Col. Jeffrey Ashley, PhD, RN, deputy commander for nursing at Landstuhl Regional Medical Center
(LRMC) in Germany and consultant to the U.S. Surgeon General on critical-care nursing, began his distinguished military career by chance. In 1985, he graduated with a BSN from Point Loma Nazarene College in San Diego, California, USA, and entered a tough job market. With few civilian job openings available, he turned his attention to military options.
“The U.S. Army recruiter wanted me to join,” he recalls. “He was the only one with a job to offer, so I became an Army nurse.”
The recruiter proved to be an ace at assessing potential: Ashley has built his entire career as a nurse and leader in the Army.
I interviewed Ashley last August in his office at LRMC—pronounced “larm-see”—where he had just completed the first 100 days of his three-year assignment.
Landstuhl Regional Medical Center
Recently designated a Level I trauma center by the American College of Surgeons, LRMC is the largest American military hospital outside the United States. Wartime and peacetime care coexist within LRMC’s diverse patient population and unique environment, where change is the norm. Well-known for its Combat Casualty Program, which receives injured troops from “downrange” locations such as Afghanistan, LRMC is also a full-service hospital.
Primary and tertiary care are provided at LRMC for more than 245,000 U.S. military personnel and their dependents stationed within the U.S. European Command (EUCOM),
as well as for casualties from U.S. operations in Europe, Southwest Asia, the Middle East and Africa. American retirees, military family members and combat casualties, including civilian contractors and non-American coalition troops, are treated at LRMC. Several times a week, Critical Care Transport Teams (CCATS) arrive, carrying critically ill and ambulatory troops from downrange. Every day, CCATS depart from LRMC, either to return downrange or to transport patients to destinations in the United States for further care and treatment.
Transition and diversity define the staff as well as the patients. Male and female active duty, National Guard and Reserve personnel from the U.S. Army, Air Force, Navy and Marines work side by side in caring for patients. In addition, more than 30 percent of LRMC’s nurses are civilians. All nursing and medical staff must be licensed in the United States, because LRMC is an American hospital. Ashley is licensed in his home state of California. Military staff, including nursing staff, may be stationed at LRMC, sometimes for only 90 days. A “long” tour is two to three years. Despite so much transition, vigorous nurse preceptor programs support cadet nurses in special summer externships and new-to-practice nurses at LRMC.
In this extraordinary environment of transition and diversity, Ashley is responsible for nursing services. He must ensure that the mission of excellent nursing care continues, regardless of who is coming or going.
“Not all nurses work for me,” Ashley says, referring to a group of advanced practice nurses and ambulatory care nurses supervised by the deputy commander for clinical services, “but my role means that I work for all nurses, and I am responsible for ensuring that all nurses have the skills and tools to be successful, regardless of their supervisory chain.”
Change and preparation standard
Being new is nothing new for Ashley. His military career has taken him through staff and progressive leadership roles in international postings, including South Korea, Honduras, Afghanistan and now Germany, and in diverse domestic locations, including Ft. Benning in Georgia; Walter Reed Army Medical Center in Washington, D.C.; Tripler Army Medical Center in Hawaii; and Brooke Army Medical Center (BAMC) in San Antonio, Texas.
At BAMC—pronounced “bam-see”— he served in a variety of roles, including chief of the Nursing Research Service, chief of the Critical-Care Nursing Service and chief nurse of the Institute of Surgical Research’s burn center. Along the way, Ashley’s work has been recognized with many commendations, including the prestigious Joint Service Commendation Medal and the Meritorious Service Medal, the latter with two oak-leaf clusters. He takes pride in his memberships in the Honor Society of Nursing, Sigma Theta Tau International and the American Association of Critical-Care Nurses.
Ashley credits the military’s educational benefits for his PhD and two master’s degrees. He earned an MSN in critical care trauma from the University of Maryland, Baltimore (1999) and completed his PhD in nursing (2005) at the University of California, San Francisco (UCSF) in just three years. In 2009, he earned a Master of Strategic Studies (MSS) degree from the U.S. Army War College.
When I observed that he graduated from the renowned nursing program at UCSF in record time, he modestly replied, “That’s all the funding that was available.” In addition to degree work, he has completed military courses in critical-care nursing, medical effects of nuclear weapons, command, advanced leadership and executive skills.
Ashley’s education has provided a progressive, well-rounded background for his roles of nurse, soldier, scholar and leader. His newest role of deputy commander brings more change, as he represents nursing at the hospital’s highest organizational level.
Ashley’s time in Texas (2005-11) was punctuated by an eight-month deployment to Afghanistan (April-November, 2006) where he coordinated the Joint Theater Trauma System (JTTS) at Bagram Air Field. At the time, he was the only trauma coordinator in Afghanistan—there were five trauma coordinators in Iraq—and his duties included teaching the system’s trauma protocols, collecting and analyzing data, and providing direct patient care when needed. As a critical-care nurse, Ashley had already “seen a lot” and attributes his successful handling of the deployment to a decade of experience. Like everyone else deployed to a combat area, he faced uncertain and stressful situations.
