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Emergencies, Disasters, and Catastrophic Events: The Role of Rehabilitation Nurses in Preparedness, Response, and Recovery
Rehabilitation nurses play an integral role in helping patients and communities plan for, respond to, and recover from disasters. This article provides an overview of various types of disasters, the terminology used by planners and responders, and the structure that governs the delivery of services, resources, and patient care. Information about specialized training in disaster response and volunteer opportunities through national and state humanitarian relief programs are provided. Although each nursing specialty lends expertise to emergency and disaster situations, rehabilitation nurses are particularly well-suited to help during times of complex, multifaceted medical and emotional responses.
Increasingly, the news is filled with reports of natural disasters and terrorist activity. There is a growing awareness that disasters can strike anytime and anywhere. Data on the frequency and type of disasters reported by the Federal Emergency Management Agency (FEMA) and the World Health Organization (WHO) support this impression. On average, a disaster occurs every day somewhere in the world (Rodriguez, Vos, Below, & Guha-Sapir, 2009) and weekly in the United States. In contrast, a fire that requires a fire department response occurs every 22 seconds in the United States (Karter, 2009). Although disasters are events of greater magnitude than emergencies (Guha-Sapir, 2000), most communities are well prepared for emergencies and have dedicated fire stations with well-trained firefighters, emergency medical technicians, and a fleet of emergency vehicles. In addition, most people at some point in their lives will participate in fire drills and are familiar with basic principles of fire safety, fire alarms, smoke detectors, and extinguishers. In general, people are not as familiar with and prepared for disasters as they are for emergencies. In part, it is easier to justify the costs associated with education, training, and maintaining dedicated resources for responding to frequent emergencies than for rare, but calamitous disasters. Furthermore, public perception of risk associated with disasters is typically low, which diminishes motivation to prepare for an infrequent event.
However, to optimally function—personally and professionally—during a complex, demanding, and potentially enduring disaster (e.g., flu pandemic), it is advantageous to possess a basic knowledge of disasters, the terminology used by planners and responders, and the structure that governs delivery of services, resources, and patient care prior to the occurrence of an actual event. In addition to this general overview, this article also describes specialized training in disaster preparedness and response and volunteer opportunities with national and state humanitarian relief programs. Finally, because rehabilitation nurses play an integral role in helping patients and communities plan for, respond to, and recover from disasters it is imperative to have a personal disaster plan in place before an event occurs to ensure that the personal needs and those of loved ones, pets, and others are met during an unfolding event. Information about how to prepare a plan is provided.
Emergencies, Disasters, and Catastrophic Events
Historically, the terms emergency, disaster, and catastrophic event were often used interchangeably. Although various scholarly papers and relief organizations may define these terms differently, there are features of each that are shared by all. In general, the short- and long-term effects and responses to different situations vary based on the type and features of the event. A hazard has the potential to cause harm to health, life, safety, or the environment and increases vulnerability, although it may not require a rapid response. An emergency is an event that moves beyond the potential of a hazard and poses an immediate threat to one's health, life, or surroundings. Emergencies are extraordinary situations that require an immediate response, but can be adequately managed at the local level by designated responders, such as police officers, firefighters, emergency medical technicians, and public health officials using local resources (Guha-Sapir, 2000). WHO defines a disaster as an event involving 100 or more persons, with 10 or more deaths, an official disaster declaration, or an appeal for assistance (Below, Wirtz, & Guha-Sapir, 2009). Understandably, major disasters typically require more resources than are available in the immediate geographic area. Essential services such as food, water, housing, health care, and sanitation are usually disrupted for prolonged periods of time. Finally, a catastrophe is a sudden and extreme disastrous event, causing an upheaval in the order of communities, which requires an extensive recovery process that fundamentally changes the surrounding environment (Homeland Security, 2008).
In 2008 there were 3,320 civilian fire fatalities (Karter, 2009); in contrast, only 10 major disasters in the United States have resulted in 1,000 or more fatalities (FEMA, 2010). However, all of these deaths occurred as a result of a single event. The psychological effects of a high death rate combined with a surge in those seeking assistance and healthcare services may easily overwhelm available systems of care. The ability of medical providers, relief workers, and disaster responder personnel to quickly mobilize and the availability of needed resources, such as water, food, and shelter, affects the recovery of the surviving population. The likelihood of an onset of a disaster-related mental or physical illness varies according to the time since the event. The postdisaster time frame is typically divided into three phases: acute or short term (1 month or less), intermediate (1â€“12 months), or chronic or long term (12 months or longer).
