shipboard nursing perceptions

Shipboard nursing on aircraft carriers: Theperceptions of twelve Navy nurses

Catherine Wilson Cox, RN, PhD, CCRN, CEN, CCNS

The purpose of this study was to describe the experi-ence of shipboard nursing on aircraft carriers. Usingthe principles of Husserlian phenomenology, 12 Navynurses previously stationed aboard aircraft carrierswere interviewed to explore their familiarity with beinga ship’s nurse. Shipboard nursing was best describedby the following essences: (1) experiencing the bestbut toughest job the Navy has to offer its nurses; (2)ensuring readiness; (3) being one-of-one; (4) operat-ing constantly in an environment of uncertainty; (5)having 2 families; and (6) making the job better for thenext generation. Since the United States is currently anation involved in wartime activities, the findings of thisstudy are timely and give a public voice to thisextraordinary experience of military nursing. Addition-ally, any nurse who is a sole practitioner may recog-nize some commonalities.

Aircraft carriers support the United States’ (US)interests and commitments throughout the world.Moreover, the Navy’s surface forces are built

around battle groups with aircraft carriers as theircenterpieces. Frequently the focal point of US military,diplomatic, and geopolitical strategy, aircraft carriersrepresent the cornerstone of Navy “operational readi-ness,” which is defined as “the ability to deploypersonnel and equipment in an expeditious manner toany part of the world in support of military opera-tions.”1 Each aircraft carrier is as tall as a 24-storybuilding, weighs approximately 97000 tons, containsover 2700 compartments, has a flight deck � 4.5 acres

Catherine Wilson Cox is an Assistant Professor at the School of Nursing& Health Studies, Georgetown University, Washington, DC and aCaptain in the US Naval Reserve.This research was sponsored by the Department of Defense Tri-ServiceNursing Research Program (TSNRP) at the Uniformed Services Univer-sity of the Health Sciences — (Grant #N00-002). Primary IRB approvalwas obtained from the National Naval Medical Center, Bethesda, MD(CIP Study #B00-020). The views expressed in this publication are theauthor’s and do not reflect the official policy or position, nor should anyofficial endorsement be inferred by, or of the TSNRP, Department of theNavy, Department of Defense, nor the US Government.Reprint requests: Dr. Catherine Wilson Cox, Georgetown UniversitySchool of Nursing and Health Studies, 3700 Reservoir Road, NW,Washington, DC 20057.E-mail: [email protected]

Nurs Outlook 2005;53:247-252.0029-6554/05/$–see front matterCopyright © 2005 Mosby, Inc. All rights reserved.
doi:10.1016/j.outlook.2005.02.007
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in area, and carries a crew of 5000–6000. An aircraftcarrier has an airport control tower, holds over 80aircraft, and features a movie theater, television station,library, chapel, gym, and medical and dental wards.2

The Navy has 12 aircraft carriers in operation. Thehealth care staff on each ship includes 6 physicians, aphysician’s assistant, 1 registered nurse, and 40 enlistedhospital corpsmen. There is 1 operating room, a 3-bedintensive care unit (ICU), a 50-bed inpatient ward, otherpatient care areas, and further ancillary spaces thatprovide radiography and endoscopy services.3

The ship’s nurse on an aircraft carrier shouldersconsiderable weight and scope of responsibility for thehealth and readiness of the ship’s crew. The enormity ofthis task requires that nurses assigned this duty be fullyprepared to serve in this capacity upon arrival to thecarrier. The initial step in this process is the formulationof a thorough and accurate description of the responsi-bilities of a ship’s nurse on an aircraft carrier. Since thisinformation did not exist in some codified and readilyaccessible form, this study was designed to elicit andcompile this critically important information from thosewith first-hand knowledge of the experience.

