Nursing competencies form the basis of the profession. They identify the knowledge, skills, abilities, education, and, often, certifications nurses must use when providing patient care.1 Disaster response depends on a special set of competencies that most nurses either are not taught or do not understand fully. In response to a series of earthquakes and tsunamis in 2005 and 2006, the World Health Organization (WHO) addressed what was needed of healthcare professionals to care for the various needs of disaster victims. Nurses were identified as key players in disaster preparedness, response, mitigation, and postdisaster care, but gaps were identified in the knowledge nurses needed to be effective healthcare providers in a disaster. So, the International Council of Nurses (ICN) and WHO worked to establish a set of 10 disaster nursing competencies.2
In 2007, the National Organization of Nurse Practitioner Faculties (NONPF) convened a panel to identify and suggest curriculum content to guide NP education in emergency preparedness and all hazards response.3 These guidelines and curriculum suggestions have not been fully formalized in NP education. This second installment of the Disaster Response Series will address nurse and NP competencies and identify where the NPs' special skills and knowledge fit into the competencies.
Disasters require competent nurses. Competence in professional nursing involves the demonstration of knowledge, skills, abilities, and attitudes to the level at which the nurse is assessed. Nurse competency, a core ability, is defined as an integration of knowledge, judgment, skills, values, and attitude to an expected standard, to fulfil the role of a nurse.4 Core competencies define professional practice through education and training in a common language and set of statements to provide clarification of the nurse's role. Disaster nurse competencies educate and prepare nurse responders and are linked to professional standards for preparing individuals for situations impacting public health and well-being.5,6
History of disaster competencies
Natural and manmade disasters impact millions of individuals every year. Due to a global increase in disaster frequency, worldwide efforts have been taken to address issues of disaster mitigation and preparedness. In 2006, the 21st Century Center of Excellence program at the University of Hyogo examined core competencies required for disaster nursing.7 In 2009, the ICN introduced a framework of disaster nursing competencies, built from generalist nurse competencies, that can be modified for cultural specificity for different countries.2,8,9 Globally, disaster competencies support the actions of the nursing community to establish disaster nursing as an area of nursing discipline.
The ICN and WHO collaborated to identify 10 disaster nursing competencies.2 These competencies are wide-ranging and many components overlap between competencies. A brief explanation of each competency is provided, with a focus on the RN in general. In the summer of 2019, the ICN met in Singapore to update the competencies, but nothing has been published about this change to date. What these competencies mean for the NP will be addressed later. Unless otherwise noted, all content in this section comes from the ICN and WHO.2
Risk reduction, disease prevention, and health promotion. The first competency is related to preparedness. In order to reduce the risks resulting from a disaster and prevent the spread of disease while promoting health at a time that is often chaotic and where the normal responders are overwhelmed, it is critical to establish a framework to use when a disaster strikes. The use of epidemiologic data and knowledge of local natural and anthropogenic disasters that can be expected in the geographic region is the foundation for planning collaborative responses and identifying vulnerable populations and the members of a multidisciplinary team that would respond in a disaster.
A major part of this competency is education. This education takes place both within the general community and the healthcare community. The nurse helps establish disaster response plans, creates assessments of available supplies in the case of a disaster, finds locations for shelters, and works with such groups as power companies to identify how power can be supplied to shelters and vulnerable populations. Much of this is done within a governmental organization that oversees the basic emergency response plan, which many governments now require.2
Policy development and planning. This competency is designed to ensure nurses understand the terms used related to disaster response, the phases of a disaster, what a disaster plan is, and so on, making education a major component of this competency. The roles of such entities as government agencies and community response networks are addressed, and attention is focused on the workplace disaster plan. Policy development and leadership in political and legislation creation are vital components of this competency.2
Ethical practice, legal practice, and accountability. The third competency addresses the ethics, legalities, and accountabilities related to a disaster. Although some licensing laws may be suspended in a disaster, a disaster does not suspend the ethical behaviors associated with caring for humans and maintaining awareness of their cultural needs and dignity when providing nursing care. This competency also identifies maintaining confidentiality when communicating and charting on victims. Nurses need to be aware of ethical versus security issues that may arise in a disaster situation.