“On base we had TV, phone, e-mail and flush toilets,” he said. “The minute we left base, we encountered huge risks, because Afghanistan was like a battlefield without a front line.”
Full colonel nurse executive
As a full colonel, Ashley is one of only a few Nurse Corps officers who hold that rank, the highest military rank at LRMC. As such, he is part of the interdisciplinary executive group that meets daily and assumes command when Col. Jeffrey Clark, MD, commander of LRMC, is not present.
Ashley’s nursing background is always invaluable. For example, he recalls hosting representatives of another country and being able to explain nursing at LRMC, as well as medical and other services. Visitors from countries seeking to establish a similar military trauma system could see the importance of having a nurse accompany the physician they send to learn about the trauma system, and they appreciate this interdisciplinary approach.
As a nurse executive, Ashley seeks “to help other nurses gain skills and the know-how to make nursing visible.” It’s an ongoing leadership challenge not unique to LRMC. As evidence, he points to a recent issue of the widely read Soldier magazine, an official publication of the U.S. Army.
“Although nursing is the largest workforce in the Army Medical Department and the No. 1 respected profession in the United States, nursing in the magazine was only associated with practitioner or case manager roles,” he observes.
Situations such as this show him the need for educating people about nursing, both inside and outside the military. Advocacy, he says, is needed at all levels.
LRMC’s first doctorally prepared deputy commander
Ashley is the first deputy commander for nursing at LRMC with an earned doctorate. Over the past decade, he has been a principal investigator, site principal investigator and associate investigator on various projects. At one time, he thought his career would focus primarily on research. His leadership role as deputy commander of LRMC has taken him in a different direction, however, although he strives to connect his education with his current administrative role.
“A PhD is good for a nurse executive in order to be a research champion and a supporter of the nurse scientist’s role,” he observes. “Often, in the past, nurses who held research roles have been pulled into staff officer roles. [My background] has allowed me to be a cheerleader, advocate and protector of these roles.”
In writing his dissertation, “Barriers and facilitators to research utilization,” Ashley acquired a strong foundation for understanding and developing nursing research and scholarship in the military. One outcome of his commitment to nursing scholarship has been increased use of nursing research and evidence-based practice (EBP). For example, when he began his previous job as chief nurse of the Burn Center at San Antonio’s Institute for Surgical Research, the nursing workforce did not have unique nursing research or protocols—only physician-provided protocols. By the time he left 18 months later, the nursing staff had generated 15 abstracts from its own EBP activities.
One of Ashley’s goals at LRMC is to build support for nursing research and EBP among nurses and other disciplines, and he is working closely with other nurse leaders at LRMC to achieve scholarly outcomes, despite staff transition. To accomplish this, he first invites nurses to identify and value their ideas and to overcome their fears, then encourages research and EBP through support and, finally, over time, expects that research and EBP will be accepted as part of the LRMC culture and that it will be a regular nursing activity on the units at LRMC. To support research, LRMC will also have doctorally prepared nurse scientists. Soon after his arrival at LRMC, Ashley inaugurated nursing grand rounds, which he regularly attends.
Communication and leadership
Ashley views effective communication as the most important component of leadership. To him, leadership begins at the bedside in one-to-one patient care and effective communication with the patient and staff members. He believes that all professional relationships need to be based on trust, and that learning how to communicate effectively among groups fosters understanding, confidence and trust.
Ashley likens nursing and leadership at LRMC to a football team in a stadium. The football field, he explains, is where the staff plays the game, and leadership perspective changes depending on where in the grandstand nursing action is viewed. For example, the head nurse may have a first- or second-tier view, which is broader than that of a staff nurse. Each successive level of nursing leadership sees a larger picture and may, therefore, have a different understanding of why plays are called.
Ashley views his role as articulating to people unable to view the game from his perspective what is happening on the field, while he simultaneously receives information to inform what he sees from higher in the stadium. All perspectives are important, he emphasizes, and communication is critical so that every participant understands those perspectives.
During our meeting, Ashley gave me Dennis and Michelle Reina’s book, Trust and Betrayal in the Workplace: Building Effective Relationships in Your Organization. The book, a resource he provides to his leadership team, identifies ways in which trust empowers groups and produces excellence, describes situations in which distrust erodes morale and outcomes, and provides strategies to address trust-related issues. Using Britain’s Houses of Parliament as a reference, Ashley is also developing his own “Parliamentary Model of Status and Power among Healthcare Professions” to explain how nurses and physicians communicate and coexist within the paradigm of health care.
During our time together, he reflected on leadership challenges of his new role by posing several questions: How do we create the context for nurses to be successful? How does nursing quantify achievement with regard to patient care? How does expert care at the bedside translate into research, in light of the short-term assignments involved? How do we explain nursing to an audience of consumers, physicians and military members? How can we create a career path for civilian nurses, whom we depend upon and want to stay at LRMC?
These are not easy questions in any health care setting, but ones that LRMC’s deputy commander of nursing is ready to address. RNL
Carol Toussie Weingarten, PhD, RN, ANEF, is associate professor at Villanova University College of Nursing, Villanova, Pennsylvania, USA