METHODSThis phenomenological inquiry was grounded in Ed-mund Husserl’s perspectives. The goal of Husserlianphenomenology is to describe the meaning of an expe-rience from the standpoint of those who have had (or“lived”) that experience.4 Husserl’s emphasis on puredescription was consistent with the purpose of thisresearch, so his phenomenological philosophy wasadopted as its theoretical framework. Streubert’s 5,6

ten-step methodology for qualitative examination ofphenomena—which is a compilation of several phe-nomenological researchers including Spiegelberg, Co-laizzi, Patterson and Zderad, Oiler, and van Manen—was selected for its clear investigational approach.

Step 1: Explicating a Personal Description ofthe Phenomenon of Interest

The researcher must clarify any prejudices prior todata collection. Better yet, one should write a descrip-tion of his/her perceptions in an attempt to acknowledgeany presuppositions about the phenomenon of interest.The fact that I never served as a ship’s nurse assisted
with this step.
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Shipboard nursing on aircraft carriers Cox

Step 2: Bracketing the Researcher’sPresuppositions

Few concepts in phenomenology have led to as muchmisunderstanding as the concept of bracketing. EvenHusserl was not consistent with his writings on brack-eting.7 The process of bracketing was Husserl’s way ofreducing the natural world to a transcendental con-sciousness.8 Bracketing is “transcendental because itconstitutes every transcendence in pure subjectivity.”9

To accomplish bracketing, the researcher must suspendthe “natural attitude” and shift to the “phenomenolog-ical attitude” in order to understand the true meaning ofexperienced phenomenon. Bracketing is a philosophicaldevice that negates the natural attitude prior to phenom-enological inquiry.10 With bracketing, only descriptionsare allowed because judgments belong in the naturalattitude. The goal of bracketing is to allow the investi-gator to render an absolutely faithful description ofwhat has been given. Phenomenology must begin andend with what is given because the first transgression inphenomenology is to transcend the given.11

Two processes that supported the concept of brack-eting were used for this study. First, pre-conceivedideas about the phenomenon of interest were explicatedthrough documentation in a journal.6 Furthermore,journaling occurred prior to and following each inter-view. Second, any perceptions and decisions werecross-checked with a colleague whenever it appearedthat individual biases were influencing the project.12

Step 3: Interviewing Participants in SettingsComfortable to the Participants

The tape-recorded face-to-face interviews took placein settings familiar to the participants. Nurses who hadbeen previously stationed on an aircraft carrier (for atleast 2 years) were purposively selected to participate inthis study. Six of the participants were female and 6were male. I initially contacted those nurses who hadleft the aircraft carriers within the past 2 years of whendata collection began. A backwards year-by-year pro-gression was utilized to solicit former aircraft carriernurses, and interviews were conducted until saturationoccurred (when no new themes emerged). In retrospect,saturation was probably reached by interview number 6or 7; however, this fact was not fully appreciated untilthe last 2 interviews. This impression is validated bySandelowski’s13 comment that novice qualitative re-searchers, such as myself, often require more samplingunits than experienced researchers and that saturationmay not be recognized until more data are collected.

Prior to the start of the formal interview, informedconsent was documented and demographic data wasobtained (in order to fully place the data into context).The interviews began with the question: “What wasyour experience as a nurse on an aircraft carrier?”When the participant felt he or she had expended his or
her description, this concluding question was asked: “Is
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there anything that you have not offered, either positiveor negative, about the experience that you would like toadd?” Requesting negative descriptions of the phenom-enon assists the researcher with determining authentic-ity and trustworthiness of the data (by allowing data tobe compared and contrasted). Most of the participantsutilized this solicitation as their time to offer a conclud-ing remark regarding their entire experience as being aship’s nurse.

Step 4: Carefully Reading the Transcripts ofthe Interview to Obtain a General Sense ofthe Experience

The interviews were transcribed prior to data analy-sis and then the transcripts were read while listening tothe audiotapes so that their accuracy could be verified.In-depth analysis of the interview data commencedafter data saturation was achieved in order to avoidimposing meaning from one participant’s interviewonto the next. During this aspect of data analysis, thetranscripts were reviewed repeatedly to gain an overallimpression of the data. Organization of the data wereaided through the use of the computer program entitledNVivo.

