When Disaster Happens: Emergency Preparedness for Nurse Practitioners

Article Outline

• Abstract
• The NP Role in Emergency and Disaster Preparedness
• Historical Underpinnings
• Primary Care and Disaster Preparation
• Disaster Risk Analysis Exemplar: State of Virginia
• Implications for Clinical Practice
• Conclusion
• References
• Copyright

Abstract 

Catastrophic events, including both natural and man-made disasters, usually create surge capacity needs for health care systems; subsequently, the ability to meet such capacity requires thoughtful preparation. While it is true that disastrous emergencies may not be prevented or controlled, it is vital for citizens to be prepared at multiple levels, including individuals, families, health care employees, and community organizations at-large, in order to mount a successful response to the event. Nurse practitioners, by virtue of their advanced biopsychosocial education, as well as their inherent role of community-based practice and collaboration, are uniquely situated to directly contribute toward these efforts.

Keywords:  disaster preparedness , nurse practitioner

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Catastrophic events, including both natural and man-made disasters, usually create surge capacity needs for health care systems; subsequently, the ability to meet such capacity needs requires thoughtful preparation. While it is true that disastrous emergencies may not be prevented or controlled, it is vital for citizens to be prepared at multiple levels, including individuals, families, health care employees, and community organizations in order to mount a successful response to the event.

Nurse practitioners (NPs), by virtue of their advanced biopsychosocial education, as well as their inherent role of community-based practice and collaboration, are uniquel y situated to directly contribute to these efforts. “Notably, since Florence Nightingale walked the wards of Scutari, nurses have used their assessment skills and clinical insights to improve outcomes for patients in emergency situations…[including a] history of responding to disasters, aiding individuals and communities in their recovery process…stopping the spread of infectious disease, managing mass immunization clinics, and providing counsel and care to citizens affected by raging flood waters.”¹

After the tragic events of September 11, 2001 (9/11), followed by Hurricanes Katrina and Ike in 2005 and 2008, the wildfires of California in 2009, the massive oil spill in the Gulf of Mexico in 2010, and the many floods and tornadoes in 2011, it is imperative that NPs engage in ongoing planning, development, and training in disaster response and preparedness. As Spellman¹ said, “The challenge faced by today's nurse is to ascertain ways in which discipline-specific expertise can be used appropriately in an emergency response effort. Pioneers in the field of emergency preparedness for nurses have prepared the groundwork for developing a curriculum and establishing competencies to guide us as we sharpen existing skills and develop the new skills needed to respond effectively to emergency events.”

As NPs continuously develop their role in primary health care, it is essential that they also offer their unique talents, skills, and abilities to fill specific roles as members of emergency and disaster planning response teams to plan for and integrate their abilities into the emergency and disaster response plan.¹ Given the barometer of disastrous events globally, it is additionally clear that emergency and disaster preparedness activities should be incorporated into NP educational curricula and targeted continuing education. However, the development of a theoretical framework to guide nursing research and evidence-based practice for emergency and disaster preparedness activities is still in its early stages.²

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The NP Role in Emergency and Disaster Preparedness 

Today, NPs have been in practice for over 40 years and are working not only in acute care and primary care settings but also in extended care, psychiatric, and intensive care settings. Since its inception, the role has focused on health promotion and disease prevention,³ both of which are ideal to provide education on how to prepare for emergencies, disasters, and catastrophic events.

NPs, working in primary care settings as community-based health care providers, have a responsibility to participate and support federal and state efforts to promote emergency and disaster preparedness.³, ⁴ As a result, NPs are increasingly found participating on emergency operations center (EOC) boards and disaster planning committees at hospital, city, state, and federal levels. Of note, the public has great expectations from the nursing profession; therefore, it is incumbent for NPs to be prepared, at both the personal and professional level, and to have procedures in place that will facilitate serving in an emergency.

For example, Qureshi et al⁵ examined the ability and willingness of health care workers to report for duty during emergency or catastrophic events. The authors discovered several common barriers to reporting for work at the site of the catastrophic event; specifically, the authors noted that taking care of personal and family health and safety needs were first and foremost important before responding to the emergency event. Other significant issues included transportation problems and care for children, elders, and pets.

The study further defined issues that affected the ability to report to work in the event of an emergency, including fear for personal and family safety and provision for personal medical care during the event. An overarching conclusion found that the most significant key element in emergency and disaster preparedness was to have procedures in place before a disaster strikes; such preparation facilitated the best response to and survival of a catastrophic event.

