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Letter to the Editor

Air Force Executive Nurse Leaders: Expanding Nursing Leadership During 1995-1999

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Lauren Brackett, BS, MSN
Robie Victoria Hughes, DNS, MSN, MA, RN, CENP

Abstract

Many great nurse leaders were pivotal in moving the nursing profession forward, but their efforts have not been recorded in history. Examining recorded history provides an opportunity to learn from our past, understand the impact of the past on current practice, and better plan to advance quality practice in the future. This article describes a study that explored the contributions to the nursing profession by the United States Air Force Executive Nurse Leadership initiative on the nursing profession between 1995 and 1999 in the context of the career of Brigadier General Linda J. Stierle. The article describes the research methods, including the oral history process. Discussion of the findings describe both her impact as an Air Force Executive Nurse Leader who significantly contributed to expanding opportunities for military nurses to lead interdisciplinary teams, command medical treatment facilities, advance medical readiness and nursing practice, and grow nursing as a science. Her influence continues today and the conclusion discusses implications for current nurses.

Citation: Brackett, L., Hughes, R.V., (September 30, 2019) "Air Force Executive Nurse Leaders: Expanding Nursing Leadership During 1995-1999" OJIN: The Online Journal of Issues in Nursing Vol. 24, No. 3, Manuscript 5.

DOI: 10.3912/OJIN.Vol24No03Man05

Key Words: Air Force nurse, military nursing, nurse leader, leadership in nursing, interprofessional collaboration, medical readiness, Nurse Corps, oral history, United States Air Force, nursing research, nursing science

Many great nurse leaders were pivotal in moving the nursing profession forward, but their efforts have not been recorded in history.Many great nurse leaders were pivotal in moving the nursing profession forward, but their efforts have not been recorded in history. Examining recorded history provides an opportunity to learn from our past, understand the impact of the past on current practice, and better plan to advance quality practice in the future. Brigadier General (Brig Gen) Linda J. Stierle is a nurse of great impact whose story has not been recorded in history, and little is known about her influence beyond the military. This article will present research that explored how the actions of an Air Force Nurse Executive leader, between the years 1995 to 1999, contributed to the development of leadership in nursing.

This research used the oral history method to present key findings from an interview with Brig Gen Stierle. The oral history method is a research methodology crucial to preserving nursing heritage. Oral histories of nurses uncover unique stories and experiences of nurses in the past, and illuminate how the past is significant to current and future nursing practice (Biedermann, 2001). The oral history of Brig Gen Stierle reveals how she contributed to the military and the nursing profession, largely by utilizing interprofessional collaboration between nursing and other health disciplines to accomplish the mission and advance nursing leadership. She also opened pathways for military nurses to demonstrate their value as commanders (i.e., interprofessional leaders), and as nurses in expanded roles and settings. Lastly, her support for military nursing research was evident and promoted the continued advancement of nursing as a scientific discipline.

Oral histories of nurses...illuminate how the past is significant to current and future nursing practice.In 2011, the Institute of Medicine (IOM) released a report on the future of nursing that stated “developing strong nurse leaders is critical if the vision of a transformed healthcare system is to be realized” (IOM, 2011, p. 9). The United States Air Force (USAF) has been producing strong nurse leaders for many decades (Lindberg, 1999). Air Force Nurse Executive Brig Gen Linda J. Stierle was a strong proponent of nursing leadership. Stierle demonstrated how nurses could excel in positions of leadership, and she advanced the nursing profession through academic and professional opportunities for nurses.

Medical Readiness was the primary responsibility for Brig Gen Stierle in her position as an Air Force Nurse Executive.Medical Readiness was the primary responsibility for Brig Gen Stierle in her position as an Air Force Nurse Executive. Medical Readiness supports the Air Force Medical Service (AFMS) mission by ensuring all Airmen under the Total Force umbrella are fit to deploy (Medical Readiness Program Management, 2017). Readiness means Airmen are medically healthy, the families of Airmen are healthy and prepared, and Airmen are medically trained to carry out world-wide operational missions. Today, the AFMS provides care to over 200,000 Airmen involved in military operations and continues to develop the readiness platform through cutting-edge research and training. Medical readiness has grown significantly in importance over the past fifteen years with the continued deployments to the Persian Gulf area over the past two decades; it remains one of the highest priorities of the AFMS (AFMS, n.d.).

