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Terrorism and naturally occurring catastrophic events provide fertile ground for nursing emergency preparedness, including deployment strategies. Are you ready to respond?
Recent world events have created a new lens through which to view nursing's role in emergency management. Continuous preparedness, similar to preparation for Magnet designation or a Joint Commission survey, is no longer optional; it's critical for success in a highly competitive and complex healthcare market. Logically, it follows that nurse leaders are responsible for organizing and delivering nursing care that encompasses the essential elements of prevention/mitigation, preparedness, and response and recovery efforts in the continuum of comprehensive emergency management. Hospital leaders need to understand and support the infrastructure required to engage nurses in responding to emergencies or volunteering for deployment to affected areas.
Terrorist events may involve chemical, biological, radiological, nuclear, and explosive (CBRNE) weapons. This assortment may evoke a variety of responses for nurses called to deliver patient care in these types of emergencies, as well as challenge the nurse's ability and willingness to respond. Nurse leaders need to be savvy in recognizing the nurses' ability and willingness to report for duty during uncertain times. (To view a range of public health threats, see Table 1.) Development and maintenance of a nursing emergency management, education, and deployment plan is critical to ensure the safety of staff, patients, families, and served communities.
An event can occur locally, regionally, or nationally. Crucial considerations for emergency staffing are based on whether the event involves a voluntary response to assist outside of your area of responsibility or whether it occurs at or nearby your facility, essentially negating the "voluntary" nature of the response.
The American Nurses Association (ANA) Scope and Standards for Nurse Administrators identifies the global responsibility and accountability of the nurse executive for nursing practice, nursing education, professional development, nursing research, nursing administration, and nursing service within the organizational context.1 Areas related to staffing, information technology, and patient care services are critical dimensions for nurse leaders to address in developing and implementing a comprehensive emergency management plan-this isn't unlike nurse leaders in Magnet organizations who have been identified as "knowledgeable and strong risk-takers who follow a well-articulated philosophy in the day-to-day operations of a nursing department."2
There's not much research on disaster nursing or emergency management nursing. Most studies center on defining nursing educational competencies. Few identified nursing leadership responsibilities, practice, or evaluation measures in disaster nursing or emergency management.3
Disaster nursing literature is primarily anecdotal in nature. Resources for nurse leaders on developing and implementing a comprehensive emergency management program are provided by the American Hospital Association (AHA), the Joint Commission, and the Federal Emergency Management Agency (FEMA).4
The following literature review includes citations from the body of published works related to nurse executive roles and responsibilities in disaster planning and response. The gap in these citations highlights the need for nursing research in this area.
[black diamond] Fahlgren and Drenkard (2002) delineate the role of the nurse executive in disaster planning and identify proactive critical decision making as a quality that nurse leaders must demonstrate in preparedness, which they concluded after experiencing the devastating effects of September 11, 2001.3 Decisions surrounding an event require both accurate assessment and efficient communication, each which require rapid response. The article determines that nurse executives are an integral partner to constructing and implementing a health system's comprehensive emergency response plan. Their role in preparedness is to organize and communicate processes for staff recall, readiness education for patients and staff, protection of staff caring for patients, policy decisions, and fiscal accountability.
[black diamond] Drenkard, et al (2002), cite experience gained by the nurse executive and other nurse leaders in response to the terrorist attack on the Pentagon and the anthrax exposures of 2001, highlighting nurse executive decision making.5 The authors describe use of the nursing process in organizing and planning for an "all hazards" approach to disaster response. Additionally, hospital staff members were identified as "essential" and a skill set inventory was completed on each employee. The skill set inventory identified clinical, technical, and clerical ability.
[black diamond] Aspects of team functioning and communication were addressed in the disaster nursing literature. Situational awareness and high-reliability teams were identified as important tools in implementing a hospital emergency incident command system.6 Improving disaster outcomes, through education and training on situational awareness, and team reliability were identified as important goals for a well-defined nursing emergency management program.
