INEQUALITIES in society, culture, and income have sometimes resulted in civil unrest, leading to an unanticipated burden of care on health care systems and nursing leaders. Civil unrest is defined as “disharmony, expressive dissatisfaction and/or disagreement between members of a community, which leads to a situation of competitive aggression that may find expression as disruption of organization, conflicts, damage to property and injuries.”1 (p156)
The relatively recent events of civil unrest in cities across the United States have raised an awareness of injustice in our society and the need to recognize the human dignity of every person. While nurses have been acknowledged as more trusted than many other public servants, nursing as a profession has largely failed to address the impact of civil unrest on nurses, the organizations we lead, and the communities we represent. Civil unrest may, and does, sometimes lead to physical violence. It is essential to recognize that while our health care roles during periods of community violence will be similar to those we take during a natural disaster event, not all of the circumstances are the same. For example, because of heightened tension between police and the general population, the presence of police in the care site may not be possible. Even if possible, it may not be desirable.2
If we approach the events that may accompany civil unrest as a type of disaster, we must recognize that the efforts of many health care professionals, especially nurses, are needed. During these times, it is likely that both hospitals and public health organizations will change their preparedness posture. They may have plans for increased staffing or ready call rosters for health care professionals in place. However, health care organizations may not recognize that the dynamics in civil unrest are more complex than those of a natural disaster. The events during civil unrest may be more like complex humanitarian emergencies, in the sense that there is an internal breakdown at the local level that may require outside intervention in order for the community to regain order.
In response to what they refer to as a “changing world” filled with “volatility, uncertainty, complexities, and ambiguities,” the American Organization of Nurse Executives (AONE) convened a working group to address the role of the nurse leader in a crisis. AONE gave a high priority to establishing good communication, projecting calm, understanding how people react, prioritizing the crisis plan, and being trusted patient advocates.3 This is consistent with what was learned during recent events in Ferguson, Missouri, and Baltimore, Maryland.
HISTORY OF CIVIL UNREST
Civil unrest is not new to the United States or the world. In the period between September 11, 2001, and the Anaheim police shooting in 2012, there were 21 nationally recognized incidents of civil unrest.4,5 Since the police shooting of 16-year-old Kimani Gray in 2013 in Baltimore, Maryland,6 there have been 12 incidents of civil unrest in the United States, some lasting days or weeks. What may surprise many is that the incidence of civil unrest is far less than what was seen in the 1960s and early 1970s, a time when the country was stirred by what many viewed as an unjust war (the Vietnam War).4,5 These decades were also a time when the nation was facing the reality that we lived in an unjust society that needed to address civil rights. The Figure demonstrates that as a country, we have consistently experienced some level of civil unrest. The good news is that we historically have come out the other side as a more just and stronger country.
The Figure includes riots, violent and/or disruptive labor disputes, and war protests. The incidents range from relatively minor or major and from a few hours to multiday events.4,5
One author of this article has spoken to many people in Ferguson since the death of Michael Brown. She discovered some commonalities among their experiences along with exceptional stories and lessons learned. The 2 most striking lessons learned were the need to train street medics and the need to address the role of security in hospitals.
During the time of civil unrest in Ferguson, the Deaconess Faith Community Nurse Ministries recognized that, unlike what often occurs in a natural disaster, there were not a large number of spontaneous unaffiliated or affiliated health care volunteers asking to participate in providing care. Consequently, they worked with the community to organize and host a Street Medic Training for interested lay leaders and health care professionals in October 2014. This was in preparation for a Moral Monday demonstration being held in the St Louis region. This training was conducted utilizing the Chicago Action Medical model for street medics. The training session focused on preparing participants with the following information and skills: providing basic first aid for protestors, handling of contact with riot agents, dealing with emergent issues of people with preexisting health conditions (ie, asthma, hypertension, etc), and counseling of those impacted by the psychological trauma of being on the front line during protests.
The Deaconess Faith Community Nurse Ministries, under the leadership of its Executive Director, the Reverend Donna Smith-Pupillo, RN, is dedicated to improving and promoting the health of body, mind, spirit, and community throughout the St Louis region.7 One of its guiding principles is to be a Care Advocate for the voiceless and marginalized in the health care system. Rev Smith-Pupillo shared with the article authors that “it is a special call for a nurse to be able to use your skills to help people concerned about justice to further the greater good.” She went on to say, “Your presence alone can make a difference.” However, she quickly pointed out that this type of response is not for everyone. Just as we see in almost every disaster, there are those who want to help, but when they get to the field where care is needed, they are not emotionally prepared for what they encounter.
Whether a nurse is working in the acute care setting of a hospital or providing care in the community, personal security is an issue during civil unrest. R. Bartram, Eastern Regional Director of Security of the Mercy Health Care System, noted that during the civil unrest in Ferguson, the safety of home health care workers needed to be addressed.8 One suggestion to help ensure the safety of these workers was to make all visits before noon because much of the unrest occurred during the evening hours. Other suggestions included rescheduling visits and, when appropriate, conducting a visit via telephone.
