USU nursing doctoral residents standardize workflows to reduce burnout and improve maternal care for service members abroad.
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| Army and Navy service members practice a hands-on procedure on a patient simulator during a skills session. Simulation lets military medical personnel at every experience level rehearse time-sensitive care before they provide it to real patients. (Photo credit: Tom Balfour, USU) |
October 21, 2026 by Hadiyah Brendel
Navy Lt. Cmdr. Amanda Mammolito is a board-certified inpatient obstetric nurse and a doctoral student in the Graduate School of Nursing (GSN) at the Uniformed Services University of the Health Sciences (USU). Before arriving at USU, she led a project that restructured the workflow of a mother-infant care unit at U.S. Naval Hospital Okinawa, Japan, so its nurses could manage unpredictable patient surges, staffing constraints, and complex care demands.
Mammolito, an Adult-Gerontology Clinical Nurse Specialist student in the Class of 2029 with a perinatal emphasis, said inpatient obstetrics is her “bread and butter.” She chose the GSN program to advance her clinical practice through process engineering, building on operational challenges she managed at overseas military treatment facilities (MTFs).
Identifying Workflow Friction in Overseas Care
Mammolito’s path to the GSN included a break from military service. After her initial tour as a Navy nurse, she separated from active duty to work in civilian hospitals. She describes much of that work as excellent, but she ultimately decided to re-commission into the Navy and, later, to begin her doctoral studies at USU.
During an assignment at U.S. Naval Hospital Okinawa from 2023 to 2026, Mammolito saw significant strain on the unit’s nursing staff from staffing shortages, a mix of experience levels, and an L-shaped floor layout that added to physical fatigue.
The strain reached even seasoned nurses, and it made her think about the newest members of the team. “If I’m feeling this as an experienced nurse, what are our novice nurses feeling?” she recalled asking.
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| Navy Lt. Cmdr. Amanda Mammolito, an Adult-Gerontology Clinical Nurse Specialist resident in the Uniformed Services University’s Graduate School of Nursing, led a project at U.S. Naval Hospital Okinawa, Japan, that standardized obstetric risk assessment and unit workflow. (Photo credit: Tom Balfour, USU) |
To address the floor layout and the lack of standardized tools for measuring acuity, or how much nursing care each patient needs, Mammolito worked with project co-leads and mentors Navy Cmdr. Amy Aparicio and Navy Lt. Brianna Garcia. Using Lean Six Sigma principles, a method focused on eliminating wasted steps and reducing process variation, the team created an Obstetric Risk Matrix and implemented an acuity tracker.
The team also re-evaluated the unit’s physical layout. The facility moved from a combined labor, delivery, recovery, and postpartum model to separate wings for labor, delivery, and recovery and for postpartum care. Moving higher-acuity patients closer to the nurses’ station and operating rooms let nurses watch those patients more closely and intervene faster when complications arose.
The changes showed results within the first three months. Staffing assignments that fell outside the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) staffing guidelines, which set recommended nurse-to-patient ratios for perinatal units, dropped from an average of 18% to below 12%. Patient satisfaction stayed above 95% throughout the transition.
Impact on Mission Focus
For service members deployed or stationed abroad, knowing their families have access to safe, responsive healthcare correlates to mission focus.
"As long as the U.S. Navy has assets and operational priorities overseas, service members and their families will need reliable obstetrical and neonatal care," Mammolito said. "Reliable maternal and neonatal care supports servicewomen’s health, recovery, and return to duty, while helping service members remain confident that their families have access to appropriate care overseas."
While the primary focus was patient safety, balancing nurse workloads also plays an important role in preserving the military healthcare workforce needed to sustain operations long-term.
Addressing Next-Generation Staffing Tools
Mammolito hopes her project brings broader attention to the need for specialized staffing tools. She presented her Okinawa findings at the AWHONN National Conference in 2024, calling attention to the lag in current electronic scheduling systems fully capturing the rapid fluctuations in patient acuity that defines obstetric triage and labor management.
"Staffing decisions must account for more than patient census; they must reflect the intensity of care, nursing expertise, and the capacity to respond to unexpected emergencies," Mammolito emphasized.
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| Navy Lt. Cmdr. Amanda Mammolito stands with the poster from her Lean Six Sigma quality improvement project, co-led with Navy Cmdr. Amy Aparicio and Navy Lt. Brianna Garcia, at the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) national convention. (Photo courtesy of Navy Lt. Cmdr. Amanda Mammolito) |
From Okinawa to Doctoral Study
The Okinawa project is the kind of work Mammolito’s doctoral program prepares nurses to lead. USU’s 36-month Adult-Gerontology Clinical Nurse Specialist Doctor of Nursing Practice (DNP) program educates nurses to practice across the three spheres of impact for clinical nurse specialists: the patient, the nurse, and the organization. Her team’s changes reached all three, from a risk matrix that sorted patients by acuity, to safer assignments for nurses at every experience level, to a redesigned unit.
The program’s curriculum is built to meet national competencies for women’s health and perinatal clinical nurse specialists, which matches Mammolito’s perinatal emphasis. It also places special emphasis on Defense Health Agency processes and structures, the same enterprise level her Okinawa poster pointed to for next steps when it recommended working with agency and information technology stakeholders on labor and delivery features that capture real-time patient acuity. Before graduating, each student in the program creates and implements a DNP project that addresses a healthcare system problem.
Looking forward, she hopes leadership in medical centers will prioritize obstetric-specific electronic staffing tools that integrate real-time triage data.
"Maternal and neonatal healthcare is essential to the health of the warfighter, the well-being of military families, and force readiness," Mammolito noted. "How we care for our servicewomen, dependents, and their babies deserves sustained attention in staffing, training, and resource planning—particularly in overseas settings where resources may be limited."