Disasters are also classified as natural or human made. Human-made disasters can be further categorized as intentional, such as acts of terrorism, or unintentional, such as technological events like the Three Mile Island accident in 1979. Common types of natural disasters include flooding, hurricanes, earthquakes, tsunamis, and tornados. There has been a move toward all-hazard planning for disasters. Although the H1N1 and H5N1 influenzas involve the spread of an infectious disease, many argue that pandemics also fall within the realm of disasters. In fact, because of the potential for significant and prolonged social disruption, President George W. Bush assigned the overall coordination of the pandemic response to the Secretary of Homeland Security.
It is evident that disasters are not uniform events. Unique differences exist between types of disasters (e.g., a hurricane is different than an earthquake) and variability exists within any specific type of disaster (e.g., some earthquakes are bigger and more damaging than others). Other parameters that define a disaster that should be considered include type of disaster (i.e., natural or human made), predictability, advance warning, frequency or probability of recurrence, duration of the disaster, intensity, and scope (DeWolfe, 2000). These elements have implications for planning and recovery and can be used when developing all-hazards plans.
Most all-hazards approaches recognize four phases of a disaster. The first phase, mitigation, seeks to minimize the effects of a potential disaster. For example, not building in a flood zone would greatly reduce the threat of damage by flooding for that particular structure. Likewise, helping patients consider how they would manage their rehabilitation medical care prior to the occurrence of a disaster could help them avoid interruption of treatment and possible negative health consequences. It is important for nurses to become familiarized with the types of disasters that are most likely to occur where they live and practice. For example, the Gulf Coast states are threatened by a recurring hurricane season, whereas the West Coast is more likely to experience unpredictable earthquakes. Disaster preparedness, the second phase, can take many forms—from preparing patients' personal disaster plans to developing a disaster plan for a medical practice or an entire community. The third phase, response, involves efforts to minimize the hazards created by a disaster. For example, if sufficient warning takes place, such as with hurricanes, it may be possible for patients to evacuate in advance of the storm to a safe shelter. If there is little if any warning, such as with earthquakes, knowing safety procedures such as moving beneath a sturdy table or to a corner of the room when the earth begins to tremble can be life saving. The final phase is the recovery. As noted above, the recovery period for major disasters can last from days to years. The demand for rehabilitation nursing services could increase significantly during this phase. Treatment would continue for existing patients and services would be initiated for new patients who have been harmed by the disaster.
In some instances, survivors may have to adjust to a new normal. In the case of a tornado, entire communities may be destroyed in a very short period of time. Personal belongings, homes, community institutions, tree-lined streets, and a favorite coffee shop may disappear during a single storm. Even though the replacement structures that are built after the storm will be new and perhaps better than what previously existed, these buildings will not be the same as what was standing before the tornado. Not surprisingly, people grieve the loss of what was, and some will have difficulty adjusting to the new normal. Rehabilitation nurses can help people during all phases of a disaster. To do so requires knowledge of the terminology used by planners and responders and familiarity with services that are available to assist others during each of the disaster phases.
Disaster Terminology and Systems
Just as the nursing profession has its own scientific language, shorthand, and workforce culture, so do the agencies responsible for preparing for and responding to a disaster. The National Incident Management System (NIMS) and the Hospital Incident Command System (HICS) are tasked with preparing for and responding to multiple types of disasters in the United States. Within NIMS, one of the core components is the Incident Command System (ICS), which is the national standard required for emergency management across all levels of government (local, state, national) throughout the United States.
An incident is an event that requires the response of emergency service personnel to prevent or minimize loss of life or damage to the environment. The ICS is based on military concepts that were developed by California fire-fighting organizations to handle large forest fires. In the past 3 decades, the ICS has further evolved and is now a standardized all-hazard approach that features an integrated organizational structure allowing response efforts to match the complexities of single or multiple events. ICS is a tactical system designed to build a comprehensive management structure from a variety of response personnel (i.e., both government and nongovernment agencies), cope with any size or kind of event, provide logistical support, guide task allocation, and avoid unnecessary duplication of services (FEMA, 2009a). Importantly, ICS establishes common terminology allowing diverse disaster management and support entities, such as hospitals, nursing homes, and other nongovernment response agencies to work together. Standard terminology helps to define the major functions of each unit and describe available resources, facilities, and personnel so that all responding parties can communicate, collaborate, and interact efficiently.
