1. Evans, Cathleen A. PhD, MSN, RN, CEN, CNE, NHDP-BC

Article Content

Biologic disasters, such as epidemics and pandemics, are the number one global health challenge.1 Disasters begin and end locally and have scope, scale, and duration variables. Definitions of what constitutes a disaster vary widely, but common to each is hazard risks impacting vulnerable human life, society, culture, infrastructure, resources, and assets.2 Interrelated, overlapping phases of a disaster are prevention/mitigation, preparedness, response, and recovery, with each phase having actionable behaviors.2 The management plan to scale staff, space, and supplies at the time of an incident, or the lack of a plan, influences human abilities to mitigate disaster-related physical and psychological challenges. Historically, when humans intersect with disaster hazards, uncertainty causes us to be unaware and unready.3

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Nurses and healthcare staff know their practice well; however, COVID-19 has exposed gaps in our disaster readiness. Hazard risks associated with COVID-19 include staffing and supply shortages, anxiety and fear of infection, inefficient communication, and staff exhaustion.4 Readiness begins with education to build knowledge, skills, and attitudes to transition abilities to change outcomes.5 A disaster creates complex environments, and disaster readiness boosts competencies for sustainable resiliency across the phases.


This article contributes a collection of free, web-based education resources to develop a foundation for disaster readiness among nurses and healthcare staff out of lived COVID-19 experiences. (See Education resources.) The suggested resources create one approach to operationalize the nursing crisis management taxonomy of skills, including task and resource management, situational awareness, teamwork, communication, emotional control, and leadership.6 Derived from nursing research, this taxonomy includes key skills applicable to disaster readiness across all healthcare staff that promote staff agility to form teams and foster resiliency for disasters.


Resources for disaster readiness

The first resource is Psychological First Aid, which encourages providers to be situationally aware to see others and recognize duress manifested as emotions, basic physical needs, or both.7,8 Tactics include active listening and connecting the person to available resources.


The second resource is the US Federal Emergency Management Agency's Introduction to the Incident Command System, ICS-100.9 This system is a flexible model used to manage and scale resources during local, state, regional, and national emergencies and disasters. The National Incident Management System is made up of the government, nongovernment, and private sector organizations that work together during disaster incidents. Command and control principles, developed by the California Fire Service in the 1970s, came out of catastrophic wildfires with loss of life and are in use around the globe.9-12


Developed by the US Department of Defense and the Agency for Healthcare Research and Quality, TeamSTEPPS is the third resource.13 This program includes team structure basics, communication techniques among and between team members, leadership, and chain of command. The chaos of high patient acuity and resource gaps makes clear, concise, consistent, and respectful communication critical to care quality, patient and staff safety, and team member well-being. Learned techniques facilitate communication to promote improved conflict resolution, shift change, and critical information exchange. Team tactics include established shift times for members to communicate strengths, concerns, and leadership gaps during briefings, huddles, and debriefings. Cross-member monitoring and self-monitoring are other techniques that steward situational awareness among team members and promote peer-to-peer support to communicate needs.


The International Council of Nurses Core Competencies in Disaster Nursing is the fourth resource.14 Eight domains, separated into basic and advanced nursing practice, focus on developing disaster readiness among nurses. The framework moves nursing disaster education from tasks, such as knowing where to report for staffing assignments, to competencies for patient management, decision-making, and self-care. The advanced level covers leadership needs for developing processes to implement guidelines and directives for nursing care.


The last resource is the National Center for Disaster Medicine and Public Health Disaster Health Core Curriculum to develop foundational competencies for professional roles during a disaster.15 Delivery of the 11 core competencies is in nine lessons.


Through the COVID-19 lens

As a biologic disaster, COVID-19 has exposed nurses and healthcare staff to hazard risks, such as scarce personal protective equipment and infection. Risk exposure increases by the number of patient encounters and time spent with patients.16 When a team member can't perform their duties due to emotional duress or physical illness, team flexibility ensures patient coverage. Team members can use Psychological First Aid strategies to assess colleagues' needs, including exhaustion-an identified COVID-19 hazard.7,8


During emergencies and disasters, patient care doesn't exist in a vacuum.17 When usual healthcare operations are disrupted, contingency standards can trigger the use of repurposed patient care areas, staff extenders, and conservation of supplies that may include reuse to deliver functionally equivalent care.18 During COVID-19, the practice problem emerged of not having enough RNs to provide patient care.4,19 Further exacerbating this shortage was healthcare job losses caused by stoppages in select sectors during the pandemic.20


A characteristic of disaster care is that staff members will often conduct activities not in their usual repertoire but always within their scope of practice. Because disasters trigger changes and variations to usual facility operations, a healthcare emergency operations plan (EOP) should include strategies to scale staff, space, and supplies. Flexible staffing plans work to meet circumstances caused by changes as the disaster evolves, as with COVID-19. If a state requests federal assets, the National Disaster Medical System can send medical assistant teams to augment hospital operations with staffing and resources.21,22 Integration of outside teams into healthcare organizations requires orientation to facility processes and unit-specific, just-in-time competencies.23 Facility leaders need to vet licensing requirements and processes to use internal or external staff extenders to ensure smooth workforce incorporation. Redundant verbal communication with follow-up written messaging and two-way communication during briefings, huddles, and debriefings is imperative.13