A major area of concern related to this competency is that of legally practicing nursing in a disaster, especially if a nurse is responding in a state where he or she does not hold a nursing license. In many states, healthcare professional licensing laws are suspended and a healthcare professional can practice in a different role, if the need arises. Knowing what local, state, and national laws apply to providing nursing care in a disaster is important when leaving one's jurisdiction in a disaster response. Public health laws must also be followed. The public health department will lead the disaster response in many government venues.10
This competency also addresses the legal and regulatory situations that may arise from the various roles a nurse responding to a disaster faces. If the nurse is a volunteer in the US, the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA) provides protection from providing care that may result in disaster-related lawsuits.11 It is important to remember that Good Samaritan laws do not always apply to healthcare providers, even in a disaster response, so the nurse needs to investigate his or her state and the state he or she may respond in meeting these competency expectations.
The last major component of this competency is that of accountability. Accepting responsibility for personal and professional behaviors is the cornerstone of this competency, along with knowing one's limits related to knowledge and skill sets in the disaster setting. These behaviors include proper delegation of nursing care to others that follows state and national licensing laws.2
Communication and information sharing. This competency covers a wide range of communication and information sharing concerns that arise in a disaster. The most important is understanding the chain of command and where the nurse is placed in that structure. This changes in each disaster and is related to the type of disaster, duration of the disaster, and local resources. How communication is established and how to report information swiftly may influence the care disaster victims receive and whether more damage occurs. Determining whom to communicate with can become an issue in the chaos that can occur during and after a disaster. Answering questions of people not related to the disaster, for example the media, is part of a special skill set under this competency. Communication includes cultural and linguistic aspects. Language barriers often worsen during a disaster and the nurse must be competent in dealing with them.
Health information management is a part of this competency. How health information is managed and secured may vary depending on the disaster. Special communication equipment may be used, as the normal methods of charting and documenting (electronic health records) may not work in a disaster. The disaster nurse who understands how to adapt to these changes displays competency in this area.2
Education and preparedness. This competency addresses education and preparedness in more detail. The disaster nurse who displays competency in this area is one who works to maintain currency in disaster nursing. The disaster nurse is expected to participate in disaster training and drills to maintain this knowledge and practice his or her skills. Participation in research is a part of this competency in order to help build the knowledge base of disaster nursing.
This competency is multifaceted; it includes personal and professional preparedness for disaster situations that range from having a personal disaster plan and jump kit with emergency supplies to evaluating the local geographic area's readiness for a disaster, as well as building and strengthening the area's disaster response plan. Disaster education for the community, self, and other healthcare professionals is a vital component of this competency.2
Care of communities. Because a disaster, by definition, affects a large geographic area with a large population, a competency in caring for communities is central to the role of the nurse in a disaster.12 The nurse should understand what the different phases of the community response are in a disaster and what nursing interventions are needed in each phase. Collecting data related to any healthcare needs, evaluating the health needs and resources to respond to those needs, and providing education are essential parts of this competency. Many of the other competencies overlap with this one, because caring for communities requires working as part of a multidisciplinary team, education and preparedness, information sharing, and more.2
Care of individuals and families. Communities are made up of individuals and families. The assessment of their healthcare needs before, during, and after a disaster as well as implementing the necessary care are some of the main roles of nurses. Assessment follows the normal approach taken in the nursing process, with an added emphasis on public health, physical, emotional, and mental health related to the disaster (for example, knowledge of biological, radiological, chemical, explosive, and burn threats). The care of individuals includes the healthcare needs of the disaster responders, ensuring that they receive any needed care.
