Emergencies and disasters, whether natural or man-made, are difficult to prepare for. The September 11 terrorist attacks in New York City, Pennsylvania, and Washington, DC, and the subsequent bioterrorist attacks with anthrax, made this abundantly clear. Although nurses may agree that there's a need for basic competencies in disaster preparedness and response in addition to the usual clinical skills, such training is not part of the required undergraduate curricula at most U.S. schools of nursing, and there is surprisingly little in the literature that addresses the role of nursing in this regard. It's therefore imperative to identify what every nurse needs to know to serve effectively as a member of an emergency and disaster response team.
Emergency or disaster? The term emergency refers to any extraordinary event or situation that requires an intense, rapid response and that can be addressed with existing community resources. Disaster refers to an event or situation that is of greater magnitude than an emergency; disrupts essential services such as housing, transportation, communications, sanitation, water, and health care; and that requires the response of people outside the community affected. 1 The term disaster particularly signifies an event that carries unforeseen, serious, and immediate threats to public health.
Natural or man-made? The World Health Organization defines natural disaster as the “result of an ecological disruption or threat that exceeds the adjustment capacity of the affected community.”2 Such disasters include large fires, extensive floods, hurricanes, and earthquakes. As defined by Guha-Sapir, man-made disasters are those resulting from events or situations that are clearly caused by humankind, such as war and armed conflict, overwhelming environmental contamination, and significant technologic catastrophe. 1
As Landesman notes, “No two emergencies or disasters are alike.”3 But in each situation, regardless of cause, the competencies nurses need to possess in order to respond effectively are essentially the same. We use the term emergency preparedness competencies to cover both emergency and disaster preparedness and response skills.
An outline for action. The first step toward emergency preparedness is the identification of who needs to know how to do what. Thus, in any setting, one of the first questions a nurse may ask is, “What's my role in an emergency?” Although there is little in the nursing literature, specifically, that addresses this subject, there are two articles worth mentioning. O'Brien found that nurses in Australia play significant roles in all phases of emergency preparedness and response, including development of disaster plans, hands-on treatment of casualties, and evaluation of response activities. 4 Shoaf and Rottman, reporting on the 1999 University of California–Los Angeles Conference on Public Health and Disasters, cited four areas of focus in emergency and disaster management: preparedness, mitigation, response, and recovery. 5 Along with a fifth area, evaluation, these offer nurses an outline for a plan of action to be taken when responding to an emergency or disaster.
THE CORE COMPETENCIES
Until now, emergency preparedness competencies specific to nurses working in the United States hadn't been identified. At the request of the Centers for Disease Control and Prevention (CDC), one of the authors of this article (Kristine Gebbie) has developed a set of core emergency preparedness competencies for public health workers. 6 This served as the model for the core competencies for nurses outlined below.
Describe the agency's role in responding to a range of emergencies that might arise. During an emergency or disaster, an organization, agency, or unit may continue functioning as usual, or it may perform special services. You'll need to know if and how the service line (the clinical unit or practice area) will change or expand during an emergency. For example, will scheduled surgeries be cancelled to create standby capacity (in terms of both unit space and surgery time) for trauma patients? Will a long-term care center become a shelter for displaced seniors? Knowing in advance exactly what's expected of the organization during an emergency or disaster gives the staff the opportunity to acquire the pertinent knowledge and to practice necessary skills beforehand. Emergency department nurses generally know their roles through citywide trauma plans for community disasters; nurses working in other settings such as long-term care facilities or home health care agencies may not have been instructed to prepare in the same way.
Describe the chain of command in emergency response. Effective emergency response requires well-orchestrated teamwork in which each member knows what the lines of authority and communication are. The Incident Command System (ICS), commonly used for defining the chain of command during emergencies, originated in the 1970s, when local, state, and federal agencies in California needed a well-coordinated procedure for fighting wildfires; it has been developed further by the Federal Emergency Management Agency (FEMA). 7 (See www.fema.gov/emi/is195.htm.)
The ICS designates common titles and roles to be used in all responding organizations and agencies. For example, during an emergency, President Jones of Organization A and Director Smith of Agency B would become “incident commanders” with specific duties and responsibilities. The system also organizes emergency response according to five major components: command, planning, operations, logistics, and finance and administration. Depending on the scale of the emergency or disaster, incident commanders can appoint information and safety officers and interagency liaisons to manage those channels. In affording diverse groups a common approach, the system facilitates communication and coordination of response efforts.
In many organizations, the nursing staff would be deployed by the operations officer; they may also take part in planning, logistics, or finance and administration.
Identify and locate the agency's emergency response plan (or the pertinent portion of it). Every nurse needs to know where the emergency response plan can be found and to be familiar with its contents before an emergency arises. If your agency frequently responds to local emergencies, it may be useful to outline the plan and your designated role in a card or small notebook; include necessary contact information and update it regularly.