Education resources... - Click to enlarge in new windowEducation resources

The use of staff extenders involves changed responsibilities to support the opening of more patient care spaces, replace absent staff, or augment the available workforce.18 Scaled staff development is a management tactic useful for small-, moderate-, or large-scale incidents and even daily volume issues. Management planning as part of the preparedness phase includes cross-training for scale-up reassignments and possible repurposed responsibilities. Staff members developed as team extenders strengthen surge capacity to flex staffing incrementally. Staff extenders need acuity-based competencies and a resource contact during patient care. In the case of extended duration disasters, such as COVID-19, just-in-time competencies can be used to retrain staff for reassignment and repurposed responsibilities. An example of this type of training is the Project XTREME Model for Health Professionals' Cross-Training for Mass Casualty Respiratory Needs to manage mechanically ventilated patients.24


Examples of staff extenders include staff members from outpatient clinics and offices caring for stable admitted patients, medical-surgical nurses integrating into telemetry units, telemetry personnel integrating into intermediate units, and intermediate nurses extending to critical care. The home unit nurses are the experts, with one nurse assigned as the team lead and resource nurse. Ideally, two nurses would be assigned: one as the team lead and one as the resource nurse. The team's size depends on the number of beds and patient acuity. Adding other staff roles, such as licensed practical nurses, clinical assistants, and respiratory or pharmacy personnel, is scaled by clinical needs with real-time decision-making. The author's COVID-19 experience was as an external extender, with a team lead and repurposed staff, such as prehospital paramedics, helping at the bedside in alternative care spaces during patient surges.


When forming teams for flexible personnel management to cover existing and new missions, remember that there are two types of teams: core and contingency.13 The core team is the first team formed that keeps the original mission. The contingency team forms from the core team with an expanded or new mission or works in a new location. Member talents contribute to the flexible, scalable nature of teams for operations, and the team lead communicates member roles.13 Adding new members to an already functioning team requires consistent orientation to ensure that new members progress through team development stages.25,26 If a new member doesn't integrate into the team, they can undermine its function. New members need a resource buddy for support and to model accountability, communication, and responsibilities. Nursing care teams achieve desired outcomes because of clear roles and responsibilities for who should be doing what, where, and when. A team approach creates more frequent patient interactions and touchpoints for patient status, which is essential during high, variable patient acuity. It should be communicated to patients that their care will use a team approach.


Undermining of a team's efficiency occurs when personnel disconnect from their assigned role and function. Another occurrence is not communicating using the chain of command. Team trust and confidence is jeopardized when members use sidebar conversations rather than constructive conversations during briefings, huddles, and debriefings.13 Confidence and trust in leadership are essential, and a good leader keeps two-way communication open with team members. An unclear chain of command can weaken a team's cohesiveness and create functional problems.


Monitoring the nurse-patient ratio aids leaders to recognize that the patient census is expanding beyond usual staffing patterns, creating the need for load leveling. The set point is 150% of usual. When reaching the set point, leaders should consider innovative staffing to mitigate load leveling.24 For example, if the nursing unit staffs to a 1:6 ratio, the nurse assignment at 150% is nine patients. This assignment would time constrain patient encounters.


Two ICS100 command and control tenets, unified command and management by objectives, are analogous with the interdisciplinary healthcare objectives of quality, safety, and efficiency.9,10 A recovery phase example of implementing unified command and management by objectives is a point-of-distribution COVID-19 vaccination clinic. The clinic, vaccine, and line managers are the leaders implementing a unified command. Management by objectives means coordinating the mission to vaccinate with quality care, safety, and distribution efficiency. Leaders need to recognize stopgaps to efficiency, such as registration backup or no-show scheduled appointments. Remedies include innovate staffing with cross-trained staff to improve registration flow or distribute vaccine doses to a nonscheduled client waitlist. Command and control principles are available as a domain in the Core Competencies in Disaster Nursing and a module in the Disaster Health Core Curriculum. Leaders who effectively use command and control principles can best manage real-time resource scaling.9-11


Developing a resilient healthcare workforce requires annual facility disaster education. Hazard risk experiences for small-, moderate-, and large-scale types of disasters provide an opportunity to build confidence for transfer to real-world incidents. Testing and evaluations ensure that the EOP processes used to scale resources work as intended. A future consideration includes developing the role of a surge manager to monitor nurse-patient ratios. If nurse-patient ratios are expanding, innovate staffing with the short-term use of staff extenders and repurposed staff should be put in place to mitigate. In a disaster occurrence, the surge manager role scales up in real time as part of a command and control response strategy. A surge manager supports facility disaster readiness to avoid a staffing crisis as seen during COVID-19.


Be prepared

Not only has COVID-19 affected nurses and healthcare staff but other disasters, such as the widely publicized weather-induced Texas power grid failure, have occurred during the pandemic. The education resources outlined in this article can offer support. Psychological First Aid helps staff members look out for each other, which is essential to mitigate burnout. Using command and control tenets helps leaders scale tasks and resource management for different incident sizes and durations. TeamSTEPPS can mitigate the role-definition stress inherent in newly formed teams. Emotional control, including self-care and the confidence to act during a disaster, can be learned through the Core Competencies in Disaster Nursing. And the Disaster Health Core Curriculum includes situational awareness and personal safety, critical for crisis management.


Disasters of varied types, sizes, and durations will continue to occur so sustained disaster readiness is vital. Facility exercises and drills help nurses and healthcare staff be more resilient across all phases of a disaster. When nurses and healthcare staff are disaster ready, patient care delivery can occur while ensuring staff and patient safety during any type of disaster, including a resurgence of COVID-19.


INSTRUCTIONS Disaster readiness essentials for a pandemic



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