This article describes the study that explored the contributions to the nursing profession by the United States Air Force Executive Nurse Leadership initiative on the nursing profession between 1995 and 1999 in the context of Stierle’s career. By providing a written record and thoughtful analysis of the contributions of Brig Gen Stierle, the history of nursing leadership is brought to life and valuable insight is offered to nurse leaders of the future. We begin the current discussion by offering implications for practice today in our conclusion. Table 1 provides an overview of military terminology for reference if needed.

Table 1. Overview of Military Terminology

Acronym

Term

Definition

AEF

Aerospace Expeditionary Force

A readily trained support team of the USAF that is rapidly deployed to respond to crises with forces tailored to achieve limited and clearly stated objectives.  

AFMS

Air Force Medical Service

An umbrella structure that encompasses all facets of providing healthcare to all military beneficiaries in the USAF. The service consists of five distinct health Corps and enlisted medical personnel.

CCAT

Critical Care Air Transport Team

A highly specialized medical asset which can create & operate a portable intensive care unit on board any transport aircraft during flight.

CCDR

Combatant Commander

A specific type of nontransferable command authority over assigned forces, regardless of branch of military service (Army, Navy, Marines, Air Force).

Corps: BSC, DC, MC, MSC, NC

Bioscience Corps, Dental Corps, Medical Corps, Medical Service Corps, Nurse Corps

The AFMS has five health care disciplines/Corps; all health care officers are a member of one of these five Corps

C/SNA

Constituent/State
Nurses Associations

The American Nurses Association represents the interests of the nation's 4 million registered nurses (RNs) through joint membership with our constituent and state nurses’ associations, direct membership in ANA, and through our partnership specialty nursing and affiliate organizations. Federal Nurses Association (FedNA) was one of 54 voting state and constituent at the time.

Deployment

Deployment

The movement of personnel or equipment to a place or position to support military action.

DoD

Department of Defense

The federal department responsible for providing military forces (Army, Navy, Marine Corps and Air Force) to deter war and protect national security of the United States.

FP

Force Protection

Force protection consists of preventive measures taken to mitigate hostile actions against Department of Defense and U.S. Coast Guard personnel, resources, facilities, and critical information. The concept of force protection was initially created after the Beirut barrack bombings in Lebanon in 1983.

Medic

Medic

A generic term used to refer to all Air Force Medical Service personnel. This includes the officers assigned to one of the five special Corps, as well as all enlisted medical personnel.

MHS

Military Health System

The Military Health System is the enterprise within the United States Department of Defense that provides healthcare to active duty and retired US military personnel and their dependents.

MTF

Military Treatment Facility

Military hospitals and clinics providing direct medical and dental care to eligible individuals.

OMG

Objective Medical Group

Organizational structure for Air Force hospitals and clinics based on how the rest of Air Force organizations are structured.

TF

Total Force

All three components of the US Air Force -Active Duty, Air Force Reserve and Air National Guard.

TSNRP

Tri-Service Nursing Research Program

A research program that supports rigorous scientific research in the field of military nursing. Military nurses from Army, Navy, and Air Force, both active and reserve are eligible to participate.

USAF NC

United States Air Force Nurse Corps

One of five health Corps/disciplines of the Air Force Medical Service. Air Force nurses are members of the Nurse Corps.

 
Research Methods

Oral history is both a product of the interview and a means of conducting the investigation.The oral history interview was used to access the significance, interpretation, and meaning of the personal stories and experiences provided during the interview with the participant. In compliance with the Oral History Association guidelines, institutional review board permission, informed consent, and audiotaped interviews were obtained by the investigator. According to Abrams (2016), the oral history method involves the process to comprehend what is said, how it is said, why it is said, and what it means.

Oral history is both a product of the interview and a means of conducting the investigation (Abrams, 2016). Active and deep listening techniques were used to help clarify and explore understanding of content. By considering the historical and political context between 1995 and 1999, this study also provided an enriched understanding of Air Force Nurse Leadership and its relevance to current initiatives in nursing.

Participant
Brig Gen Linda J. Stierle served as Director of Medical Readiness and the 12th Chief of the USAF Nurse Corps (NC), Office of the Air Force Surgeon General at Bolling Air Force Base in Washington, District of Columbia, United States of America (USA) from May 1995 to November 1999. In her primary role as Director of Medical Readiness, Stierle was responsible for ensuring that all Air Force Medics, enlisted and officer, as well as the Medics of the USAF Reserve and Air National Guard were medically prepared to carry out military operations around the world (Medical Readiness Program Management, 2017; AFMS, n.d.).

