March 2014 41 design, development, implementation, evaluation, and year, provide leadership and supervision to the interns, CURRENT S TATUS AND FUTURE R EF EREN C ES J Am Vet Med Assoc J Am Vet Med Assoc Field Manual 4-02.18: Veterinary Service Tactics, Techniques, and Procedures Army Med Dept J J Am Vet Med Assoc A UTHORS

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42 http://www.cs.amedd.army.mil/amedd_journal.aspxAfter 100 years, Florence Nightingales philosophy words ought to be distilled into action remains relevant. With the Institute of Medicine1 setting a 2020 goal of having 90% of all practice evidence-based and includ ing evidence-based practice (EBP) in the core compe tencies for healthcare professionals, EBP has emerged as a strategic vehicle for distilling words or research into actions that produce optimal care. Despite a decades-old movement and support from entities such as the IOM and National Institutes of Nursing Research, a majority of universities continue to emphasize research over EBP, and practicing nurses continue to experience a lack of leadership support for EBP in their work settings.2 How to improve nurses EBP knowledge and skills.2Models and curriculum that are designed to increase knowledge with the help of mentors are more numer ous in civilian than military settings. Searches in Eng lish databases such as CINAHL, OVID, and PubMed for civilian-military EBP training partnerships yielded few articles. However, one of those articles detailed his torical background and establishment of a culture dedi 3 The purpose of this article is to discuss a partnership between a group of local civilian hospitals and one mil itary medical center formed under the auspices of the Hawaii State Center for Nursing (hereinafter referred to as the Center) to develop EBP knowledge and skills in clinical staff nurses. Experienced EBP civilian and military mentors assisted with the training, resulting in an 18-month program which makes the recommenda tions of both Nightingale and the Institute of Medicine a reality. FRAMEWORK F OR TEACHING E BP The American Association of Colleges of Nursing iden ment. Through these competencies, nurses are expected to acquire the skills, knowledge, attitudes, and behav iors to deliver safe, optimum care and improve patient outcomes. These competencies, known as the Quality and Safety Education for Nurses (QSEN) program, are: (1) patient-centered care, (2) teamwork and collaboration, (3) evidence-based practice, (4) quality improvement, (5) cy, nurses must be able to critically read research and ways that optimize patient outcomes, healthcare policies, and processes within healthcare systems.4Blooms taxonomy is a framework designed to assist faculty in developing common language and congruent curriculum objectives to achieve educational goals 5 The intent of the taxonomy is to frame learning objectives in a way that encompasses educational levels, subject courses, and educators. The revised taxonomy focuses on learn ing objectives in 2 dimensions: knowledge and cogni tive processes. There are 4 knowledge subdimensions: factual, conceptual, procedural, and metacognitive; and Achieving Army Nursing Evidence-Based Practice Competencies Through a Civilian-Military Nurse PartnershipLTC Leilani A. Siaki, AN, USA Debra D. Mark, PhD, RN COL Denise L. Hopkins-Chadwick, AN, USAA B S T RAC TDespite the Institute of Medicines goal of 90% of all practice being evidence-based by 2020, educational and practice institutions are not on target to achieve this goal. Evidence-based practice is one of 5 core elements of the Army Nurse Corps patient care delivery system and a key focus of the Hawaii State Center for Nursing. In order to increase evidence-based practice (EBP), a civilian-military partnership was formed to include healthcare organizations in the state, optimize resources, and share strategies for successful practice changes statewide. The partnership has been successful in meeting each of these goals using national EBP competencies and Blooms taxonomy as a guide. The article presents a discussion regarding the history, processes, and outcomes of this partnership.

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January March 2014 43understand, apply, evaluate, and create.5 For example, factual knowledge learning objectives for the cogni tive process of remembering would focus on students students should be able to make judgments about a par ticular idea or event based on facts and apply these factcompetency. Educators designing a curriculum to ad dress the evidence-based QSEN competency might con sider having students memorize steps in an EBP model (factual), describe how each step builds on and informs the process as a whole (analyze), and then demonstrate the application of one or more steps in the model (ap ply). Nurses who successfully achieve the learning ob jectives in each dimension are expected to possess the knowledge, skills, and behaviors necessary to compe tently engage in EBP. The QSEN competencies set with in Blooms taxonomy provided the framework used to guide this partnership as shown in Table 1. C IVILIAN AND M ILI T ARY O RGANIZA T IONS I NVOLVED IN THE E BP E DUCA TION PAR TNERSHI PA rmy N urse C orpsFrom the days of Florence Nightingale until now, educa tion, practice, and training directed at improving patient care has been a consistent focus for civilian and military nurses alike. Early Army nursing leaders were neither nurses, Dorthea Dix, and Clara Barton, founder of the American Red Cross, were teachers and strong patient advocates. Today, the Chief of the Army Nurse Corps (ANC) is a major general, the current Army Surgeon General, a lieutenant general, is a nurse, and both of them have made education and evidence-based practice a priority. The ANC philosophy regarding professional practice is a comprehensive approach to patient care. Designed to decrease practice variance and improve patient out comes, the Patient CaringTouch System (PCTS) is com prised of 5 core elements: enhanced communication, capability building, evidence-based practices, healthy work environments, and patient advocacy.8 LTG Horoho writes that evidence-based practice is one of the key ele ments in the PCTS. Under her direction, PhD-prepared nurse scientists along with clinical nurse specialists and healthcare systems analysts have been embedded in centralized patient care settings for the express purpose of translating existing science into practice. The culture has been transformed from one where scientists only worked on single studies to generate new evidence to one where both original science and translation of evi dence is common practice. While the ANC worked to develop the PCTS, nurse scientists at the Tripler Army Medical Center (TAMC) spearheaded efforts to create a robust EBP culture.3 These same scientists also took the lead in forming the civilian-military partnership de scribed in this article.Tripler A rmy M edical C enter proximately 52% of the Earths surface. It is home to the ically-based regional medical commands in the US Army and the Center of Excellence in Disaster Manage ment and Humanitarian Assistance. During World War II, TAMC had 1,000 beds. Currently, it has 231 beds, American Samoa, and residents from the former US Micronesia, and the Commonwealth of the Northern Marianas Islands. Over 2,000 patients a day receive care in the outpatient clinics, and over 200 babies are born at TAMC every month.9,10Professional nursing practice at TAMC is guided by the PCTS. As noted, education and EBP are key elements of PCTS. Education regarding EBP begins with new em ployee orientation and continues at the unit level. Em ployees are encouraged to bring their ideas or questions to their unit-based practice councils (UPC). If those ideas or questions evolve into a project, the process generally follows the Iowa model.11 Essentially, after re ceiving UPC approval, the project champion assembles the project. Both unit-based and hospital-wide practice councils track projects and provide the hospital leader ship/command team with regular updates. Librarians, nurse scientists, and clinical nurse specialists at TAMC support teams during all stages of the process, including selection of outcome measures and dissemination. Based on statewide participation, 2 or 3 TAMC teams a year are accepted into the Center 18-month EBP program.H awaii S tate C enter for N ursingThe State of Hawaii is committed to improving patient safety and the quality and delivery of healthcare to the 1.2 million residents across urban and rural regions of this island-state. The Center was established by the state legislature in 2003 to address nursing workforce issues.12 In less than a decade, the Center has become the hub of professional nursing in Hawaii. Always with a focus on the nursing community as its constituent, the TH E U NI TE D S TATES AR M Y ME DI CA L DEPA R TMENT JO U R NA L

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44 http://www.cs.amedd.army.mil/amedd_journal.aspx Table 1. Blooms Taxonomy knowledge and cognitive process dimensions mapped within the Quality and S afety E ducation for N urses competencies.The 3 Quality and Safety Education for Nurses Evidence-Based Care and Quality improvement Practice Elements Knowledge Attitude Skills/BehaviorBlooms 6 Cognitive Process Subdimensions R emember R etrieve or recite relevant knowledge from long-term memory (facts definitions, lists). Analyze Break into constituent parts and how r/t to each other & to overall struc ture or purpose. Understand C onstruct meaning from instructional communications (oral, written, graphic). Apply C arry out or use procedure (models, interviews, pre sentations, simulation). Evaluate M ake judgments based on criteria and stan dards: critiques, reports, guidelines. Create S ynthesize or reorganize elements to form a new, coherent, or functional whole.Blooms 4 Knowledge SubdimensionsFactual K nowledge of isolated content elements K now E BP versus re search language. D emonstrate knowl edge of health research methods and processes. I dentify the components of research evidence, clinical expertise, and patient/family/commu nity values. V alue all components of E BP. A ppreciate strengths and weaknesses of scientific bases for practice. A ppreciate the strength of evidence on provision of care. E mploy efficient and effective search strate gies to answer focused clinical or health system practices. E xhibit current knowl edge of best evidence related to practice and healthcare systems. D evelop knowledge that can lead the translation of research into E BP. I mplement care practices based on strength of available evidence. Conceptual M ore complex organized knowledge D efine E BP versus research. I dentify principles that comprise the critical appraisal of research evidence. S ummarize current evi dence regarding major diagnostic and treat ment actions within the practice specialty and healthcare delivery system. E valuate organizational cultures and structures that promote E BP. V alue cutting-edge knowledge of current practice. C hampion the changes re quired that support E BP. C ritically appraise original research and evidence summaries related to area of practice. Build consensus among key stakeholders through the use of change theory to create E BP. Procedural H ow To S tate 5 S teps of I owa model of E BP. I dentify efficient and effective search strate gies to locate reliable sources of evidence. D etermine evidence gaps within the practice spe cialty and healthcare delivery system. V alue development of search skills for locating evidence for best practice. A ppreciate the gaps in evi dence related to practice V alue working in an interactive manner with the I nstitutional R eview Board. L ead and marshal the resources for change that supports evidencebased practice. U se coaching skills to engage nurses in evi dence based practice and research. Promote a research agen da for evidence that is needed in practice specialty and healthcare system. A ctively engage with the I nstitutional R eview Board to implement research strategies and protect human subjects. Metacognitive C ognition in general & awareness of ones own cognition A wareness of personal level of knowledge/ experience with E BP. U nderstand the need to define critical ques tions related to practice and healthcare system delivery. I dentify strategies to ad dress gaps in evidencebased guidelines. A nalyze how the strength of available evidence in fluences care (assess ment, diagnosis, treat ment, and evaluation). A ppreciate that orga nizational systems can significantly influence nursing's efforts in E BP. A ppreciate that all nurses can partici pate in creating E BP. V alue knowing the evidence base for one's practice specialty area. R ole model clinical deci sion making based on evidence, clinical exper tise, and patient/family/ community preferences. U se quality improvement methods to address gaps in evidence based guidelines. U se health research methods and processes, alone or in partnership with scientists, to gener ate new knowledge for practice. Participate in designing organizational systems that support E BP. A C HIE VIN G AR M Y N U R S IN G EVIDENCE -B ASE D PR ACT I CE CO MPETENC IES THRO U GH A CIVILI AN -MILI TARY NU R SE P AR TNE R SHI P

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January March 2014 45 Center collaborates with nursing professionals, the community, and state in the spirit of consen sus building and teamwork. One of the Centers legislative mandates is to conduct research on best practice and quality outcomes. This mandate, along with national and local trends and imperatives, created the stimulus for enhancing EBP capacity. As a re sult, an innovative statewide program was im plemented to meet demands for quality nursing care and improvements in patient outcomes.C ivilian PartnersOver the past 5 years, the Center has engaged 15 different healthcare organizations, detailed in pitals, one behavioral health facility, one critical access hospital, 2 long-term healthcare facilities, one womens and children hospital, and 2 reha bilitation hospitals. With the exception of 3 acute care hospitals and one team of nursing faculty, all facilities are located on the island of Oahu. M E THODOLOGYPartnerships achieving a mutual goal that neither partner can nerships have the potential to bridge gaps that exist between science, policy, and practice13-15 and ultimately improve care. This exchange of ideas, resources, funding, and expertise serves to enhance capacity, resulting in the in the bedside.14,21The nature of partnerships vary and are depen dent upon the period of time, local political con ditions, the nature of the problem or goal, and the stage of development of the interventions.22 Capitalizing on these conditions requires recog nition that each partner is ready to share a com mon vision, similar interests, an understanding of each other, and a willingness to move with optimistic uncertainty.Civilian-military partnerships described in the healthcare literature relate primarily to civilian trauma experts providing training to military healthcare providers for injured Soldier care or working with other nations to provide needed humanitarian assistance and disaster response. Table 2. E vidence-based practice projects in H awaii, 2009-2012. The number of each type facility participating is in parentheses.Type of Facility EBP Topic Acute Care H ospital (7) A ccidental extubation in pediatric critical care patients A dvanced care planning based on cultural beliefs/ practices A lternative therapy pain management in postoperative joint patients A mbient noise levels C hildbirth education C linical simulation for medication errors in orthopedic/neuro/vascular units C onscious sedation safety C ulture of transparency to support bedside patient safety D ecompensation in heart failure patients E arly sepsis screening in the ER and hospital G roup therapy for adolescents in inpatient psychiatric setting H ospital discharge instructions for adults H ourly rounding for toileting I ntraoperative skin preparation for adult hand surgical patients L ength of stay, negative outcomes and costs for adults >18 years of age M anagement of sacral pressure ulcers M edication errors in adult surgical patients N onpharmacological sleep for SICU patients O rganizational change at the unit level Pain management for opioid-dependent orthopedic patients Patient choices for coping with labor Patient/staff communication Perioperative management of adult patients with sleep apnea x 2 Perioperative hyperglycemia management Pulmonary management of spinal cord patients R eduction in hospital-acquired pressure ulcers R estraint use reduction in medical/surgical andcritical care units R estraint use reduction in emergency department Shift report process for adult patients S imulation training for staff nurses S urgical site infections in antepartum/surgical ward Trauma informed care V ascular access device selection in long term intravenous patients Behavioral H ealth H ospital (1)S uicide reduction in inpatient settings R estraint use reduction in aggressive behavior children <8 years old A ggressive behavior in children <12 years old Fall prevention Critical Access H ospital (1)H ospital-acquired infections L ong Term Care Facility (2)Pain management for residents with dementia Fall prevention x 2 Pediatric H ospital (1)V entilator weaning readiness R ehabilitation H ospital (2)Fall prevention Patency of peripheral intravenous lock in children Pediatric pin site care in pediatric population with external fixation Post surgery bowel function S urgical/pin wound dressing

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46 http://www.cs.amedd.army.mil/amedd_journal.aspxAlthough military medical facilities are geographically located among their civilian counterparts across the na tion, little is published about the linkages between and among military and civilian healthcare providers.Blooms Taxonomy and Quality and S afety E ducation for N ursesGuided by Blooms revised taxonomy, learning objec tives directed at EBP competency applicable to both civilian and military environments were developed. These objectives focused on facilitating nurses EBP skills, knowledge, attitudes, and behaviors. The learn ing objectives organized by the knowledge and cogni tive process dimensions are listed in Table 1.EBP W orkshop and I nternship C urriculumThe Center offers an annual 2 half day workshop lim ited to 35 participants to ensure individualized attention and team support. The workshop covers each step of the Iowa Model11: Identify triggers. Form a team. Assemble and critique the literature. Synthesize the literature. Pilot the practice change. Implement the practice change. Evaluate the practice change. The agenda consists of didactics followed by activities and exemplar presentations from previous team mem bers, offering invaluable insight into the EBP process. Prior to the workshop, teams submit a problem state ment that serves as the foundation for workshop and internship activities. If possible, a team participating in the workshop consists of a staff nurse, an advanced practice registered nurse (APRN), and a nurse manager. Within this format, the staff nurse serves as a change champion; the APRN acts as an opinion leader, assisting with identifying and critiquing literature and develop ing implementation strategies; and the nurse manager provides administrative and logistical support. Teams from TAMC are encouraged to include both civilian and military registered or practical nurses or other inter ested staff. A contingency plan in the event of military deployment or change of assignment is included in the initial application. Due to competing demands, nurse managers at TAMC are not generally on the teams but have an open invitation to attend any of the internship program sessions described below. While all facets of the Iowa Model are covered during the workshop, a thorough understanding of the model companion internship program deconstructs each phase into manageable steps and focuses on strategies for im plementation of the project. The 18-month internship program is structured around bimonthly meetings that provide 4 hours of interactive didactic content which re inforces workshop material, followed by teams sharing status reports and actions to resolve barriers and restart stalled projects. FINDINGSPartnershipsPartnerships in nursing are common, especially those relating to academic-service partnerships. Naturally evolving from an applied science, nursing education necessarily involves clinical partnerships. A recent sys tematic review reported that nursing academic-service partnerships have 4 main stages: (1) mutual potential Although the intent of this review was to inform clinical nursing education reform efforts, it is consistent with what others describe as necessary elements of success ful partnerships13,15,28-30 and will be used as a blueprint to describe this civilian-military nursing partnership to enhance evidence-based practice capacity in Hawaii.Partnership H istory and FoundationsThe Army Nurse Corps recognized the importance of EBP and has emphasized and supported its implementa tion for the past decade. Support included training by Dr Marita Titler* to implement EBP programs, which re sulted in an EBP pilot program at TAMC. Modeled after the Advanced Practice Institute at the University of Iowa and facilitated by Dr Titler, the pilot included an initial workshop, an 18-month internship program, facilitation 3The success of this TAMC-wide EBP program served as the basis for the Centers statewide initiative. Drivers for the statewide program were the Centers legislative man date, the transition of facilitators of EBP at TAMC to the Center and a large civilian medical center, and an ex pressed community need for EBP competencies to meet M utual Potential Benefits partnership: (1) increasing EBP capacity; (2) accessing and optimizing resources; and (3) sharing strategies for successful implementation of practice changes. All 3 *Professor and C hair, D ivision of N ursing Business and H ealth S ystems, U niversity of M ichigan S chool of N ursing.A C HIE VIN G AR M Y N U R S IN G EVIDENCE -B ASE D PR ACT I CE CO MPETENC IES THRO U GH A CIVILI AN -MILI TARY NU R SE P AR TNE R SHI P