Describe emergency response functions or roles and demonstrate them in regularly performed drills. Effective emergency response requires that each team member know what to do and how to do it. The nurse's role may be essentially unchanged or it may entail different duties—for example, working as backup staff member in the intensive care unit, supporting families in the emergency department, being on call at home, or reporting for duty at the local health department. To ensure competence during an emergency or disaster, it is important that tasks be practiced. Know which types of emergencies are likely to occur in your area and which health conditions are likely to result from them. Some occurrences, such as terrorist attacks, are less predictable; still, by possessing and practicing competencies, you'll be better prepared to handle all types of emergencies.
Demonstrate the use of equipment (including personal protective equipment) and the skills required in emergency response during regular drills. All nurses know how to safely operate equipment that they use daily. But during an emergency, they may be required to use unfamiliar equipment. Knowing the setting to which you're likely to be dispatched affords the opportunity to learn how to use such equipment in advance. You also need to know how to protect yourself. This requires awareness of possible contaminants and knowledge of appropriate methods of protection. Some emergency response activities require simple universal precautions while others require more sophisticated protections.
Demonstrate the correct operation of all equipment used for emergency communication. Teamwork and communication are essential during emergency response. For example, a nurse may serve as a communication link between the hospital and health department. Professional staff members often don't know how to use common communication equipment, and the simplest task becomes cumbersome and consumes too much time. Practicing with the equipment beforehand can eliminate this.
Describe communication roles in emergency response
- within your agency.
- with news media.
- with the general public (including patients and families).
- with personal contacts (one's own family, friends, and neighbors).
Every organization or agency should delineate specific roles and responsibilities that apply to both internal and external communication. You'll need to know the communication roles of others, in addition to your own, to refer information requests appropriately. During emergency response, communication within an agency generally follows the usual chain of command. Communication with the news media is usually delegated to a single office or person.
Communication with the public occurs at various levels of formality. For example, discussion with patients and their families tends to be conversational and informal; a somewhat more formal, scripted exchange would take place over a telephone hotline. Each nurse must be prepared to perform a role in communication at this level. For example, staying current with CDC (see www.cdc.gov) or health department information regarding anthrax will help ensure that the information you dispense is accurate.
Personal communications also must be considered. Because the nurse won't be able to focus on emergency response duties if worried about the safety of family members, significant others, friends, and pets, provisions for them should be planned in advance. An overall family emergency plan can be useful and is easily developed using the suggestions developed by the American Red Cross (ARC) and FEMA (www.fema.gov/library/yfdp.pdf).
Identify the limits of your own knowledge, skills, and authority, and identify key system resources for referring matters that exceed these limits. During an emergency, nurses often perform tasks outside their usual domain. But because nurses are generally seen as being exceptionally versatile, they're likely to be asked to perform tasks or to assume roles that are far beyond that domain. For example, a nurse who ordinarily works with adults may be asked to work with children, although she may not be familiar with pediatric medication concerns. It's important both to recognize when one is past the limit of one's knowledge, skills, or authority and to know where to direct the request or need so that appropriate answers or services can be provided. In other words, be clear with yourself and others about what you know and what you do not know.
A nurse working in a disaster shelter should be able to recognize the presence of an acute illness or injury and know how to arrange the patient's transfer to a facility that can provide the appropriate level of care. For example, in the case of a patient with crushing chest pain, you would arrange his immediate transfer by ambulance to the ED.
Apply creative problem-solving skills and flexible thinking to the situation, within the confines of your role, and evaluate the effectiveness of all actions taken. No matter how well prepared in the core competencies you are, there will be times when you'll need to think on your feet. Situations won't necessarily arise and develop exactly as the preparedness plan describes. Systems, equipment, or plans may fail. Creative problem solving entails addressing a situation with whatever resources are available at the moment; nurses tend to be good at this because it's a skill also used under ordinary circumstances. Once you take action, you should evaluate its effectiveness on an ongoing basis. If you refer a problem elsewhere, follow up to see that it was appropriately addressed.
For example, suppose an emergency plan calls for the use of mobile telephones for internal communication, but when a disaster occurs, reception may be interrupted. The nurse manager decides to assign a runner to hand-carry messages to and from the facility's command post until the reception problem is corrected. She also checks regularly on the status of the mobile communication system.
Recognize deviations from the norm that might indicate an emergency and describe appropriate action. Regardless of setting, most patients spend more time with nurses than with any other health professional. Because nurses are so familiar with normal patterns of health and illness in the communities and organizations they serve, they're well positioned to recognize deviations in them. Early detection of such a change and prompt notification of the proper authorities can enable early warning of an impending emergency or disaster, or of a shift in community needs during the response.
For example, suppose a school nurse notes a large number of similar complaints not common in the community or season and reports the finding to her supervisor, who in turn notifies the epidemiology office at the local hospital. The finding may indicate the beginning of an infectious disease outbreak, and an emergency response may be warranted.
