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the rest of the interested FNPs to take the TC3 course to en- of EMS fellowships. J Spec Oper Med. 2017;17(1):101–104. doi:
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The limitations of this EBP pilot project include the limited 3. Petit NP, Stopyra JP, Padilla RA, Bozeman WP. Resident involve-
literature related to nurse practitioners (NPs) working in pre- ment in tactical medicine: 12 years later. Prehosp Disaster Med.
hospital, austere, military/combat/battlefield, or tactical envi- 2018;34(2):217–219. doi:10.1017/S1049023X19000013
ronments. In addition, this was an EBP pilot study and not a 4. Feyereisen S, McConnell W, Thomas C, Puro N. Physician domi-
formal research project. Although the participants’ responses nance in the 21st century: examining the rise of non-physician au-
and written exams were blinded to the project leader, having tonomy through prevailing theoretical lenses. Sociol Health Illn.
the ability to compare a test group against a control group 2021;43(8):1867–1886. doi:10.1111/1467-9566.13366
would have added validity to the results. Additionally, while 5. Alfes CM, Manacci CF. Taking simulation to new heights: design-
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every effort was made not to introduce bias into the EBP pilot 445. doi:10.1016/j.ecns.2014.05.006
study the FNPs knew the topic of the pilot study, which may 6. Alfes CM, Steiner SL, Manacci CF. Critical care transport train-
have introduced bias. Finally, other non-physician providers ing: new strides in simulating the austere environment. Air Med J.
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an evidence-based pilot study that improved or added to the 8. Ruskin KJ. Helicopter air ambulance services. Curr Opin Anaesthe-
siol. 2019;32(2):252–256. doi:10.1097/ACO.0000000000000700
body of knowledge in an area of nursing or for nurses/nurse 9. Green D, Ruel J. Impact of advanced practice prehospital pro-
practitioners. Second, the university-based flight program em- grams on health care costs and ED overcrowding: a literature
ploys flight nurse practitioners and already had a standing review. Adv Emerg Nurs J. 2020;42(2):128–136. doi:10.1097/
group of nurse practitioners willing to participate in the study. TME.0000000000000291
10. van Vliet R, Ebben R, Diets N, Pelgrim T, Loef J, Vloet L. Nurse
practitioners and physician assistants working in ambulance care:
Conclusion a systematic review. F1000Research. 2020;9:1182. doi:10.12688/
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Historically, the tactical physician has been the advanced-level 11. Boutonnet M, Raynaud L, Pasquier P, Vitiello L, Coste S, Ausset
provider rendering care and medical direction to the SWAT S. Critical care skill triad for tactical evacuations. Air Med J.
team in training and operational callouts. When the tactical 2018;37:362–366. doi:10.1016/j.amj.2018.07.028
physician is absent, evidence demonstrates that NPs are the 12. Woo BFY, Lee JXY, Tam WWS.. The impact of the advanced
ideal advanced-level providers to stand in their place over practice nursing role on quality of care, clinical outcomes, patient
other disciplines due to their level and depth of training. With satisfaction, and cost in the emergency and critical care settings:
the rise of the NPs over the past 20 years, many gaps in health- a systematic review. Hum Resour Health. 2017;15(1):63. doi:10.
1186/s12960-017-0237-9
care have been closed as NPs continue to expand their practice 13. D’Angelo MR, Seibert D, Wanzer L, et al. Operational readiness:
horizon. As NPs continue to increase their self-efficacy, they redesigning advanced practice registered nurse (APRN) curriculum
will continue to push boundaries. The TC3 course is the na- for an evolving battlefield. Mil Med. 2019;184(3–4):e156-e162.
tional standard for tactical medical training. Statistically sig- doi:10.1093/milmed/usy269
nificant and clinically relevant data from this EBP pilot study 14. Georgiev R, Stryckman B, Velez R. (2019). The integral role of
demonstrated that the FNPs’ tactical self-efficacy, knowledge, nurse practitioners in community paramedicine. J Nurse Pract.
2019;15(10):725–731. doi:10.1016/j.nurpra.2019.07.019
and skills increased after the TC3 course. Additional training 15. Harper PN, Taylor N, Royal P, Smith MB. Role of the pre- hospital
is still needed to sustain and nurture the self-efficacy of the treatment team on the UK military exercise SAIF SAREEA 3.
FNPs before they assume the role of the LET-NP in support of BMJ Mil Health. 2020;166(6):421–424. doi:10.1136/bmjmilitary-
a metropolitan SWAT team. 2019-001366
16. Karimi-Shahanjarini A, Shakibazadeh E, Rashidian A, et al.
Because this was an EBP pilot study, the outcomes, and re- Barriers and facilitators to the implementation of doctor-nurse
sults are not generalizable outside of the FNP population of substitution strategies in primary care: a qualitative evidence syn-
the Level 1 trauma center’s university-based flight program. thesis. Database Syst Rev. 2019;4(4):CD010412. doi:10.1002/
14651858.CD010412.pub2
Further studies will need to be conducted before results can be 17. Pilgrim CHC, Hendel S, Eatough N, Graves M. Treatment at
generalized. However, the flight program will use these data point of injury – Forward movement of surgical assets to address
to plan future TC3 courses to increase the tactical self-efficacy non-compressible truncal haemorrhage. J Mil Veterans Health.
of the rest of its interested FNP population as it prepares to 2022;30(1):41–50. doi:03.2022-92674215/JMVH
implement the role of the LET-NP. This project also brings to- 18. Smith T, McNeil K, Mitchell R, Boyle B, Ries N. A study of macro-,
gether the current body of knowledge regarding NPs working meso- and micro- barriers and enablers affecting extended scopes
in prehospital and tactical environments. of practice: the case of rural nurse practitioners in Australia. BMC
Nurs. 2019;18:14. doi:10.1186/s12912-019-0337-z
19. van Vliet R, Deddens GJ, Evenhuis R, Moors XRJ. A survey of
Disclosures the current nurse practitioner and physician assistant workforce
The author has no potential competing interests to disclose. in Dutch ambulance care. Int J Nurs Stud Adv. 2022;4:100099.
doi:10.1016/j.ijnsa.2022.100099
Funding 20. Wright D, Baker T, Muthersbaugh H, Platt T, Kerr R, Miller J. Po-
No funding was received for this work. sition statement: the role of the EMS physician assistant (PA) and
nurse practitioner (NP) in EMS systems. Prehosp Emerg Care.
2021;1. doi:10.1080/10903127.2021.1977878
References 21. Butler FK. Two decades of saving lives on the battlefield: Tactical
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