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January March 2014 47 istered nurses implementing approximately 50 differ ent EBP projects from 15 different healthcare facilities across the state have developed competencies in EBP. Many of these nurses have gone on to lead other EBP projects, are functioning as EBP experts in their institutions, and/or have taken positions in quality management. Resource access and optimization are afforded by the Centers central role in the community. It is in a position to not only lead this statewide initiative, but guide a co hesive effort, bringing together previously fragmented programs. This centralized approach provides a distinct advantage of shared resources in terms of education, ex pertise, and personnel. The Center provided a dedicated Project Coordinator for 10 hours each week; an Agency for Healthcare Research and Quality grant supported ation with the University of Hawaii gives access to a nursing faculty member who directs the program, a stat istician, and a medical librarian. Likewise, TAMC pro vides military and civilian nursing faculty and library support services. The EBP workshop and internship program is a shared experience. Teams across institutions become familiar with their colleagues projects and work environments over the 18 months. At each internship meeting, we ask the teams to provide an update on their project. This serves the purpose of assisting each other with strategies to overcome barriers and share successes for achieving milestones.From C ompetition to C ollaborationHawaii has an unusually collaborative spirit. This may be due to its geographic isolation, incomparable diver sity, or great weather. Regardless, faculty were sensitive to the fact that discussing triggers for the various proj ects would expose nursing care problems. Every effort was made to focus on quality improvement, avoid any criticism, and create a safe environment for open discus sion. Once the environment was perceived as safe, the teams from the 15 facilities had little hesitation to col laborate in this process and work together.Joint PracticeNursing care delivery issues are rarely unique and it was the hope of the Center that teams would work on similar practice changes across institutions. At one point, 4 fa cilities were addressing fall prevention: a rehabilitation hospital, a medical center, a long term care facility, and a mental health hospital. Another opportunity existed obstructive sleep apnea in the postoperative patient. Despite offers to provide additional facilitation, sharing of materials, etc, neither of these potential joint prac tices came to fruition. Anecdotally, logistics, time, and practices than a willingness to work together. Organiza tional cultural differences may have been another factor.Beneficial O utcomes EBP program include patients, nurses, and healthcare institutions. First and foremost, the patients at these 15 facilities were provided evidence-based care for a vari ety of patient care issues as shown in Table 2. TAMC practice projects across the continuum of care: Ambient noise levels Alternative therapy pain management in postopera tive joint patients Childbirth education Clinical simulation for medication errors in ortho pedic/neuro/vascular units Decreasing inpatient length of stay Intraoperative skin preparation for adult hand sur gical patients Medication errors in adult surgical patients Perioperative management of adult patients with sleep apnea Reduction in hospital-acquired pressure ulcers Surgical site infections in antepartum/surgical ward These projects spanned from pediatric populations to the elderly, from ambulatory to critical care settings, and from direct to indirect patient care delivery. Eight of the 11 TAMC projects have been institutionalized as new standards of care. several ways. Not only did participants develop EBP skills, they also enhanced their nursing professional and leadership acumen as well. Participants of the Cen ters EBP program obviously gained knowledge about hand how to implement and evaluate projects. Applica tion and translation of this knowledge to the bedside is not only critical to changing to an evidence-based practice, but is undoubtedly the hardest part. Changing the behavior of others and permanently inculcating that ible leadership styles, commitment to the process and outcome, and a great deal of persistence.

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48 http://www.cs.amedd.army.mil/amedd_journal.aspxThe bene ts of EBP capacity building to healthcare institutions are most obviously changes and improvements to patient care delivery and outcomes. Other bene ts are not always readily tangible. For example, the maturation of professional and leadership skills among the nursing staff contribute to the organization by in uencing the behavior of their colleagues, functioning as EBP faculty, disseminating results of EBP projects both locally and nationally, and identifying additional needs of the institution and implementing new projects. COMMENTSuccessesCivilian-military partnerships can and do work. In this instance, the statewide EBP program met goals of multiple institutions simultaneously while lling gaps in resources that single institutions could not do on their own. The collaborative efforts of civilian and military nurse leaders, scientists, clinicians, and developing EBP experts effected practice changes that enhanced quality care, cost savings, and professional development.Quality ImprovementThe QSEN competencies focus on providing new graduates with tools necessary to improve patient safety and healthcare quality. Practicing nurses continually address safety and quality, yet may have graduated prior to the QSEN initiative and therefore possibly lack experience using evidence-based approaches. While this practice gap is only just now being addressed at the national level,4 Hawaiis statewide civilian-military partnership has been successful at increasing EBP competency of staff and improving patient safety for over 5 years. Patient satisfaction, fall rates, and medication errors have improved. Additionally, TAMC nurses have had opportunities to disseminate their successes via podium and poster presentations at national and international conferences. Three manuscripts are in development and are scheduled for publication in September 2014. The professionalism and leadership demonstrated through the EBP projects have also led to increased interest in advanced education and new job opportunities for participants, many of whom have themselves become EBP mentors.Cost SavingsA criticism of EBP is that the process is directed more at cost reduction rather than improving quality of care.31 In Hawaii, costs for sending one individual off-island for expert training can exceed $2,200. In some instances, EBP does increase costs of care. For example, extra nursing care time and supplies were required to implement one practice change. However, the driving impetus behind acceleration of the EBP movement was the 1999 Institute of Medicine (IOM) report on quality care. According to a 2012 IOM report,32 missed prevention opportunities, care fragmentation, and inef ciencies resulted in over $200 billion (109) in excess costs. Quality care itself can increase cost effectiveness by decreasing those missed opportunities through an EBP approach. For example, the childbirth education project at TAMC saved patients about $300 in out-of-pocket expenses. Streamlining discharge processes on one medical surgical oor at TAMC resulted in cutting associated costs almost in half.Professional DevelopmentWhen asked about their successes, most participants credited their organizational leadership with creating a culture of EBP and the initial workshop as most critical to their ability to complete and institutionalize their projects. Speci c aspects of support participants found helpful were the onsite availability of PhD prepared nurses, librarians, digitally available toolkits/handouts from the workshop, and the ongoing mentorship support from both TAMC and the Center. One attendee remarked The library support was also helpful because it was very intimidating trying to organize that amount of articles at rst. Several participants spoke passionately regarding their sense of professional ful llment in that they felt they were truly making a difference in patient outcomes: I remember feeling alive during our project. That period of time was a very emotional experience. It felt like we were doing what nurses are educated to do. Others talked about their ability to mentor others: Even now at my new post, whenever a question pops up about EBP I feel more than comfortable answering it and it reminds me of how much I learned though the project. These personally communicated comments echo sentiments noted in the literature.2,33,34Importance of LeadershipLeaders and their role in supporting EBP cannot be overstated. Balancing scal stewardship, personnel, and policy to deliver optimal care has been especially challenging these past few years. Leaders must be committed to the process as results may not be seen for more than a year despite the resources spent. Since inception, attendees of the partnership have consistently identi ed leadership support as critical to their success: The leaders were all committed to change of culture from the research staff, the doctors, the medical library staff, and the nurses.Internal LeadershipEvidence-based training and practice implementation uses considerable resources in terms of time, nances, clinical work schedules, and scholarly support. In ACHIEVING ARMY NURSING EVIDENCE-BASED PRACTICE COMPETENCIES THROUGH A CIVILIAN-MILITARY NURSE PARTNERSHIP

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January March 2014 49 the unique nature of this civilian-military partnership that had been in place. It is beyond the scope of this ar ticle to describe these changes, however, military atten dance and participation in non-Department of Defense conferences and workshops, even for medical education, was severely curtailed. Extensive across-the-board bud get cuts further limited the ability of TAMCs leadership to support liberal participation. During this timeframe, despite these restrictions, 9 more individuals were able to participate in the program due to the commitment of TAMC nursing leadership. Military attendees noticed: the thing that was most helpful was the command sup port of what we were doing. Everyone was aware and supportive along the way. The command support cre ated an atmosphere where our peers, subordinates and leaders were open to change. Future military participa tion will depend in part on ongoing regulations and the E xternal L eadershipLeaders across the state facilitated the work of each participating institution and EBP team. The Centers EBP steering committee advised the program, provided oversight, and marketed the program within their insti tutions. Dr Titlers train-the-trainer model facilitated the development of EBP faculty. These faculty members de velop their own EBP expertise by teaching content at each workshop and internship program. They also are available to their own institutions for individual consul tation. Over time, EBP team members become leaders and experts concerning their topic.Perceived Barriers culture are EBP mentors, partnerships between aca demic and clinical settings, EBP champions, time, re sources, and administrative support.3,35-39 To overcome these barriers, multifaceted active dissemination strate gies are needed to promote the use of research evidence in clinical and administrative healthcare decision-mak ing. These strategies need to address both the individual practitioner and organizational perspective. This part nership and the corresponding educational program was designed to overcome as many of these barriers as possible.Personnel C hangesTurnover in any organization can be cited as a major disruption to practice change and this is certainly true in healthcare delivery systems, including military facili ties. Deployments and personnel transfers can uninten tionally stall or derail EBP projects. This partnership provided the continuity needed to counteract effects of military operations. Rarely did all military EBP team members leave at the same time. New team members were quickly brought up-to-date by both remaining team members and Center faculty. Additionally, the PCTS goal of decreasing practice variance extended to military nurse scientists and clinical nurse specialists. Newly arriving military faculty were already familiar with the Iowa model of EBP and were able to quickly and almost seamlessly integrate into the partnership. The infrastructure provided by the Center combined with internal efforts at TAMC were effective in mitigat ing most effects from personnel changes. S UMMARY Evidence-based practice is a core element of the Army Nurse Corps vision. Educating nurses about the EBP process facilitates the remaining PCTS elements de in implementation and enculturation. The mutual ben nizations in surrounding communities facilitated and enhanced the abilities of nurses at both civilian and mil itary treatment facilities to implement EBP into practice and put words into action. Healthcare organizations facing comparable issues should consider a similar part nership as a vehicle for increasing EBP capacity, profes sional growth, and improved patient outcomes. R EF ERENCES1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health Washington, DC: The National Academies Press, 2011. 2. Melnyk B, Fineout-Overholt E, Gallagher-Ford L, US nurses: critical implications for nurse leaders and educators. J Nur Adm 3. Mark DD, Latimer RW, Hardy M. Stars aligned for evidence-based practice: a tri-service initiative Nurs Res 4. Bednash GP, Cronenwett L, Dolansky MA. QSEN transforming education. J Prof Nurs 5. overview. Theory Into Practice 2002;41(4):212-218. Lesniak R. Expanding the role of women as nurses during the American civil war. ANS Adv Nurs Sci 2009;32(1):33-42.

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50 http://www.cs.amedd.army.mil/amedd_journal.aspx tial to disaster relief. Am J Nurs 2004; 104: 35-38. 8. Horoho P. Army nursing: transforming for a new century of caring. Army Med Dep J October-De cember 2011:4-9. 9. News brief; 2008. Available at: http://archives.star bulletin.com/2008/04/20/news/story09.html. Ac cessed April 2013. 10. Tripler Army Medical Center. Internal Medicine Residency Overview. Available at: http://www. tamc.amedd.army.mil/residency/mchk-dm/medi cine.htm. Accessed September 2013. 11. Iowa model of evidence-based practice to pro mote quality care. Crit Care Nurs Clin North Am 12. Hawaii HB No. 422, Act 198: Relating to a Cen hawaii.gov/dcca/pvl/boards/nursing/statute_rules/ act198.pdf. Accessed October 11, 2013. 13. partnerships for nursing faculties and health ser vice providers: what can nursing learn from busi ness literature? J Nurs Manag 14. From fragmentation to alignment. Can J Public Health 2009;100(1)(suppl I):1-4. 15. novation networks between academia and industry: an imperative for breakthrough therapies. Nat Med. Easton A. Public-private partnerships and public health practice in the 21st century: looking back at the experience of the Steps program. Prev Chronic Dis ronch M, Moursi AM. Public-private collaboration to improve oral health status of children enrolled in Head Start in New York City. N Y State Dent J 18. nerships to facilitate safe and quality transitions in care. Nurs Econ 19. chusetts oral health initiative (CMOHI): successful public-private community health collaboration. J Public Health Dent 20. proving early childhood developmental services through public-private partnerships. Issue Brief (Commonwealth Fund 21. Luijten PR, van Dongen GA, Moonen CT, Storm translational medicine: concepts and practice ex amples. J Control Release 22. ships as the foundation of implementation and tury. Adm Policy Ment Health 23. L. Implementing innovation through educationpractice partnerships. Nurs Outlook 24. care in Southeast Asia: military-civilian partner ships and the role of the US Navy ship Mercy. J Craniofac Surg 2012;23:1950-1953. 25. civilian collaboration in trauma care and the se nior visiting surgeon program. New Eng J Med teams: do military-civilian collaborations work?. Army Med Dep J Nabavi FH, Vanaki Z, Mohammadi E. Systematic review: process of forming academic service part nerships to reform clinical education. West J Nurs Res 2012;34(1):118-141. 28. Marshall S. Partnership to build research capacity. Nurs Econ 29. Casey M. Partnershipsuccess factors of in terorganizational relationships. J Nurs Manag 30. MacPhee M. Developing a practice-academic part nership logic model. Nurs Outlook 31. Melnyk BM, Fineout-Overholt E. Evidence-Based Practice in Nursing & Healthcare: A Guide to Best Practice 2nd ed. Philadelphia, PA: Lippincott Wil liams & Wilkins. 2011. 32. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Acad emies Press, 2012. 33. Hockenberry M, Brown T, Walden M, Barrera P. Teaching evidence-based practice skills in a hospi tal. J Contin Educ Nurs 2009;40(1):28-32. 34. tive strategies for teaching evidence-based practice in accelerated second-degree programs. J Nurs Educ A C HIE VIN G AR M Y N U R S IN G EVIDENCE -B ASE D PR ACT I CE CO MPETENC IES THRO U GH A CIVILI AN -MILI TARY NU R SE P AR TNE R SHI P

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January March 2014 51 35. characteristics and context on research utilization. Nurs Res McCloskey D. Nurses perceptions of research uti lization in a corporate health care system. J Nurs Scholarsh 2008;40:39-45. Rogers E. Diffusion of Innovations New York, NY: Free Press; 2003. 38. Titler MG. Translation science and context. Res Theory Nurs Pract 2010;24(1):35-55. 39. S. Nurses perception towards evidence-based practice: A descriptive study. Nurs J Singapore. 2013;40(1):34-41.A U THORSLTC Siaki is Deputy Chief, Center for Nursing Science and Clinical Inquiry, Madigan Army Medical Center, Tacoma, Washington. Dr Mark is Director, Doctor of Nursing Practice Program and Nurse Researcher, Hawaii State Center for Nursing, School of Nursing and Dental Hygiene, University of Hawaii at Manoa, Honolulu, Hawaii. COL Hopkins-Chadwick is Dean, Academy of Health Sciences, Army Medical Department Center and School, Fort Sam Houston, Texas. She is also the Army Surgeon General Consultant for Nurse Education and Nurse Enlisted Training.

