Authors

  1. Livornese, Karen MSN, RN-BC, CCRC, CFN
  2. Vedder, Jena MS, RN

Abstract

In a world after 9/11, Hurricane Katrina, and Sandy Hook, plenty of literature has emerged on the subject of disaster management, but little is specific to the emotional well-being of the health care staff dedicated to serve during a crisis. Disasters, whether natural or man-made, are episodic but becoming more frequent. Nurses may find themselves in hospitals affected by a disaster, awaiting a surge of patients while supplied with only limited resources. Or, they may be deployed to austere environments where they are challenged to operate clinics, surrounded by the rubble of an earthquake. In these situations, nurse leaders need to ensure that staff members are trained to be effective disaster health care resources before crises occur. Training includes education on what nurses may observe, how they will be utilized in an emergency situation, and how they can best handle a chaotic environment, both during and after the event, in a manner that will help them keep their emotions in balance. Training before a disaster will help nurse responders develop a plan for their personal responsibilities so they can focus on the mission. The time to start training is not when the disater occurs. In a chaotic environment, most nurses will not have the necessary reserves to begin learning new concepts. Prepared nurses and their leaders must be ready to use their training prior to any crisis. They need to be able to assess that their colleagues are not suffering because of lack of sleep, food, or emotional support. Even after a disaster has initially been resolved, and nurse responders have returned to their families, nurse leaders need to follow up with their team. It may actually be during the postcrisis period that nurse responders need the most emotional support.

 

Article Content

THE INTERNATIONAL COUNCIL OF NURSES has developed a framework for Disaster Nursing Competencies.1 Although the framework emphasizes the enormous amount of psychological and emotional stress that accompanies disaster, it also states that these issues are often overlooked. Most of the framework focuses on the victims of disaster, not on the emotional well-being of nurse responders and their leaders. Emotional support for caregivers must set a realistic stage for nurse responders before, throughout, and after disasters. This is key to nurse resilience.

 

As nurse leaders ensure appropriate training of staff, they must assess the ability and willingness of nurses to serve during disasters, because crises events are always potential realities for health care providers. Leaders themselves must be prepared to stay emotionally balanced during disaster situations. They will need to create a culture where nurses look out for one another, perhaps through a formalized "Buddy System." Nurse leaders must communicate clearly with all team members, keeping in mind that deploying to a disaster is not the time to train. In addition, crises situations are not the time to address long-standing community issues inherent to standard nursing care. Nurse leaders need to ensure that there is adequate follow-up with all staff members after the crisis. A strong nurse leader understands that the emotional health of nurses will be of the upmost importance in a disaster. Planning ahead for their emotional and psychological well-being will benefit all.

 

Individual, organizational, and environmental barriers such as family priorities, organizational policies addressing time and attendance, and the actual environmental nature of the event itself, are important factors that need to be addressed prior to a disaster.2 In addition, by planning for provision of logistical support, coordination, and liability protection for the nurses who are willing to work through a disaster, the institutions and leaders will demonstrate a commitment to keeping nurses emotionally balanced through highly stressful situations. In a 2015 study, Yan and colleagues3 revealed that nurses deployed to earthquake disasters in China suffered significant emotional and psychological stress. Interviews after the events made it clear that none of them were trained in disaster nursing.

 

It is also clear that if nurses know that their personal issues regarding the disaster have been addressed before they deploy, it will reduce their stress while demonstrating the institution's commitment to them and their well-being.

 

Training prior to a disaster and creation of an individual plan for disaster responders' families are both key for keeping nurses and nurse leaders resilient. According to author Cole Edmunson, "Understanding and embracing the complexity instead of fighting against it can help best prepare nurse leaders for their role in crises."4 Communication, calm behavior, and constant adjustment to fluid situations are how nurse leaders will assist in keeping their staff emotionally balanced.

 

In 2013, Vitello-Cicciu and Quin5 shared that, during the Boston Marathon bombings, nurse leaders individually checked in on staff, provided wellness activities for every shift, and assessed coping skills of nurses. Their presence and clear communication made them strong nurse leaders and helped create stronger disaster nurses as well.

 

McAllister6 states that resilience in children depends on social connection with family and peers. These same factors are important for development and maintenance of adult resilience. Nurses need to be connected to their families, friends, and peers after crises. Getting home, and back to "normal," may not be the smooth transition that disaster nurses expect.