Step 5: Reviewing the Transcripts to UncoverEssences

Essences compose the basic units of common under-standing of any phenomenon.6–8 There was no attemptto order sentences into themes at this point. Over 2500passages pertaining to the experience of shipboardnursing aboard aircraft carriers were eventually isolatedand assigned to 98 codes (otherwise known as “nodes”in NVivo). Data management occurred when some ofthe codes obviously went with others.

Step 6: Apprehending Essential RelationshipsOnce the transcripts were coded, the next step of

apprehending essential relationships began. UsingNVivo, an “assay scope” of all of the codes in relationto each participant was run. The assay scope of 98codes revealed codes which were common to theparticipants (meaning that at least 7–12 of the partici-pants had significant statements attributed to that code)and which codes were not (meaning that �6 of theparticipants had significant statements related to thatcode). The NVivo assay scope of the significant com-mon codes was printed, along with their extractedpassages, and the reports were used to apprehendessential relationships.

By reading and re-reading the extracted passages ofthe common codes, and practicing the concept ofbracketing, all possible forms the experience could takefrom all angles was examined. By adding and deletingcertain features, and recognizing when the experienceno longer exemplified the concept, what was essential
to the experience was eventually identified. Once an
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essence emerged, it was recorded and the next step ofdata analysis ensued in order to describe the newessence.

Step 7: Developing Formalized Descriptions ofPhenomena

For this step, the word processing capabilities of thecomputer were used. Portions of the description wereentered and deleted until an accurate depiction of theessence was captured. When in doubt, I returned to theextracted passages of the common codes and read andre-read them until an accurate representation of theessence materialized. Eventually, shipboard nursingwas best described by 6 essences.

FINDINGSEssence 1: Experiencing the Best butToughest Job the Navy Has to Offer Its Nurses

The participants felt that shipboard nursing on air-craft carriers was one of the best but toughest jobs theNavy has to offer its nurses. They experienced a greatsense of pride in being called the “Ship’s Nurse.”Carrier nursing was a worthwhile experience that in-cluded both rewards and challenges. The rewards in-cluded practicing in an autonomous environment; goingto sea and experiencing what the Navy was all about;feeling a sense of mission and contributing to thatmission; and traveling to unique locations. Among thejob’s challenges were working in a dangerous workenvironment that incapacitated or even killed ship-mates; being away from home when deployed; partic-ipating in exercises to get the ship ready for sea travel;navigating equipment and supply issues; and adjustingto the constant turnover of both the medical departmentpersonnel and the ships’ crew. All of the nurses felt thatshipboard nursing was not without its challenges; how-ever, they were pleased that they had a chance toexperience what the Navy was all about:

It was probably the most challenging, demanding,rewarding, and exciting job I’ll ever have in theNavy . . . . You really got a sense of what theNavy was all about . . . when you’re out tosea. . . . You can see the Navy working, launchingjets and doing underway replenishments and see-ing every aspect of the Navy at once from everysailor doing their job . . . so it was really kind ofneat to be a part of something bigger and you felta sense of mission and you felt your contributionto that mission.

Despite some difficulties, the participants felt goodabout their tours as shipboard nurses and commented onhow they sometimes missed the experience:

I have nothing negative to say at all about my touras a carrier nurse . . . . It will always be one of themost profound experiences of my career and my
life. It was more than a job; the ship was my home
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and the crew was my Navy family for 3 years. Thecall sign of our ship [was] “Courage” and I sawexamples of it at every level everyday.

With sadness, 1 participant confessed that the demiseof a shipmate was this nurse’s first exposure to atraumatic death. The exemplar also illustrates the factthat the nurse practiced in an environment of uncer-tainty, and that the setting could prove dangerous attimes. At one point, this nurse experienced a moment oftrepidation:

We had an F-14 pilot get killed. . . . Two F-14s. . . were flying towards each other and they gottoo close . . . one clipped the other. . . . One of[the pilots] died . . . so they brought him on board. . . . Nobody ever explained to me what to dowith somebody who dies . . . . Going through thatprocedure, we had to cut off his flight suit . . . theyhad to do a number of x-rays on him . . . .Immediately, when I realized that there was some-body dead, I started shaking. I was shocked.Because . . . up until then, everybody lived. Thenit occurred to me how dangerous their job was. Igained my composure and went back to work.