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52 http://www.cs.amedd.army.mil/amedd_journal.aspx 1 a THE ARMY PR A C TIC A L NURSE C OURSE Infusing Evidence-Based Instructional Strategies to Prepare Todays Military Practical Nurses for Tomorrows Practice A BS T R A C T

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January March 2014 53 C OURSE FR A MEWORK PREVIOUS R ESE A RCH 3 3 3 U SI N G E VIDE N CE I N E DUC ATION PR A C TICE son et al E VIDE N CEBA SED E DUC ATION C OURSE IN I TI ATIVESC omputer Assisted L earning Programs TH E U NITE D S T A TES A R M Y ME D I CAL DEP AR TMENT JO U R N AL

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54 http://www.cs.amedd.army.mil/amedd_journal.aspx I ncorporation of G aming S oftwareJeopardy Anatomy and PhysiologyMedi cal TerminologyMath for Pharmacology U se of a C lassroom Performance S ystem H uman Patient S imulators re V ideo R ecordings of All L ectures 11 13 In Multimedia principle. Contiguity principle. Modality principle. Signaling principle. I N FUSIN G EV I D EN C E -BA SE D I NST R U C TION AL S T RA TE G IES T O PR EP AR E TODAYS MIL IT ARY PRAC TI CAL N U R SES FOR TO M ORROWS PRAC TI C E

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January March 2014 55 Personalization principle. 17 R ESUL T S AN D OBSERV ATION S C omputer-Assisted L earning

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56 http://www.cs.amedd.army.mil/amedd_journal.aspx C omputer G aming Applications Who Wants to be a Mil lionaire Hollywood Squares C lassroom Performance S ystem H uman Patient S imulators L ecture V ideos I N FUSIN G EV I D EN C E -BA SE D I NST R U C TION AL S T RA TE G IES T O PR EP AR E TODAYS MIL IT ARY PRAC TI CAL N U R SES FOR TO M ORROWS PRAC TI C E

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January March 2014 57 C ON CLUSION S AN D R ECOMME N D ATION S mentation of the Jeopardy R EF EREN CES Taxonomy of Educational Objectives: The Cognitive Domain Educating the Net Com

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58 http://www.cs.amedd.army.mil/amedd_journal.aspx Commun Rev E-learning: Strategies for Deliver AU THORS I N FUSIN G EV I D EN C E -BA SE D I NST R U C TION AL S T RA TE G IES T O PR EP AR E TODAYS MIL IT ARY PRAC TI CAL N U R SES FOR TO M ORROWS PRAC TI C E

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January March 2014 59 5 FRAMEWORK F OR STUDY 7 8 OPERATIONAL D E F INITION S The Effects of Using a Human Patient Simulator Compared to a CD-ROM in Teaching Critical Thinking and Performance A B S TRACTBackground: Methods: Results: P P P Conclusion:

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60 http://www.cs.amedd.army.mil/amedd_journal.aspx B ACKGROUND OF SIMULATION 11 T HE EFF ECTS O F U S ING A H UM AN PA T IE N T SIMU LA TOR COMP A RED TO A CD-ROM IN T E A CHING C R I T I C AL T HINKING AN D P ER F ORM AN CE

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January March 2014 61 R E S EARCH QUE S TION M ETHOD S SAMPLE H UMAN P ATIENT SIMULATION C OMBAT C A S UALTY C ARE CD ROM

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62 http://www.cs.amedd.army.mil/amedd_journal.aspx C RITICAL T HINKING IN STRUMENT C ontent Validity D etermination of R eliability C OMBAT P ER F ORMANCE I N S TRUMENTC ontent Validity metnot met R eliability r r r r R E S ULT S P T HE EFF ECTS O F U S ING A H UM AN PA T IE N T SIMU LA TOR COMP A RED TO A CD-ROM IN T E A CHING C R I T I C AL T HINKING AN D P ER F ORM AN CE

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January March 2014 63 P C OMMENT 7 A CKNOWLEDGEMENT R EF ERENCE S Int J Nurs Educ Scholarsh Nurs Educ Perspect Nurs Educ Perspect Summary of means standard deviations of results.Outcome Human Patient Simulator G roup (n=19) CD-ROM Group (n=14) Control Group (n=16) Post Hoc A nalyses C ritical thinking, pretest 66.28 12.0 66.10 12.06 64.65 11.33 HP S vs CD P =.239 HP S vs control P =.003* CD vs control P =.077 C ritical thinking, posttest 78.6 69.2 74.10 13.9 67.00 9.1 P erformance, pretest 49.47 13.4 43.73 13.2 46.13 12.2 HP S vs CD P =.000* HP S vs control P =.000* CD vs control P =.171 P erformance, posttest 89.84 18.7 49.40 12.2 42.07 9.1*mean difference is significant at the 0.05 level

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64 http://www.cs.amedd.army.mil/amedd_journal.aspx Nurs Educ Perspect Int J Nurs Educ Scholarsh J Nurs Educ CRNA J Nurs Educ Nurs Educ Perspect J Nurs Educ Acad Emerg Med Nurs Educ Per spect Nurse Educ Crit Care Nurs Clin North Am Crit Care Nurse AACN Clin Issues Int J Nurs Educ Scholarsh Nurse Educ Br J Theatre Nurs J Am Coll Surg Crit Care Med Chest Acad Med J Nurs Educ Simul Healthc Nurs Educ Perspect J Nurs Educ Int J Nurs Educ Scholarsh AORN J J Perinat Neonatal Nurs A UTHOR S T HE EFF ECTS O F U S ING A H UM AN PA T IE N T SIMU LA TOR COMP A RED TO A CD-ROM IN T E A CHING C R I T I C AL T HINKING AN D P ER F ORM AN CE

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January March 2014 65Army Nursing has long been a leader in the advancement of nursing standards in the United States. For example, in 1976, Army Nursing took the lead in establishing stan dards that make nursing one of the most trusted profes sions in our country when a baccalaureate college degree was set as the minimum standard for entry-level Army Nursing practice.1 Today is no different as Army Nursing continues to raise the educational standard for its organic faculty, nurse scientists, and advanced practice nurses. THE REQUI R EMENT FOR DOCT O R ALL EVEL F ACUL T Y In 2008, the 23rd Chief of the Army Nurse Corp, MG Patricia Horoho, launched a campaign plan with a sys tem for patient care delivery at its core.2 The foundation of that plan, the Patient CaringTouch System, consists of 5 elements (patient advocacy, enhanced communication, capacity building evidence-based practice, health work environments) and is designed to reduce patient care delivery variance though evidenced-based nursing care to achieve best patient outcomes. In support of build ing the capability to deliver evidence-based nursing care, the Army Nurse Corps (ANC) has a requirement for uniformed faculty to teach in several of its graduate programs as discussed below. In order to teach in Army tialed in the specialty in which they are seeking appoint ment and possess a terminal degree (PhD, DNP, DNSc). The US Army Graduate Program in Anesthesia Nursing has a total requirement of 18: 4 at the Phase I site, and 2 at each of the 7 Phase II sites (Tripler Army Medical Center (AMC), Honolulu; Madigan AMC, Fort Lewis, WA; Womack AMC, Fort Bragg, NC; William Beaumont AMC, Fort Bliss, TX; Carl R. Darnell AMC, Fort Hood, TX; San Antonio Military Medical Center, TX; and Eisenhower AMC, Fort Gordon, GA. The Graduate School of Nursing (GSN) at the Uni formed Services University of the Health Sciences has a total requirement of 6: one faculty member in each of the 5 programs within the GSN (PhD, Nurse Anesthe sia, Family Nurse Practitioner, Behavioral Health Nurse Practitioner, Perioperative Clinical Nurse Specialist) and the Commandant of the GSN. Army Nursing is building 4 Phase II sites to support the clinical and capstone requirements for DNP graduate students for the primary care programs associated with the GSN: Womack AMC, Beaumont AMC, Madigan AMC, and Darnell AMC. Each of these sites will require one doctoral level faculty member. The Army Nurse Corps also has one faculty member at the Baylor Program in Healthcare Administration at the Army Medical Department Center and School (AMEDDC&S). The total requirement for faculty with terminal degrees at all of the teaching venues is 29. However, there are other requirements in the ANC for terminal degrees, the Chief of the Department of Nursing Science at the AMEDDC&S, and at each of the 5 Centers for Nursing Science and Clinical Inquiry located at the major Army many of these positions have adjunct faculty appoint ments and are expected to teach in a variety of programs. There are also several specialty producing programs lo cated at the AMEDDCS that require graduate degrees. Although they do not currently require doctorate de grees, the ANC is tracking these programs as they may require a higher degree in the future. These programs include the Public Health Program (1 position), the Psy chiatric Nurse Program (2 positions), the Perioperative Nurse Program (2 positions), the Leader Development Program (4 positions), the Center for Professional Education and Training (1 position), the Defense Medical Readiness Training Institute (2 positions), the Medical Simulation Training Center (1 position), the Flight Med ic Program (1 position), the combined Intensive Care/ Emergency Room Nurse Program (7 positions), and a se S TR A TEGIE S T O P R OVI D E DOCT O R ALL EVEL F ACUL T Y In crafting the strategy to provide doctoral level faculty, the ANC has relied heavily upon established standards and best practice guidelines. In its position statement concerning academic preparation of nursing program Raising the Educational Standard for Army Nursing Faculty

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66 http://www.cs.amedd.army.mil/amedd_journal.aspxfaculty,3 the American Association of Colleges of Nurs ing (AACN) states that while institutional programs are culturally diverse, some standards are universal; a doctoral degree is required for faculty that have prima ry responsibility for overseeing all graduate and post graduate education. Additionally, the AACN report The Essentials of Doctoral Education for Advanced Nursing Practice4 outlines several desirable characteristics for advanced faculty, including diverse backgrounds and intellectual perspectives in the specialty areas of their students while providing a mix of practice and research experience. The primary strategy to build a force structure with the required academic preparation for the ANC is the Longterm Health, Education and Training (LTHET) Program. grees. It should be noted that the vast majority of these starts will enter advanced practice programs and con sequently will not be used as faculty for several years after graduation in 2015. It is expected that about only 6 of the graduates will be available for assignment to fac ulty positions after completion of the doctoral degrees. These include post-masters DNP completion candi dates (3), PhD in neuroscience candidates (2), and PhD are obtaining doctoral degrees on their own. This is par ticularly popular with our advanced practice providers who are obtaining DNP degrees at civilian universities across the country. Although the difference between the requirements and shortage continues to exist with the ANC. With a mini mum requirement of 29 doctoral-degree faculty posi be a challenge in meeting force structure requirements. A variety of reasons exist for the persistent shortage of positions outside the sphere of faculty positions. the service. specialties. The continued increase in the number of doctoral degrees for accredited graduate programs. Currently, not all incumbents of the required positions The ANC is considering several strategies to mitigate imate specialty known as an Area of Concentration for Nurse Researchers so that the inventory could be man career path to senior ranks within the ANC; and increas ing the authorizations for PhD programs in the LTHET process in future years. This could also include civilian programs, expand the use of civilian nursing personnel prepared at the doctoral level for positions within our educational and training platforms, and encourage and expand on the BSN to PhD/DNP pathway for junior of force structure faster than the current pathway of bach elor, master, and then doctorate degree, and would have the ANC at an early stage in their career, extending their utilization for those who stay for an entire career. This innovative model has been used successfully at major universities with top-ranked schools of nursing, such as the University of Michigan and Vanderbilt University.5Army Nursing has embraced the position statement by AACN of faculty characteristics in our own pro grams and to those programs to which we send students through the LTHET program (PhD and research and DNP completion programs). This long-term strat egy will insure that the ANC will have the appropriate faculty base to meet its needs in the future. It will also tientCaring Touch System to achieve the best outcomes possible in the delivery of patient care. REFER ENCE S1. Feller CM, Moore CJ, eds. Highlights in the His tory of the Army Nurse Corps Honolulu, Hawaii: 2. Horoho PD. Army nursing: transforming for a new century of caring US Army Med Dep J December 2011;4-5. 3. American Association of Colleges of Nursing. Pre ferred vision of the professoriate in baccalaureate and graduate nursing programs [internet]. 2008. Position paper. Available at: http://www.aacn.nche. edu/publications/position/preferred-vision. Ac cessed November 25, 2013. 4. AACN Task Force on the Practice Doctorate in Nursing. The Essential of Doctoral Education for Advanced Nursing Practice. Washington, DC: American Association of Colleges of Nursing; 2006. Available at: http://www.aacn.nche.edu/pub lications/position/DNPEssentials.pdf. Accessed November 25, 2013.R AI S I N G TH E EDUC A TIONAL ST AN D AR D F OR AR MY NU RS I N G F A CULTY

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January March 2014 67 5. Hinshaw AS. A continuing challenge: the shortage of educationally prepared nursing faculty. Online J Issues Nurs [serial online]. 2001;6(1):3. Available at: http://www.nursingworld.org/MainMenuCat egories/ANAMarketplace/ANAPeriodicals/ ShortageofEducationalFaculty.aspx. Accessed November 25, 2013.A U THORS Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland. Sciences, Army Medical Department Center and School, Fort Sam Houston, Texas. She is also the Army Surgeon General Consultant for Nurse Education and Nurse Enlisted Training.

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68 http://www.cs.amedd.army.mil/amedd_journal.aspxI have been a legal advisor to Army Medical Department (AMEDD) commanders and staff at the levels of Army community hospital, ambulatory health clinic, medical center, regional medical command, and the Headquar of The Surgeon General for over a decade. I have often been surprised at the inadequate knowledge and under standing of the law at each level, invariably due to a lack of experience and/or education about the legal obstacles, pitfalls, and landmines that AMEDD leaders and per sonnel face in todays highly complex federal healthcare environment. As an assistant professor at the Academy of Health Sci ences in the AMEDD Center and School (AMEDDC&S), I learned about the Joint Medical Executive Skills Insti tutes (https://jmesi.army.mil/) Executive Skills Program Competencies which are segregated into 7 major groups as shown in the Figure. Some of the listed competencies have legal foundations title, the legal foundations within Emergency Manage ment and Contingency Planning are not obvious, but public health law is an important, mandatory aspect of any such emergency planning effort. On the other hand, study of law, whatever the area of concentration. In the fundamental to every medical competency and thus de serves to be thoroughly taught within the AMEDD, not only to leaders but to their supporting personnel as well. THE PROPOSALSpecificsI propose a comprehensive plan and structure that fo cuses on 12 major areas of law: Each of the 12 areas would have more advanced and fo cused subparts that could be taught in courses either in Legal Education for Army Medical Department Leaders and SoldiersMAJ Joseph B. Topinka, JAGC, USAA Proposal from a Lawyer Who Has Advised AMEDD Leaders and Soldiers for Nearly a Decade Joint Medical Executive Skills Institute Competency ModelMilitary Medical Competencies Medical Doctrine Military Mission Total Force Management Medical Readiness Training Emergency Management and Contingency Planning Leadership and Organizational Management Competencies Strategic Planning Organizational Design Decision Making Change Management Leadership Health Law and Policy Competencies Public Law Medical Liability Medical Staff By-Laws Regulations Accreditation and Inspections Health Resources Allocation Competencies Financial Management Human Resource Management Labor-Management Relations Materiel Management Facilities Management Information Management and Technology Ethics in the Health Care Environment Competencies Personal and Professional Ethics Bioethics Organizational Ethics Individual and Organizational Behavior Competencies Personal and Professional Individual Behavior Group Dynamics Conflict Management Interpersonal Communication Public Speaking Strategic Communication Performance Measurement and Improvement Competencies Population Health Improvement Clinical Investigation Integrated Health Care Delivery Systems Quality Management and Performance Improvement Patient SafetySource: Joint Medical Executive Skills Institute website, https://jmesi.army.mil/documents.asp Discipline Standards of conduct (federal employee ethics) International law of Health law Public health law Fiscal law Labor law Quality assurance Claims Contract law Administrative law Human subject research law

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January March 2014 69counsel. Foundation courses would be taught in each diers in advanced individual training, followed by more focused courses on the most current legal issues prior to the assumption of higher level leadership positions.Areas of LawDisciplineDiscipline covers several competencies such as Total Force Management, Change Management, Leadership, Human Resource Management, Labor-Management Re lations, Personnel and Professional Ethics, Personal and Professional Individual Behavior, Group Dynamics, and the concept of discipline between military personnel and civilian personnel. Discipline issues regarding civilian personnel fall under labor law. Discipline pertaining to military personnel is found under the Uniform Code of Military Justice* (punitive actions), regulations in place to implement military justice, and the many regulations that deal with nonpunitive actions (administrative ac tions). Discipline in the military is a command-driven effort. Unlike the civilian world where lawyers make decisions to prosecute, in the military, lawyers advise and commanders make decisions. Commanders can de termine to take no action, initiate administrative action, dispose of offenses with nonjudicial punishment (NJP), or dispose of offenses by court-martial. Whatever the decision, advice of legal counsel is certainly key, but AMEDD commanders and leaders must be knowledge able of the basic concepts; in other words, they cannot depend on legal counsel to teach them the basics each time a discipline issue emerges. There is really no equivalent of NJP in the civilian sector. It is a critical process which allows a commander to handle discipline at the lowest level in the military environment. A commander who knows how to use NJP can dispose of misconduct quickly, and can also send a message to the unit that he or she is a person of integrity ics, and Personal and Professional Individual Behavior as Soldiers realize that they will be treated fairly at the lowest level possible, and that there is no need to refuse that low level procedure and demand a court-martial. From my experience, I have come to believe that NJP is not well understood among many AMEDD midlevel leaders. For example, a year ago I was addressing NJP surprised that a Soldier could refuse NJP and demand a court-martial. Either the student was never taught the concept or it was not effectively presented. I quickly in corporated NJP basics into that class instruction. The experience discussed above is certainly not an in dictment of our current teaching of discipline law within ship Course (BOLC) and Captains Career Course (CCC) contains a basic class on military justice in which we discuss such issues as NJP and the commanders role in discipline. In the last couple of years, the CCC has even conducted mock Article 15 hearings in a small group setting wherein each student plays a role in the hear ing. Most recently, the AMEDDC&S has initiated an Introduction to Basic Army Medicine (IBAM) course in which junior enlisted Soldiers are given classes on many issues including military justice. Additionally, I have both taught and supported pre-command courses where NJP has been reviewed. All told, these examples of ef forts to teach military justice are noble and important as good order and discipline are critical in the operation of a military and fall squarely within the competencies of Military Mission and Leadership. However, the ad equacy of this instruction should still be examined. For the subject within those venues? Also, are there other venues where the topic could be taught in more detail? When I asked the previously mentioned student about NJP and about instruction on the subject in a prior class, the student recounted a very short class on military jus tice years before in BOLC, but admitted no memory of anything from the class. But for that Military Medical Law elective course, the student may never have learned any details of the concept. The above student example may be instructive regarding the direction the AMEDD should follow pertaining to teaching military justice. It is one thing to teach a mili tary justice foundation course in BOLC, CCC, or IBAM. However, lesson planning and delivery for a class in a program for a particular department in the Academy of session at a military treatment facility or medical unit in *The Uniform Code of Military Justice (UCMJ), a federal law (64 Stat. 109, 10 USC, chap 47), is the judicial code which pertains to members of the United States military. Under the UCMJ, mili tary personnel can be charged, tried, and convicted of a range of crimes, including both common-law crimes (eg, arson) and Nonjudicial punishment is outlined in Article 15 of the UCMJ. The legal process involving NJP is commonly referred to as simply Article 15. The general rule is that Article 15s should be given for minor offenses under the UCMJs punitive articles. Imple mentation of NJP in the Army is detailed in chapter 3 of Army Regulation 27-10 .1T HE UNITED S TATES A RM Y MEDICAL DEPARTME N T J OUR N AL