 

GETTING READY AND PREPARED

Besides ensuring that nurses are trained for providing care during crises, nurse leaders must consider and have a mitigation plan for barriers to deploying throughout the disaster. Disasters are episodic and chaotic. Taking on unfamiliar roles during a crisis is a possible cause for emotional stress. For example, an orthopedic nurse may find himself/herself cast in the role of case manager. An operating room nurse may be tasked with delivering psychological first aid. Training for these unanticipated duties prior to the disaster is imperative.

 

Personal preparedness for a variety of crises starts with learning about different types of responses. Medical needs during a hurricane will be very different from medical needs following a terrorist attack. Nurses and nurse leaders will probably need to take on various roles. Knowing that this is a realistic probability ahead of time, and thinking through what an individual may be called upon to do as a professional nurse, are integral in mental preparedness for both the nurse and nurse leaders. By being flexible and willing to step outside their normal roles, nurses will be able to deliver care to patients with confidence regardless of the type of disaster. During disaster training, nurse leaders should encourage individual nurses to take a personal assessment of their own strengths and weaknesses, so they will know which skills they can offer during a crisis. Knowing their own strengths will assist each nurse by mentally priming and building their own confidence. Nurse leaders may also encourage nurses to take advantage of opportunities for additional training offered by the facility through participation in disaster drills.

 

Of course, how well nurses are trained will be a moot point if they are unable or unwilling to respond to a call to join the disaster team when the disaster actually occurs. In 2005, Qureshi and colleagues7 interviewed 6428 health care workers from 47 health care facilities in New York City and the surrounding metropolitan area to determine their ability and willingness to come to work during a catastrophic disaster. This study revealed barriers to willingness to come to work. Cited reasons included fear and concerns for family and self (most frequently reported), personal health problems, and child or elder-care issues. In 2016, Veneema had a similar finding, but also revealed that nurses said that they needed commitment from their institutions to make deployment possible. This commitment was described as logistical support, expense reimbursements, and liability protection.2 Nurse leaders must recognize these fears and concerns and may even share them, as the disaster may be affecting their own families.

 

Nurse leaders need to ensure that nurses are aware that personal preparedness is as essential as training to deliver care during a disaster. Nurses need to ask themselves what will happen to their own children, elderly parents, and pets if they are required to stay at the hospital for a multiday response. By making personal family action plans, the nurse, supported by the nursing leader, will be ready to respond to the crisis without distraction. Planning for several different locations and options that can provide safe and prolonged care for the nurses' family members will decrease stress and will give nurses more freedom to focus solely on the medical needs of patients during the crisis.

 

Sidebar 1

Several years ago, a unique opportunity presented itself for a specialized response team. A community in crisis requested mental health resources. Several of us were identified as having the skills and knowledge to be able to help respond to this need. Once each member of the team was identified, we began meeting to prepare ourselves for how to respond to the crisis.

 

Organization within the team was key to helping each team member understand the role he or she would play in the response. As a team, we begin learning all that we could about the local community and what the impact of the crisis was on healing. This response was not typical in that the team had time to prepare. We were able to set clear objectives for providing care, create community presentations, identify local resources, and develop processes that could be utilized during the response to assist the community to recover.

 

That this team worked together prior to the activation for the response was invaluable to its overall success. Knowing the details of the required response ahead of time allowed us to set expectations for what could realistically be accomplished. As a result, we were able to utilize the skills and resources of the team, while preventing team members from feeling like they failed or did not do everything they could to help.

 

-Jena Vedder, MS, RN

 

WHEN DISASTER STRIKES

When a team of nurses arrives at a disaster site, whether this is a community hospital, a clinic, or a field aid station, leaders may find that policies and procedures painstakingly outlined by subject matter experts for this particular disaster do not apply. This could induce emotional stress on the nursing staff as well as the leader.

 

Vitello-Cicciu and Quin5 documented the experience of nurse leaders during the Boston Marathon Tragedy. What was most important for nurse leaders to help their staff work through this disaster was to hold on to their values of collaboration, ethics, transparency, and flexibility. By using skilled communication, promoting an emotionally sound environment by making daily rounds, speaking individually with staff, and providing wellness activities every shift, leaders were able to motivate the team to continue their great work during this chaotic time.5

 

Edmonson et al4 note that the priority focus area in a crisis is communication. Communicating early, and openly, while portraying a confident, unflappable posture will ease the possibility of team members reacting with unstable emotions during disasters. While communicating well, the nurse leader also needs to delegate tasks and take inventory of staff deployments and specific assignments. He or she needs to consider partnering inexperienced staff with veterans to help provide support and monitor responses to additional stress. If the event is prolonged and staff begins to demonstrate symptoms of fatigue, the nurse leader may consider rotating roles and duties to allow individual periods of time in less stressful environments, while still supporting the disaster response. Although nurses and nurse leaders need to be flexible in chaotic environments, this is not the time to initiate training for the nurse responders.

