Abstract
Nurses routinely provide essential and integral core functions in the field hospital environment, such as daily operational service delivery planning and management, clinical governance and scope of practice supervision, workforce management and skillmix allocation highlight the need for constant flexibility and adaptation when planning, allocating, and maintaining an effective and efficient deployed operational clinical workforce roster to ensure optimal and quality service delivery is achieved. Nurses should not only be appropriately skilled and trained, but most importantly, supported in the translation and adaptation of their nursing practice into the context of an austere and environmentally challenging setting. In addition, nursing staff need to have an awareness of the host nation’s health and societal culture, language, and potential barriers, which may impact on the abilities to effectively deliver clinical care. Strong nursing leadership is pivotal in ensuring effective and efficient running of a deployed field hospital with limited resources in an austere and environmentally challenging setting. In the context of overwhelming demand, limited resources and a low-tech environment, there is a requirement for a flexible, adaptable, multi-skilled nursing workforce to adequately meet the needs of the population at risk.
Introduction
Strong nursing leadership is pivotal in ensuring the effective and efficient running of a deployed field hospital with limited resources in an austere and environmentally challenging setting. In the context of overwhelming demand, limited resources, and a low-tech environment, there is a requirement for a flexible, adaptable, multiskilled nursing workforce to adequately meet the needs of the population at risk.
Delivery of care in an austere disaster environment creates many unique nursing challenges: operating in a resource-limited multidisciplinary team, identifying relevant scopes of practice, specialized skill sets and currency requirements, competency and skill mix considerations, human resource management, and patient flow.
In the ever-increasing age of technology in health care, a return to the foundation principles of nursing care and application of “clinical medicine” in the absence of many modern diagnostic tools is fast becoming the primary domain of the widely acknowledged aging generation of nurses. The absence of high-tech modern diagnostic tools in the disaster setting necessitates a return and emphasis on the basic clinical skills as foundation principles of nursing care.
Planning
Service Delivery/Roles
Ensuring safe and optimal quality standards of care to an affected population mandates broad and diverse areas for responsibility encompassing far beyond direct clinical care only; concurrently meeting unique, rapidly changing demands associated with delivering and maintaining an acute-care field hospital. Such responsibilities often require dual, complementary clinical and operational approaches to leadership, necessitating the designated nursing team leader to be highly flexible and adaptive in their leadership and nursing practice when translated into in an austere, complex disaster environment.
A dual medical/nursing clinical operational co-leadership model jointly enables the holistic, interdisciplinary provision of leadership, management, and oversight of delivery of clinical field services:
ensuring the highest standard of clinical care is delivered by the field facility
ensuring compliance with global minimum technical standards related to patient and clinical care service delivery
ensuring occupational work health and safety requirements are met in clinical areas
coordination, rostering, and allocation of individual clinical staff duties
identification of clinical infrastructure support requirements (water, power, lighting, environmental control) and communication to logistics
monitoring and identifying patients presenting with specific, specialist care needs: infectious, obstetric, palliative, and so on
identifying potential indicators of infectious disease outbreaks and communicating to taskforce leader
oversight of team morale and welfare
Clinical team leaders (CTLs) require the expert knowledge, skills, and understanding of their respective professions to efficiently provide both clinical oversight and governance of the field facility, while also providing high-level support to the taskforce leader. A CTL should only engage in direct patient care where clinical load exceeds capacity and with the knowledge and agreement of the taskforce leader.
Role of the Nursing Team Leader
As is common practice in many modern health-care systems throughout the world, the nursing team leader in an austere field hospital environment is primarily responsible for the ongoing operational management of the clinical facility; working in tandem and close partnership with the medical team leader ensuring the delivery of optimal care. In contrast, however, the nursing team leader’s role in the field hospital environment differs significantly and is extremely challenging and demanding; encompassing many diverse responsibilities including management, coordination, liaison, clinical, operational, and administrative tasks daily, which would not ordinarily be encountered by a sole practitioner during their standard nursing practice when not deployed into an austere field hospital environment (Table 28.1 and Figure 28.1). Each of these broad areas of responsibility requires the nursing team leader to be highly flexible and adaptive in their leadership and nursing practice and they are explored in further detail below.