Essence 2: Ensuring ReadinessThe nurses’ primary and most time-consuming job

was ensuring readiness by coordinating the medicaltraining team. In this capacity, they developed scenar-ios, simulated medical casualties throughout the ship,and conducted various briefings regarding each drill.Orchestrating these exercises involved substantial as-similation with all of the departments on the ship;consequently, the nurses got a lot of “face time” withthe leaders on each ship.

The top 3 job responsibilities mentioned consistentlyduring each interview were (1) acting as the medicaltraining officer, (2) caring for the inpatient ward, and(3) monitoring quality assurance (QA). In addition tothese primary responsibilities, each nurse held at least10 collateral duties. The method of assignment ofcollateral duties was sometimes inexplicable; however,letting a legitimate duty go unfulfilled was inconceiv-able to these nurses:

At one point, I kind of reached a breaking pointand tried to be departmental training coordinator,ward nurse, ICU nurse, training team leader,credentials nurse, QA nurse, and try[ing] to dohealth promotions, and wear all the hats, and tryto have balance. It was really difficult.

Essence 3: Being One-of-OneThe nurses were considered one-of-one because they

were the only nurse assigned to their carrier as the“Ship’s Nurse.” Not only did they represent nursingservices for their ship, they were nursing services. The
nurses felt an incredible sense of responsibility to their


job. They were on call 24/7. The nurses knew theirships inside and out and made it a point to visit all of theships’ spaces, especially in their capacity as coordina-tors of the medical training teams. It was not uncom-mon for the nurses to be stopped in the passagewaysand consulted on matters ranging from the crew’s ownhealth care needs to questions about a family member’shealth status. Everyone on the ship recognized thenurse.

If the nurses had patients in the ICU, they couldcount on getting very little sleep because they had todeliver direct patient care round-the-clock. They couldnot initially count on their corpsmen (whose roles areakin to licensed practical nurses) to be their substitutebecause the corpsmen were not yet trained to take careof critically ill patients. Whereas the physicians couldtradeoff on their coverage, the nurses could not becausethey were one-of-one. As the only nurse, experiencingthe autonomy of critical care nursing could be both anexciting and frightening prospect:

I had no corpsmen that had any inpatient experi-ence whatsoever. You are the only ICU nurse,which means when I [had] my two ICU beds full,I was literally catching a catnap on the floorbetween the two patients. . . .

Essence 4: Operating Constantly in anEnvironment of Uncertainty

The nurses constantly operated in an environment ofuncertainty. They could never be sure of what wasgoing to happen next and always wondered about the“ifs”: if their qualifications were sufficient to get the jobdone; if they could trust their corpsmen with theinpatient ward; if the ships’ crew could manage atrauma victim given the training the nurses had coordi-nated for them; if they could handle a critically injuredpatient in their ICU; and if they could manipulate thesometimes archaic equipment they had inherited. Feel-ing a strong sense of support from their leaders wasparamount in allowing the nurses to excel in their roleas the ship’s nurse while practicing constantly in anenvironment of uncertainty.