NPs can significantly help the process of emergency and disaster preparedness by providing critically important information, including education, to the public in daily practice. For example, Bradley et al⁶ studied the importance of including natural support systems when planning a public health response to address the emotional and behavioral consequences of bioterrorism. They noted that natural support systems include schools, family physicians, clergy, and other faith-based organizations that traditionally have been important in helping individuals deal with disasters and other traumatic events. The authors proposed the incorporation of integration of such natural support systems in the response planning of a community disaster plan. Planning templates and more information are available on the Federal Emergency Management Agency (FEMA) and Centers for Disease Control and Prevention (CDC) Web sites.⁷, ⁸

Reaching out before a disaster to, for example, faith-based parish nurses and practitioners and developing not only lines of communication and expectations but also responsibilities and authority is the next step. In an effort to explore, identify, and highlight these inherent support systems, NPs are typically familiar with such information about their community and the public-at-large and subsequently can support the critically important nature of their participation in interdisciplinary community-based disaster planning.

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Historical Underpinnings 

Prior to 9/11, most catastrophic events were primarily dealt with by FEMA. Before requesting assistance from FEMA, the governor of the catastrophically affected state was required to declare a state of emergency. FEMA was created on March 30, 1979, to coordinate the response to US disasters, particularly those that overwhelmed the resources of local and state authorities.

The aftermath of 9/11 and the threat of more terrorist attacks to the nation prompted the establishment of a new government cabinet, the Department of Homeland Security (DHS), on November 25, 2002. DHS is the third largest cabinet department of the federal government, with FEMA ultimately being subsumed as an agency within DHS. This resulted in DHS having the ultimate government responsibility for preparedness, response, and recovery to natural disasters, as well as the responsibility of protecting US territory and citizens from terrorist attacks and other disaster-related prevention and relief efforts.⁷, ⁸, ⁹

DHS uses civilian first responders, local emergency response professionals, to prepare for and respond to terrorist attacks, natural disasters, or any other large-scale emergency. Subsequently, the National Incident Management System (NIMS) was developed in 2004 by DHS and designed to help first responders from different jurisdictions and disciplines work together when a community has exhausted local resources and can no longer support the disaster management and relief operations. Using NIMS in an emergency situation provides a unified approach to incident management.⁹

Training on the incident command system (ICS) is vital to understanding NIMS. The ICS is designed to provide a common organizational structure that allows an immediate response to emergencies by establishing a clear chain of command that enables the coordination of personnel and equipment at the site of an incident. DHS has developed a minimal core of competencies for individuals expected to participate in an emergency, including training for ICS and NIMS.⁹ Additionally, in 2002, President Bush created the Citizens Corps to give an opportunity to American citizens to participate in emergency preparedness, thereby placing more responsibility on local disaster-relief groups to deal with the effects of both natural and man-made disasters.¹⁰

Of relative significance to the NP community, these programs and educational opportunities provide an avenue to volunteer to participate at various levels within local organizational structures. Opportunity exists to participate at the state and national levels during both preparedness planning and a disaster.

The 3 main nongovernment organizations tasked with health-related disaster relief are the American Red Cross, the Medical Reserve Corps, and Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP). ESAR-VHP is a federal program to establish and implement guidelines and standards for the registration, credentialing, and deployment of medical professionals in the event of a large-scale emergency. The program is administered by the Department of Health & Human Services. ESAR-VHP standards are mandated to American states and territories, enabling an enhanced national interstate and intrastate system for using and sharing health care professionals. Learning about these organizations and aligning with them is how the NP community will respond to future health-related disasters, locally, regionally, and nationally.

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Primary Care and Disaster Preparation 

The Standards of Clinical Nursing Practice¹¹ provides a holistic framework for the practice of nursing. Today's nurses are faced with the challenges of responding to natural, man-made, and technological disasters. In the United States, although disaster-related content is now included in the National Council Licensure Examination (N-CLEX), little time is spent in teaching or learning this information during the basic nursing education program. Education at the master's or doctoral levels fare no better.¹², ¹³ However, within the realities of practice, nurses are challenged with the foundational, professional, and social responsibility to assist individuals, families, and communities to maintain and improve their health often through the primary care setting.

