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Feature: DISASTER RESPONSE SERIES: PART 4

The personal and professional responsibilities of NPs in disaster response

Zak, Concetta L. DNP, MBA, FNP-BC; Wood, Laura Kay DNP, RN, CMCN; Adelman, Deborah S. PhD, RN, NE-BC; Fant, Catherine PhD, RN-BC

Author Information
doi: 10.1097/01.NPR.0000660348.25701.bb
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Figure

NPs blend expertise in diagnosing and treating health conditions with an emphasis on disease prevention and health management while bringing a comprehensive perspective and personal touch to healthcare.1 NPs possess the same fundamental training and licensing as RNs with an advanced education at the master's or doctoral level. In addition, NPs play a crucial role in providing care to vulnerable patient populations.2,3 The NP's role in healthcare is multidimensional, including clinical practice, teaching, research, and administrative tasks.4 By virtue of their advanced education and scope of practice, NPs are uniquely situated to contribute to disaster efforts by offering their talents, skills, and abilities as they transition from direct care providers to members of disaster response teams.5

The RN's role in a disaster has been well established and documented, but the NP's role is less defined and researched.6 As NPs' scope of practice continues to evolve, their role in disaster care will expand. This expansion needs continued support from educational preparation to licensure to medical liability.

The first article of this series described the four phases of disaster response: mitigation, preparedness, response, and recovery.7 The second article of the series presented NP competencies and how they align with disaster nursing competencies.8 In 2019, after the second article of this series was completed, the International Council of Nurses (ICN) released the Core Competencies in Disaster Nursing Version 2.0.9 The new competencies have been reorganized from the original four phases and 10 competencies to eight new domains to align with the work of other health professions.9 The new domains are: preparation and planning, communication, incident management systems, safety and security, assessment, intervention, recovery, and law and ethics.9 Further, the ICN identified three levels of competency in disaster nursing based on complexity. These are based on nurses' disaster education and preparedness. Level I is an RN with basic disaster education; Level II includes any RN who has achieved Level I and is designated or wishes to be designated as a disaster responder; Level III has not yet been included in Version 2.0, but is for nurses wishing to serve on a deployable team. In 2007, the National Organization of Nurse Practitioner Faculties (NONPF) published the APRN Education for Emergency Preparedness and All Hazards Response report; that guideline, together with the ICN and NONPF core competencies, will serve as a framework for this article.8

Domain 1: Preparation and planning

The ICN recommends that nurses be personally and professionally prepared for a disaster, work with other healthcare professionals through training exercises in their institutions, and know the policies and procedures those institutions have in place for a disaster response. This includes being knowledgeable about current emergency resources. Domain 1 goes into more detail for the advanced or specialized disaster nurse responder, identifying competencies at the level of planning disaster drills for an institution and community. Based on these planned drills, training, and exercises, the advanced nurse responder incorporates the results of the training and real disaster results to improve outcomes and change policies and procedures as needed.

Domain 1 also examines how to treat vulnerable populations in the community. The advanced nurse also communicates the roles and responsibilities of the disaster nurse to nonnursing disaster team members. Another important role for the advanced nurse responder is ensuring that the core competencies are taught in nursing programs and training sessions.9

Several studies have analyzed healthcare workers' willingness to respond to a disaster as a result of personal preparedness. Brice and colleagues surveyed staff in a large academic tertiary-care hospital to assess characteristics of personal readiness for disaster. This study suggested that being familiar with the work emergency plan and having a fully developed family emergency plan increased the likelihood clinical healthcare workers would respond to a disaster.10 NPs should develop a personal disaster plan and encourage their patients to do the same. This may include ensuring that they have enough medical supplies and medicine, and how to prepare a home emergency kit.5,9

On November 15, 2016, Centers for Medicare and Medicaid Services finalized its Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers report. Agencies are required to have emergency preparedness policies that include: how they use volunteers; conduct emergency preparedness exercises; and collaborate with local, tribal, regional, state, and federal emergency officials to maintain an integrated response during a disaster.11 Given the great number of providers and facilities affected by this rule, it is critical that APRNs and other responders participate in education and drills. Prepared clinicians will be integral members of disaster-planning response teams, where APRNs can assume various roles as leaders, managers, or team members. This training will enable the APRN to take a proactive role in anticipating risks and vulnerabilities of institutions and the community. As primary and acute care providers, NPs are familiar with their communities and the public-at-large, healthcare and public health systems, and federal, state, and local legislation related to public health security, bioterrorism, and all-hazards responses.5,12