Caring for the inpatient ward (which was 1 of thenurses’ key job responsibilities) included training the 2or 3 corpsmen assigned to the ward. Because the nurseswere involved with various activities around the ship,they had to be able to trust the corpsmen to be their eyesand ears on the ward. This proved to be a challenge,since most of the corpsmen initially assigned to theward had no experience with direct patient care. Thenurses strived to develop their corpsmen’s clinicalcompetency levels and were amazed at the progress alot of the corpsmen made under their mentorship. Theyrecognized that the more they devoted to the training oftheir corpsmen, the more they could trust the corpsmento report pertinent patient information when they were
otherwise engaged. Since the nurses were on call 24/7,

they had to relinquish some control in order to survivethe experience:

I think the biggest challenge of a ship’s nurse isdeveloping your corpsmen . . . . No matter whoyou are, no matter how good you are, 24 hours aday, seven days a week, at some point, you’regoing to have to get sleep and some point, you’regoing to have to shower, [and] you’re going tohave to eat. So . . . at some point, you’re going tohave to leave the ward, and trust the ward, and thepatients, to the corpsmen. If you can’t do that . . .you’re not going to make it because physically,Mother Nature says you have to eat, you have tosleep, you have to have socialization, or you justwon’t do well.

Essence 5: Having Two FamiliesThe nurses had 2 families: their significant others

and their shipmates. Working with the Line community(which consists of the war-fighting population of theNavy such as the officers that man the ships, fly aircraft,and operate submarines) was a great experience for thenurses. Never before had they seen such amazingteamwork, and felt such a sense of camaraderie, andthey realized that once they left their ships, they wouldmost likely never experience this again. Because theyworked, lived, ate, and socialized with the crew, theylearned about their lives. The Line community demon-strated its respect by allowing the nurses to becomeequal players in the ships’ operations:

I didn’t have a lot of ship savvy when I got there.But these folks saw . . . somebody who caredabout the ship . . . . So here’s somebody who theydidn’t just see as a nurse . . . . There’s that otheraspect of it: You’re a [nurse] . . . but you’re also. . . a Naval citizen. You’re going there to be partof that ship. And you’re a shipmate. So they neverjust blew me off because I was a nurse.

Essence 6: Making the Job Better for the NextGeneration

The nurses wanted to make the job better for theirsuccessors. Because their own shipboard orientationhad been varied and ill-defined, they felt it imperativethat their replacements be better prepared than theywere when each assumed the duty of an aircraft carriernurse. This philosophy spilled over into their subse-quent tours whereby they took advantage of opportuni-ties to prepare their Navy colleagues for non-hospitalassignments.

The participants’ highest recommendation was toassign a second nurse to each carrier. If a second nursecould not be allocated, then the nurses recommendedhaving peers from a Navy hospital transferred to the
ships when the carriers went out to sea:
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I was literally running almost from one drill set,zipping through the medical department, gettinginto the ICU. I had a box of 10 syrettes of demerolin 1 pocket and a box of 10 syrettes of morphinein the other pocket as I’m running around the ship.And I’d come down into [the] Medical [Depart-ment]. I had the different names . . . labeled on thetubex and then I would give them a little bit of IV[intravenous] push med [medication] for pain.And then, boom! I was out the door again afterdocumenting . . . that I gave something. And then,boom! I was out running more drills or attendingmore meetings. That was absolutely ludicrous. Icouldn’t have been getting but maybe 3 hours ofsleep every night. That’s another reason why youkind of need another nurse.

Step 8: Returning to Participants to ValidateDescriptions

Lincoln and Guba’s14–15 criteria for evaluating thequality of an inquiry (transferability, dependability,confirmability, and credibility) were applied to thisstudy. To confirm the credibility of the findings, ex-haustive descriptions were shared with each participant.Once some minor changes were made, all 12 partici-pants agreed that the exhaustive description accuratelyreflected their experience as the nurse on an aircraftcarrier.