 

Sidebar 2

In 2012, Hurricane Sandy had a devastating impact on the medical and nursing home facilities in New York and New Jersey. An organized large-scale response to assist with evacuating facilities and staffing medical shelters was requested. The local systems were overtaxed, overwhelmed, and not able to meet the medical and mental health needs of people displaced by the hurricane.

 

For the disaster team, arriving at the scene and taking inventory of the magnitude of the multistate response was overwhelming. The large number of providers who responded to the call to provide medical assistance complicated the situation because, for many, this was their first time providing nursing care during a crisis. They were neither trained nor prepared to provide the necessary care. A large disaster with human suffering tugs at the very reason we became nurses, but it is not the time for nurses to start training. Inexperienced and unorganized individual nurses can complicate, rather than help, a crisis situation.

 

During the response to Hurricane Sandy, I was lucky enough to work with a seasoned and highly competent provider. From the moment we arrived, we witnessed a prepared, trained leader who was confident in decisions, clearly communicated plans, set expectations, and demonstrated that he cared about individual caregivers. These leadership skills were the glue that held us together as we spent long days in shelters providing care with limited resources and an ever-growing number of patients.

 

Within the initial 24 hours, staff began getting overwhelmed. They showed signs of stress reactions. The leader pulled everyone together to discuss what was happening, normalize the reactions, and make adjustments to the assignments. Responders were paired to provide mutual support and to ensure that their "buddies" were taking breaks, staying hydrated, and eating. One person at each shelter was identified to provide "force" health protection. The role of the nurse providing force health protection was to monitor the entire staff at the shelter, looking for signs of decompensation. They handed out water to providers while serving as an "ear" when needed.

 

Having a leader who displayed empathy to the staff helped prevent burnout. The staff in the shelter felt comfortable discussing personal challenges as well as their feelings related to the response efforts. Many expressed that they were disheartened due to their inability to provide care to the standard they were used to. The leader addressed those feelings and reinforced a consistent and realistic message about medical care that can be delivered with minimal resources in an austere environment. Nightly discussions and debriefs were instituted to allow an outlet for staff emotions. Team members were able to discuss grief and stress reactions in a safe and supportive environment. The buddy role extended to off duty hours. Buddies encouraged each other to exercise, communicate with loved ones, share a meal, and maximize sleep.

 

-Jena Vedder, MS, RN

 

AFTER THE CRISIS

During a disaster, a nurse or nurse leader may not demonstrate signs of significant emotional stress as they concentrate on the crisis. This does not mean that they have not been affected by their experience. During a disaster, a nurse may uncover disturbing issues that were in the community prior to the crisis event. The desire to provide solutions to long-standing community issues and to address endless patient concerns adds an unexpected additional aspect of emotional stress. Nurses have responded to disasters, only to be confronted with clinical problems they are unable to solve. A study in China (Yan) has revealed that most nurses were not prepared to talk to earthquake victims about personal problems beyond their physical injuries.3 As victims opened up and shared their issues, it was quickly apparent that the nurses were not equipped for this. China has experienced many earthquakes over the last several years. As a result, this has been an opportunity for research on the experiences and reactions of the nurses deployed to care for the victims. Yan's research reinforced that most, if not all, nurses sent to disaster sites were not trained in disaster nursing.8 Nurses who were sent to care for earthquake victims completed a questionnaire about the nursing skills they used or needed during their assignment to the disaster areas. Out of 19 skills that the nurses ranked to be important in the earthquake disaster, psychological crisis intervention was #5. Psychological crisis intervention was also ranked as #2 as a training need and ranked #1 for additional skills needed.8 Nurses self-reported that they were not prepared for the psychological trauma inflicted upon the victims. Subsequently, they themselves experienced emotional stress. In addition, when these nurses arrived home, they had no follow-up support for their distress.

 

The nurse leader needs to follow up with his or her staff after a disaster. This can be done with debriefings or telephone calls to check in with individual team members. Disaster responses bring mixed emotions, and allowing staff to verbalize their reactions early on begins the process of building resiliency. The nurse leader needs to validate all feelings and acknowledge different personnel reactions to the shared event. Leaders need to address any ongoing emotional responses to the event while providing the opportunity for counseling and access to additional resources. Touching base with all nurses is crucial. As memories of the disaster fade, the emotional trauma that a nurse might feel will not be addressed unless the nurse leader uncovers it, or the nurse feels safe and supported enough to ask for help.