NPs have a responsibility, as do all general practitioners, to identify vulnerable patient populations and facilitate the preparedness of these individuals. Vulnerable groups may be the elderly, individuals with poor physical or mental health, individuals with multiple comorbid conditions, individuals who are socially isolated, individuals who take certain medications, or those with a limited ability to speak English. Individuals who have an established relationship with a primary care provider can be given information and guidance regarding resources and services in order to build their resilience and reduce the risk of adverse outcomes at the time of a disaster.13 The COVID-19 pandemic has highlighted the importance of disaster nursing. (See The COVID-19 pandemic.)

NPs are leaders in translating knowledge into practice, as well as leading practice inquiry to improve outcomes and improve disaster plans based on the results of disaster drill evaluations.9 By translating the current knowledge and experience from nursing practice, NPs can generate new practice inquiries as they relate to disaster responses. NPs may also organize and participate in events during National Preparedness Month during the month of September, as well as develop educational offerings for the public, nurses, and other healthcare providers.5,9

Domain 2: Communication

The ICN has recommended that the general professional nurses understand and properly use disaster terminology when communicating in a disaster response; be able to prioritize information properly; ensure resources that cover regional languages are available and distributed to the right populations; and document appropriately. In addition, the advanced nurse has a role in securing critical documentation during a disaster. At the advanced or specialized level, nurses should participate in planning disaster communications systems that meet the needs of the disaster responders, plus, be responsible for the inclusion of training for nurses on disaster communication.9

A disaster response is usually managed as an authoritarian hierarchy with a central command center from which efficient communication is disseminated among the different responders and teams. The command center is of vital importance to facilitating effective teamwork and decision-making. However, responders have different responsibilities, goals, and expertise that can affect the way information is shared and interpreted. Further, there may be differences in culture, command structure, and specialist terminology that further hinder clear communication and interpretation of data.14 NPs have crisis communication skills that can be used to help mitigate these issues. The advanced nurse and identified others on the disaster team are also responsible for creating appropriately worded media releases.9

Communicating with victims with different backgrounds and primary languages that are different from the responders' can cause a delayed response and provision of care, adding to the stress of the disaster.15 Vipler described these challenges when responding to the disaster in Puerto Rico after Hurricane Maria: “Since Puerto Rico is a U.S. territory, most of the younger patients we evaluated were fluent in English, having learned the language in school. However, for the older patient population, the language barrier did pose a significant challenge despite the 58 individuals (including 5 physicians) on board who were fluent in Spanish.”15

NPs in a disaster are integral to establishing communication and relationships with local healthcare agencies, law enforcement, and other disaster organizations, including nongovernmental organizations. They can create a climate of mutual trust with the teams by communicating clearly and accurately and understanding and utilizing principles of risk communication with individuals, groups, and agencies. NPs can develop culturally and spiritually sensitive media and public service announcements that are appropriate for the population affected by the disaster.12

Table
Table:
The COVID-19 pandemic

Domain 3: Incident management

ICN has stated general professional nurses should assist in defining an organizational incident plan for a disaster response where they work that is consistent with national standards. Debriefing and postdisaster meetings are conducted after disasters; these are opportunities for nurses to contribute lessons they have learned, adding to plans for improving future training and disaster responses. From this process, action plans can be developed that will help standardize and improve nursing care and practice. Domain 3 also addresses the requirement for disaster nurses to practice according to and within the scope of their licenses regardless of the location of the disaster. As needed, the advanced nurse should assign healthcare responders within their scope of practice, taking care to ensure any healthcare responder is adequately prepared before being assigned a role.9

The NP in this domain can provide leadership fostering collaboration with the integrated health team and the community to improve health and access to healthcare. The NP can be involved in the postevent feedback and assessment of the response with emergency management and public health entities by participating in the analysis of the event and the development of “lessons learned” to improve planning for a future response.9

Domain 4: Safety and security

The ICN states that general professional nurses should be mindful of the safety of all disaster responders, including themselves. This can be difficult because of the dangers a disaster can pose to responders. More victims can result from disaster if responders fail to take care of themselves and each other, adding to the chaos and further overwhelming healthcare requirements in a disaster. During a disaster, the APRN must ensure basic infection control practices are followed, as much as possible, and may have to plan for isolation of contaminated patients and disaster responders, and quarantine victims as directed by the authorities. Further, the advanced nurse needs to repeatedly assess the disaster responders, including nurses, to identify any physical or psychological healthcare required and the type of support needed.