Health maintenance is supported through 2 basic and overlapping components: health promotion and disease prevention. Normal functional health management includes evaluating how the individual “protects self against overwhelming situations and changes.”13 Health promotion activities related to emergency and disaster preparedness surround maintaining a normal pattern of coping and stress tolerance. If an individual has a pre-established emergency plan it may make it easier to cope with and tolerate the stress of a catastrophic event.⁷

Emergency preparedness measures typically fall under primary prevention. Disease prevention refers to avoidant behaviors that individuals use to protect themselves from diseases or conditions, such as immunizations and any other measures focused on preventing disease transmission. On April 17, 2007, a vaccine to prevent human infection against 1 strain of the avian influenza (bird flu) virus was approved by the Food and Drug Administration (FDA). If the vaccine is needed, it will be distributed by public health officials.¹⁴ For example, NPs working in primary care settings may be asked to set up “flu clinics” or participate in mass vaccination efforts.

As they are uniquely positioned to provide care in roles that shift from RN to NP and back as the need demands during this altered disaster state, much work is accomplished. NPs use knowledge learned in both roles to provide the very best of those roles. Not only can the NP order the flu shots, assess high- and low-risk patients, and treat adverse reactions, they also know their local community population and its idiosyncrasies, which could influence the success or failure of this effort.

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Disaster Risk Analysis Exemplar: State of Virginia 

According to Blaikie et al,¹⁵ disaster occurs when hazards, natural or man-made, meet vulnerability. All communities are at risk for disasters. For instance, using the State of Virginia as an exemplar, a risk assessment reveals that Virginians may be vulnerable to hurricanes, winter storms, thunderstorms, toxic spills, earthquakes, tornadoes, terrorism, flooding, or fires.¹⁶ Since 1996 the Commonwealth of Virginia has had 19 major disaster declarations, and the information provided in Table 1 supports the argument that all communities are at risk for a major disaster. Consequently, it is useful for primary care nurses to similarly examine the past decade of catastrophic declarations that have occurred in their own state and local community to assist in future disaster-preparedness planning.

zTable 1. Major Disaster Declarations for the Commonwealth of Virginia

Of additional concern, economic losses related to disaster are also tremendous and include direct costs, indirect costs, and secondary effects. Direct costs are related to physical damage, including productive capital and stocks, economic infrastructure, and social infrastructure. Indirect costs deal with the disruption to the flow of goods and services, including the cost of medical expenses and loss of productivity. Secondary effects refer to short and long impacts of the disaster that affect the overall economy and socioeconomic conditions. Each have a significant impact on long-term human and economic development by affecting the pace and nature of capital accumulation.¹⁶ Therefore, it is vital to disseminate the importance of emergency preparedness to potentially decrease some of these losses.

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Implications for Clinical Practice 

The changes in the global climate (including environmental, societal, and political facets) demand citizenry preparedness. The nurse practicing in the primary care setting must help educate citizens on the importance of being prepared in the event of a natural or man-made disaster. It is commonplace to believe that public health agencies are going to respond immediately in a case of an emergency; however, the reality is that it could take a minimum of 72 hours for any mechanism to come into place and for the government to respond. During this critical period, individuals need to be ready to take care of themselves until help arrives.

A number of additional factors may increase the response time. For example, emergency responders may have great potential for distraction if they are not prepared at home for the immediate safety of their own family. The latter would compromise not only their ability to respond immediately but potentially their level of effectiveness.

Blessman et al¹⁷ studied the “at-home” preparedness of 100 emergency responders. They concluded that 15% of the participants were considered as “better prepared,” and only 8% were rated as “most prepared.” In another study, Mackler, Wilkerson, and Cinti¹⁸ surveyed paramedics to determine if fear of infection would compromise their ability to care for persons suspected of carrying smallpox. The authors discovered that, among the 95 paramedics who responded to the survey, more than 80% would not remain on duty if a vaccine or protective gear were not available. These numbers reveal a reality that, given certain circumstances, not even the first responders may be available to help the community during a catastrophic event and may further delay the anticipated response typically expected by citizens.

Preparing for a health emergency has been traditionally viewed as the domain of public agencies; however, the demands imposed by the events in the past decade have strained the existing public health infrastructure. Although local, state, and federal agencies, including the Centers for Disease Control and Prevention (CDC), have provided funding for emergency and disaster preparedness planning, the cost, benefits, and sustainability are still debatable. Public health agencies are usually underfunded, and public health providers routinely play multiple roles because of limited budgets. The reality is that, although public health has been identified as the key responder in emergency and disaster preparedness, ever shrinking municipal budgets make it difficult for many public health providers to prioritize planning for community emergencies and disasters. Furthermore, many health departments lack personnel with the necessary expertise in planning, emergency response, communicable disease control, and post-exposure management of biological agents.