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70 http://www.cs.amedd.army.mil/amedd_journal.aspxCreating a foundation in a class with students from all military occupational specialties is an absolute neces sity, but what does a physician assistant, a social worker, a pathologist, a nutritionist, or an administrator need to Standards of ConductWithin the AMEDD, frequent ethics issues face per government resources, postgovernment employment, unauthorized commitments, and political activity. From the perspective of almost 20 years teaching Standards of Conduct (SOC), I think we in the AMEDD do a good job training personnel on the basic rules. The SOC are imple mented by Department of Defense 5500.7-R: Joint Ethics Regulation .2 The SOC apply directly to the competen cies of Personal and Professional Ethics and Personal and Professional Individual Behavior The SOC also impact Financial Management and even Information Manage ment and Technology, especially considering the use of information technology systems, such as electronic mail, social media, and internet access. As I inform my students, these rules exist as guidelines to assure that our conduct is that which taxpayers would expect of their governments employees. If we cannot live up to those standards, the taxpayers will not have trust in our con duct and our leadership. In addition, the rules can also have punitive or administrative repercussions, which are usually highly motivating personal considerations. In addition to my work teaching SOC at the course or as part of orientations and annual training, the AMEDD has a number of excellent, highly experienced ethics counselors at MEDCOM commands throughout the country. My concerns are two-fold. First, I think that we do not have enough time to teach in more detail and focus for such groups as resource management person nel, contract personnel, personnel holding government purchasing cards, and clinicians. I know clinicians who to attend a class, or who do not understand that SOC is different from the biomedical ethics that they may have been taught in the past. Second, we do not always teach SOC in an effective manner such that the subject matter is easily absorbed into peoples minds. Throughout my career, I have often encountered a class of people who were in attendance only because the class was mandato ry. Their thoughts and concerns were obviously on their other responsibilities, and interest in my class material was not a priority. Since my goal was to inspire and teach the rules that would empower them to act in an ap propriate manner as executive branch employees within the Department of Defense (DoD), I would incorporate experiences, cases, examples, humor, or anything to en gage their interest and, most importantly, impart to them the knowledge they needed. Adherence to the SOC or executive branch ethics is ultimately a personal responsibility. Ethics counselors cannot monitor the activities of every executive branch employee. Ethics counselors also cannot be expected to teach a person to understand ethical conduct in a onehour class at an orientation or mandatory annual train ing. It must be a way of life that is inspired by teach ers, articles, and programs designed accordingly. The inspiration of even the best of instructors or counselors within an organization is just an example for a limited group of students. Our goal should be an inspirational program to teach and encourage employees to conduct themselves with only the highest ethical standards with in the AMEDDs unique medical environment.International Law of Armed ConflictDuring the last decade, the subject of Law of War (also increasingly important for personnel deploying to com bat theatres. Over my many years of teaching this sub ject, invariably students have expressed the opinion that the term Law of War is seemingly contradictory in and of itself. My reaction has always been to address the importance of the subject and the true intent behind the training. It is a DoD requirement to train in the sub ject, but more importantly, I have always noted that an understanding of the Law of War is critical to the com petencies of Medical Doctrine Military Mission Medi cal Readiness Training Strategic Planning Public Law Personal and Professional Ethics, and even Bioethics. I am concerned when students indicate that they have gone through many Law of War classes but demonstrate little grasp of the concepts. Are we not teaching this subject correctly? Do we not have the right focus? Are we not conveying the basic concepts that will enable them to follow what is in fact either law or DoD policy? I believe that many times we train to time and not to standard, and consequently we often do not focus on the issues that can really impact medical personnel in a combat environment. While I think our foundation they are only the basics. Future leaders and more ex perienced medical personnel really should explore the laws and policies that are in place and apply the lessons that have been learned over the years through our expe riences with those laws and policies in an operational setting. For example, in my classes I often address ex amples from the Vietnam war era, or from Operations Enduring Freedom or Iraqi Freedom, but I can never go L E G AL E DUCATIO N F OR A RM Y MEDICAL DEPARTME N T L EADERS A N D S OLDIERS

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January March 2014 71 into the detail that I feel is necessary; I simply do not have the time. With the right amount of time, the right mix of students with various experiences, and the right examples or case studies, students could explore many of the issues addressed by the Law of War and use their experiences and understanding to learn more about how they apply to the competencies noted above, competen decade, AMEDD personnel have been in harms way and have experienced a great deal. The legal medical aspects of those experiences should not be minimized. Our challenge will be to incorporate those lessons learned related to the Law of War and apply them to educational programs in the future.Health LawThe Army has no formalized training in health law ex cept advanced civil schooling every few years for one military lawyer to receive an advance law degree in health law. It is important to establish a more expan sive form of training in health law within the AMEDD to prepare personnel in all the competencies of Health Law and PolicyPublic Law, Medical Liability, Medi cal Staff By-Laws, Regulations, and Accreditation and Inspections Although the area of Health Law and Policy is considered essential within the Joint Medical Executive Skills Program, in my opinion, we really do not have sector, health law is a topic that appears with regularity in the press and has become a growing practice over the last 10 years. Unfortunately, military health law advice and education, while valued, is in short supply. After I arrived at the Academy of Health Sciences, I did not expect to be regularly invited to give a class on in formed consent, the Health Insurance Portability and Accountability Act (HIPAA), advanced directives, and quality assurance, to name a few. Also unexpected was the small number of structured legal medical classes im bedded in many of the medical education programs. Re cently, one of my former students asked why a course I taught did not have more classes on legal medical issues. He explained that my short block of instruction left him and other class members curious and feeling a bit unpre pared. In response, I could only offer him some on-line resources and provide him with some articles I had col lected that could be helpful. The health law industry in the civilian sector is expanding, health regulations are on the rise, and healthcare legal issues abound. I foresee that military medicine will not be immune to the com ing tide of health law legal issues.Public Health LawIn both military and civilian sectors, most people do not have a clear understanding of public health law, because they really do not have a clear understanding of public health. Public health has different concerns from medi cal care, encompassing the prevention of disease, pro longing life, and promoting health. It is preventive in na ture and public health law is oriented to that perspective. Fairly early in my experience with the AMEDD, I was requested by the installation medical and dental activity (MEDDAC) to provide legal advice on establishing and advising the new position of Public Health Emergency my education in public health law. After a great deal of research, I understood the critical nature of a PHEO and the necessity for a PHEO to have legal counsel who un derstood all the federal and local state laws about such issues as quarantine, isolation, presidential declarations, and public health emergency declarations. Most PHEOs were leaders in preventive medicine so I began to spend more time dealing with preventive medicine person nel. Before long, I realized that public health and public health law went well beyond the competency of Emer gency Management and Contingency Planning. It ad dressed issues such as chronic diseases, infectious dis eases, safety, nutrition, food safety, healthcare-associ language and access to care, obesity, and prescription drug shortages, just to name a few. These issues affect the military and must be addressed. For example, I have cedures under Army Regulation 600-1003 which may involve the possibility of contacting local public health be a very sensitive procedure not only involving DoD guidance pursuant to HIPAA and state or local laws or policies. Another example involved providing reason able break time to allow a civilian employee to express breast milk after her return to work following the birth of a child. While some argued this fell under labor law, it also was an issue covered under public health law. The subject of public health law extends beyond the scope of this article, but it cannot be denied that legal issues in the public health arena are ever increasing in the lexicon of todays society. We talk about energy drinks and how their ingredients could affect the health of young people, in and out of the military, beginning to show effects within the competency Medical Readi ness Training. We talk about sugary sodas and their size restriction in places like New York City as a means to combat chronic diseases and obesity, a concern within

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72 http://www.cs.amedd.army.mil/amedd_journal.aspxthe competency Population Health Improvement. Child hood obesity and its impact on recruiting and chronic diseases affects Strategic Planning. Past experiences with public health emergencies always involve determi nation of who has jurisdiction over the mattermunici pal, county, state, or federal, part of Emergency Manage ment and Contingency Planning. We should ensure that AMEDD personnel are taught the basics of public health and public health law so that they are prepared to under stand the issues facing the local communities near the military treatment facility (MTF) in which they work. Leaders should be conversant with laws governing fed eral, state, and local cooperation that is critical in dealing with any public health matter. Most importantly, legal aspects of the difference in perspectives of public health (the population) and medical care (the patient) must be clearly understood. In light of The Surgeon Generals Performance Triad4 (activity, nutrition, and sleep) initia tive for a system for health, it appears that public health will become an even more prominent consideration for the AMEDD, and public health law will become a more important concern for its leaders and personnel.Fiscal LawLiterally every unit or organization in the AMEDD is involved with the competency of Financial Manage mentthe management of the obligation and expendi ture of funds appropriated by Congress and allocated for AMEDD use. Money is the blood of the AMEDD body, having an effect on all the competencies of the Health Resource Allocation group of competencies as shown in the Figure. Fiscal law is an area of the law that has no counterpart in the civilian sector, because it is founded ultimately on what Congress says we can and cannot do based on its constitutional power to fund the federal government. Government funds come in various colors and various periods of availability for new obligations based on the guidance given by Congress. Depending on the ac tivity undertaken, the funds required to do so may vary depending on the nature and structure of the activity, the authority for the activity, the magnitude of the activ ity, the timing of the activity, and the actions previously taken by others with regard to the activity. Only one color can be correct by law. Some funding actions raise little or no issue, while color, timing, and availability of funds may make others problematic, which is when the many times. The basic rules of Purpose (funds may be obligated and expended only for the purposes authorized in an appropriation acts or law), Time (the period of time during which budgetary resources may be used to in cur new obligations is different from the period of time during which the budgetary resources may be used to incur expenses), and Amount (obligations and expendi tures may not exceed the amounts established by law) are straightforward. However, unlike other areas of the law where the absence of some prohibition is a potential within the AMEDD, such as purchasing from unauthor ized sources, exceeding purchase thresholds, making split purchases, using government funds for personal ing more than needed, and using the wrong appropria tion for a purchase. Such problems fall directly under the competencies of Financial Management and Person nel and Professional Ethics in that they are inappropriate actions on the part of employees and/or organizations in violation of law, policy, or rules. Such actions can also 1341-1342 and 1517) and require an investigation, with possible administrative or punitive sanctions, and may even require a report to Congress and the President re sulting in embarrassment to the AMEDD. Currently, we do not have any standard program to resources that are used to help in certifying government sentatives, or the occasional ad hoc class that is taught only at the request of a local resource management of just for comptrollers and their personnel, it is an impor tant topic that could conceivably impact Decision Mak ing, Leadership, and Strategic Planning, in addition to those competencies already mentioned.Labor LawOne of my former Staff Judge Advocates would often provide 10% to 20% of its legal resources to the local MTF although that MTF only represented a very small A great deal of that support was labor law related. As a former labor attorney, I can attest to the fact that la bor law support addresses competencies such as LaborManagement Relations, Human Resource Management, Public Law, Regulations, Total Force Management, Leadership, Organizational Design, and several more. Dealing with a civilian workforce covers a large horizon L E G AL E DUCATIO N F OR A RM Y MEDICAL DEPARTME N T L EADERS A N D S OLDIERS

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January March 2014 73 of legal areas including discrimination under the Equal Employment Opportunity program, harassment, civil ian misconduct, Hatch Act (5 USC 7324) violations (unauthorized political activities), collective bargaining unit relations, and unfair labor practices, to name a few. While serving as a Command Judge Advocate at a major medical center, I became concerned that we had only a single supporting labor attorney, who also supported the entire installation at which the MTF was located. She was barely able to handle the workload, so I began to work some of the more rudimentary labor actions at the MTF in order to ease that workload. I was her eyes and ears in the MTF, but I also helped educate leaders and supervisors about the various aspects of dealing with ci vilian employees. I generally felt that with a little educa tion, leaders and supervisory personnel could avoid the common pitfalls that were generating incredible legal workloads at other MTFs. My opinion today regarding labor law has not changed. If anything, that opinion has become more established as the civilian labor population of the AMEDD has in creased. We need more structured classes imbedded in courses for clinicians and nonclinicians alike who will have professional relationships, supervisory or other wise, with civilian employees in the future. Reliance on that one supporting labor attorney, or the local Civil ian Personnel Advisory Center, or the supporting human resource specialist(s) may not be enough to react to a crisis. More importantly, such a situation will not be conducive to the creation of an environment that is designed to prevent labor issues. My sense is that with the proper education, AMEDD leaders and/or managers can better understand the parameters of their authority. They can be empowered to take the necessary steps to create an employment environment where discrimina tion, inequity, and ignorance about civilian employee rights are absolutely minimal.Quality AssuranceI generally try to address quality assurance (QA) in some of my classes because it is an important subject when dealing with documents and information produced by or pertaining to activities such as privileging, infec tion control, patient care assessment, medical records review, health resources management review, and iden and risks (risk management, patient safety, and incident reports). Only The Surgeon General may authorize re lease of QA documents or information outside of DoD, so there is great sensitivity around these documents, the information generated in these documents, and the ac tivities covered by the military quality assurance statute (10 USC 1102). From a legal standpoint, there is spe cial sensitivity with regard to the procedures involving health provider misconduct and malpractice that affect the privileges of physicians, dentists, nurses, and other healthcare practitioners as this deals with the competen cies Personal and Professional Individual Behavior, Pa tient Safety, and Quality Management and Performance Improvement. When I address quality assurance in my classes, I try to always ask my students if they can tell me what QA really is and describe how Army Regulation 40-685 implements QA within the Army. Some respond with empty stares. Others confuse it with HIPAA. Still oth ers, normally clinicians, understand the basic concept but do not understand QAs impact on privileging. I explain how substandard care, clinical performance, or nonclinical misconduct can start a whole adverse action process that could ultimately impact their clinical ca reers, including licensure termination or reports to the National Practitioner Data Bank and/or the Healthcare Integrity and Protection Data Bank. The students reac tion is often one of surprise and disbelief. The ignorance was normal from class to class. Unfortunately, it is not uncommon in the legal profession. Years ago when I review of a clinicians privileges, I realized how very little I knew. I had a steep, accelerated learning curve. I believe that all AMEDD personnel need some sense of QA and the QA Program within the AMEDD. It cov ers such a wide variety of topics in its own right, and protects the subject matter of those topics in a way that is often unique to the outside viewer, whether within or outside of the military. However, the QA program also deals with some of the most sensitive issues in terms of clinical conduct and its impact on the overall quality of Army healthcare.ClaimsBased on my experience as a command judge advocate, a regional judge advocate, and the Deputy Staff Judge Advocate at MEDCOM, I think that most AMEDD per sonnel think about 2 things when they see the topic of claims. First, they think about a military move where their household goods have been stolen or damaged, and they make a claim under the Military Personnel and Ci vilian Employees Claims Act (31 USC 3721) at the local jury, death, or property damage caused by the negligence of military personnel acting in the scope of employment or occurring incident to noncombat operations where the

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74 http://www.cs.amedd.army.mil/amedd_journal.aspx(28 USC 1346(b), 2671-2680). The subject of claims does indeed relate to both of these types of claims and the subject certainly falls under the competencies of Public Law and Medical Liability. But there are other types of claims worthy of note, especially those that af fect Financial Management at all levels of the AMEDD. Care Recovery Act (42 USC 2651-2653) can be a signif icant source of revenue for a MEDDAC or MTF that has caused by a third party (such as a motor vehicular acci of coordination and integration between the supporting is so that a patient encounter is properly reported at the to put patients on notice of the rights of the MEDDAC or MTF to subrogate any damages received by the DoD recovery program are those facilities that understand the value that can be generated by the program. They have the dedicated staff and focus from the leadership to ensure that medical care provided is ultimately paid for by the outside parties that caused the injuries. The money collected can then be used by the facility for pa tient care, training, and equipment. The Third Party Collection Program (TPCP) is a con gressionally mandated program that allows a MEDDAC or MTF to recoup expenses for medical care provided health insurance. This is very different from the MAC program and often confused with the MAC program. This program is just as important to MEDDACs and MTFs in that they can legally generate additional reve nue that can go to support the medical organization. But very often, the confusion over the 2 programs is part of the reason that the TPCP does not get the same visibility as the MAC program, yet it could also generate a great deal of revenue for a medical facility. I do not propose that we make students and all AMEDD personnel experts in federal claims law, but I do think it is important that we teach people the clear differences among tort claims, personnel claims, MAC claims, and TPCP claims. Personnel claims support the morale of military members and tort claims are a reaction to neg tive Claims and TPCP are efforts to recoup expenses in curred in the provision of medical care. In all probability, clearly understood how useful and important these last limitations.Contract LawSeveral years ago, I was asked, over the telephone, to or clinic was planning in regard to an existing contract that provided support to the organization. I explained that I had to see the contract in order to provide an an swer. The initial response was silence. The caller then indicated that he had never seen the contract. Indeed, he was clearly surprised in that he expected that I would be able to provide some general advice without the contract in hand. Contract law does not work that way. There is no doubt that our dependency on contracts in the AMEDD has grown over the years which places em phasis on the competencies Financial Management, Ma terial Management, Facilities Management, Information Management and Technology, and Human Resource Management as the AMEDD contracts for a great deal of personal services. When I arrived as the Deputy Staff Judge Advocate at MEDCOM in 2008, there were 2.5 contract attorneys on staff. When I left in 2012, I had helped in the hiring of over 8 attorneys in the Contract and Fiscal Law Division, and the hiring of an attorney in each region who had a responsibility in advising on ac quisition matters. The need for contract law advice was considerable, but with that need existed the requirement for better understanding of contracts within the organi zation for which the contract was required. Contracting by federal government entities is governed by a myriad of laws, regulations, rules, and guidelines, beginning with the Federal Acquisition Regulation, and percolating down through the separate departments am certainly not advocating that AMEDD personnel in general be schooled in the provisions and details of this regulatory matrix, but I do strongly support providing AMEDD personnel with knowledge of the basics of the acquisition process to cover certain concepts: There must be an understanding of the role of the the Army is distinct and unique. Such authority is limited to that designated person, but all too often commanders and leaders think that their leader ship position gives them the inherent authority to enter into contracts. Such a misinformed notion could easily result in an unauthorized commitment, There must be an understanding of the foundational principles of contracting. There are 2 parties to a L E G AL E DUCATIO N F OR A RM Y MEDICAL DEPARTME N T L EADERS A N D S OLDIERS