Data Collection
To guide the interview process, Hughes used a 78-item, semi-structured survey based on an original nurse survey developed by Dr. Lucinda McCray, Professor of History at Appalachian State University. An expert panel of executive nurses was utilized to suggest appropriate modifications to the questions for use to interview an Air Force executive-level nurse. The interview with Brig Gen Stierle took place in 2016, and lasted approximately six hours. The interview was transcribed verbatim, and the accuracy of the transcription was sent to the participant to double check accuracy of content.

Data Analysis
Through careful analysis of the interview with Brig Gen Stierle, this study identified the contributions of Air Force Nurse Leaders and explored the impact of the contributions on the nursing profession. First, I (L. Brackett) transcribed the interview verbatim. Then I worked with the co-author to immerse ourselves in the data by reading through the interview transcript thoroughly several times. Next, we worked to identify key areas of Brig Gen Stierle’s areas of impact, and then categorized them (e.g. military and nonmilitary). To confirm the accuracy of our analysis, we discussed the findings until consensus was reached and validated the findings through review by the interviewee.

Findings

Analysis of the interview content led to several interesting themes about Brig Gen Stierle’s career and leadership in the profession of nursing. In this section we will discuss each of these, including context; interprofessional leadership; demonstration of nurse leadership value; and the maturing of nursing science.

Context
On May, 1, 1995 Brig Gen Stierle made history as the first dual-hatted Air Force Nurse Corps Chief to become the Director of Medical Readiness within the Office of the Surgeon General (Smolenski, Smith, & Nanney, 2005). Stierle was informed by the USAF Surgeon General, after being competitively selected for promotion to be the 12th Chief of the USAF Nurse Corps, that her primary position would be the Director of Medical Readiness. Her responsibilities as the USAF Nurse Corps Chief were secondary and an additional duty to be managed with the assistance of a deputy Corps Chief.

The significance of this dual-hatted position should not be underestimated.The significance of this dual-hatted position should not be underestimated. Stierle broke through the glass ceiling for nurse leadership within the USAF and paved the way for the first USAF nurse to become the USAF Surgeon General. On June 04, 2018, Dorothy Hogg, the sixteenth Chief of the USAF Nurse Corps was promoted to Lieutenant General and became the twenty-third Surgeon General of the USAF, the first female and first nurse to ever be selected for this position in the seventy-year history of the USAF. All previous Air Force Surgeon Generals were physicians. Stierle demonstrated that a nurse could excel in leadership positions outside of the traditional nursing hierarchy.

Brig Gen Stierle took office as Director of Medical Readiness during a time when readiness was critical to the operational mission of the AFMS (Lindberg, 1999). In 1991, the Persian Gulf War, Operation Desert Shield/Desert Storm (ODS/DS) required large-scale deployments of military personnel within seventy-two hours; the deployment was the largest since the Vietnam War (Murrey, 1999; AFMS History Office, 2016). The large-scale deployment left some military treatment facilities (MTFs) severely understaffed and unable to meet the healthcare demands of the military beneficiary patient population, which included active duty personnel and their family members, and military retirees and family members entitled to military healthcare. In some of the same geographic locations, civilian healthcare was also limited because there was mobilization and deployment of the USAF Reserve personnel from that area (Mazzuchi, Trump, Riddle, Hyams & Balough, 2002; AFMS History Office, 2016). Back-filling these deployed personnel with USAF Reserve and Air National Guard personnel eventually allowed MTFs to meet the healthcare needs of their beneficiaries.

With the new medical readiness mission at the forefront of her mind, she began to lead the change and demonstrate interprofessional leadership and the value of nursing leadership.After studying the medical deployments of the Persian Gulf War, the AFMS realized a more timely and efficient response to deployment was needed (Mazzuchi et al., 2002; AFMS History Office, 2016). Brig Gen Stierle used lessons from ODS/DS to formulate her goals and objectives when she became Director of Medical Readiness in 1995. Stierle saw “a need for a smaller, lighter, further forward, more capable medical readiness platform and a more robust aeromedical evacuation system than ever before” (Stierle, interview transcription, 2016). With the new medical readiness mission at the forefront of her mind, she began to lead the change and demonstrate interprofessional leadership and the value of nursing leadership.

