Nurses, as an integral part and the largest component of the health care team, must be prepared for disaster situations. Disasters occur all over the world, sometimes with warning and sometimes without, making it even more essential to have effective planning and preparedness training programs for nurses. As stated by Powers in International Disaster Nursing , “the goal of disaster nursing is ensuring that the highest achievable level of care is delivered through identifying, advocating and caring for all impacted populations throughout all phases of a disaster event, including active participation in all levels of disaster planning and preparedness.” Many of these duties have fallen on public health nurses and emergency department nurses; however, all nurses will be called upon when a catastrophic event occurs.
Historically, nurses have responded to the call for help when needed. Starting with times of war, this desire and sense of duty to provide care for patients in need have placed the profession on the front lines of disasters. Many of these events occurred in nurses’ own backyards; however, countless others have taken it upon themselves to volunteer and travel away from home to respond. Because nursing professionals often desire to help those in need in an unconventional setting, it is our duty to prepare those who respond to disasters.
Historical perspective
Florence Nightingale, the pioneer of modern nursing, functioned as a disaster nurse during the Crimean War. Taking 38 other women with her to Turkey, she assumed the management responsibilities of the barracks hospital. Wartime health care is similar to disaster health care in that the needs far outweigh the resources. Nightingale worked tirelessly to develop a rudimentary standard of care for the soldiers. This required adaptation of previous knowledge and skills in order to provide care to these soldiers. This ability to adapt is one of the building blocks required for disaster nurses.
Clara Barton, another pioneering nurse, worked diligently during the Civil War providing care to soldiers and then founded the American Red Cross in 1881. Barton had a keen understanding of the needs of the soldiers and what she could do to help. She came to be known as “the angel of the battlefield.” By her example, and the establishment of the American Red Cross, a new precedent for volunteerism was set.
In modern day medicine, nurses tend to focus on the refined medical skills learned in school and practiced in normal settings. During a time of need, these innovators in disaster nursing focused on providing food, water, and shelter. Although in the twenty-first century there have been great advances in health care in disaster settings, nurses must not forget the holistic approach and importance of basic human needs. During a disaster situation, a nurse must be flexible and adaptable in order to fill whatever role is necessary at the time, ensuring the best care for all patients.
The flu pandemic of 1918-1919 affected millions of people worldwide; in all, 20 million people perished during this time. This incredible number of people affected by flu required a large number of nurses and doctors to care for them. The health care system was entirely overwhelmed, requiring the establishment of alternate care sites. In one treatment facility in Camp Dodge, Iowa, nurses were able to adapt to an exponentially rising patient population. In a twelve-day period, the number of patients quickly rose from 1254 to 7863; however, the initial nursing staff of 245 nurses only marginally increased to 442. The supply of nurses could not keep up with the exceptional demands of the growing patient population, yet the nurses’ adaptability and flexibility allowed them to provide the best care possible with the resources available. The ability to work outside of their normal duties and adapt to the disaster at their feet was crucial.
Over the last century the specialty of emergency nursing has developed because the rapid evaluation and treatment of patients during wartime was noted to save lives. Prior to this time it would have been the responsibility of a nurse in the community to respond to a disaster. The development of the specialty of emergency medicine, emergency departments, and emergency medical systems has redirected small disasters to be cared for directly in emergency departments.
These few examples chronicle the development of disaster medicine and disaster nursing, both created out of necessity. Although these subspecialties are needed sporadically, when an event occurs they become essential. It is important to explore the relatively new subspecialties and develop the fundamental knowledge and the skill sets necessary for the nursing personnel to function at the time of disaster.
Current practice
Education and Principles of Disaster Nursing
Many of the key skills that nurses perform in their day-to-day roles make for exceptional providers in disaster settings. Some of the key skills that nurses embody are the ability to prioritize and delegate tasks, think critically, be adaptable and flexible, and advocate for themselves and the patients that they care for. With these skills and further training nurses are well equipped to handle disaster situations. Each nurse maintains his or her own specialty and scope of practice, but without the combined efforts of all members of the health care team the patients suffer. This becomes even more important during disasters. Responding to disasters requires a cohesive team of individuals with comprehensive understanding of their skill sets and how to function within the team. As noted by the International Council of Nurses, “Nurses, as team members, can play a strategic role cooperating with health and social disciplines, government bodies, community groups, and non-governmental agencies, including humanitarian organizations.” Nurses, as an integral part of this team, require training and education in order to function successfully in these roles.
Disaster preparedness is not just being prepared and knowing what to expect when responding to a disaster but also assisting in the formulation and execution of a response plan for one’s own community and workplace. Nurses should have at least a basic understanding of the following principles:
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The Incident Command System (ICS): In the United States the ICS is used as a standardized framework for chain of command. To function during a disaster, nurses should be well versed in the principles of ICS.
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The local and regional disaster response plan: Nurses must have an understanding of preexisting disaster plans in their communities and facilities. This would include knowing where and when to report during times of disaster and what role they are expected to fill within the response system.
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Self-preparedness: It is necessary to discuss and develop an individual and family preparedness plan. The nurse, as a responder, will be away from his or her family for an uncertain period of time, so it is essential that a well-developed family plan is devised ahead of time. One should also be mentally prepared for this separation.
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Community resources: Understanding of available resources allows for more effective care of those in need (i.e., available alternate care sites, blood bank capabilities, pharmacy stockpiles, and shelters).