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January March 2014 75 contract; one the legal buyer, the other the legal seller. The legal buyer must have the authority to enter into the contract. Federal contracting laws are different from those that pertain in the civilian sector. The acquisition process is not just about contracts but also the process that results in the contract, in cluding acquisition planning, contract solicitation and award, and then contract administration. Bad acquisition planning results if the customer does not know what it wants but then realizes last min ute that it needs something tomorrow. If the cus requirements cannot be properly researched and addressed through solicitation. If the customer has no idea of how the contract is managed, the result is almost invariably bad contract administration. Whatever the approach, the teaching of contract law should be in conjunction with the Health Care Acqui sition Activity and its supporting legal counsel so that the students of today can be the sophisticated contract customers of the future.Administrative LawBefore my initial assignment into the AMEDD, I was already heavily involved in administrative law. Admin istrative law covers many of the areas we have already addressed such as contract law, labor law, standards of the 12 areas of law that should be taught because it also covers other subtopics such as the Privacy Act (5 USC 552a), the Freedom of Information Act (FOIA) (5 USC 552), environment law, administrative investigations, installation management, and intellectual property, to name just a few. Each of these areas is important and is seen as issues at MEDDACs and MTFs around the Army. They are directly relevant to the competencies of Public Law, Regulations, Military Mission, and Lead ership. Outsiders who want copies of internal, clinical procedures make requests under FOIA. A person who wants a copy of his nonmedical personnel records re quests those records under the Privacy Act. There are environmental considerations pertaining to the disposal of hazardous substances or whether a new MTF build ing can be built on a particular piece of ground. Upon receipt of a complaint, a commander or supervisor nor mally investigates in order to determine the facts at hand before any decision is made. Administrative law matters are simply not just the purview of the installation where the MTF is located. Military treatment facilities and MEDDACs are often virtually installations unto themselves with a wide va riety of issues similar to those found at the installation level. They contain retail exchange facilities, work with outside agencies for space requirements, investigate nonpeer issues such as misconduct, and manage the deal with a host of legal subjects that do not fall within a particular class of law, but that does not detract from the fact that administrative law topics need to be taught; whether as a special study elective or a block of instruc tion as part of an overall course.Human Subject ResearchHuman subject research law is a very specialized area of law. It deals with bioethics and clinical inves tigations and is highly regulated, therefore requiring a solid understanding of governing regulations Legal is sues abound at local institutional review boards which oversee research projects within regional medical com mands and at medical centers. I am concerned about by participants, and protocols which could possibly vio late bioethical standards within the AMEDD. Further, I counsel experienced in this practice across MEDCOM facilities and medical centers. Much of the consider able knowledge and experience in this area is found at the US Armys Medical Research and Material Com mand (MRMC). Except for a solid class taught in the Army-Baylor Graduate Program in Health and Business Administration and some ad hoc classes taught by sea soned command judge advocates or MRMC legal coun sel, there really is not a structured class or course on medical research within the AMEDD or the Army. The Army-Baylor class is a model that could be emulated and expanded, not only at the Academy of Health Sci ences but throughout the AMEDD. THE RESULTS While there is no way to predict the result of a more comprehensive, coordinated, and nested approach to le gal education for AMEDD personnel, the results would be an improvement over an assortment of classes that are merely reused from course to course and from ba sic to advance levels. There is no clear plan in effect to teach legal subject matter to prepare personnel based on the Joint Medical Executive Skill Institutes list of required competencies. Army medicines personnel are facing ever increasing legal issues due to the nature of military healthcare, the increased civilian employee workforce, and the greater need for contracting within the military heath system. Such a plan is long overdue, and its supporting rationale, while mostly anecdotal, is based on the reality of experiences from practice. There

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76 http://www.cs.amedd.army.mil/amedd_journal.aspx least, AMEDD personnel should be able to identify po to such issues only after they reach crisis proportions. A C K NO W LEDGEMENTDr Karin Zucker, JD, has been teaching organizational ethics in the Army-Baylor MHA/MBA program for many years, as well as teaching health law and ethics in other courses at the AMEDDC&S. Her dedication and success has ensured the continuity of legal education within the AMEDD, and were inspirations for this article. The proposal in this paper was represented in a poster presentation displayed at the 3rd Annual Academy of Health Sciences Graduate School Research Day on De cember 11, 2013. Electronic copies of the poster are avail able from the author upon request.R EFERENCES1. Army Regulation 27-10: Military Justice Washing ton, DC: US Dept of the Army; October 3, 2011. 2. Department of Defense 5500.7-R: Joint Ethics Regulation Washington, DC: US Dept of De fense; 1993 w/change 7, November 17, 2011. Avail able at: http://www.dtic.mil/whs/directives/corres/ pdf/550007r.pdf. Accessed December 10, 2013. 3. Army Regulation 600-100: Army Leadership Wash ington, DC: US Dept of the Army; March 8, 2007. 4. Horoho PD. A system for health: essential element of national security. US Army Med Dep J OctoberDecember 2013;4. 5. Army Regulation 40-68: Clinical Quality Manage ment Washington, DC: US Dept of the Army; 2004 [revised 2009].A UTHORMAJ Topinka is an Assistant Professor in the US Military-Baylor University Graduate Program in Health and Business Administration, and is the Legal Instructor at the Army Medical Department Center and School Leader Training Center, JBSA Fort Sam Houston, Texas. The coin depicted here is symbolic of the team-centric theme addressed in this article. The AMEDD | JAG Corps partnership has been the driving force shaping legal guidance of seasoned health law advisors within the Army for many years. The coin was designed by the author in 2009 with the inspiration of the employees and staff at the L E G AL E DUCATIO N F OR A RM Y MEDICAL DEPARTME N T L EADERS A N D S OLDIERS

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January March 2014 77Military services are required by the Goldwater-Nichols Act of 19861 and Chairman of the Joint Chiefs of Staff In struction 1800.01D2 to provide professional military education (PME) to their members. The US Air Force imple ments this guidance through Air Force Instruction 362301 .3 While operating the Department of Defense (DoD) on continuing budget resolutions for the last 4 years may have been challenging for the services, the recently en acted budgetary sequestration requirements have dealt a severe blow to DoD and service expenditures. The reduc tion in available budget and the coincident personnel cuts threaten to strain the in-resident PME system. The Air Force sees these challenges as an opportunity to evaluate their current PME approach and consider alternatives. PME is the foundation upon which the Air Force devel ops competent leaders. It is a critical tool, as is the mili tary leadership education of the other services, in the de National Defense Strategy. In Air Force PME, students learn tenets of leadership, strategy, international policy, and other topics germane to the military profession. Al though the content has evolved, the PME model for Air rank, has remained relatively unchanged since the birth of the US Air Force from its Army Air Corps origin in 1947.4 To this end, the Air Force is currently considering a Learning Air Force approach to PME.5 The Learning Air Force approach adopts a blended learning method, which consists of both correspondence and in-residence learning events. For instance, some courses would be attend revised and considerably shorter in-residence Although Air Force leaders are considering the Learn ing Air Force approach, this blended learning method raises new questions and potential challenges about how changes to the current PME system might impact both OVERVIEW This article offers an initial investigation into the po tential effects of transitioning to a blended learning ap backs of in-residence PME, and then examining ways designing a blended learning system. The Background section provides a precise examination of correspon dence and blended learning techniques in the context of the Learning Air Force approach. We then provide a detailed qualitative content analytic examination of the Innovating to Integrate the Intangibles into the Learning Air ForceCapt Benjamin T. Hazen, USAF MAJ Fred K. Weigel, MS, USA Maj Robert E. Overstreet, USAFABSTR A CT United States federal law and other regulations require the US military services to provide professional military ing and manpower. Additionally, the operations tempo remains high despite the withdrawal of troops from Iraq and the planned withdrawal from Afghanistan. The resulting time and budget constraints will likely make it eted in-residence professional military education programs. Thus, the Air Force is considering a new lifetime learning approach to professional military education. As the Air Force seeks to develop its new paradigm, we the drawbacks of professional military education. The blended approach we present can create a richer, more meaningful learning experience for the service member, while simultaneously lowering the cost per member and providing greater opportunity to attend in-residence professional military education.

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78 http://www.cs.amedd.army.mil/amedd_journal.aspx in the Method section. Surprisingly, this has not been done previously. In the Discussion section, we integrate the research results with a review of extant literature to suggest the adoption of innovative technologies that might help to enable the Learning Air Force concept or enhance the current PME experience via retaining ben the Air Force retains the existing PME system or adopts the proposed Learning Air Force PME approach, the suggestions we present in this article can be incorpo ommendations can apply to and be integrated into sister service PME programs. BA CKGR O UND proach are still being developed by senior leaders,5 there is an emphasis on correspondence learning. As tech nology continues to evolve and the Air Force becomes more dependent upon its information infrastructure, this emphasis is not only prudent, but perhaps essen tial. Additionally, problems with replicating education, the number of service members served, and the distance to the education training site diminish with correspon dence methods. However, when examining what course content should be delivered to students via a correspon dence method, some intangibles associated with attend ing PME in a strictly in-residence fashion may be lost. In the context of this study, intangibles refer to those aspects of attending in-residence PME that are not ex plicitly incorporated into curriculum, but still affect out comes from attendance. Examples of such intangibles job functions while attending PME in-residence. CO RRESP O NDENCE A ND B LENDED L E A RNING W ITHIN THE L E A RNING AIR F ORCE The Air Force transition to a correspondence or blend ed learning platform offers an opportunity to mitigate current shortcomings of in-residence PME; however, residence should be considered when designing a cor respondence or blended learning PME curriculum. We current in-residence and correspondence PME models using analytical methods. Then we posit several sugges via adoption of innovative technologies. developmental education, intermediate developmental education, and senior developmental education. Squad tion program that is attended by captains with approxi mately 6 years of commissioned service. Air Command and Staff College is the intermediate developmental education program that is attended by majors with ap proximately 12 years of commissioned service. Air War College is the senior developmental education program that is attended by lieutenant colonels and colonels with approximately 18 years of commissioned service. With Air Force PME roughly equates to the Army, Navy, and Marine Corps programs. Currently, 2 methods exist for completing Air Force PME. The preferred method is selection to attend PME in-residence, however, there are a limited number of positions for Air Command and Staff College and Air PME will have to complete the correspondence (known synonymously as distance learning) version of the pro gram. Professional military education by correspon dence is accomplished outside of a traditional classroom setting using a variety of different delivery models at The Learning Air Force concept presents an alternative to the current paradigm, the blended learning approach.5 A course or curriculum is considered blended if 30% to 79% of the work is accomplished in a distance learning format.6 The Learning Air Force concept proposes that 5 would begin PME distance learning. At certain times in their career, corresponding roughly with the current attend an abridged in-residence PME program. For ex a blended format, Air Force captains would take courses every year via distance learning. These courses would provide captains the opportunity to practice and hone the skills covered by the distance learning portion with in a shortened in-residence program. Though there were concerns about online, distance, and blended learning models when they initially became popular during the 1990s, research now suggests that the learning outcomes garnered from these sources and other correspondence methods of learning are compa rable to traditional learning.6-8 As Larson and Sung7 of INNOV A T I NG TO INTEGR A TE THE INT A NG I B L ES I NTO THE LE A RN I NG A I R FORCE

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January March 2014 79 Based on the research performed over the last several years, it has become a foregone conclusion that there is between face-to-face versus online delivery modes.Therefore, the Air Force could accomplish its academic objectives via distance learning, using the in-residence portion of the Learning Air Force to allow airmen to practice the skills they learned. However, some skep tics argue certain topics are better taught in tradition al classroom settings.9 These critics argue that those courses involving human interaction enhance learning (eg, leadership courses) may lose some of their effective ness if taught in a distance or blended environment. For gram provides 8 weeks of cooperative learning, where students learn as a team, which is enhanced by the so students). Cooperative learning has been shown to be more effective than individualistic, competitive learn ing; students who are part of a team working towards a common goal typically achieve a higher level of learn ing than students working alone in competition with their colleagues.10Cooperative learning results in a greater transfer of knowledge than is generally achieved with individual istic or competitive learning.10 provides students with the opportunity to build a team of guided discussion and analytical writing to allow students the opportunity to make their experiences relevant. engaging and analytical way. The current curriculum includes team-building and problem-solving activities, and team sports that keep students engaged in the learn ing process. Each team is challenged to set goals and overcome obstacles; the team is also encouraged to so the dorms, socialize together outside of work, and face the cooperative style of learning within the Squadron Force format could diminish this cooperative learning of in-residence attendance can be carried forward to a blended learning model. While critics may argue that correspondence is the wrong forum for learning leadership, this view might be changing with technology. Roman argues that the US military remains rooted in an industrial-age paradigm, where control is emphasized over command.11 To illus methods of communication increasingly allow followers to be geographically separated from their leaders. Lead ership by walking around may soon be replaced with leadership by virtual presence (text messages, video teleconferencing, etc). In summary, available technologies can supplement cor respondence learning to ensure that most, perhaps even can facilitate the Learning Air Force concept to a degree phase of our study because, unfortunately, such targeted discussion of intangibles as they relate to the Air Force is absent in the literature. Therefore, in the second phase of our study, we describe technologies that can be used military leadership education programs via correspon step was to uncover the intangibles of in-residence PME. We discuss our qualitative approach in the next section. R ESE A RCH METHOD A ND R ESULTS Because there are no established studies and, therefore, no established measurement instruments, we chose a qualitative content analytic, open-text response survey as our data collection instrument to provide respondents to attending PME in-residence without our biasing their responses.S ample Frame and D ata C ollectionOur target population was captains in the Air Force. At the captain level, in-residence PME attendance ap proaches 100%. Additionally, many captains complete the correspondence version prior to attending in-resi dence. These captains are at the onset of their career and are likely to have the most to gain or lose over the course process. The research sample consisted of all individuals currently attending PME in-residence at Maxwell Air Force Base, Alabama, the primary in-residence location who would typically attend in-residence PME. We sent e-mail invitations for the on-line survey to all attendees process, we assured potential participants of anonymity

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80 http://www.cs.amedd.army.mil/amedd_journal.aspxand that we would not release raw results or identifying information. In total, the sample contained 725 potential participants. After 2 weeks of data collection, 132 questionnaires were returned; of these, 124 were complete and useable for the study, resulting in a response rate of 17.1%. The demo graphic breakdown resulted in 100 males and 24 females, and the majority of participants (n=106; 85.5%) were be tween 26 and 35 years of age. Three (2.5%) participants were younger than 26 years and 15 (12.1%), older than 36 years. On average, participants have 1.3 dependents (SD=1.2) and deploy 94.4 days per year (SD=75.8). To collect the necessary data for analysis, we devel oped an open-text response survey consisting of 6 de mographic questions and 2 open-ended questions. We compiled these questions and demographic items onto a web-based questionnaire for ease of distribution, ease of data collection, and for increased accuracy (that is, a 1. From a career development perspective, what are the advantages of an in-residence vs a cor respondence PME course? What are the intan 2. From a career development perspective, what are the disadvantages of an in-residence vs a might one make to attend in-residence PME?C ontent Analysis and R esultsContent analysis is one method used to derive various themes from a body of text to assess several forms of documentable communications.12 It is a research tech nique for reducing large quantities of text into a more manageable form for inference and analysis.13 In this research effort, we adopted procedures for problemdriven content analysis, using steps outlined by Krip pendorff.14 For our qualitative analysis of the survey data, we used MAXQDA (VERBI GmbH, Berlin, Germany), a qualitative data analysis package, to organize, recall, and analyze the data. To begin, we uploaded all data to create a unique MAXQDA project and started the proj ect by separating data into 2 categories, corresponding to the 2 open-ended questions posed to participants. The second category represented potential drawbacks. The next step of content analysis calls for identifying themes in the data and counting the number of occur rences of each theme. Unfortunately, the literature did not yield a theoretical or practical framework with which to guide our search. Therefore, we chose a Grounded Theory approach to extracting relevant themes from the data. Grounded Theory takes into account pragmatic ideas proffered by participants to generate a theoretical framework from the collected data.15-17 In other words, the theory is grounded in the data, as opposed to a theory chosen a priori. The Grounded Theory approach calls for identifying emerging themes from the qualitative data and categorizing responses according to these themes. the unit of analysis was any expression mentioned by a participant that noted an intangible consequence of in-residence PME. Each expression was represented in the data by an independent text segmentwords, a sen tence, or a paragraphthat describes the consequence. input garnered during data collection, thus grounding the results from the data as opposed to researcher prede termined theoretical framework. The data suggest 6 pri under some of the primary themes. Although research team members analyzed the data together to reach 100% the reliability of the results. Using a random number generator, the research team generated a sample of 20% of the responses for an outside participant to indepen dently analyze. The outside researcher was asked to in dependently match each text segment in the 20% sample to the appropriate themes from the Table. We calculated to assess reliability of content analysis researchto be 14INN O V A TING T O R ET A IN B ENE F ITS, MINIMIZE D R A WB A CKS The results suggest that networking, time for learn ing, practical application of materials, rich discussion, prestige, and use of facilities are important intangible we recommend that regardless of the format of future retained. In addition, the results suggest that time away from primary duties and family, lost career opportuni ties, and a lack of specialized curriculum are currently viewed as chief drawbacks to the current in-residence PME model. In the remainder of this article, we suggest several INNOV A T I NG TO INTEGR A TE THE INT A NG I B L ES I NTO THE LE A RN I NG A I R FORCE