Interprofessional Leadership
During Brig Gen Stierle’s four-year tenure, she demonstrated that nurses could be leaders of interprofessional teams and used interprofessional collaboration to advance medical readiness. Stierle transformed the current medical readiness platform using force protection (FP) and a readiness doctrine aimed at improving rapid medical deployment. The purpose of FP is to ensure the safety and security of military personnel and resources involved in diplomatic operations outside of the country (Force Protection Fundamentals, 2019). Basically, FP was central to Stierle’s philosophy in the position of Director of Medical Readiness.

In 1996, a second attack by an Iranian-backed Saudi Arabian militant group on American military personnel took place (Gross, 2016; AFMS History Office, 2016). The eight-story apartment building in the Khobar Tower complex was bombed and left nineteen Airmen dead and four wounded (Gross, 2016; Murrey, 1999). The Khobar Tower bombings exposed loopholes in the current FP program, such as the unclear division of protective authority between the Secretary of Defense and the Secretary of State, as well as the limited authority of the Combatant Commander (CCDR) over temporary personnel or military components not directly under their command (Mazzuchi et al., 2002). As a result of these communication and supervisory issues, Department of Defense (DoD) military components were at risk for not having optimal FP (Mazzuchi et al., 2002; Murrey, 1999).

As an interprofessional team member, she demonstrated that nurses have the knowledge, skills, and abilities to lead teams that make large-scale impact.The outcomes of joint lessons learned from the Khobar Towers bombing incident were increased authority granted to the CCDR and a new Memorandum of Understanding (MOU) between the Secretaries of Defense and State clearly outlining FP responsibilities. This more logical and organized approach led to an increase in protection for personnel. Stierle recognized that this increased focus on FP was an opportunity to provide even more momentum for the reengineering of Air Force medical readiness. As an interprofessional team member, she demonstrated that nurses have the knowledge, skills, and abilities to lead teams that make large-scale impact. One of her interprofessional strengths was that she knew how to focus on the opportunities, instead of the normal resistance to change frequently associated with a new idea, direction, or project.

In 1998, the AFMS shifted the assignment of military personnel to support operational contingencies anywhere in the world with the development of the Air Force Aerospace Expeditionary Force (AEF) doctrine. The AFMS changed from setting up large Air-Transportable Hospitals (ATHs) designed to treat large numbers of patients in combat theaters to now stabilizing patients with Expeditionary Medical Support (EMEDS) and then rapidly evacuating wounded or seriously ill personnel to definitive care facilities. EMEDS was designed to provide trauma care capabilities for young and relatively healthy patients involved in warfighting missions. The operational emphasis was on patient flow through the various elements of the deployed medical network. Patient flow could be measured by a metric of capability for the rate at which each component of the deployment system could triage, stabilize, treat, and evacuate patients.

The EMEDS and enhanced Aeromedical Evacuation with the addition of the Critical Care Air Transport Teams (CCATTs) greatly reduced the time between injury and receiving the appropriate level of care (Snyder, Chan, Burks, Amouzegar, & Resnick, 2010) and resulted in significant decreases in morbidity and mortality. The AFMS did not have written medical readiness doctrine at the time, but during Stierle’s tenure, she orchestrated the creation of doctrine to align with the line of the Air Force doctrine utilizing AEF Concepts. The AFMS medical readiness doctrine helped to guide current and future decisions regarding how to best support combat operations.

Brig Gen Stierle worked to increase the number of nurse practitioners in the readiness manpower mix to ensure that the AFMS was postured to provide the right skill mix...Brig Gen Stierle worked to increase the number of nurse practitioners (NPs) in the readiness manpower mix to ensure that the AFMS was postured to provide the right skill mix for war fighter support during contingencies and to provide the system and commanders with maximum flexibility. When she advocated to increase the number of advanced practice registered nurses (APRNs) on the readiness manpower docket, she did not lose consideration for the other members of the interprofessional medical readiness team. She considered how this change in structure would impact the welfare of the other healthcare professions (e.g., physician assistants), and their upward mobility opportunities.

