Surveillance of Military Nurse Outcomes During Corporate Restructuring

BACKGROUND: The National Defense Authorization Act for fiscal year 2017 mandates that all military treatment facilities (MTFs), previously operated by Army, Navy, and Air Force specific medical departments, merge into one agency called the Defense Health Agency (DHA). This movement from separate governing bodies to one overarching body mimics a corporate restructuring in that there will be centralization of administrative governance and support, integration of quality metrics, and joint efforts to lower operating costs. In times of corporate restructuring or merger, nurses may experience higher levels of stress and lower job satisfaction in the workplace. During this transition, military nursing staff may experience increased stress,
changes in workload and work processes, and face communication challenges. The movement of MTFs to DHA may also provide opportunities to improve efficiency, staff support, and communication across the enterprise. Given the unknown impact of the transition on nursing staff, surveillance of nurse-related outcomes is important, particularly when you consider the relationship between these measures, care quality, staff retention, and patient reported satisfaction.

PURPOSE / AIMS: The purpose of this study is to examine nurse-related outcomes in Army, Navy, and Air Force acute and ambulatory care settings during the transfer of MTFs from service specific military medical departments to the DHA. The aims of this study are to:
1. Study the associations between nurse-related outcomes (i.e., job satisfaction, burnout, intent to leave, and potentially preventable losses), the nursing practice environment, and nurse-reported care quality in Army, Navy, and Air Force MTFs after their transfer to the DHA. All variables will be measured in staff nurses and nurse managers in acute and ambulatory care settings and nurse practitioners in the ambulatory care setting.
2. Compare the nursing practice environment, job satisfaction, nurse intent to leave, and potentially preventable losses before (April/May of 2016) and after the transfer to DHA at Army MTFs.

DESIGN: A non-experimental, cross-sectional and pre-post comparative study design is used for this study. The cross-sectional aspect of the design allows for study of relationships between job satisfaction, burnout, intent to leave, potentially preventable losses, and nurse-reported care quality as well as test the nursing practice environment as a mediator between these variables. The pre-post component of the study design addresses aim two, allowing for a model predicted standardized mean score comparison of job satisfaction, burnout, intent to leave, potentially preventable loss and the nursing practice environment before and after the DHA transition.

METHODS: Generalized liner mixed modeling will be used to evaluate the associations between the independent predictors (job satisfaction, burnout, intent to leave, and potentially preventable loss) and the outcome, nurse reported quality care while accounting for the non-independent, nested sample (e.g., participants within units and units within hospitals). The mediating effect of the nursing practice environment on these relationships will also be examined using the three step Barron and Kenny method. To assess the mean differences between job satisfaction, intent to leave, potentially preventable loss, and the nursing practice environment before and after the DHA transition z-scores will be calculated and tested for statistically significant differences between the groups.

RELEVANCE TO MILITARY NURSING AND NURSING SCIENCE: The results of this study may identify workforce-related changes, which MTF or DHA leadership, can use to spotlight high performers or address with evidence-based intervention to improve job satisfaction and retention. Should this study reveal positive staff impressions of care quality, this information could be used to assure military healthcare staff and patients that despite the transition, high quality care continues to be provided by the MHS. Additionally, findings from this study will be used to develop interventions to help future MTFs transition with success.