[black diamond] Nurse leaders should provide an environment conducive to disaster education, preparation, and evaluation. Significant concerns surrounding workforce availability during and after events have been identified. In the aftermath of September 11, 2001, Quershi, et al (2005), studied healthcare workers' ability and willingness to respond to disasters in 47 metropolitan New York healthcare facilities. Several barriers were identified relating to staffing during catastrophic events, such as transportation, child care, elder care, and pet obligations.7
A cascade of actions is activated by the Veterans Health Administration in preparing for response to events and mission assignments under the National Response Plan (NRP). The Department of Veterans Affairs, Office of Nursing Services, chartered a collaboration with the Emergency Management Strategic Healthcare Group (EMSHG) and the National Nurse Executive Emergency Preparedness Workgroup to review disaster-related staffing procedures. One of the initial tasks of the group was to delineate disaster deployment activities and competencies to ensure quality nursing care. Core competencies were developed for nursing leaders and clinical staff from the EMSHG principles and a review of the International Nursing Coalition for Mass Casualty Education standards.7,8 The competencies were designed for preparing the nurse leader to respond to community emergencies and staff deployment. The nurse leader competencies described below are consistent with the each of the 14 Magnet Forces related to excellence in nursing care and improved patient outcomes.1
Nurse leader disaster competencies are defined by four domains: assessment, technical skills, risk communication, and critical thinking. (For elements, objectives, and strategies of each domain, see Table 2.) The assessment domain elicits aligning best practices for altered standards of care during an event. Technical skills encompass the ability to implement the incident command structure and efficiently manage human materials and fiscal resources. Risk communication involves the ability to impart complex information simply, clearly, and efficiently during such events. Elements of critical thinking include problem solving and decision making based on priority appraisal and evaluation of the disaster event.
It's important that the nurse's skill set matches the requirements of the event. The nurse leader is well advised to have a straightforward discussion with staff members about the physical environment and working conditions they might encounter during deployment to a disaster event. Hallmarks of the optimal nurse volunteer are: clinical competency, emotional maturity, adequate physical endurance, flexibility, adaptability, and the ability to exhibit resiliency.
Having identified the basic nurse leader disaster competencies, it's important to discuss the specific nurse leader pre- and postdeployment responsibilities. (See Table 3.) The nurse leader's responsibilities extend from the time of the request for volunteers through staff return and debriefing. Prior to deployment, the nurse leader should ensure that involved staff members have a competency validation pack and, where possible, are deployed with mobile communication devices.
The staff nurse competency validation pack should include at least the following documents: nursing license, basic/advanced cardiac life support (BCLS/ACLS) certification, relevant specialty nursing certification, and documentation of relevant clinical competencies. A facility-issued cellular phone is an appropriate telecommunication device for deployed staff.
The nurse leader is required to demonstrate leadership disaster competencies, namely, understanding the Incident Command System (ICS), and an emergency management plan that includes tracking operational, labor, and capital costs. A plan to "backfill" positions at the sending institution and a contingency plan for patient documentation are also recommended. The nurse leader should be aware of the date for demobilization and staff return, allowing for adequate rest periods for the returning staff. Staff debriefing and assisting staff by managing personnel issues are important elements that the proficient nurse leader will identify. Ensuring appropriate facility-based recognition for the deployed staff's willingness and ability to participate in the disaster event response is recommended.
A strategy for encouraging volunteers from the ranks of staff nurses is to create a Web site where staff can locate information about deployment, elements needed for a useful personal/family preparedness plan, and a template for creating a plan, as well as obtain relevant emergency management and disaster nursing education. It's critical to provide staff with a venue for information sharing regarding disaster management and response.
Nurse leaders must ensure that the core competencies for clinicians identify the key skills set intended to prepare staff for conditions that may be encountered during events. It's important for clinical staff to maintain proficiency and skills that are used infrequently, yet needed during emergency response situations. Updating competencies can be accomplished through an online or an annual review process and review of the current literature. Nurse volunteers need to be able to identify and match their current skill set and preparation with the necessary skills defined by the disaster event. There are three elements inherent in staff nurse disaster core competencies: assessment, risk communication, and critical thinking. (See Table 4.)