Brig Gen Stierle was a successful team leader because she strengthened the AFMS readiness capability with a redesigned medical readiness platform that best supported the priorities of medical readiness at the time. She led the reengineering of Air Force Medical Readiness which would result in a lighter, leaner entire military healthcare system (MHS) and increased capability to save lives. She directed the total redesign of a 320-million-dollar War Reserve Materiel program to deliver state-of-the-art medical care under any condition, anywhere in the world. Her visionary restructuring of expeditionary medical and aeromedical evacuation personnel and equipment unit type codes positioned the AFMS to support Expeditionary Aerospace doctrine. Stierle was one of the original pioneers of the “Mirror Force” strategy, developing and deploying plans and tactics to realize a Total Force culture within the AFMS.

She valued multidisciplinary efforts because she recognized the importance of different educational preparation, experiences, and viewpoints when problem solving and accomplishing the mission...The description of these interprofessional approaches strongly confirmed the high level of success that Brig Gen Stierle had in transforming the platform of medical readiness successfully, but her leadership approach also deserves recognition. She valued multidisciplinary efforts because she recognized the importance of different educational preparation, experiences, and viewpoints when problem solving and accomplishing the mission. As she described it, Stierle knew that an inclusionary approach to development of new medical readiness doctrine would result in greater commitment and ownership. The doctrine would become a stabilizer through future leadership transitions and help the AFMS achieve its preferred future.

Using a collaborative approach to restructure the medical readiness mission, Stierle propelled the authorship of a powerful tool that would drive the preparation for future AFMS deployments. In short, this team-oriented nurse executive provided the framework for medical readiness doctrine, impacting operations and structure that continue to be foundational and is still utilized and updated by the Air Force leaders of today (Congressional Record, 1999; Air Force Medical Service, n.d.).

Demonstrate Nurse Leadership Value
Just as Brig Gen Stierle recognized the need for a multidisciplinary approach to the reengineering of medical readiness, she also recognized the need for a similar approach for nursing services. She had a well-established reputation as a leader in strategic planning, when she brought the Total Nursing Force leadership, officer and enlisted personnel, from all three components (Active Duty, Air National Guard, and Air Force Reserve) to develop a Total Nursing Force Strategic Plan. She used the Hoshin Kanri methodology because each participant in the process has equal status (Ennals, 2010). This method originated in post-World War II Japan and is founded on the guiding principles of inclusion, creativity and communication. This process and structure resulted in a common focus on goals and tasks to advance initiatives that impacted the Total Force Nurse Corps then and even today.

...she also recognized the need for a similar approach for nursing services.In 1993, the AFMS started transitioning to the Objective Medical Group (OMG) structure to better align with the overall organizational structure of the Air Force. With the new OMG structure for all Air Force MTFs, healthcare professionals were recognized as simultaneously satisfying both the Air Force line construct of command and control and ensuring that accreditation requirements for a healthcare facility were achieved. Within the OMG, four squadrons, based on services provided and support required and called “product lines,” were designated: Medical Operations, Aerospace Medicine, Dental, and Medical Support (Silverman, 2009).

This was only the beginning of nurse role expansion...Stierle continued to open doors for nurses to demonstrate their leadership value.This change in AFMS leadership structure allowed officers to serve as commanders over any one of the four medical squadrons or over the entire Medical Group in alignment with the already existing Air Force Wing structure for the Maintenance, Flying, and Support Groups. As squadron commanders within the Medical Group, healthcare leaders were now responsible for upholding and administering disciplinary action in accordance with the Uniform Code of Military Justice, along with maintaining healthcare accreditation requirements. The medical command responsibilities differed from their line officer counterparts (i.e., all Air Force officers other than attorneys, chaplains, and health professionals) in that commanders were often dual-hatted in the healthcare functional role and as the squadron commander role. This was only the beginning of nurse role expansion; as Director of Medical Readiness and Chief of the Nurse Corps, Stierle continued to open doors for nurses to demonstrate their leadership value.

Under the new OMG structure, Brig Gen Stierle restructured career trajectories for nurse officers and provided them with a variety of operational, staff, and executive leadership experiences (Smolenski, Smith, & Nanney, 2005). This was extremely important for the advancement of nurses considering the Air Force Nurse Corps awards career promotion based on the “three-legged stool” of operations, staff and leadership experience, and performance (USAF NC, 2013).