Emergency Support Function (ESF) #8 is a Public Health and Medical Services directive that provides the mechanism for coordinated federal assistance to supplement state, tribal, and local resources in response to a public health and medical disaster, potential or actual incidents requiring a coordinated federal response, and/or during a developing potential health and medical emergency. This process includes responding to medical needs associated with mental health, behavioral health, and substance abuse considerations of incident victims and response workers. Services also cover the medical needs of members of the “at risk” or “special needs” population described in the Pandemic and All-Hazards Preparedness Act and in the National Response Framework (NRF) glossary, respectively. It includes a population whose members may have medical and other functional needs before, during, and after an incident.¹⁹ Dovetailing with this national directive, Hyde et al²⁰ note that, unless adequate support for appropriate staffing and workforce development is available for implementation, the necessary resources to respond when another disaster strikes may not be available.

Nurses are the largest group of health care providers.²¹ As such, nurses would be considered essential personnel to be called upon when preparing for response to terrorist strikes or other disasters. The ability of individual nurses to respond depends on many factors, such as clinical competence, personal safety, and safety of family members.²² NPs can be instrumental in preparing other nursing professionals to respond to community needs in the event of a disaster. For example, to prepare personnel at their workplace, primary care nurses can develop and implement programs, such as an all hazards plan.²³ This state and local guide

…provides emergency managers and other emergency services personnel with information on FEMA's concept for developing risk-based, all-hazard emergency operations plans. This guide clarifies the preparedness, response, and short-term recovery planning elements that warrant inclusion in state and local emergency operating plans (EOPs). It offers FEMA's best judgment and recommendations on how to deal with the entire planning process—from forming a planning team to writing the plan. It also encourages emergency managers to address all of the hazards that threaten their jurisdiction in a single EOP instead of relying on stand-alone plans. This guide should help state and local emergency management organizations produce EOPs that serve as the basis for effective response to any hazard that threatens the jurisdiction; facilitate integration of mitigation into response and recovery activities; and facilitate coordination with the federal government during catastrophic disaster situations that necessitate implementation of the federal response (FRP).²³

Other strategies for NPs include educating clients with regard to personal disaster preparedness and modeling personal preparedness. This may include asking patients to ensure adequate medicine and medical supplies are available to them for packing in an emergency and directions to build a home emergency kit, as well as showing how they have prepared kits and family emergency plans themselves.²⁶

Further, NPs can organize or participate in events that emphasize emergency preparedness during September, the designated National Preparedness Month, such as the information Get a kit, make a plan, be informed, and get involved⁸ to distribute to their patients. This information, established by and disseminated by DHS, educates the public about disaster preparedness. An example is: “[Being] prepared to improvise and use what you have on hand to make it on your own for at least 3 days or longer. While there are many things that might make you more comfortable, think first about fresh water, food, and clean air.”¹, ²⁴

The goal for NPs is to develop procedures that will limit injury and detrimental effects to the population within their community. NPs will partner with their local hospitals, physician offices, public health clinics, and urgent care centers, who should anticipate their role in a catastrophic event, such as a large-scale E. coli disease outbreak that may require triage, direct care, or care management of a large number of patients, even in an acute care facility.²⁵

NPs are inherently planners, and this role should be maximized within the interdisciplinary emergency preparedness team in all communities. By meeting with hospital planners, city public health officials, and health policy planners, the public's needs can be anticipated in the event of a disaster. NPs can help organize the community response to be able to address the needs of each group, participate in developing educational offerings targeting both medical personnel and the public, and assist institutions with the development of response, triage, and treatment policies for community disasters.

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Conclusion 

Disaster preparedness maximizes safe conditions, decreases vulnerability, and minimizes risk to individuals when they are confronted by a hazard. NPs can serve as role models by being current and prepared to face disaster. NPs can attend independent study programs sponsored by FEMA,²⁵ including webinars, the Just-In-Time training classes taught by the American Red Cross, and the Health Services Disaster Workshop,²⁶ all free of charge, some with continuing education units.

Nurses can also promote emergency and disaster preparedness at the workplace. For example, the California Primary Care Association (CPCA) has been an active participant in emergency preparedness efforts that have lead to the Clinic Emergency Preparedness Project²⁷ to assist community clinics and health centers to develop and maintain an emergency management program to guide their responses to all emergencies, regardless of cause. The template is a “fill in the blank” format and includes planning language, procedures, policies, and forms needed to create a comprehensive plan.²⁸

Specifically, the CPCA²⁹ has established 4 Phases of Emergency Management:

By increasing awareness of national, state, and local efforts, including the availability of educational and program resources, NPs can strengthen preparation efforts that can be invaluable—and literally lifesaving—for catastrophic events that affect their communities.

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References 

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