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January March 2014 81 minimized via innovative technologies. Recent research has suggested that image digitizing systems (eg, video, photography) and mobile computer devices such as smart phones and touch-screen tablets will be in greater use for education over the coming years.18 We focus on 2 exceptional alternatives that can be employed to im prove PME. Subsequently, we address how such tech nologies can be procured and sustained. Mobile T echnologiesThe 2011 Horizon Report highlights 2 technologies that are already beginning to change the way complex sub and game-based learning.19 According to Pew Internet and Mobile Life Project research, 66% of people be tween the ages of 18 and 29 own a smartphone, and the number continues to rise.20 In the US, 55% of universi ties have activated mobile applications for students to use with functions that include providing school wide emergency alerts, making coursework accessible ondemand, and enabling collaboration for students on-thego.21 Apple demonstrates these capabilities in an appli cation called iTunes University22 which allows faculty to create courses and disseminate material using PDF documents, e-books, videos, and other media to provide cheap online courseware to students around the world. T heme (Percentage of respondents commenting (n=124)) 1 Meeting and socializing with others G aining first hand understanding of what peers do across the Air Force Meeting and socializing with others for the purpose of enhancing one's career Meeting and socializing with others for the purpose of friendship H aving ample time for learning T ime for learning that does not interfere or compete with other Air Force obligations T ime available to reflect upon one's career in the Air Force T ime available to reflect upon oneself T he opportunity to practice the skills learned in the classroom in a real-world, hands-on environment without consequences of failure T he opportunity to apply leadership training in a hands-on leadership laboratory team building and group dynamic concepts T he opportunity to hone interpersonal and social skills amongst others (ie, T he opportunity to speak in front of a live audience and obtain formal and informal feedback 4 T he enhanced quality of communications at in-residence P M E C ommunication quality directly attributed to the face-to-face communication medium T he belief that thoughts and opinions will not be recorded or leave the class room environment 5 Feeling that the Air Force uses in-residence P M E as a discriminator for ad vancement and other opportunities Drawbacks 1 41.1% T he feeling that one is letting their home station team members down by T he potential for a crew member to go noncurrent T ime spent away from one's loved ones and personal life at home station T he perception that one might miss out on opportunities presented while career enhancement opportunity

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82 http://www.cs.amedd.army.mil/amedd_journal.aspxMany highly regarded institutions (including Stanford and MIT) are currently using iTunes University to pro vide content to their students on both Windows and Macintosh operating systems. The use of mobile appli cations in PME would allow the Air Force to provide coursework to students on devices the students already own and use, which will likely help enhance the rich ness of discussion and courseware that was cited by While mobile technologies present a tenable solution, one must also factor software and hardware costs into the decision-making process. For example, a mobile application can cost as much as $250,000 to develop.23 Another consideration is the cost to secure such a net work.24 We believe a full cost-effectiveness business case is an essential element before determining how to implement Learning Air Force should leadership pursue that course of action.G aming T echnologiesMobile communications devices may be suitable to provide videos, readings, and other coursework to students, but advancements in gaming technology offer the Air Force an opportunity to create a virtual learn ing environment that can potentially meet many of the current PME objectives while retaining some of the intangibles previously mentioned. The current outdoor, hands-on leadership lessons create an environment de signed to prompt students to apply effective problemsolving, teambuilding, leadership, and communication techniques. Our results suggest that such practical ap in-residence PME attendance. The US Army has already adapted virtual environments to training, working with the commercial gaming indus try to produce complex environment simulators. In August of 2012, the Army unveiled the Dismounted Soldier Training System (Figure 1), designed to place soldiers in a virtual environment to explore terrain, interact with civilians and enemy combatants, coordinate tactics, and 25 The ing, and Instrumentation partnered with programmers from commercial software developers to use the CryEn gine 3 graphics engine to create a realistic virtual envi ronment, which may be useable to supplant or supple gine 3 is the latest version of the graphics engine used to develop the popular Crysis video game series. Indeed, this framework could be used in the development of Air Force PME software focusing on retaining intangible discussion, and practical application of course material, while executing learning from a distance. Many new games require players to use the same prin ciples in order to be successful. As Gee26Digital games are, at their heart, problem solving spaces that use continual learning and provide pathways to mas tery through entertainment and pleasure. Not surprising ly, there has been a growing interest recently in so-called serious games that involve learning the sorts of domains, skills, or content that we associate with school, work, health, citizenship, knowledge, construction, or commu nity building, and not limited to pure popular form of entertainmentIn the past, computer games were designed for entertain ment purposes. However, new games have become com plex enough to fuse education and entertainment. Game developer Valve demonstrated this new fusion when it released Portal 2 in 2011. The game, which features a cooperative mode, puts multiple geographically sepa rated players in a 3D environment and requires them to think critically to solve puzzles of increasing complexi ty. The Associated Press named Portal 2 the game of the year in 2011 and more than 3 million copies of the game have sold.27 Valve has even released an educational tool based on the game called Teach with Portals a class room version of the game that allows teachers to build lesson plans around concepts found within the game.28S oftware C ollaboration T oolsMany sophisticated collaboration tools are now available for small scale electronic platforms. The Air Force could easily use existing packages augmented with common ly used communications methods to achieve a robust INNOV A T I NG TO INTEGR A TE THE INT A NG I B L ES I NTO THE LE A RN I NG A I R FORCE

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January March 2014 83 collaboration environment through the use of personal electronic devices. The easiest and most cost-effective Blackboard could be used to deliver academic content similar to how it is used with the in-residence portion of PME. Students could access Blackboard on their per sonal computers or personal electronic devices. Defense Connect Online could then be used to deliver real-time or recorded seminars to students and afford them a place to meet in a virtual environment, which would help to and communication feedback. The Connect mobile ap plication provides the capability of video conferencing from a phone. For familiarity purposes, students could choose to use other video technologies, such as Skype, provided they record and save conferences for instruc tor review. Indeed, there is a variety of commercial offthe-shelf video teleconferencing platforms that could be used by the Air Force and other services.S oftware S upport C onsiderationsTo properly implement these and other education-based technology, it is essential the infrastructure is both avail able and capable of supporting the systems. We provide several approaches to address this concern.Legacy and Aging Technology SupportSupport for aging infrastructure and hardware is a key consideration when deciding on the appropriate platform for a given software solution. Software requirements do not often change after an initial release. What must be examined is the level of sophistication for which the Air Force or other services can effectively plan during its initial course software deployment. This limitation will determine number of concurrent users, the visual complexity, and overall processing capabilities for the generation of technology being studied. Air Force com munication squadrons typically anticipate and budget to replace user workstations every 2 to 3 years, which ap ware growth. In 2010, the average American upgraded their mobile device every 21.7 months.30 By tailoring a software solution to accommodate personal electronic of Android and Apple iOS devices, the Air Force can ef fectively obviate a communications squadron update for educational devices cycle. In the event that the Air Force must maintain a small collection of tablets or small media devices at education than workstations and typically have a longer usable lifetime. The update time frame, which is consistent between the government and the commercial market, would be the approximate amount of time Air Force ed ucation software should reasonably be required to sup port older hardware. This is typically 5 to 7 years. Air Force control over education software will drive device replacement and update. If major versions and updates to the curriculum can be planned for approximately every 3 years, then such updates will be able to take advantage of hardware modernization. Software, on the other hand, will not require as frequent updating. For comparison, the simulation software used for war gam ample. This software is relevant both educationally and visually, and is almost a decade old. Another example by the US Army in 2009 (Figure 2). It is a technologi cally advanced game that is still relatively popular on the internet. These 2 examples demonstrate that strong applications can be created for platforms well within the anticipated hardware cycle limits. By catering to personal electronic devices, the requirement to support legacy or very old equipment is reduced to supporting equipment only a few years old.Rapid Procurement and Curriculum UpdatesSpeed and agility are keys in the cyber domain. These keys translate to any technological capability, includ ing education. However, there are many barriers to the adoption and use of educational innovations.31 A com puter-based course affords the Air Force rapid updating if control is appropriately managed at the correct level. The idea of rapid updates or acquisitions is familiar to the Air Force community at large as Big Safari. The Big

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84 http://www.cs.amedd.army.mil/amedd_journal.aspxSafari concept is used to accomplish special projects on a quick-reaction basis to deliver time-sensitive ca pabilities in an expedited fashion.32 The positive lessons learned from the Big Safari program could be applied to the PME environment as a means to keep up with the evolving curriculum and the continuous updating of technology to support it. The presentation of updated a cumbersome technological solution. An agile techno logical solution would provide an environment to allow for a rapid update of the accredited material. CONCLUSI ON As the Air Force continues to evolve in order to sustain its position as the most powerful air, space, and cyber force in the world, the way it conducts its PME must also evolve. As General Welsh states in his Vision for Education and training are the foundation of our air power advantage. To maintain this advantage in the fu ture, we must safeguard and reinforce that foundation. All Airmen, whether teacher or student, have a role in best-educated, and best-trained air force in the world. We development programs to move beyond classroom-based instruction and incorporating leading-edge educational concepts. Through a personalized, career-long building block approach, we will eliminate duplicative and extra neous training, returning valuable time to our Airmen.33The Learning Air Force approach might offer a viable retained and the existing drawbacks diminished. Focus tive content analytic examination of the intangible ben the disadvantages; and we synthesized our research with the literature to propose the adoption of innovative technologies that can enhance the PME experience. Fol lowing our suggestions can reduce costs, improve the quality of education, expand the scope of the education experience, and potentially increase student enjoyment. Further research in this area should extend the analysis current study to strengthen the results. Other research opportunities exist as well. An experiment or quasiexperiment, designed to empirically evaluate the affect of the intangibles on PME outcomes is an obvious next step. Indeed, while the unit of analysis in our study is a robust PME system are not individual-level outcomes; they are organizational-level outcomes and can be ap plied across all services. It is, in part, through a wellcontinue to meet their commitments and execute their roles in the National Security Strategy. ACKN O WLEDGEM ENTThis article originated from research conducted by Think James Bartran, Capt Regis Billings, Capt Joseph Evans, Capt Richard Fancher, Capt Brittany Gilmer, Capt Erica McCaslin, Capt Jon Pollock, Capt Paul Stinson, Capt Jared Tenpas, and Capt Drew Warner.R EF ERENCES1. Goldwater-Nichols Department of Defense Re organization Act of 1986. Statutes at Large 100 (1986). Chapter 5, sec 151. Title 10, United States 2. CJCSI 1800.01D ucation dtic.mil/cjcs_directives/cdata/unlimit/1800_01.pdf. Accessed November 14, 2013. 3. Air Force Instruction 36-2301: cation AFI36-2301.pdf. Accessed November 14, 2013. 4. Davis RL, Donnini FP. cisms Press; 1991. 5. Air Education and Training Command. Maxwell Air Force 6. Allen IE, Seaman J. Pearson and Quahog Research Group, LLC; 2013. tions/survey/changing_course_2012. Accessed November 20, 2013. 7. Larson DK, Sung C. Comparing student perfor 8. Ruth D, Conners SE. Distance learning in a core ing outcomes and post-course performance. 9. Rushkoff D. Online courses need human element to educate. CNN Opinion website; 2013. Avail rushkoff-moocs/index.html?hpt=hp_t3. Accessed January 15, 2013.INNOV A T I NG TO INTEGR A TE THE INT A NG I B L ES I NTO THE LE A RN I NG A I R FORCE

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January March 2014 85 10. ing preferences and the classroom learning envi policy. 11. Roman GA. Accessed November 20, 2013. 12. Neuman LW. 6th ed. Boston, 13. Weigel FK, Rainer RK, Hazen BT, Cegielski CG, Ford FN. Use of diffusion of innovations theory in medical informatics research. Inform 14. Krippendorff K. Sage Publications; 2004. 15. Glaser BG, Strauss AL. 16. Charmaz K. Lon 17. Strauss AL, Corbin J. Grounded theory method eds. Thousand 18. Bohler JA, Weigel FK, Hall DJ. Educational tech nology gap theory. Americas Conference on In gel/1/. Accessed November 21, 2013. 19. Johnson L, Smith R, Willis H, Levine A, Haywood K. educause.edu/ir/library/pdf/hr2011.pdf. Accessed November 21, 2013. 20. mentary/2012/February/Pew-Internet-Mobile.aspx. Accessed January 26, 2013. 21. Big gains in going mobile; slow movement towards computing-2011-big-gains-going-mobile. Accessed January 28, 2013. 22. tion/itunes-u. Accessed January 20, 2013. 23. Thomas C. How much does it cost to develop an blog/cost-develop-app/. Accessed February 7, 2013. 24. Kumar V, Telang R, Mukhopadhyay T. Optimally Securing Interconnected Information Systems and Assets. Paper presented at Sixth Workshop on the Economics of Information Security; June 7, 2007; weis07.infosecon.net/papers/64.pdf. Accessed No vember 21, 2013. 25. lodeck. pbcs.dll/article?AID=2012306120012. Accessed January 28, 2013. 26. Gee JP. Deep learning properties of good digital M, Vorderer P, eds. 27. valvesoftware.com/games/portal2.html. Accessed 28 January 2013 28. com/ Accessed November 20, 2013. 29. Moore GE. Cramming more components onto in tegrated circuits. courses/cs352h/papers/moore.pdf. Accessed No vember 21, 2013. 30. bilefuture.org/page/handset-replacement-cycle.pdf. Accessed January 31, 2013. 31. proposed framework for educational innovation dissemination. 32. intell/systems/big_safari.htm. Accessed July 28, 2013. 33. Welsh MA III. A Vision for the United States Air Pages/130110-vision.aspx. Accessed November 21, 2013.AUTHORS the 911th Air Refueling Squadron, Seymour Johnson Air Force Base, North Carolina. MAJ Weigel is an Assistant Professor, Army-Baylor Graduate Program in Health and Business Administration, US Army Medical Department Center and School, JBSA Fort Sam Houston, Texas. Maj Overstreet is an Assistant Professor, Air Force Institute of Technology, Wright-Patterson Air Force Base, Ohio.

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86 http://www.cs.amedd.army.mil/amedd_journal.aspxTHE PROBLEM There is a widespread belief among educators and students that changing answers on a multiple choice test is detrimental. The common thought is that most students change their answers from right to wrong. This belief has been perpetuated by some faculty despite evidence to the contrary. Students are also affected by memories of past exam performances. Memories of changing an swers from right to wrong have more emotional impact than wrong to right and, therefore, tend to remain much more a part of acute awareness. Since 1929, there have been over 30 studies investigating issues related to an swer changing behavior on objective tests. The consis objective tests. As a part of the US Army Graduate Program in Anesthesia Nursing (USAGPAN) process improvement program, the faculty queried USAGPAN students and found that the vast majority believed that if they changed their answers, they changed them from right to wrong. Research studies concerning answer changing behaviors have been conducted on education majors, psychology majors, math majors, and medical students. However, there are no investigations of anesthesia nursing students relative to changing their answers on multiple-choice exams. The purpose of this project was to determine if anesthesia nursing students are more likely to change their answers from wrong to right, right to wrong, or wrong to wrong. B ACKGROUND AND L I TERA T URE R EVIEW As early as 1929, Mathews1 investigated answer chang ing behaviors on objective or multiple choice tests in college students. He found that 24 of 28 representative students believed that when they changed their answers, it resulted in a change from right to wrong. An analysis of 22,000 multiple choice items on tests taken by these students revealed that there were 555 changes, and of these, 53% actually resulted in higher scores. Geiger2 choice test answers in upper level college accounting courses. Of the 279 students studied, only 34 believed that changing answers would result in gaining points while 192 believed that changing answers would re sult in losing points. Fifty-three students believed that changing answers would have no impact on their score. Of those 279 students, 265 or 95% changed at least one answer on their tests, and 78% gained points attributed to changing answers. Harvill and Davis3 examined answer changing behav students. They found that in multiple choice tests ad ministered in 6 courses (biochemistry, gross anatomy, pathology, psychiatry, immunology, microbiology), stu dents changed answers from wrong to right from 61% to 75.8% of the time. They also found that students made also investigated the reasons for changing answers. They asked students to select from a list of reasons why they changed their answers which included the following: 1. Reread and better understood the test item. 2. Rethought and conceptualized a better answer. 3. Gained information from another test item. 4. Gained information from the instructor.To Change or Not to Change a Multiple Choice AnswerDon Johnson, PhD, RN Susan Anderson, MSN, RN Sabine Johnson, MSABS T RAC TIt is a common belief that changing answers on multiple-choice examinations is detrimental, and such action usually results in changing from right to wrong. Over the past 60 years, studies have shown that changing an behavior may be perpetuated by faculty despite evidence to the contrary. As a part of the US Army Graduate Program in Anesthesia Nursing process improvement program, the investigators examined answer changing behaviors of nursing anesthesia students. The results of this evaluation supported conclusions from previous studies in that the odds of students changing from wrong to right was 72% and from right to wrong was 20%.