The findings from this effort indicated that nurse-led projects saved millions of dollars for medical treatment facilities.In May 1995, Brig Gen Stierle spearheaded an evaluation of over 70 nurse initiatives. The findings from this effort indicated that nurse-led projects saved millions of dollars for medical treatment facilities (MTFs). General Stierle illustrated some of the financial impact that the Nurse Corps contributed to healthcare during a testimony to Congress (Lindberg, 1999). In October 1995, the AFMS redistribution of field grade manpower authorizations resulted in a gain of 83 major and 56 lieutenant colonel authorizations to the Nurse Corps (Lindberg, 1999). The increase in promotion for nurses is evidence of Stierle’s success as both a leader and an advocate for the nursing profession.

Under Brig Gen Stierle’s leadership, nurses also received more fellowships and career-broadening assignments to enhance their practice beyond the clinical nursing role. In 1995, Education with Industry Fellowships were initiated for nurse officers and nurses were successfully incorporated into health maintenance facilities and The Joint Commission on Accreditation (Smolenski, Smith, & Nanney, 2005). These fellowships had not been available to Nurse Corps officers in the past. Additional nursing fellowships were offered to all members of the NC in 1998, including tracks in executive nursing, risk management, and medical readiness planning (Smolenski, Smith, & Nanney, 2005). The first Air Force Congressional Nurse Fellow had a follow-on assignment as the first NC officer to become the Surgeon General’s Public Affairs Officer and paved the way for others. When she retired at the completion of her three-year assignment, she was followed by another NC officer. During her tenure as Corps Chief, Stierle ensured Air Force nurses were better prepared to demonstrate their leadership value in a wide variety of roles and settings.

In October 1997, nurses became eligible to compete for all Air Force MTF and aeromedical evacuation command positions. Nurses were selected in the OMGs for 18 of the 58 command positions (Smolenski, Smith & Nanney, 2005). Brig Gen Stierle advocated for increasing the number of Corps neutral leadership positions for command, allowing any officer within the AFMS, regardless of Corps, to be eligible to serve as Medical Group Commanders at MTFs. She believed that with Corp neutral positions, all AFMS officers would have an equal opportunity to compete for command based on their merit. The AFMS and the Air Force would be better served due to the most qualified leaders filling the leadership positions, regardless of Corps. By April 1999, nurses commanded 25 percent of Regular Air Force medical facilities, 37 percent of Air Force Reserve medical units, and 12 percent of Air National Guard medical units (Smolenski, Smith, & Nanney, 2005).

At the time, USAFA graduates were not allowed to become nurses because the USAFA Commandant did not view nurses as future leaders.Once Brig Gen Stierle successfully advocated for increasing the number of Corps neutral command positions, she addressed the previously fixed mindset of the United States Air Force Academy (USAFA) in regard to nursing leadership. At the time, USAFA graduates were not allowed to become nurses because the USAFA Commandant did not view nurses as future leaders. However, now that nurses served in the OMG squadron and group commander positions, the USAFA leadership had the evidence that nurses are leaders. Because of Stierle’s groundwork in nurse role expansion, the USAFA selected graduates to enter into a Master’s of Science in Nursing Program for Adult Nurse Practitioners at Vanderbilt University starting in 1997.

Maturing Nursing Science
In 1992, Congress funded the Tri-Service Nursing Research Program (TSNRP), a program promoting research by military nurses. The program leaders requested review by the IOM in 1995, and the Committee on Military Nursing stated research was “an investment regarded as necessary in all other sectors of healthcare,” therefore it should also be regarded as essential to military nursing practice (Felton, McCorckle & Redman, 1998; IOM, 1996). During Brig Gen Stierle’s tenure, nursing was gaining momentum as a military health discipline. Stierle continued this momentum by encouraging an environment of scientific excellence in nursing. She realized that military nursing research would support military nurses in advancing their practice, including areas such as healthcare systems and delivery, mission readiness, and quality of care. Furthermore, she understood that research findings generated by the TSNRP had the power to advance nursing practice outside of the military healthcare system (MHS) and improve care delivery in the civilian sector.

...she understood that research findings generated by the TSNRP had the power to advance nursing practice outside of the military healthcare system and improve care delivery in the civilian sector.Progress in information technology allowed for more timely dissemination of research findings and contributed to the readiness preparation of the military (Saba, Pravikoff, & Peltze, 2000). Through the TSNRP, Brig Gen Stierle improved care to support the medical readiness platform and to advance nursing clinical practice. Because of her support of the TSNRP, military nurse researchers were able to make an impact far beyond military nursing. Today, the American Nurses Association (ANA) promotes evidence-based practice as a cornerstone for nurses (Stevens, 2013). It can be said that Stierle was a pioneer in supporting the generation of a body of military nursing research that informs early evidence-based nursing practice in military and civilian settings. The TSNRP is still active, and the research conducted by military nurses continues to have wide-ranging implications for the nursing profession (Hatzfeld & Jennings, 2017).