Proper use of personal protective equipment (PPE) and any risks in safety or security should be noted and reported to the proper administrator. The advanced nurse is also responsible for teaching other responders about the proper use and types of PPE. To help ensure ways to mitigate any safety risks to disaster responders, the advanced nurse can assist in generating action plans focused on safety and security.9

Domain 5: Assessment

In Domain 5, the ICN stated general professional nurses should report events or symptoms that an emergency is occurring among patients, families, or communities and then rapidly complete physical and mental health assessments. Performing triage in a disaster is a role that most nurses are not comfortable performing. It should focus on the type of disaster and the potential positive treatment outcomes provided to a victim. In any event, the advanced nurse will continue to assess victims they are caring for and respond to their changing needs rapidly. The advanced nurse should ensure that all disaster nurse responders have the latest information related to the specific disaster and to report any changes noted to the next level of disaster administration, creating any new notifications about changes as needed. Advanced nurses should incorporate disaster triage training in nursing programs, disaster training sessions, and assessment courses. The last area of focus is to help communities identify vulnerable populations and work with agencies such as power companies and police forces to plan for their special needs in a disaster.9

The role of the NP in Domain 5 includes managing diagnosed and undiagnosed victims, using their advanced health assessment skills and diagnostic strategies, prescribing medication, and other treatments within their scope of practice. They should continually assess the incident and prioritize treatments and requests for additional providers, medical supplies, volunteers, and other resources as indicated. In addition, they coordinate transitional care as indicated by the status of each victim.9

Domain 6: Intervention

The ICN advises the competencies for a general professional nurse for Domain 6 should include: the ability to perform basic first aid, provide isolation for anyone who has a communicable condition(s) that may spread, and provide decontamination of victims and disaster responders when needed and as directed. Because a disaster, by definition, overwhelms a community's resources, nurses must work to extend precious resources as much as possible. Quality patient care that is grounded in triaged priorities and the resources on hand is one of the primary skills described in Domain 6, with the nurse often having to deal with surge capacity activities, as particularly highlighted by the COVID-19 pandemic, and management of large numbers of not only victims and their families, but the deceased as well, with respect and compassion.9

Competencies for the advanced nurse in Domain 6 include ensuring that all disaster and emergency plans within the institution are followed and by all nurse responders and that basic first aid is implemented as needed. When needed, institutional plans for setting up and ensuring isolation units are available in a disaster is part of the advanced role. The nurse must also be trained in the different types of chemical, biological, radiological, nuclear, and explosives (CBRNE) exposures that may result from a specific disaster and what decontamination methods should be used. Assigning nurses to the proper role in a disaster based on the institute's emergency/disaster plan will ensure that nursing's participation in the disaster and any resulting surge activities will be carried out appropriately.9,12

NPs have the unique ability to shift their function from NP to RN and back as needs change. For example, NPs can not only order vaccinations, assess levels of patient risks, treat unexpected reactions, but also know their communities and their idiosyncrasies that might impact the success of care following a disaster. This might also include anticipating and facilitating plans for evacuation, treatment, and shelter for victims. They can assume a leadership role in guiding colleagues and other responders/volunteers to assist with the management of victims while recognizing the role of others, including federal, state, and law enforcement agencies.9,13

Domain 7: Recovery

The ICN states the general professional nurse responder will assist in a healthcare facility remaining open during or after a disaster occurs. The general disaster nurse and advanced nurse can set up needed referrals for the victims and their families to receive the required care after discharge from an institution or triage center. After an active disaster, the advanced nurse will participate in a debriefing that will help with the transition back to normal for the victims and responders, plus identifying those who need more support.12 Competencies for advanced nurses revolve around sharing with administration leaders their assessment of the physical and psychological needs that exist as part of the recovery phase.9

The role of the NP in this phase is to provide leadership to foster collaboration with the integrated healthcare team and the community to improve health and access to healthcare. They should be involved in the postevent feedback and assessment of the response with emergency management and public health entities by participating in analysis of the event and identifying lessons learned to improve planning for future responses.3,12 NPs are leaders in translation of knowledge into practice, as well as leading practice inquiry to improve outcomes and participate in the improvement of disaster plans based on the results of drills evaluation.3 This is an important role as it pertains to disaster planning and response, as the role of NPs has not been well documented or studied. By translating the current knowledge and experience from nursing practice, NPs have an opportunity to generate new practice.