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Personal abilities and shortcomings: While working in an unfamiliar setting with unfamiliar people, it is necessary to stand firm in one’s knowledge base and skill sets. Being able to communicate this to the team will allow for proper delegation of tasks, therefore providing safe and effective care to patients. Prior to the occurrence of a disaster, nurses should consider and understand their emergency skill set.
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Participation in disaster drills: Often hospitals will run disaster drills simulating a variety of scenarios, from biological, mass casualty, and internal disasters. Nurses must be involved during these drills because they will be integral parts of a real-world disaster response.
Nursing Within the Disaster Cycle
When one thinks of disaster nursing or disaster medicine as a whole, it is often the response phase that gets most of the attention. Without mitigation and preparation, however, the response to a disaster would be disorganized at best. As defined by the World Health Organization (WHO), a disaster is “A serious disruption of the functioning of a community or a society causing widespread human, material, economic, or environmental losses which exceed the ability of the affected community or society to cope using its own resources.” Although many nurses have neither the desire nor the ability to travel domestically or internationally to all disasters, this does not exclude them from potentially needing to respond to a nearby event. Disasters happen every day and often in our own backyards; therefore nurses of all skills and specialties should have a basic knowledge of the four phases of the disaster cycle.
Mitigation
During mitigation it is imperative to complete accurate vulnerability assessments. It is this phase in which providers can assess a situation and make changes in order to decrease the likelihood that events, human-made or natural, will become disasters. Nurses, with a firm grasp on the abilities and resources within their communities and facilities, should be involved in the assessment and then planning of this stage. This requires close evaluation and analysis of the risks that exist and the resources required. It is during this time that a disaster plan should be developed after a thorough hazard vulnerability analysis (HVA). Nurses should assist with the HVA in this phase.
Throughout history, and in modern day disaster settings, there are often secondary disease processes that infiltrate a disaster zone, particularly in events that occur in developing countries. As nurses, one of the interventions that should be implemented is that of vaccination. When a disaster causes gross displacement of a population and results in large-scale sheltering, there is greater risk of disease. Vaccinations not only play important roles in disease management in such settings but also help prevent pandemic events, such as influenza. Vaccinations are not the only nursing practice that can mitigate disease in a disaster. Basic knowledge of good hygiene practices, such as hand washing and use of antiseptic solutions, are important in postdisaster settings because they help to prevent the outbreak of communicable diseases. During this phase nurses are highly involved in teaching the community and fellow health care practitioners.
Preparedness
During the preparedness phase, nurses should help develop the disaster plan for their hospitals or working facilities. It is of utmost importance that nurses during this phase are involved in the discussion of surge capacity and patient care aspects of the developing disaster plan. In this phase nurses should also develop plans for their own families and encourage other medical personnel to do the same. Knowing that when a disaster strikes, health care workers will be needed to provide medical care, it is exceptionally important that all have a plan for their own families during this time.
The plans developed during the preparedness phase should be exercised regularly and include all parties that would be involved in a real disaster. It is important that the first time response plans are enacted not be during an actual disaster. Nurses should have a chance to practice their roles during drills in order to be competent in the tasks that may be outside of their normal responsibilities.
Response
Nurses are vital during the response phase. Due to the number of nurses in the health care field, they will carry out the majority of the care delivered to the injured or ill. To be successful in this phase, nurses must have a basic understanding of the disaster plan, as well as the pathophysiology of the unique diseases and injuries they may encounter. Nurses will be responsible not only for direct patient care, but also for patient flow, surge capacity operations, and the utilization of resources. The available supplies may be limited and require careful distribution and rationing. With potentially limited resources, nurses will need to be flexible and adaptable in order to optimize the quality of care delivered to the affected masses. Having a firm understanding of expected disaster operations and the ICS system within the facility or community will allow nurses to be more efficient and effective in their individual roles.
Another important role nurses may be asked to perform during this time is that of disaster triage. Triage is a skill set that nurses routinely exercise and therefore they are well suited to take on this role in a disaster. Disaster triage using the simple triage and rapid treatment (START) technique and the traditional nursing emergency severity index (ESI) triage used in the United States looks to prioritize patients based on acuity. However, in disaster triage there is the addition of the deceased/expectant category, where an individual has either expired or will likely die despite medical interventions. During a disaster it is necessary to sort the overwhelming patient population by acuity and prioritize their medical care. The WHO defines disaster triage as “a process designed to prioritize casualty care to ensure care is available to those who need it most urgently and that the greatest number of casualties survive.” During disaster triage, nurses must prioritize care to optimize resource utilization and ensure that the greatest number of patients survive.
Recovery
After a disaster occurs communities must return to their normal state. This process may overlap with the response phase. During this phase communities start to heal and rebuild. The length of this phase can vary considerably based on the type of disaster. The recovery process will include significantly more than the rebuilding of structures and reestablishment of the physical appearance of the community. Nurses should be aware and in tune with the needs of their patients during this phase. “The immediate drama and high profile of the relief responses can absorb and exhaust compassion and support, leaving the ongoing recovery phase without the required critical attention and funding. Thus long-term health and socioeconomic consequences are not reduced and may even result in a secondary disaster.” While the community rebuilds physically it is essential for nurses to closely observe how their communities heal mentally, emotionally, and physically and assist in this process. Although usually not the primary victims of disaster, health care workers must be vigilant about stress debriefing and their own personal recovery.
The disaster cycle is a continuum. Part of the recovery phase is personal reflection in order to function successfully at home, at work, and in future disasters. We must not forget, but we must also look back and learn. Shortcomings in prior disaster preparation and response should be looked at as the framework for developing an ever-growing skill set and improvement in future responses.
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