Throughout her career, Brig Gen Stierle was a staunch advocate for formal education. Not only did she provide opportunities for USAFA graduates in nursing, but she also persistently addressed the need for increased formal education for NC officers. During her tenure, she was able to justify the requirement for increased educational opportunities for doctoral preparation for NC officers. In the first forty-five years of the USAF Nurse Corps, very few nurses had ever been selected for doctoral studies. After justifying these educational requirements, this number was increased by competitive selection of several NC officers being competitively selected to pursue aDoctorate of Philosophy or Doctorate of Nursing Practice when the NC Educational Selection Board convened. She knew increasing the number of nurse researchers was critical to the advancement of the nursing profession.

Believing that all nurses should be engaged members of their professional association, Brig Gen Stierle was also an active participant as one of five Federal Nursing Chiefs with the ANA. She was also strongly committed and spear-headed a four-year endeavor to secure a national voice and representation for military nurses. It eventually led to the unprecedented vote by the ANA leadership to establish a federal nurse constituency for Army, Air Force, Navy, and Public Health Service commissioned nurses. In March 2000, The Federal Nurses Association (FedNA) became an ANA voting member along with fifty-three other Constituent /State Nurses Associations (C/SNAs).

Summary

Brig Gen Linda Stierle transformed the lens through which nursing was viewed from 1995 to 1999 by excelling in the dual-hatted role of Director of Medical Readiness and Chief of the USAF Nurse Corps. Her interdisciplinary approach to leadership facilitated powerful solutions to major issues like medical readiness. She also championed a collaborative, multidisciplinary healthcare delivery system that valued and optimized the unique contributions of all Corps and all ranks. As the Nurse Corps Chief, she encouraged and supported nurses to compete for leadership positions in every facet of the healthcare system, as well as positions outside of healthcare. She unequivocally demonstrated that nurses are qualified to lead interdisciplinary teams and be strong candidates for any leadership position. She believed that ultimately it is not about a particular Corps being more qualified than another, but who is the most qualified leader, regardless of Corps, for a particular leadership position.

Brig Gen Stierle’s story suggests nurses in leadership positions should consider using a collaborative, inclusive approach to effectively address high-impact issues in healthcare.Brig Gen Stierle’s story suggests nurses in leadership positions should consider using a collaborative, inclusive approach to effectively address high-impact issues in healthcare. Stierle persevered to increase opportunities for engagement and promotion in nursing which gave nurses the chance to demonstrate their value outside of the traditional nursing role. It is not surprising that this increase in opportunities was accompanied by an increase in promotion for nurses and expansion of Corps-neutral positions.

While Brig Gen Stierle’s primary focus was medical readiness, she understood that nursing existed outside of the military. She used the TSNRP as an innovative way to be an Air Force Nurse Leader with an impact outside of her organization. Stierle was one of the executive nurse leaders who undoubtedly transformed the landscape of military nursing, resulting in developing strong nurse leaders for the 21st century. After over twenty-nine years of service in the USAF, Stierle retired and became the Chief Executive Officer (CEO) of the ANA (L. Stierle, interview with South Carolina Nurses Association, 1994/2009). She accepted the ANA CEO position in 2000 because it allowed her to continue to focus on her two life-long passions of her country, the USA, and her chosen profession, nursing. She retired from the ANA in 2009, but her legacy of leadership is still reflected in the impact she made on the organization and the nursing profession as a whole. Table 2 provides a brief overview of the major contributions of Brig Gen Stierle described in greater depth in the article.