The safety concerns of staff working in the acute care setting were different but equally significant. Leaders in the Mercy security department stayed in contact with administrators throughout the hospital to communicate measures taken to ensure safety for the workers in the acute care setting.8 Hospital nurse leaders and other administrators were acutely aware of the varying views of protestors. Because it was likely that, at some point, protestors, police officers, or both might present to the hospital for care, the administration and staff needed to know how to respond and to ensure provision of nursing care that demonstrated a respect for human dignity.9
For example, during the unrest in Ferguson, 2 protestors presented to one of the local hospitals for care. One presented to the hospital independently. The other was brought in by the St Louis County Police Department to determine whether the person could be taken to jail without jeopardizing the individual's health.8 Although the presence of security personnel at the hospital was increased during August and November 2014, staff had to be reminded of the purpose of the security personnel, as well as the rights of those protesting and picketing. It was not the role of the local police department to respond to protestors who engaged in legal activities, but they would respond if protestors engaged in illegal activities, such as blocking patients' access to the facility.8 It is important to remember that in such situations, the presence of police in the hospital can be viewed by protesters as adversarial, so their presence may make the situation more difficult to manage.
These situations point out the similarities and differences between natural disaster response and actions best suited to the civil unrest. The 3 primary differences are the role of security, the availability of volunteers, and the importance of being the trusted patient advocate. In a disaster, communities and response organizations can be overwhelmed with the number of volunteers. There is no massive outpouring of volunteer spirit during civil unrest. The need to train street medics is emblematic of this distinction. Likewise, the role of trusted advocate can help diffuse any tension that may exist within the health care setting between those who identify with the protesters and those who identify with the police. Trust is a key quality that nurses bring to the table during civil unrest.
In the Missouri event, nurse leaders in the local county health department worked with staff to ensure they were able to meet the community's needs. The main location of the Saint Louis County Department of Public Health is approximately 2 miles from Ferguson and serves many clients who live in that town or in neighboring communities. During the early days of civil unrest, several measures were taken to provide residents with care. These included delivering medications to residents when they were unable to leave their homes because of safety concerns. Communicable Disease Control remained opened. However, personnel did not go into Ferguson or neighboring communities to conduct case finding in the immediate aftermath of rioting and violence.10
Many families in Baltimore have been impacted by decades of racial injustice, poverty, and multiple adversities. This has resulted in poor access to basic human needs such as employment, quality education, and healthy foods. These conditions are associated with an accumulation of exposure to traumatic events, compounded by circumstances that result in physical and mental health disparities. Ultimately, these lead to poor health outcomes.8,11 In April 2015, the death of an African American man injured while in police custody spurred several days of angry protest and civil unrest in Baltimore City.12 This event sparked a strong response across the nation and forced sentiments to the surface that have been brewing among Baltimore's citizens for decades. Fires were set in the city; assaults were perpetrated against police officers; and 7 community pharmacies were looted by thieves seeking opioid medications. The resulting burden upon the city hospitals and local health department was significant and long lasting.
Between April 27 and May 8, 2015, the Baltimore City Health Department was a lead agency in the unrest response and recovery activities. Emergency physicians and nurses participated in many facets of the disaster response. Just as occurs in an emergency medical situation, a “public health code” was eventually proposed as a model for centralizing, reacting to, and debriefing after situations of civil unrest.13
CONSIDERATIONS FOR NURSES
As nurses, we must all decide what role we will play during a crisis. To do this, we must each ask the following:
- Can you respond?
- Do you have family responsibilities that must take priority (dependent elder, young children)?
- Will your job allow you time off?
- Are you physically able to respond?
- Are you psychologically prepared?
- Are you trained?
- Are you prepared for the possibility of being arrested?
One nurse shared with the authors that she could not risk being arrested, or losing her job, and as a result not be able to feed her children. This was not an unusual response from nurses who wanted to take part in the protest because they felt the need to stand for justice. Another nurse said, “I invested this money in school so I'm not just going to throw that away because I want justice. I can't afford to do that, but I can vote. I can be heard in a way that I can't get locked up.” Another nurse leader, the Reverend Tracy Blackmon, RN, was able to take vacation time because her place of employment was supportive of her work. On the contrary, a student nurse leader reported that she was told by angry community members she would never get a job. She stated some even tried to get her school to denounce her work rather than support her choice.
Nurses must keep the focus on the humanity of the situation.3 We must ask ourselves if we will support our nurse leaders who choose to be active participants in protests. Will we support our student leaders? Are we prepared to be the ones that offer to train the street medics?