1. Assessment includes both self-assessment and situational awareness. An expert level of nursing assessment is needed to identify special-needs community-based populations that are uniquely vulnerable during an emergency event. For example, this population may include members who are immunosuppressed, oxygen dependent, wheelchair confined, or in need of hemodialysis. An array of medically complex high-acuity nursing-care-dependent therapeutic modalities may be needed in these populations.
2. Risk communication includes development of a tested personal and professional preparedness plan. Staff nurses must also be knowledgeable about their facility and community disaster plan. Additionally, they should remain keenly aware of concepts related to privacy, confidentiality, and infection control.
3. Staff nurse emergency response core competencies including critical thinking, prioritization, skillful clinical reasoning, and diagnostic decision making are essential. Nursing emergency response may require creative thinking and the ability to adapt and respond rapidly.
Pay careful attention to predeployment staff screening. An assessment of employee "fit" is critical to the nurse's success and satisfaction while providing care in unusual and often challenging circumstances. With a wide range of public health threats possible, varied environmental conditions, and the uncertainty of the scope of the deployed nurse's assignment, nurse leaders must be prepared to address countless issues. (See Table 5.)
Participants in voluntary disaster deployment should have a minimum of 1 to 2 years of clinical nursing experience and be above "satisfactory" in performance, attendance, and physical health. Other considerations in staff deployment include:
[black diamond] individual staff member ability to participate in an accurate self-assessment of retained knowledge of patient care processes and procedures during disasters.
[black diamond] provision of critical incident stress debriefing by qualified staff to all returning staff.
[black diamond] use of electronic media for staff disaster education.
[black diamond] creation of a Web site for nursing staff engaged in disaster response. The site can contain the required disaster education, template for creating a family preparedness plan, deployment checklists, and other locally defined response items.
[black diamond] quarterly evidence-based literature searches forwarded to deployment eligible staff and/or placed on the facility Web site.
The past few years, nurse leaders have seen new levels of chaos and the emergence of new settings in which to provide care, mitigate, and react. Disaster response occurs in diverse settings, often in austere physical conditions and under heightened emotions. These conditions may impact staff willingness to continue in a deployed role. Before recruiting or sending caregivers into a crisis situation, carefully consider the staff selected for deployment, the length of staff deployment, and potential challenges in the disaster environmental working/living conditions.
The nurse leader core competencies and responsibilities presented in this article are defined for unique situations. Additionally, the information shared provides contemporary nurse leaders with the "right stuff" to guide successful disaster preparation and response-while ensuring quality patient care.
1. American Nurses Association. Scope and Standards for Nurse Administrators. Available at: http://www.ana.org. Accessed April 25, 2007. [Context Link]
2. American Nurses Credentialing Center. Magnet Recognition Program Application Manual. Silver Spring, Md: American Nurses Credentialing Center; 2005. [Context Link]
3. Fahlgren TL, Drenkard K. Healthcare system disaster preparedness, part 2: nursing executive role in leadership. J Nurs Adm. 2002;32(10):531-537. [Context Link]
4. Federal Emergency Management Agency. Are You Ready? An In-Depth Guide to Citizen Preparedness. 2004. FEMA publication IS-22. Available at: http://www.fema.gov/areyouready/. Accessed September 12, 2006. [Context Link]
5. Drenkard K, Rigotti G, Hanfling D, et al. Healthcare system disaster preparedness, part 1: readiness planning. J Nurs Adm. 2002;32(9):461-469. [Context Link]
6. Autrey P, Moss J. High-reliability teams and situation awareness: implementing a hospital emergency incident command system. J Nurs Adm. 2006;36(2):67-72. [Context Link]
7. Quershi K, Gershon R, Sherman M, et al. Health care workers' ability and willingness to report to duty during catastrophic disasters. J Urban Health. 2005;82(3):378-388. [Context Link]
8. Department of Veterans Affairs. Emergency Management Principles and Practices for Healthcare Systems. EMSHG publication. Accessed at: http://www1.va.gov/emshg/page.cfm?pg=122. [Context Link]