Step 9: Reviewing the Relevant LiteratureAn exploratory search using electronic databases

revealed only 1 article about nursing on aircraft carri-ers16; thus, findings from this study will fill a huge void.Nonetheless, I was later directed to look at literatureregarding the practice of nursing in non-traditionalenvironments, and discovered that rural nursing alsorequires adaptability and flexibility, and that nurses inrural communities fear the “what ifs” as well, butwelcome the autonomy that nurses aboard ships alsovalue.17,18

Step 10: Distributing the Findings to theNursing Community

I had the honor of presenting my findings to theChief of the Nurse Corps, the Nurse Corps assignmentofficers, and the Director of Aerospace Medicine Pro-grams and their staffs in 2002. At this moment, theparticipants’ highest recommendation to assign a sec-ond nurse to each carrier has not been implemented(primarily because the role of the ship’s nurse has beenmodified since this study, with the addition of newpersonnel to the Medical Department on each carrier).However, before this study, each carrier nurse reportedto a non-nurse in the Force Surgeons’ offices in bothSan Diego, CA and Norfolk, VA, which meant thatnon-nurses were telling the ships’ nurses how to per-
form nursing care on the carriers. The Navy Nurse
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Corps has since placed a senior nurse in the ForceSurgeon’s office on both coasts, which was 1 of thehighest recommendations the participants advocated.

DISCUSSIONThe nurses valued the opportunity to perform a tour ofduty outside of a traditional hospital. When they wentout to sea on the carriers, they finally understood whatthe Navy was all about. They were also committed tothe organizational values of their ships’ commands. Theleadership style and empowerment opportunities avail-able to the ships’ nurses positively related to their senseof job satisfaction. What’s more, group cohesion defi-nitely promoted both organizational and professionaljob satisfaction for the participants. In their role as theship’s nurse, they constantly remembered that theyrepresented the United States in their role as Navalofficers:

I think being part of a big command that has suchan enormous mission, you get this great sense ofpride that just comes out of you. It’s like, “Wow!”You see yourself steaming in with the wholebattle group and you are part of something that isstriving to represent this country. You’re workingup so that you can deploy and essentially be theambassador. That’s how we were made to feel. Itwas impressed upon us that you’re the ambassa-dor. So to be part of that as a nurse, you’rethinking, “I was in nursing school. Never did Ithink I’d be considered an ambassador of mycountry representing this ship ashore.”

When reviewing the transcripts, I came to the real-ization that gender made no difference in the experienceof shipboard nursing on aircraft carriers—the inter-views of the male versus the female participants weremuch more alike than different. Furthermore, thewomen participants never saw themselves as womenfirst. They envisioned themselves primarily as Navalofficers and could not understand why people askedthem if they felt out of place when reporting to themale-dominated ships. They just considered themselvesto be doing their duty: “People did their jobs.. . . Therewere times where I won’t say you forget that you’re awoman, but you’re just doing your job so you don’tthink of it.”

Obviously, the participants’ experience as the ship’snurse on an aircraft carrier was a momentous, careerlife-event for each nurse, since they all remarked onhow lucky they were to have had such an assignmentbecause many Navy nurses never set foot on a shipthroughout their entire careers. The participants filledinnovative roles that allotted for more autonomy thanthe nurses had previously experienced. Shipboard nurs-ing on aircraft carriers provided a diversified opportu-nity that the nurses will remember for the rest of their
lives. A prevailing thought among the interviews was


exemplified by the comment: “Gosh, it’s a good feelingto be called ‘ship’s nurse.’ There’s only one of you.”

CONCLUSIONThe findings have provided valuable insight into nurs-ing practice in a service-unique environment and willalso assist Navy Nurse Corps leaders with makingappropriate assignments for nurses seeking a job on aship. Additionally, since there is a paucity of literatureon this topic, the results have given a public voice tothis extraordinary experience of military nursing. More-over, any nurse who is a sole practitioner may recognizesome commonalities. As I conclude this article, I cannothelp but think about the nurses currently stationed onour aircraft carriers. They are playing an integral part intheir ships’ readiness and one cannot help but appreci-ate their role in maintaining our nation’s freedom. Ionly hope that the findings from this study will maketheir job better for generations to come.

This study was conducted during my dissertation process at GeorgeMason University in Fairfax, VA and I would like to thank myDissertation Committee (Dr. Jeanne Sorrell, Dr. Janet Hale, and Dr.Evelyn Jacob); my consultant, Dr. Helen Streubert Speziale; and Dr.JoAnn Grif Alspach for her editorial comments.

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