RECOMMENDATIONS FOR NURSE LEADERS
Disaster preparedness and response are a cycle that begins with planning and continues through recovery. In disaster response, there is an initial desire of the public to respond and help others. As the recovery drags on, the enthusiasm of the larger community and health care professionals diminishes long before the recovery is complete. During civil unrest, there are many who want to join the protest and/or support the protesters. As nurses, we must remember that long after the celebrities and the cameras have gone, the community and the nurses who live in the impacted communities need a constant presence and assurance that others in their profession are there to support them.
Based on the lived experience of those writing this article, the people we have met along the way, the literature available, and the leaders who emerged during community crises, there are 10 “musts” in preparing for civil unrest. These include the following:
- Training of hospital security in crowd control during riots.
- Identification of local leaders to be trained for emergency management and as street medics.
- Inclusion of local leaders and students in drills that teach how to stay safe during a riot.
- Establishment of a communication plan for local leaders, street medics, and hospitals.2
- Modeling of behavior by nurse leaders, who manage the largest workforce in the hospital and are trusted members of the community. (It is essential that the nurse leader model what they expect from other organizations.2)
- Recognition of the intersection of complex issues by nurse managers who can then intervene with staff when there is a lack of understanding.
- Planning of an orderly triage by enlisting the support of local and prominent community leaders.2
- Planning for the use of mobile clinics or provision of home visits during the crisis.
- Designing of hospital and community partnerships to help heal young people impacted by violence with case management, mentorship, and evidence-based trauma interventions.14
- Training of all nurses in trauma informed care.
Nurses know that preparedness and training are critical to successful patient outcomes. Preparedness and training for civil unrest are essential to not only patient outcomes and emotional well-being but also organizational and community outcomes. Nurse leaders must recognize that managing patients and personnel requires being aware of and addressing myriad emotions and prospective on social issues that lead to civil unrest, which is above and beyond the issues of security, crisis communication, and alterations in practice necessary during a disaster. Nurses are members of a profession who can lead the way for humane, competent care even during times of civil unrest.
1. Ballantyne B. Medical management of the traumatic consequences of civil unrest
incidents: causation, clinical approaches, needs and advanced planning criteria. Toxicol Rev. 2006;25(3):155–197.
2. Pinkert M, Bloch Y, Schwartz D, et al Leadership as a component of crowd control in a hospital dealing with a mass-casualty incident: lessons learned from the October 2000 riots
in Nazareth. Prehosp Disaster Med. 2007;22(6):522–526.
3. Edmonson C, Sumagaysay D, Cueman M, Chappell S. The nurse leader role in crisis management. J Nurs Adm. 2016;46(9):417–419.
4. Wikipedia Contributors. List of incidents of civil unrest
in the United States. https://en.wikipedia.org/w/index.php?title=List_of_incidents_of_civil_unrest_in_the_United_States&oldid=741453857. Published 2016. Accessed September 28, 2016.
5. Armstrong Economics. Listing of US civil unrest
/statistics/listing-of-us-civil-unrest-incidents. Published 2016. Accessed September 28, 2016.
6. Goodman JD, Stelloh T. Police kill 16-year-old they say pointed a handgun. The New York Times. March 10, 2013. http://http://www.nytimes.com
/2013/03/11/nyregion/16-year-old-killed-by-new-york-police.html. Accessed November 15, 2016.
7. Deaconess Faith Nurse Ministries. Mission, vision, and values. http://http://www.faithnurses.org
/about/mission-vision-values. Published 2016. Accessed September 26, 2016.
8. Bartram RC. Civil unrest
in Ferguson, Missouri: security's role in preparing for man-made surge events. J Healthc Prot Manage. 2015;31(2):1–9.
9. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Silver Springs, MD: American Nurses Association; 2015.
10. Missouri Department of Health & Senior Services. Civil unrest
: seniors & vulnerable populations. http://health.mo.gov/emergencies/ert/pdf/HunterShawVaisvilCivilUnrest.pdf. Published 2015. Accessed September 26, 2016.
11. Nelson S, Carpenter L, Vivrette R, Connors K. Reflections from Baltimore: the role of early childhood mental health providers in responding to community unrest
. Reflections. 2015;21(3):53–56.
12. Stolberg SG, Babcock S. Scenes of chaos in Baltimore as thousands protest Freddie Gray's death. The New York Times. April 25, 2105. http://http://www.nytimes.com
/2015/04/26/us/baltimore-crowd-swells-in-prot-est-of-freddie-grays-death.html. Accessed November 22, 2016.
13. Khaldun JS, Warren KE, Wen LS. Baltimore's unrest: perspectives from public health and emergency physician leaders. Disaster Med Public Health Prep. 2016;10(2):293–295.
14. The Ferguson Commission. Forward Through Ferguson: A Path Toward Racial Equity. St Louis, MO: St. Louis Public Library; 2015.