Table 28.1 Overview of key clinical nursing lead roles and responsibilities by phase of deployment
| Predeparture | |||
|---|---|---|---|
| Ensure they have a thorough situational awareness of the deployment mission and destination environment | Support the taskforce leader in delivering mission briefings, and deliver a specific briefing on expected clinical case load and clinical service requirements | Familiarize themselves with the skillsets and competencies of all clinical staff | Create a roster to match anticipated clinical service requirements |
| On mission | |||
| Support the team leader in delivering morning briefings with a focus on the clinical order of business for the day | Roster staff into clinical roles, including night shift and emergency on call if applicable | Ensure adherence to organizational clinical protocols | Act as a resource for treating clinicians as workload and operational requirements dictate |
| Actively monitor team welfare and report to the team leader regarding any specific points of concern | Oversee medical record keeping and data collection in conjunction with the nominated data collection officer | Convene the ad hoc “ethics committee” to assist with difficult ethical decisions surrounding individual patients | |
| Postmission | |||
| Support the team leader in preparation and collation of postdeployment report | Participate in senior organization postdeployment debriefings | Act as a resource and support for returned team members where relevant | Monitor team welfare and report to the team leader regarding any specific points of concern |
Management Role
rostering 24-hour clinical services: inpatient, outpatient, and emergency on-call services
daily allocation of staff roles and rotations
maintenance of skill mix across all clinical areas: primary health care, maternal/child health, triage, emergency clinic, resuscitation area, operating theater, medical/surgical, and pediatric wards
ensuring staff occupational work health and safety in all clinical areas
identifying and responding to critical incidents
monitoring team morale and individual well-being; clinical facility rounds (minimum four times per day recommended)
Coordination Role
clinical flow and referrals of patients between outpatient and inpatient areas
inpatient bed management and allocation
identifying and facilitating patient transfers: aeromedical and ground
facilitation of discharge planning
embedded external clinical staff, such as host ministry of health (MoH) staff and other emergency medical team (EMT) specialist cell teams (where applicable)
Liaison Role
taskforce mission leader, EMT team leader, and clinical (medical) co-lead
MoH
external clinical agencies: nongovernmental organizations (NGOs), government organizations, and military
local community representatives: police, social welfare, and pastoral care
media and VIP guest visits
EMT logistics’ team leader and staff
EMT clinical staff: medical, nursing, pharmacy, radiology, allied health, and paramedical
family: patients and staff
Clinical Role
member of the senior ethics group: decisions around limitations of care, palliation, and critical incidents
expert/specialist advice and support to individual clinical areas
monitoring and identifying clinical presentations with special needs: infectious, obstetric, palliative, and so on
identifying and facilitating nursing care for high dependent or specialized-needs patients
oversight care pathways/plans
daily inpatient ward rounds (every 12 hours)
clinical equipment management and troubleshooting
Operational Role
clinical stores’ consumable supply levels and resupply requirements
identification of clinical infrastructure support requirements: water, power, lighting, and environmental control
oversight of cleaning and maintenance for clinical areas
oversight of inpatient kitchen and patient nutrition
patient and family hygiene and sanitation
Administrative Role
reporting births and deaths
daily patient tracking and reporting
daily field hospital activity situation report
While the breadth of responsibilities encountered as nursing team leader can be both arduous and highly challenging, many are not dissimilar to those potentially encountered in senior nursing management positions during the conduct of standard daily business in an acute-care hospital. Conversely, the predominate point of difference in the field-hospital setting, however, is the environment and context in which nursing leadership practice occurs. Extreme resource limitations (both human and physical) can significantly overwhelm or disintegrate local health systems, unprecedented patient volumes, acuity (across all age ranges and specialties), and the requirement to deliver clinical acute care services in temporary, standalone, fully self-sufficient, environmentally challenged, and isolated footprints.
Leadership and Governance Structure
Training and Education
The Sphere handbook states: “Health care is a critical determinant for survival in the initial stages of a disaster[2].” Without qualified nurses to address the health-care needs of disaster-affected communities and people, the ability to alleviate human suffering is severely limited.
Considerable collaborative work has been undertaken by the World Health Organization (WHO) and International Council of Nurses (ICN) following specific recognition of the need for core competencies identified in Disaster Nursing:
Nurses, as the largest group of committed health personnel, often working in difficult situations with limited resources, play vital roles when disasters strike, serving as first responders, triage officers and care providers, coordinators of care and services, providers of information or education, and counsellors. However, health systems and health care delivery in disaster situations are only successful when nurses have the fundamental disaster training.
Nurses must be able to work internationally, in a variety of settings with nurses and health care providers from all parts of the world. To assure a global nursing workforce ready to respond in the event of a disaster, competencies are essential[3].
ICN subsequently developed and established a supporting competency framework for disaster nursing, which is organized under four main thematic areas:
mitigation and prevention
preparedness
response
recovery and rehabilitation
Within these four areas, a further 10 domains were identified and subclassified as illustrated in Figure 28.2.
Figure 28.2 ICN framework disaster nursing competencies
The ICN disaster nursing competencies assume the generalist nurse possesses the basic skills in emergency and trauma care, including respiratory and airway assessment, pain management, cardiovascular assessment, management of hypovolemia and fluid replacement, burn assessment, hemorrhage management, mental status assessment, eye lavage, and management of crush injuries and fractures[4].
More specifically relevant to the EMT field-hospital environment, recommendations for a global operational learning framework[5] outline a foundation three-stage approach, which has been identified to assist in the optimal preparation, education, and training of EMT clinicians:
1. Professional competence and license to practice
2. Supported adaptation of technical and nontechnical professional capacities into low-resource emergency context
3. Preparation for an effective team performance in the field
In summary, therefore, to enable nurses to excel in their role while deployed into a field hospital, it is essential that they are not only first and foremost appropriately skilled and trained, but also secondly, and most importantly, supported in the translation and adaptation of their nursing practice into the context of limited resources in an austere and environmentally challenging setting.
Related posts:
Chapter 6 – Training and Accreditation
Chapter 3 – Definitions, Needs, Scenarios, Functional Concept, and Modes of Deployment
Chapter 11 – Auxiliary Medical Services in a Field Hospital
Chapter 7 – Personnel
Chapter 17 – Wound Management in a Field Hospital Environment
Chapter 24 – Intensive Care Unit Buildup Within a Field Hospital Setting
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