Normal nursing care is often not possible in the disaster setting. Triage, trauma care, and flexibility with how to provide the needed care are often nursing specialties the nurse may not practice as part of the daily nursing role. In a disaster, such normal tasks as chest compressions and hand washing may not be possible and may require clinical judgment in prioritizing what is essential disaster healthcare versus ideal nursing care in the normal environment. Another aspect covered by this competency is that of caring for the survivors of a disaster and the family and friends of those who die in a disaster. Cultural sensitivity in handling the body and the survivors must be attended to in a respectful manner.2
Psychological care. Disaster events have a psychological impact on individuals impacted by a disaster event, disaster nurse responders, and other responders. Images of the dead and dying; exposure to severely injured adults and children; and the loss of friends, family members, and colleagues can result in a variety of symptoms, such as anxiety, fear, and depression. Understanding the signs of distress that the victim and healthcare responders may display is part of this competency, and includes disbelief about what happened, fear it may recur, trouble sleeping and eating, changes in temperament, and even physiologic responses, such as headaches, vomiting, and skin changes.13
Disaster nurse responders need to be aware of the phases of psychological response to a disaster event, able to recognize and understand adaptive and maladaptive behavioral responses, and the impact disaster events have on the population in order to apply the appropriate mental health interventions and resources. Those individuals with predisaster mental health problems should continue treatment plans and be monitored closely for new symptoms. Nurses need to recognize that psychological reactions are unique to the individual and that symptoms and reaction times will differ from person to person. Disaster events increase psychological distress and place disaster survivors and responders at risk for mental health issues, such as posttraumatic stress disorder. Psychological care measures mitigate the suffering and promote a reconstructed life.2
Care of vulnerable populations (special needs populations). Vulnerable and special needs populations consist of older individuals, pregnant women, children, individuals with disabilities, those with chronic conditions, and those considered at higher risk than others. These individuals may reside in rural, suburban, or urban areas, and their healthcare problems may also connect to various socioeconomic factors, such as housing. Disaster nurses attend to the physical, psychological, and social health domains working in collaboration with other healthcare members to assist, refer, and meet the resource needs of the vulnerable individual. All these factors come together to impact the relationship between vulnerability/special needs and recovery for at-risk individuals.
Disaster nurses advocate for vulnerable populations, are concerned about how to address healthcare delivery during and after a disaster, and provide necessary interventions and support for vulnerable populations with special needs.14 Safeguarding the welfare of at-risk individuals before, during, and after a disaster requires adequate planning to anticipate and address the needs of vulnerable populations. Disaster nurses, working in collaboration with other members providing disaster healthcare, need to define, locate, and reach at-risk groups within their community to better anticipate the needs of vulnerable individuals.2
Long-term care needs. Disaster nurses are actively involved in supporting individuals and families to develop both short- and long-term plans addressing individual physical and psychological needs while working in collaboration with other healthcare members to assist, refer, and meet resource needs. Disaster nurses also address the impact of a disaster event on communities by collaborating with other healthcare members and organizations to improve the response phase through sharing information regarding referrals, resources, and strategies to improve members' lives. Ensuring that disaster victims receive the necessary postdisaster care through finding the proper agencies to continue postdisaster care is also part of this competency. This may include helping these agencies recover from the disaster, as well.2
Implications for the NP
NPs have always focused on health promotion and disease prevention.15 Established NP core competencies from the NP Core Competencies Content Work Group published by NONPF in 2017 clearly align with the ICN and WHO's disaster response nursing competencies in all areas.2,16 This section will highlight the overlap in specific NP and nursing disaster competencies as well as discuss the APRN Education for Emergency Preparedness and All Hazards Response published by NPNPF in 2007.3 Unless otherwise noted, all content in this section comes from the National Panel for APRN Emergency Preparedness and all Hazards Response Education.3
Leadership. NPs provide leadership to foster collaboration with multiple stakeholders, demonstrating the competency of leadership using critical and reflective thinking. When disaster strikes, NPs are ready to work with patients, communities, integrated healthcare teams, and policy makers to plan and improve healthcare for all affected. They are knowledgeable about how to build and maintain a therapeutic team in order to provide optimum care while embracing the cultural diversity and individual differences that characterize patients, populations, and the healthcare team.