 

Sidebar 3

The time of returning home after providing care in a crisis can be confusing. The feeling of euphoria that resulted for assisting in the response, and the adrenaline from the stress are leaving your body. Reality hits when the demands from home confront you as you walk in your door. Understanding that this is a period with feelings that need to be acknowledged helps build long-term resiliency and prepares you for the next disaster response.

 

Reaching out to others who shared your experience assists in your journey to normalizing feelings and addressing any challenges with adjustment to your "real" life. Awareness of personal feelings and how they are impacting you after the response ends is important. Communicating concerns early and often will help prevent long-term feelings of failure, while allowing for processing and cognitive reframing of the situation. A negative feeling after a disaster response experience is a normal reaction to an abnormal event. How the feelings are addressed will directly correlate with the long-term outcome of the nurse and future willingness to respond to disaster events.

 

An important task following a disaster is the completion of an after action report and participation in a debrief. Both of these tasks allow all members to be heard. Discussion of challenges that were encountered and suggestions for things to consider in future responses are paramount to preparedness for the next response. It is common for learnings to occur due to situations that were not considered when policies were written or supplies were ordered. Having first-hand experience better prepares the nurse and nurse leader to make adjustments to policies or reconsider supplies needed for the next disaster response.

 

Over the months following the disaster, negative or anxious feelings may continue to surface. Coping skills can deteriorate. You can't predict how you will respond to a crisis until you have actually experienced an event. Taking steps to return to hobbies and activities that provided stress relaxation and positive emotion before the event is a good coping tactic. Seek additional professional assistance if needed. Know and understand what resources are available to you. If you don't know-ask! Each experience adds knowledge and skills that prepare you for the next disaster, builds resilience, and ultimately protects your emotional well-being.

 

-Jena Vedder, MS, RN

 

CONCLUSION

Nurses and nurse leaders are on the journey of creating a pathway to disaster preparedness. Addressing the emotional well-being of nurse responders and leaders is key to building resiliency and an effective team. With each disaster and subsequent response, more information needs to be shared about best practices, and areas that need to be developed. Consider early on that emotional stress will impact nurse responders. Train early, and remember to assess for decompensation, poor coping skills, and stress during disasters. Make a point to institute follow-up calls with responders after the event. Pull together teams within the hospitals to consider preparation for both man-made and natural disasters that can impact the community. Start conversations, develop plans, and enact ongoing training exercises. Do not wait to do this, because during a disaster, response is the worst time to acknowledge that you are not prepared and emotionally ready. Building these strategies into the normal routine of health care organizations will foster confidence, empower the nursing staff, and promote long-term mental health wellness for your team.

 

REFERENCES

 

1. International Council of Nurses, World Health Organization, 2009. INC framework of disaster nursing competencies. http://http://www.wpro.who.int/hrh/documents/icn_framework.pdf?ua=1. Updated 2009. Accessed October 14, 2016. [Context Link]

 

2. Veenema TG, Griffin A, Gable AR, et al Nurses as leaders in disaster preparedness and response-a call to action. J Nurs Sch. 2016;48(2):1-14. [Context Link]

 

3. Yan L, Turale S, Stone T, et al A grounded theory study of "turning into a strong nurse": earthquake experiences and perspectives on disaster nursing education. Nurse Educ Today. 2015;35:43-49. [Context Link]

 

4. Edmonson C, Sumagaysay D, Cueman M, et al The nurse leader role in crisis management. J Nurs Adm. 2016;46(9):417-419. [Context Link]

 

5. Vitello-Cicciu JM, Quin M. Looking through the eyes of nursing leaders: the Boston marathon tragedy. J Nurs Adm. 2013;43(9):436-437. [Context Link]

 

6. McAllister M. Resilience: a personal attribute, social process and key professional resource for the enhancement of the nursing role. Prof Inferm. 66(1):55-62. Accessed October 18, 2009. [Context Link]

 

7. Qureshi K, Gershon RR, Sherman MF, et al Healthcare workers' ability and willingness to report to duty during catastrophic disasters. J Urban Health. 2005;82(3):378-388. [Context Link]

 

8. Yan YE, Turale S, Stone T. Disaster nursing skills, knowledge and attitudes required in earthquake relief: implications for nursing education. Nurs Educ. 2015;62(3):351-359. [Context Link]

 

disaster management; emotional well-being; nurse leadership