Domain 8: Law and ethics

ICN has advised the competencies for general professional nurses related to the law and ethics and how practice expectations change in a disaster and what policies and procedures can be enforced legally. Although it may be difficult, ethical practice during disaster response is extremely important and is grounded on the principle of doing the most good for the most people and what can realistically be done with the resources available. These utilitarian principles guide all levels of disaster nursing practice. The APRN can help create policies that will guide a healthcare facility in a disaster and develop a framework for how resources will be used within an institution.9,16

Lessons have been learned, especially after Hurricane Katrina, in which valuable patient information and documents that validated providers' credentials were lost.16 Fortunately, during the hurricanes of 2017, Nursys, the nurse licensure verification system, became functional, providing a location for this critical information to be stored and easily accessed.16 This verification system plus state boards of nursing can assume a role in safeguarding the public.16

Another mechanism in facilitating the credentials of nurses is the Nurse Licensure Compact. However, none of the compact states' rules currently include NP licensing. For RNs, this is a mechanism that allows nurses licensed in those states that subscribe to the compact to quickly respond to disasters in multiple states. However, not all states belong to the compact, and some states may suspend the licensing laws during a disaster when more healthcare providers are needed and not available. The variability in the licensing requirements during a disaster means that NPs must be fully aware of the requirements for licensing during a disaster in a particular state or their state(s) of licensure.16

What can be done in a disaster is defined by laws at all levels—local, state, and federal. During disasters, the rights of the public supersede those of the individual and the usual standards of care that would be practiced in nondisaster situations. Laws and statutes coordinate jurisdiction between local, state, and national levels. Parameters of a disaster response, scope and standards of the response, and authority to act are determined by the legal system. The Crisis Standards of Care by the Institute of Medicine made recommendations regarding the modification of standards of care based on the type of disaster.17 The Public Readiness Emergency Preparedness Act provides healthcare responders immunity from lawsuits under certain conditions (no pay was accepted for the disaster response and practice did not occur above the level of knowledge of the healthcare provider).11,18 The Uniform Emergency Volunteer Health Practitioners Act is another avenue that protects providers from lawsuits.19

Unfortunately, Good Samaritan laws do not universally protect providers in all states, so each NP needs to check their state laws and the laws in states in which they may respond.16 NPs should understand the standards of care and laws wherever the disaster occurs. Further, NPs need to understand that there is no immunity from a lawsuit in postdisaster care. This means it is important to know when a disaster is deactivated and standards of practice and licensing laws return to nondisaster levels.16

Conclusion

As recent events have highlighted, disasters, including pandemics, necessitate changes in practice. The roles an NP may assume in a disaster are varied and change based on the type of disaster, level of response, phases of response, and needs of the community. Having a basic understanding of the types of disasters that may occur in the geographic area an NP practices in, as well as comfort levels in responding and disaster training, will help the NP be prepared to step into any role required in a time of disaster. It is critical that NPs are prepared at both personal and professional levels to successfully serve in a disaster.

REFERENCES

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14. Waring S, Alison L, Carter G, et al. Information sharing in interteam responses to disaster. J Occup Organ Psychol. 2018;91(3):591–619.
15. Vipler B, Nissan D, Darling N, et al. Disaster response to Puerto Rico: an internal medicine humanitarian response aboard the USNS COMFORT. Mil Med. 2018;183(11–12):252–257.
16. Neil HP. Legal issues and disaster preparedness: are you ready for a community disaster? Part two. MedSurg Nurs. 2014;23(3):8–9.
17. The National Academies of Sciences, Engineering, Medicine. Crisis Standards of Care: a systems framework for catastrophic disaster response. 2012. www.nationalacademies.org/hmd/Reports/2012/Crisis-Standards-of-Care-A-Systems-Framework-for-Catastrophic-Disaster-Response.aspx.
18. US Department of Health and Human Services. Public Readiness and Emergency Preparedness Act. 2019. www.phe.gov/Preparedness/legal/prepact/Pages/default.aspx.
19. American College of Surgeons. Uniform Emergency Volunteer Health Practitioners Act. 2006-2018. www.facs.org/advocacy/state/uevhpa.
Keywords:

disaster response; International Council of Nurses (ICN); leadership; licensing laws; National Organization of Nurse Practitioner Faculties (NONPF); personal protective equipment (PPE)

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