Table 2. Major Contributions of Brigadier General Linda J. Stierle, US Air Force (Retired)

Contribution

Relevance to Nursing

Time Frame

Started and served in a dual-hatted role never before held by a nurse

Nurses can be successful leaders of interprofessional teams and non-nursing programs

1995 - 1999

Reengineered current medical readiness platform to include modernization of aeromedical evacuation and more NPs

Nurse practitioners are recognized as essential component of a successful medical readiness platform by increased operational flexibility and provided increased job security for NPs

1995 - 1999

Created the Total Nursing Force Strategic Plan

Resulted in unity among the Air Force military nursing community

1995 - 1996

Contributed to the implementation of Objective Medical Group (OMG)

Nurses held 25% of all dual-hatted role as commander/chief executive officer and health professional at MTFs by 1999

1993 - 1999

Conducted evaluations of 70 nurse-led initiatives 

The importance of nurse-led projects and the resulting outcomes were recognized

1995 - 1996

Increased professional and educational opportunities for nurses in the military

Nurses have increased pathways to promotion and professional development

1995 - 1999

Increased the number of Corps-neutral leadership positions

Nurses had equal opportunities to demonstrate their value as a leader and to self-actualize

1997 - 1999

Allowed USAF Academy (USAFA) graduates to enter into nursing after graduation

Justified to the USAFA Commandant that nurses were leaders

1996 - 1997

Promoted the Tri-Service Nursing Research Program and Electronic Access to Nursing research 

Nurses become more involved in research and have pathways to disseminate findings to the general population

1995 - 1999

Increased educational opportunities for doctoral preparation for nurses

Nurses have the education to conduct nursing research and contribute to the profession

1995 - 1999

Established federal constituency for Army, Air Force, Navy, and Public Health Service currently commissioned nurses as a Constituent Member Association of the ANA

Military Nurses had a larger voice in the national nursing community

1996 - 2000

 
Conclusion: Implications for Nurses

The analysis of the leadership of Brig Gen Stierle can guide the approaches of nurses and nursing organizations interested in promoting nursing leadership. While the historical and political climate has changed since 1999, the approaches Stierle used have been validated by current nursing literature and are still relevant to nursing. From the oral history, it is clear that putting nurses in a position to lead interdisciplinary teams affords them the opportunity to display their knowledge, skills, and abilities to other disciplines. Based on Stierle’s success in as an interprofessional leader, nurses may be more likely to be successful in interdisciplinary settings if they use collaborative approaches and perspective with their team.

...it is clear that putting nurses in a position to lead interdisciplinary teams affords them the opportunity to display their knowledge, skills, and abilities to other disciplines.Throughout the interview, Stierle also demonstrated an awareness of the broader context, and applied this context to drive her solutions. Educating nurses about trends in healthcare or current events may give nurses the power to generate more effective solutions to address issues in healthcare. Stierle gave Air Force nurses the opportunities needed to grow and succeed, and current nurse leaders must provide nurses with similar opportunities to develop academically and professionally.

Lastly, support for the TSNRP assisted Stierle in making an impact, not only in the military, but also in her chosen profession of nursing. Brig Gen Stierle firmly believes, then and now, as she stated in her interview, “that nurses are the true health care generalists and ‘the glue’ that holds the health care delivery system together. And when nursing is strong, individuals, organizations, and communities reap the benefits of nursing strength.”

Acknowledgements
We would like to acknowledge Brig Gen Stierle for her willingness to describe and explain the depth of her career during this oral history process, and her permission to share the information received in a formal publication.

Brig Gen Stierle was fortunate to have during her four plus year tenure the support of two exceptional teams, as well as a succession of deputies for both Medical Readiness and Nursing. She requests that we acknowledge Colonels Nina Rhoton and Teresa Page for Nursing Services, and Colonels Rick Jenkins and Robert Ferguson for Medical Readiness.

Authors

Lauren Brackett, BS, MSN
Email: lbracke2@jhu.edu

Lauren Brackett completed her Master’s in Nursing (MSN) at the Johns Hopkins School of Nursing. She has a BS in Human Development from the University of California, Davis. Currently, Lauren is involved with nursing research through the Research Honors Program and as a Research Associate for Dr. Victoria Hughes at the Johns Hopkins School of Nursing. Lauren is interested in increasing leadership opportunities for new graduate nurses and exploring the benefits of nurse leadership on organizational outcomes.

Robie Victoria Hughes, DNS, MSN, MA, RN, CENP
Email: vhughes@jhu.edu

Dr. Victoria Hughes is an Associate Professor at the Johns Hopkins School of Nursing. She has a DNS from Louisiana State University, an MSN from the University of Alabama in Birmingham, and a BSN from the Medical University of SC in Charleston. Victoria served for 27 years within the United States Air Force. Her clinical background is as an Advanced Practice Psychiatric Nurse Practitioner, licensed in Florida. Her research focus is on nursing leadership development within the cultural context and strategies to promote effective nurse leaders for the future.

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© 2019 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2019


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