Technology and information literacy. NPs demonstrate literacy skills in complex decision-making, using technology systems to capture data and integrate appropriate technologies for knowledge management and healthcare improvement. They assess the patient and caregiver's education needs to provide effective, personalized care. The NP can assume an integral role in disaster preparedness by providing information and education to the public as part of his or her practice. By conducting an assessment of their community agencies and how to optimize communication and coordination of support efforts, the NP's participation in interdisciplinary community-based disaster planning as well as during a disaster adds depth to the planning and mitigation required for disaster response preparedness.15
Policy. NPs demonstrate an understanding of the relationship between policy and practice. They contribute to the development of healthcare policy and analyze the implications of healthcare policy across disciplines. As mentioned above, knowing the scope of practice for the NP and the changes in that scope of practice that may arise during a disaster is of great importance when responding to disasters. In addition, NPs implement strategies to improve healthcare delivery while incorporating their knowledge of the relationship between healthcare issues and social determinants of health as advocates for better disaster preparedness plans in their communities.16
Health delivery system. NPs apply knowledge of organizational practices and healthcare systems to improve the delivery of healthcare, especially during a disaster. The NP seeks to minimize risk to patients and providers while facilitating the development of healthcare systems that address cultural diversity of populations, providers, and other stakeholders. Each of these is especially important in a disaster response when the normal lines of healthcare delivery may be disrupted.
The NP is competent in evaluating the impact a disaster may have on health delivery and the environment, analyzing the organizational structure, function, and resources needed to improve care as well as collaborating in planning transition across the continuum of care. As part of both interdisciplinary and intradisciplinary teams, NPs assume an integral role in the planning and management of disasters, as well as postdisaster debriefing and follow-up. They are competent in evaluating systems in order to coordinate disaster efforts during a time of chaos, planning for disaster preparedness, and postdisaster recovery efforts.
Independent practice. NPs function as independent practitioners and demonstrate the highest level of accountability for professional practice. They treat acute and chronically ill patients providing the full spectrum of health services including: health promotion, disease prevention, health protection, anticipatory guidance, counseling, disease management, and palliative and end-of-life care. In most states, they possess prescriptive authority either independently or as delegates, while managing the health and illness of patients, families, and communities. NPs are competent in providing patient-centered care, taking into consideration the cultural diversity of their patients and establishing the patients or caregivers as full partners in decision-making regarding their treatment and health.
During a disaster, the NP conducts a comprehensive assessment of the victims that includes differentiation of acute and chronic changes and medical and psychiatric disease processes including atypical presentations that may occur when exposed to toxic substances. They may also have to perform advanced practice procedures such as suturing, casting/splinting, or being first assist during surgical interventions or performing surgery based on their experience and training. In addition, the NP will assume a vital role in the postdisaster recovery period by assessing community members' coping mechanisms and ability to adapt to a new environment and lifestyle.
The NP should acquire the competencies required to deliver care effectively during disaster events. Nurses and NPs are the clinicians most challenged during a disaster event, as they are often the next to respond after first responders. In order to protect populations devastated by disasters, disaster nurse responders will need to incorporate all competencies addressing disaster prevention, preparedness, response, and recovery phases. The establishment of disaster nurse competencies serves in preparing nurses from all specialties to safeguard the health and well-being of individuals, as well as reduce the death toll from such disaster events. Understanding how NP core competencies fit within the role of the disaster nurse and disaster nurse competencies forms a solid foundation for the NP who responds to a disaster.
The International Council of Nurses, in the Summer of 2019, updated and released their new core competencies for disaster nursing. The new competencies can be found at https://www.icn.ch/sites/default/files/inline-files/ICN_Disaster-Comp-Report_WEB_final.pdf. Nothing in the new report and competencies changes the content of the second article in this series.