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January March 2014 875. Remembered more information. 6. Used a clue or cue within the test item. 7. Made a clerical correction. 8. Corrected a mathematics error. 9. Gut Feeling that the new response was a better response. 10. Replaced one guess with another. 11. Other. The two reasons for changing answers most often se lected were rethought and conceptualized a better an swer (accounting for 34.8%), and reread and better un derstood the item (accounting for 23.2%). Interestingly, these students changed from wrong to right 66.3% of the literature. Answers changed because of clerical or mathematical correction accounted for only 5% of the reasons selected but were associated with an 87.5% inci dence of changing from wrong to right.3Kruger et al4 investigated the reasons for the belief in the instinct. They conducted studies on 1,561 students who completed a multiple choice midterm exam in psycholo gy. They found in 3,291 changed answers, 51% changed from wrong to right and 25% changed from right to wrong. They compared the actual results with the student predicted results and found that students predicted that they would change from wrong to right 33% of the time and from right to wrong 42% of the time. The in vestigators investigated why the students overestimated underestimated the effectiveness of changing an answer. They found that changing an answer produced more re gret and frustration even though the end product was no different than sticking with an answer when it was wrong. This lead to more self-recrimination and the ex ory. The investigators postulated that memories caused by action (changing an answer) are stronger than those caused by inaction (staying with same answer), which instinct. Bauer et al5 examined the answer changing behaviors of 79 third-year medical students. They found that 72 of 79 students changed at least one answer on a general medicine exam, and of those students, 48.2% changed from wrong to right while 21.6% changed from right to wrong. They also found that students who changed their answers improved their test scores by an average of 1.4 points. Additionally, these researchers investigated the effects of informing one group of students of the swers changed more answers than those who had not re ceived such information. They also subsequently scored higher on their exams, although the difference was not Di Milia6 examined the tendency of students at both the graduate and undergraduate level to change answers. Di Milia found that although the overall percentage of answers changed was low (1% to 2% of all answers re viewed), over half the students changed at least one an swer, and the scores were improved for those who did. PROBLEM ST A TEMENT There have been no investigations examining the an swer changing behaviors of nursing anesthesia students. M E THODS This process improvement project used a retrospective descriptive evaluation method. The sample consisted of 34 students enrolled in the US Army Graduate Program in Anesthesia Nursing. Twenty-seven were Army Nurse Army students were direct accession. The age ranged from 28 to 53 years. The rank ranged from second lieutenant to lieutenant colonel. The investigators reviewed 9 multiple choice exams completed during Clinical Anatomy & Physiology 1 and Clinical Anatomy & Physiology 2. These courses have been taught by the same instructor for at least 15 years and the exam questions have established repeat reliabil ity and validity. sisting of 531 multiple-choice questions, were reviewed for erasures. There were 18,054 answers reviewed as determined by the calculation of 34 students times 531 questions. was uncertain. There was no discrimination made in de sures were counted as a change regardless of the reason, including clerical changes. The total number of changes was calculated as follows: wrong to right (W-R); right to wrong (R-W); and wrong to wrong (W-W). If an individual changed an answer THE U NI T ED S TAT E S AR M Y MEDI CA L DEP A R TME NT JO U R NA L

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88 http://www.cs.amedd.army.mil/amedd_journal.aspx marked was the answer counted and the multiple era sures were counted as one change (whether it be from W-R, R-W, or W-W). An odds ratio of changing from percent of the sampled students believed that they should not change an answer and that they should go with their R ESUL T S AND I M P LICA TIONS The results of this project were consistent with previ ous studies. The odds of changing from wrong to right was 72%; the odds of changing from right to wrong was 20%; and the odds of changing from wrong to wrong was 6.8%. There was a 3.6 times greater chance of changing from wrong to right compared to changing from right to wrong. There was a 10 times greater chance of changing from wrong to right compared to changing from wrong to wrong. As a process improvement project, the investigators be of changing answers on a multiple choice exam. The re of the literature are now incorporated into the curriculum of the test-taking strategies class presented at the beginning of each class year. Sound decision making principles should be used in changing answers. Changing answers on a whim is not advocated. In an attempt to dispel some of the longheld myths regarding the results of changing answers on multiple choice tests, students should be informed of ing the following: Students may gain information for one test item from other test items. Students reviewing their answers often discover they have misread or misunderstood the question and make changes accordingly. Students who change answers usually change from wrong to right. Reviewing an exam can have positive results as it is in review that students often discover they have made any mistakes and can make appropriate corrections. REFERENCES1. jective tests. J Educ Psychol 1929;20(4):280-286. 2. choice answers: student perception and perfor mance. Education 1996;117(1):108-116. 3. sons for changing answers on multiple-choice tests. Acad Med 1997;72(10 suppl 1):S97-S99. 4. Kruger J, Wirtz D, Miller DT. Counterfactual J Pers Soc Psychol May 2005;88(5):725-735. 5. Bauer D, Kopp V, Fischer MR. Answer changing in multiple choice assessment change that answer when in doubtand spread the word!. BMC Med Educ 2007;7:28. 6. ams: the positive impact of answer switching. Educ Psychol 2007;27(5):607-615.A U THORSDr Johnson is a Professor and Director of Research, US Army Graduate Program in Anesthesia Nursing, US Army Medical Department Center and School, JBSA Fort Sam Houston, Texas. Ms Anderson is the Senior Quality Assurance Specialist, US Army Graduate Program in Anesthesia Nursing, US Army Medical Department Center and School, JBSA Fort Sam Houston, Texas. Ms Johnson is a Research Associate with the Geneva Foundation. TO CH AN GE OR NO T T O CH AN GE A M U L T IPLE CHOI C E A NS WER

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January March 2014 89Military medicine has faced a steadily increasing chal lenge of providing care for critically ill and injured chil dren in a variety of operational and humanitarian mis sions. Civilian populations have accounted for a grow ing percentage of combat casualties due to the evolving nature of war. This increase is demonstrated by the com parison of civilian casualties during World War I, which in which that total has been as much as 80%. Children, due to their innate physiological and developmental vulnerabilities, often make up a disproportionate share of victims and have been shown to have higher mortal ity rates than adults in combat surgical hospital emer gency admissions. Complicating this increasing preva lence of critically ill and injured children is the fact that healthcare providers, outside of pediatric and pediatric surgical subspecialty trained individuals, have limited training and experience in this area. Although several pediatric critical care and pediatric surgical textbooks have been written, many are voluminous books with extensive physiological and research focus, and, more importantly, are not focused on the unique challenges faced by the military. Army and the Borden Institute have recently released a revised volume of the Textbook of Military Medicine se ries that addresses this gap. Pediatric Surgery and Medi cine for Hostile Environments is edited by COL Michael extensive experience in the care of critically ill and injured pediatric patients in academic and operational situations. In addition, they recruited numerous subject matter experts to contribute to individual chapters. The book is logically organized with 3 sections encom passing resuscitation and critical care, surgery, and medicine topics. The resuscitation section begins with an excellent overview of the approach to the pediatric trauma patient and advances to topics such as anesthe sia, vascular access, mechanical ventilation, and others. cal transports in a hostile environment which covers unique pediatric physiological and logistical issues. The surgical and medical sections are each laid out by systems. Together they cover a wide spectrum of dis eases that a practitioner might face, including common and uncommon conditions. Chapters are well organized and cover presenting symptoms, diagnosis, and recom cover the full range of pediatric surgical subspecialties including burns, orthopedics, ophthalmology, and oto laryngology as well as less commonly covered subjects such as urology and dental. The medicine section be nursing care, then covers a variety of diseases organized by systems before concluding with chapters on unique pediatric aspects of heat and cold injuries; chemical, bio logical, radiological, nuclear, and explosive injures; and pharmacotherapeutics. All chapters are primarily written in a bulleted format with useful tables throughout, thus providing a large amount of information in a concise format. Chapters A New Volume in the Borden Institute Textbooks of Military Medicine SeriesPediatric Surgery and Medicine for Hostile EnvironmentsEditors COL Michael M. Fuenfer, MC, USA COL Kevin M. Creamer, MC, USA

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90 http://www.cs.amedd.army.mil/amedd_journal.aspx are of high quality and complement the information within the text. The majority of chapters have very lim ited physiology and epidemiology discussions, but that is not the purpose of this book since larger reference books are available for those so inclined. It should also be noted that this book is not intended to be a reference for planning and responding to environmentally caused humanitarian disasters where public health resources would be more warranted. This book is perfectly tai lored to its intent as stated in the title, Pediatric Surgery and Medicine for Hostile Environments I highly recommend this book to every deploying medi cal provider who might be faced with the unique chal lenges of providing pediatric critical and surgical care in a combat and/or austere environment. Further, it should be a standard reference at military treatment facilities located in combat and/or austere environments. Ac tive duty military medical personnel may obtain one complimentary book directly from the Borden Insti tute using an online order form (http://www.cs.amedd. purchased either through the Borden Institute (202-512AUTHOR Medical Education and Chairman of Pediatrics at the Lake City.PEDIATRIC SURGERY AND MEDICINE FOR HOSTILE ENVIRONMENTS A NE W VOLUME IN T H E BO RDEN INSTITUTE TE X TBOOKS OF MILITA RY ME D ICINE SE R IES

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January March 2014 91Abstracts of Podium Presentations from the 3rd Annual Academy of Health Sciences Graduate School Research DayDevelopment of a Traumatic Brain Injury Assessment Score Using Buonora JE, Mousseau M, Latour L, Diaz-Arrastia R, Pollard H, Rizoli S, Baker A, Rhind S, Mueller G Uniformed Services University of the Health Sciences Program in NeurosciencePurpose/Hypothesis: At present, there is no effective method to objectively assess mild traumatic brain injury identify proteins that will serve as circulating biomarkers for the assessment of mTBI. The goals of this research were to identify novel brain proteins targeted by TBI-induced autoantibodies and to determine if these proteins contribute to a circulating biomarker signature useful in the diagnosis and assessment of mTBI.Participants: A tissue-sharing agreement was established with 2 separate ongoing clinical TBI studies (Cohort 1: mild to moderate; Cohort 2: moderate to severe). Patients recruited for both studies were adults admitted to an emergency room with a diagnosis of head injury. Admission plasma samples were obtained from Cohort 1 (n=154) and 2 to 7 days post-injury. Cohort 1 was evaluated against commercially purchased controls. Cohort 2 (n=106+44 controls) had plasma samples obtained at admission, 6, 12, and 24 hours post-injury.Design/Methods/Materials: noblotting in rodents and protein microarray in humans. Serum from control and brain-injured rats was used to interrogate immunoblots of the entire rat brain proteome fractionated on large 2-dimensional gels. Proteins performed using a protein microarray platform containing over 9,000 human proteins. Within-subject compari sons were made between samples that were collected immediately following TBI and 30 days post-injury, times that would reveal the full expression of a TBI-induced autoimmune response. Findings from the 2 autoimmune roles as novel TBI biomarkers. Immunosorbent electrochemiluminescent assays were developed for two of the novel biomarker proteins (peroxiredoxin 6, cyclin-dependent kinase 5) and 6 established neuropathology biomarkers. Study samples were interrogated against the newly established panel of biomarkers.Findings/Results: The mean plasma values of 5 of the candidate TBI biomarker proteins in Cohort 1 (mild/mod P.03 to P<.0001) elevated at both admission and 2 to 7 days post-injury compared to controls. The mean plasma values of 5 of the candidate TBI biomarker proteins in Cohort 2 (moderate/se P.01 to P<.001) elevated at admission, 6, and 12 hours post-injury compared to controls. The summation of the fold-changes observed in the plasma levels of 5 biomarkers differentiated control samples from both the mild to moderate cohort and the moderate to severe, with scores of 5, 17, 32 respectively.Conclusions: Value/Relevance: This research has 2 major outcomes which are medically relevant in the mTBI research. First, assessment score that is sensitive for the detection of mTBI and can be standardized across clinical settings. The following research abstracts were presented on December 11, 2013, as part of the 3rd Annual US Army Acad emy of Health Sciences Graduate School Research Day at JBSA Fort Sam Houston, Texas.

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92 http://www.cs.amedd.army.mil/amedd_journal.aspxEffects of Trigger Point Dry Needling on Pain and Disability in Individuals With Patellofemoral Pain SyndromeSutlive TG, Golden A, Harm K, Morris W, Morrison J, Moore JH, Koppenhaver S US Army-Baylor University Doctoral Program in Physical TherapyPurpose/Hypothesis: Patellofemoral pain syndrome (PFPS) is a prevalent knee disorder in military populations. A novel yet increasingly popular treatment for PFPS is trigger point dry needling (TDN). The purpose of this study was to determine if TDN is more effective at reducing pain and disability than a sham treatment in individuals with PFPS. Participants: knee pathologies. The participants mean age was 30.85.4 years, and a mean body mass index of 26.83.8.Design/Methods: Participants underwent a standardized clinical examination and were randomized into a TDN treatment group or a sham treatment group. The TDN group received treatment that consisted of insertion of an acupuncture-like needle into the most painful 6 sites of the quadriceps femoris muscles of the symptomatic lower extremity based on a palpation examination. The sham grouped received a simulated treatment with a sharp object and guide tube without puncturing the skin. The same investigator performed all TDN and sham treatments. Participants and data collectors were blinded to treatment group. Outcome measures of pain, disability, and overall status were self-reported by participants on a Lower Extremity Functional Scale, Kujala Anterior Knee Pain Scale, and Global Rating of Change Questionnaire. Participants also performed 3 functional activities (squat, step-up, and step-down) and rated their knee pain during each activity on a numeric pain rating scale (NPRS). Outcome measures were collected before treatment and were reassessed immediately after treat ment and again at a 72-hour follow-up appointment. The data were analyzed with a mixed-model 23 repeated measures analysis of variance, with independent variables being Group (TDN treatment and sham control) and Time (pretreatment, immediately posttreatment, and 72 hours posttreatment). The hypothesis of interest was the Group|Time interaction. The alpha-level was set a priori to .05 using a 2-tailed test.Results: Both groups exhibited a clinically meaningful reduction in pain and disability based on the composite NPRS P =.608). Neither sure from baseline to 72 hours posttreatment.Conclusion: These data suggest that TDN treatment is not more effective than a sham TDN treatment at reducing short-term pain and disability in individuals with PFPS when used as an isolated treatment approach.Value/Relevance: the TDN group suggest the need for further investigation. Future studies should include multiple sessions of TDN, longer follow-up times, alternate needling sites (eg, hip muscles) and TDN treatment in conjunction with therapeutic exercise. A BSTRA C TS OF PO DIU M P RESENTATI O NS F R OM THE 3 RD A NNUA L AC ADE MY OF H EA L TH SC IEN C ES G RADUATE SC H OOL R ESEAR C H D A Y

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January March 2014 93 Assessing Motivation for Eating and Intuitive Eating in Military Service MembersCole RE, Clark HL, Heileson J, DeMay J, Smith M US Military-Baylor University Graduate Program in NutritionPurpose/Hypothesis: To assess the motivations of normal weight versus overweight service members for eat ing in order to tailor future nutrition intervention programs. Research suggests there are 3 motivations for eat objective of this study is to determine if individuals with a normal body mass index (BMI) are intuitive eaters (motivated to eat for physical reasons), while overweight individuals are motivated by other factors.Subjects: Of the 295 participants, the majority were male (71%), Caucasian (56%), Army (91%), enlisted (71%), a mean age of 30.18.6 yr, and BMI of 27.04.2 kg/m2. The majority of participants had more than 2 years of college education (53%), never smoked (67%), performed aerobic activity at least 3 times per week (76%), and were physically active greater than 30 minutes per session (57%). Methods:tals, and training environments at Joint Base San Antonio Fort Sam Houston (70%) and Joint Base LewisMcChord. Height (cm) and weight (kg) were measured in duplicate and averaged. BMI was calculated as m/kg2 and dichotomized as normal (18.5 to 24.9 kg/m2) or overweight (25 kg/m2). Two validated surveys were administered: Motivation for Eating Score (MFES; 43-item 5-point Likert scale) and Intuitive Eating Score (IES; 21-item 5-point Likert scale). Descriptive data were reported as frequency and meanSD. Mann Whitney T-test and nonparametric correlation analyses were conducted for BMI category with MFES, IES, and =0.05 with an 80% power.Results: When subjects were dichotomized by BMI status, 64% were overweight (n=190). About 74% of normal BMI subjects accurately perceived themselves to be at the right weight whereas 35% of overweight subjects incorrectly perceived themselves to be at the right weight. Of the high BMI group, 65% were attempt subscales between normal and overweight subjects, such that normal weight were more likely to be physical eaters (P =.001; r= 0.165) and less likely to be environmental/social eaters (P =.016; r= 0.117). There was no tended to rely on hunger and satiety cues ( P =.023; r= 0.112) more than overweight subjects.Conclusions: Normal weight participants were more likely to eat for physical/intuitive reasons compared to overweight participants. There is a disparity between actual BMI status and perceived weight, especially in overweight subjects, which potentially disrupts the ability to eat intuitively and propagates dieting behaviors. eating may improve eating behaviors, self-perception, and, ultimately, BMI status. Relevance: The DoD spent approximately $1.9 billion in healthcare costs associated with obesity in 2009, adversely affecting military readiness. In 2010, the DoD lost approx $60 million in training costs and discharges associated with approximately 1,200 initial enlistees failing to meet the height and weight standards within their rather than behavior change. These results may support transitioning away from a dieting model for weight management to one of following internal physiological cues to achieve a normal BMI.