Participate in continuing education to maintain up-to-date knowledge in relevant areas. As environmental, political, or societal conditions change, the nature of emergencies and disasters will also change—and so must the plans, methods, and technologies used in emergency response. Regular continuing education in specific areas can help nurses keep abreast of these changes. For example, when biological threats such as bovine spongiform encephalopathy (“mad cow disease,” which has been implicated in cases of Creutzfeldt-Jakob disease in humans) and anthrax loomed recently, providers found that they needed to know more about emerging infections. Many such resources exist. For example, an electronic subscription to the Morbidity and Mortality Weekly Review (www.cdc.gov/mmwr), which is free, offers information on seasonal disease trends and other community public health matters. Professional association meetings and hospital-based journal clubs are other good sources of current information. Remember that it's important to consider the reliability of the source of information, especially in regard to new types of emergencies or potential disasters. When emergent events are covered by both the lay press and professional journals, the most credible sources of information for application to clinical practice should be sought.
Furthermore, any kind of change—of one's role in an organization, of equipment, or of technique—is likely to affect how one responds. A staff nurse who becomes a supervisor will need to acquire new management competencies; for example, she'll need to know the protocol for communicating with the emergency medical services team during an emergency response. All nurses must keep abreast of changes in personal protective equipment and isolation techniques.
Participate in evaluating every drill or response and identify necessary changes to the plan. Most emergency response plans are works in progress. As conditions change in an organization, community, or nation, the emergency response plan will have to evolve. Each drill or response provides information that can be used to improve the plan. Nurses should be fully involved in the ongoing evaluation process.
After each drill or response, there is usually a meeting for the purpose of identifying what went well and should be kept in or added to the emergency plan, and what needs improvement and should be practiced or revised. This gives every nurse the opportunity to review the emergency response experience and to contribute to the development of the plan.
ADDITIONAL CORE COMPETENCIES
These competencies are specific to nurses who have managerial or leadership responsibilities.
Ensure that there is a written plan for major categories of emergencies. Nurse administrators must be sure that the unit, department, or organization they're responsible for has a written emergency preparedness plan. Unit and departmental plans must be compatible with the organization's plan, and the organization's plan must be practicable for individual department and unit implementation. Nurses should be represented on the organization's emergency preparedness committee.
Ensure that all parts of the emergency plan are practiced regularly. Emergency preparedness and response plans that are never practiced or that are poorly understood will probably be useless. The Joint Commission on the Accreditation of Healthcare Organizations requires regular emergency management drills at least annually (specific requirements vary by type of facility), and some states mandate biannual drills. Practice can take the form of either actual drills or “tabletop” exercises using either spoken or written scenarios and responses. This allows nurses to practice performing their roles, to give critiques of each other's performances, and to assist with plan improvement.
Ensure that identified gaps in knowledge or skills are filled. Once a drill or an emergency response has been executed, both that which went well and that which wants modification must be identified and then addressed. What works in a drill may not work well during a real emergency.
In the Eye of the Storm
A Brooklyn hospital puts its emergency and disaster preparedness plan to the test.
On September 11, 2001, core nursing competencies for emergency response were tested throughout my hospital. Eighty-eight patients (mostly self-referred) from the site of the attacks on the World Trade Center were seen that day. We found that our quarterly hospitalwide drills of the emergency plan prepared the staff to respond appropriately.
After several laboratory and administrative staff members saw the first plane strike the south tower, the emergency response plan went into immediate effect. Patient care rounds began at once. To ready space for new admissions, an effort was made to expedite patient discharges and transfers to long-term care and rehabilitation facilities (for example, by contacting private car and ambulance services for early patient pick-up), and case managers contacted community-based skilled nursing facilities and adult homes to find additional beds. In each department, managers reassigned patient care activities and released staff members to the emergency labor pool.
Department heads and those assigned to the pool met in the executive boardroom, where, as defined by the emergency plan, a command post was established. Run by two senior administrators, the command post deployed staff to necessary outposts, and managed communication throughout the institution. Portable phones with walkie-talkie components helped staff to communicate, as did video conferencing technology, which the command post used to contact another hospital in the network.
Meanwhile, emergency department personnel accessed disaster supplies and equipment located in central supply. While clinicians were preparing for incoming patients, housekeeping, clerical, and other nonclinical staff did their best to ensure that adequate food, water, and other supplies were available if needed. Psychiatric and other mental health services and pastoral care were offered to staff members directly affected by the tragedy.
Afterward, evaluations of the emergency response plan by administrators and staff members were generally positive, yet they revealed a few weaknesses. For example, in a revised plan to be released within the next six months, an ambulatory presurgical testing site will replace labor and delivery as an alternate treat-and-release site. A location in the long-term care facility will become the designated command post, and a conference room in a nearby assisted living program will be assigned as media headquarters.
Emergency preparedness and disaster response planning have always been an important aspect of emergency nursing practice. Yet today's JCAHO accreditation standards—which call for monitoring of the level of staff participation in preparation for emergencies or disasters—reflect the need for organization-wide involvement. The preparedness of our staff enabled them to perform well, despite the fact that many were personally affected by the loss of family and friends.—Cathy Norton Lind, MSN, RN, CEN, FN, Director of Emergency Services, The Brookdale University Hospital and Medical Center, Brooklyn, NY