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94 http://www.cs.amedd.army.mil/amedd_journal.aspxShaping Student Attitudes Towards Healthcare Teams Through a Hybrid and an Online Interprofessional Education Course: Results F rom a Pilot StudySanchez-Diaz PC, Parker RA, Valdes MS, Ramirez MN, Narayanan S, Dominguez DG, Jones ME University of the Incarnate WordPurpose/Hypothesis: Patient safety and issues of quality health care are driving forces in the transformation of health professions education and highlight the need for redesigned systems of care. In 2011, the Interprofessional Education Collaborative Expert Panel developed a set of core competencies considered essential for preparing healthcare professionals and to address policy and accreditation issues. Interprofessional education (IPE) occurs when students from 2 or more professions learn about, from, and with each other in a collaborative environment. Creating an IPE calendar that accommodates student schedules from different healthcare programs about the effectiveness of online education in meeting the goal of preparing students in the interprofessional competencies. The purpose of this study was to compare the effects of a hybrid and an online IPE course on student attitudes toward healthcare teams. Participants: All 20 students participating in the hybrid IPE activities completed the preand postparticipation measurements. Thirty-one students volunteered for the online IPE activities and 14 completed preand postpar ticipation measurements (40% return rate).Design/Methods: Both hybrid and online courses were completed within a minisemester (8-week period) and both combined teacher-centered and student-centered approaches. We used the Attitudes Towards Health Care Teams (ATHCT) Scale survey as preand posttest measurement to assess the impact of a hybrid and an online IPE course in the attitudes of healthcare professional students. All statistical analyses were performed with P value was less than or equal to .05.Findings/Results: ences between groups in any of the 3 survey subscales team value (F=0.845, P=. cy (F=0.451, P=. 507) and shared leadership (F=0.240, P=. ences between professions in baseline ATHCTS total scores (F(4,29)=1.899, P=. 137) or posttest scores (F(4,29)=0.373, P=. 826). 2. Effect of hybrid versus online IPE course on student attitudes toward health care teams: Students in the on(F(1,32)=6.135, P=. 019). 3. Within group differences for hybrid and online IPE course on student attitudes: Students in the hybrid course 19= 3.209, P=. 05) while students (t13= 2.801, P=. 015). Conclusions: Comparable attitude changes were observed in participants after completion of the hybrid and onin interprofessional education.Value/Relevance: courses on attitudes towards health care teams that involves health administration, nursing, pharmacy, physical therapy and optometry students. Future work including a larger number of subjects along with non-IPE professional students as control will enable us to more fully determine the effects of online and hybrid interprofes sional education courses on student attitudes towards healthcare teams. A BSTRA C TS OF PO DIU M P RESENTATI O NS F R OM THE 3 RD A NNUA L AC ADE MY OF H EA L TH SC IEN C ES G RADUATE SC H OOL R ESEAR C H D A Y

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January March 2014 95 The Effect of Patient-Centered Medical Home Implementation on Cervical Cancer Screening Compliance Rates at the Screaming Eagle Medical HomeHarasimowitz E, Hawkins M, Jeremy T, Cuyler M, Mangelsdorff AD, Kim F US Army-Baylor University Graduate Program in Health and Business AdministrationPurpose/Hypothesis: To analyze the change in cervical cancer screening compliance rates in accordance with Healthcare Effectiveness Data and Information Set (HEDIS) metrics to determine the effect of patient-centered medical home (PCMH) implementation on preventive care at Fort Campbell, Kentucky. The PCMH is a primary care model that focuses on preventive services and provider continuity. Cervical cancer screening is a vital preventive screening procedure that, according to literature, will increase under the PCMH model. Subjects: Women aged 24 to 64 enrolled in the Fort Campbell Parent DMIS ID from January 2011 to December 2012 (n=155,924) were examined for compliance with the HEDIS metric for cervical cancer screening. This metric requires women to receive a pap smear every 3 years starting at age 21 in order to meet compliance standards. Patients were included in this study if they had 3 months of enrollment and at least one primary care encounter between January 2011 and December 2012. Patients were categorized as PCMH if the patient was Community Hospital.Materials/Methods: We conducted a logistic regression to predict the effect of PCMH implementation on cervi cal cancer screening. This study further controls for age, marital status, health status (measured by number of Results: From January 2011 to December 2012, 19.9% of the total patient months were enrolled at the PCMH location. Compliance with cervical cancer screening was 80.3% at the PCMH location, and 75.8% at the noncervical cancer screening than those at the non-PCMH location (AOR=1.161; 95% CI, 1.123-1.200). Each P<.05) in all categories. Conclusions: The PCMH approach to primary care demonstrated improved cervical cancer screening compli enced the likelihood of enrollees screening compliance. Further studies are needed to study the effect of PCMH on additional preventive measures. Relevance: Within the last 3 years, the Military Healthcare System (MHS) has begun implementing the PCMH model as a way to curb rising healthcare costs and improve the overall patient population health status. This by compliance with preventive services.

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96 http://www.cs.amedd.army.mil/amedd_journal.aspxEffect of Dry Needling on Infraspinatus Muscle F unction, Shoulder Mobility, and Pain Sensitivity in Patients with Shoulder PainKoppenhaver S, Croy T, Trachtenberg R, Ciccarello J, Waltrip J, Pike R, Walker M, Flynn T US Army-Baylor University Doctoral Program in Physical TherapyPurpose/Hypothesis: It is postulated that dry needling enhances function and decreases pain in people with subacromial impingement syndrome (SIS). However, only a single case study to date supports this claim. Therefore, the purpose of this study was to investigate the effect of dry needling on shoulder muscle function, mobil ity, and pain sensitivity in subjects with SIS. Subjects: Fifty-six volunteers with clinical symptoms of unilateral SIS (36 men, 20 women; aged 44.1.1 years; body mass index=28.44.6 kg/m2; median months since initial SIS onset=11.23 (IQR 4.3, 36.9)) were recruited and completed the study.Materials/Methods: Participants completed a standard history and physical examination including the Penn Shoulder Score (PSS) questionnaire, shoulder range of motion (ROM), pain pressure threshold (PPT), and ultrasound imaging (USI) of their infraspinatus muscles bilaterally during a submaximal isometric contraction. rotation, horizontal adduction using a standard goniometer. PPT measurements were taken in 3 tender locations of each infraspinatus muscle with a digital pressure algometer. Percentage change in USI measured infraspinatus muscle thickness was from rest to contraction. Treatment consisted of dry needling to trigger points at 3 locations in each infraspinatus muscle. ROM, PPT, and USI measurements were repeated immediately after treatment and again 3 to 4 days later. After follow-up, participants were dichotomized into clinical improvement or no clinical improvement based on whether they surpassed the minimal detectible change of the PSS (11.4 points). Separate 232 repeated measures analysis of variance was conducted on ROM, PPT, and USI measures for shoulder (symptomatic vs asymptomatic), time (pretreatment, posttreatment, and 3 to 4 day follow-up), and clinical improvement (improved vs not improved). Results: Initial PPT was statistically more pain sensitive in the symptomatic shoulder than on the asymptomatic shoulder (P =.003 to P P =.010 to P interactions in PPT indicated that the decrease in pain sensitivity after dry needling was largest in the symptomatic shoulders (P =.034) of participants that improved clinically (P =.035). Similarly, ROM in each direction was initially statistically less in the symptomatic shoulder than in the asymptomatic shoulder (P<.001 to P P<.001 to P duction, and internal rotation ROM was greatest in the symptomatic shoulders (P =.001 to P =.038), while the improvements in external rotation and horizontal adduction was greatest in participants that improved clinically (P =.003 to P in either shoulder regardless of clinical outcome.Conclusions: Dry needling to the infraspinatus muscle increases shoulder mobility and pain pressure thresholds of symptomatic shoulders in subjects with SIS. Relevance needling treatment, potentially decreasing lost duty time due to shoulder pain. A BSTRA C TS OF PO DIU M P RESENTATI O NS F R OM THE 3 RD A NNUA L AC ADE MY OF H EA L TH SC IEN C ES G RADUATE SC H OOL R ESEAR C H D A Y

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January March 2014 97 Mentors Offering Maternal Support (M.O.M.S.): A Military Intervention Program for Decreasing Prenatal Maternal Anxiety and Depression and Building ResilienceWeis KL, Walker KC, Lederman RP US Military Education & Training CampusPurpose: Explore the effectiveness of a mentored program to decrease prenatal maternal anxiety and depres sion while building resilience and coping. Participants: Consented n=278; 50 Control and 48 Treatment have completed all elements of the program. The majority of the sample were wives of military service members. Twenty-eight participants were active duty. Method: vention treatment (M.O.M.S.) arm or a standard prenatal care control arm. Self-report questionnaires included: ience. Mixed models were used to determine differences in the slopes across pregnancy between the treatment and control groups for each measure.Results: 0.85, P 2.04, P.001) and 0.94, P P.05).Conclusions: mester of pregnancy, was shown to decrease prenatal anxiety and depression and increase resilience. Prenatal anxiety related to maternal identity formation and preparation for labor are predictive of preterm birth and low birth weight. Relevance: The Surgeon General of the United States has urged the development of psychosocial interventions focused on decreasing maternal anxiety and depression. Military mothers and families are at an increased risk of maternal anxiety and depression and have requested unique military support groups led by peers.

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98 http://www.cs.amedd.army.mil/amedd_journal.aspxWINNING P O STER P RESENTED AT THE 3 RD A NNUA L AC ADE MY OF H EA L TH SC IEN C ES G RADUATE SC H OOL R ESEAR C H D A YThe poster selected best of the presentations as part of the 3rd Annual Research Day held December 11, 2013, at the Graduate School, Academy of Health Sciences, AMEDD Center & School, Fort Sam Houston, Texas. The Effects of Epinephrine and Vasopressin on Survival from Cardiac Arrest Following Desipramine Overdose in a Porcine Model MAJ Ken Gore, CPT Brian Gallahan, CPT Tammy King, CPT Heather Leal, CPT Brian Lowery CPT Kyle Stevens, 1LT Allen Bolido 1LT Jennifer Brady Don Johnson, RN, PhD US Army Graduate Program in Anesthesia Nursing Significance In 2012 more Soldiers committed suicide than those who lost their lives in combat. 349 Military Suicides 313 Combat Deaths Every 80 minutes a veteran commits suicide. At least 20% combat veterans suffer from post traumatic stress syndrome (PTSD). Over 80% of PTSD patients suffer from another psychiatric disorder, commonly alcohol abuse or dependence. PTSD accounted for 52% of mental health diagnoses treated at Department of Veterans Affairs facilities. Patients with PTSD and alcohol co dependence are at an increased risk for suicide. Data strongly suggest that there is a correlation between increased suicides and PTSD. Because of PTSD and other psychiatric conditions, health care providers have prescribed antidepressants at an all time high. Approximately 17% of deployed Soldiers were on at least one form of an antidepressant. Desipramine, an antidepressant, is one of the preferred medications for treating depression, alcohol abuse, and PTSD. An overdose of Desipramine may lead to cardiac arrest. According to the Advanced Cardiopulmonary Life Support (ACLS) guidelines, Epinephrine and/or Vasopressin may be used in conjunction with cardiopulmonary resuscitation (CPR). Based on limited evidence based data, the American Heart Association (AHA) recommends 1 mg of Epinephrine or 40 units of Vasopressin (one time dose) be administered intravenous (IV) for patients in arrest No studies have investigated the most effective treatment (Epinephrine or Vasopressin) of cardiac arrest from an overdose of Desipramine. Problem Statement It is not known the most effective treatment of cardiac arrest for patients who have an overdose of Desipramine. Research Question The following research question guided the study: Is there a statistically significant difference in survival between the use of CPR + Epinephrine; CPR + Vasopressin; and CPR only groups in the treatment of subjects in cardiac arrest from Desipramine? Methods The study was a prospective, between subjects design using 21 Yorkshire, adult male swine. Pigs were randomly assigned to one of three groups: CPR + Epinephrine (n = 7); CPR + Vasopressin (n = 7); or CPR only (n = 7) Swine were acclimated for 4 days. Telazol 5mg/kg and Glycopyrrolate 0.2mg were administered 10 minutes prior to general anesthesia. Isoflurane was used for anesthesia. An ear vein and the right carotid artery were cannulated for monitoring and for drug administration. Monitors were applied. Swine were allowed to stabilize for 10 minutes. A toxic dose of Desipramine (8 mg/Kg) was administered until there was a non perfusing rhythm. Anesthesia was discontinued; after 30 seconds of a continuous nonperfusing arrhythmia, CPR was started using a mechanical device, the Thumper. The Thumper was used to automatically compress the sternum at a predetermined depth of 1 1/2 inches at a rate of 100 beats per minute. Compressions were continued with ventilations with 100% oxygen at a ratio of 30:2 (compressions to ventilations). After two minutes of CPR, 1 mg of Epinephrine was administered to that group and continued every 3 minutes; 40 units of Vasopressin was administered one time to that group; or CPR only was used for that group without any medications. Every 2 minutes CPR paused. Pulse and rhythm were assessed. 0 2 4 6 8 CPR Only CPR + Vasopressin CPR + EpinephrineNumber Success of Treatment by Group Theoretical Framework Methods Continued When the pigs in all groups were found to have either ventricular fibrillation or ventricular tachycardia, the investigators defibrillated them beginning with 200J and subsequently increased to 360J. If the treatment resulted in a return of spontaneous circulation (ROSC) defined as a sustainable rhythm that maintains a systolic blood successful. The pigs were monitored for a total of 40 minutes if successful; otherwise the treatment was discontinued after 30 minutes. If the treatment did not result in ROSC, CPR was discontinued and documented as unsuccessful. Results None of the pigs in the CPR only group and 1 in the Epinephrine + CPR group survived; all 7 of the pigs in the Vasopressin + CPR group survived. (See chart above) A multivariate analyses of variance (MANOVA) was performed on the pretest data that included weight, temperature, blood pressure, and pulse. There were no significant differences between the groups indicating that they were equivalent on those parameters (p > 0.05). The Fishers Exact Test indicated that there was no significant difference between the CPR only and the Epinephrine + CPR groups (p = 1.00); a significant difference between CPR only and the Vasopressin + CPR groups (p = .001); and a significant difference between Epinephrine + CPR only and Vasopressin + CPR groups (p = .005). The odds of survival in the Vasopressin + CPR group was 225 times greater than CPR only (p = 0.008) and 65 times greater than Epinephrine + CPR group (p = 0.015). Conclusions The results strongly suggest that Vasopressin + CPR is much more effective than CPR only or Epinephrine + CPR. Future studies should be implemented using humans. The results of this study has the potential of saving lives of patients who have an overdose of Desipramine

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January March 2014 99 The headquarters and primary instructional facility of the Army Medical Department Center and School, Joint Base San Antonio Fort Sam Houston, Texas.

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100 http://www.cs.amedd.army.mil/amedd_journal.aspx T HE U NITED S TATES A R MY MEDI C A L DEPART MENT JO URNA L

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SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewe d print medium to encourage dialogue concerni ng health care issues and initiatives. REVIEW POLICY All manuscripts will be reviewed by the AMEDD Journal Â’s Editorial Review Board and, if re quired, forwarded to the appropriate subject matter expert for further review and assessment. IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST 1. Related to individual authorsÂ’ commitments: Each author is responsible for the full disclosure of all financial and personal relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state explicitly whether potential conflicts do or do not exist. Auth ors should do so in the manuscript on a conflict-of-interest notification section on the title page, pr oviding additional detail, if necessary, in a cover letter that accompanies the manuscript. 2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this assistance, if any. 3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done so in the manuscript. 4. Related to project support: Authors should describe the role of the study sponso r, if any, in study design; collection, analysis, and interpretation of data; writing the repo rt; and the decision to submit the report for publication. If the supporting source had no such involvement, the authors should so state. PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH When reporting experiments on human subjects, authors must indi cate whether the procedures follo wed were in accordance with the ethical standards of the responsible co mmittee on human experimentation (institution al and national) and with the Helsinki Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, the authors must explain the rationale for their approach and demonstrate that the institutional review body explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether t he institutional and national guide for the care and use of laboratory animals was followed. INFORMED CONSENT Identifying information, including names, initials, or hospital numbers, should no t be published in written descriptions, photographs, or pedigrees unless the informat ion is essential for scientific purposes and the patient (or parent or guardian) g ives written informed consent for publ ication. Informed consent for th is purpose requires that an identifiable patient be shown the manuscript to be published. Authors should disclose to these patients whether any potential id entifiable material might be available via the Internet as well as in pr int after publication. Patient consent should be written and archived, either with t he Journal the authors, or both, as dictat ed by local regulations or laws. GUIDELINES FOR MANUSCRIPT SUBMISSIONS 1. Manuscripts may be submitted either via email (preferred) or by regular mail. Mail submissions should be in digital format (preferably an MS Word document on CD/DVD) with one printe d copy of the manuscript. Ideally, a manuscript should be no longer than 24 double-spaced pages. However, exceptions will always be considered on a case-by-case basis. 2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles should conform to those guidelines as cl osely as possible. Abbreviati ons/acronyms should be limited as much as possible. Inclusion of a list of article acronyms an d abbreviations can be very helpful in the review process and is strongly encouraged. 3. A complete list of references cited in the article must be provided with the manuscript, with the following required data: Reference citations of published articles must include the auth orsÂ’ surnames and initials, arti cle title, publication title, year of publication, volume, and page numbers. Reference citations of books must includ e the authorsÂ’ surnames and initials, b ook title, volume and/or edition if appropriate, place of publ ication, publisher, year of copyright, and specific page numbers if cited. Reference citations for presentations, unp ublished papers, conferences, symposia, etc, must include as much identifying information as possible (l ocation, dates, presente rs, sponsors, titles). 4. Either color or black and white imagery may be submitted with the manuscr ipt. Color produces the best print reproduction quality, but please avoid excessive use of multiple colors and shading. Digital graph ic formats (JPG, TIFF, GIF) are preferred. Editable versions with data sets of any Excel charts and graphs must be included Charts/graphs embedded in MS Word cannot be used. Prints of photographs are acceptable. If at all possible, please do not send photos embedded in PowerPoint or MS Word. Images submitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of each photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and photos are indexed to each other. Clearly indicate th e desired position of each photo within the manuscript. 5. The authorsÂ’ names, ranks or academic/certification credenti als, titles or positions, current unit of assignment, and contac t information must be included on the title pa ge of the manuscript. Submit manuscripts to: EDITOR, AMEDD JOURNAL AHS CDD BLDG 2841 3599 WINFIELD SCOTT RD STE B0204 JBSA FORT SAM HOUSTON, TX 78234-4669 DSN 471-6301 Comm 210-221-6301 Email: usarmy.jbsa.medcom-ameddcs.list.amedd-journal

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