For example, the Incident Commander typically has experience or advanced training in disaster response and is responsible for directing emergency operations and decisional authority for how all actions will be coordinated. To carry out response activities, people at each setting are assigned oversight for one of five major functional areas in the ICS: command, operations, logistics, planning, and finance. The ICS can be used to assign rehabilitation nurses to key emergency management duties and designate needed equipment and supplies to carry out tasks. To learn more about the ICS, two online courses are offered at no cost by FEMA—Introduction to the Incident Command System for Healthcare IS-100HC and Applying ICS to Healthcare Organizations IS-200HC (see http://training.fema.gov/IS/crslist.asp). In addition, the Center for HICS Education and Training posts a variety of educational materials, forms, and guidance for nurses and other healthcare professionals on their website (see http://www.hicscenter.org/pages/index.php).
There are numerous opportunities for rehabilitation nurses to volunteer at the local, state, or international levels. Nurses can help develop and coordinate disaster preparedness plans at an individual, group, or systems level. For example, patients may require assistance with both pre- and postdisaster planning to manage their medical conditions. Rehabilitation nurses may be called upon to assist in planning the institutional response of hospitals, nursing homes, and medical practices. State departments of health and nongovernment organizations may desire guidance when planning for vulnerable populations, people with medical conditions, and operation of special needs shelters. In addition to the organizations listed in Table 1, there are a variety of religious organizations and international relief associations that also sponsor disaster-response teams. These major organizations have materials posted on their websites that explain how to apply, obtain required training, and complete the process to become credentialed as a disaster volunteer. Notably, the time to volunteer is before an event occurs.
In the days following the terrorist attacks on September 11, 2001, healthcare professionals traveled to New York City to volunteer their clinical services. Unfortunately, these self-deployed people could not be part of the formal response effort because they were not credentialed and posed a potential safety risk to themselves and others. In recognition of the need to have a screened, registered, and trained cadre of healthcare clinicians, the Department of Health and Human Services integrated the initiatives of the Medical Reserves Corps (MRC) and the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP).
The Office of Civilian Volunteer Medical Reserve Corps (OCVMRC) oversees the tasks required to establish, train, and maintain a national network of community-based volunteers. Each local MRC unit provides screening, credentialing, and training with the goal of supporting routine public health activities and preparedness and response efforts with other agencies during times of disaster (MRC, 2008). The ESAR-VHP program provides oversight for the development of standardized state-based programs for registering and verifying the credentials of volunteer health professionals (MRC, 2008). Each state ESAR-VHP registry uses a set of national standards to create a response system that can quickly identify and coordinate the services of volunteer health clinicians in a disaster. To achieve this objective, each state program is responsible for collecting and verifying information on the identity, licensure status, and credentials of healthcare professionals who wish to volunteer. Other relief organizations, including the American Red Cross, conduct similar background checks to verify identity and credentials of their volunteer relief workers. In addition to these organizations, opportunities exist with professional organizations and faith-based responder groups. To coordinate response of medical personnel, increased effort has been made to include clinicians during the disaster planning phase as well as in the response framework. To find volunteer opportunities, contact one of the agencies listed in Table 1 or one of the professional organizations listed in Table 2.
Most organizations involved in disaster relief efforts provide ample opportunities for advanced training and education (see Table 1). The MRC often offers courses on such topics as surveillance and reporting of infectious disease, responding to people affected by weapons of mass destruction, and the distribution and administration of flu vaccines. Furthermore, many independent study courses can be accessed online from the FEMA website (see http://training.fema.gov/IS/crslist.asp). Some of the courses currently offered by FEMA include the principles and organization of ICS, all-hazards recovery and mitigation, and emergency preparedness and response for specific types of disasters (e.g., radiological, earthquakes, hurricanes) and populations (e.g., special needs, students, tribes). It is advantageous to seek out additional training opportunities to learn about ICS to develop and enhance competencies in disaster preparedness.
Personal Disaster Plan
Although each disaster has its own unique challenges, adequate preparation can strongly influence outcome. Just as institutions develop a disaster plan, nurses should have a personal plan in place for times of disaster. Recommendations for amount and type of supplies, evacuation, sheltering, and plans for contacting family and friends will vary by the type of the disaster but typically include adequate amounts of water, food, medicine, and other essentials such as batteries and pet food to independently survive a minimum of 3 days. A variety of plans, recommendations, and checklists can be downloaded from Homeland Security (FEMA, 2009b), the American Red Cross, and the Centers for Disease Control and Prevention (American Red Cross, 2006). It is difficult to work during a disaster, but even more so if you are worried about the welfare of family, friends, and pets. If you are part of a disaster response effort, personal advance preparation is necessary.
Disasters and Nursing
Nurses' involvement in disaster response efforts dates back to providing treatment to wounded soldiers in battle zone field hospitals during the nineteenth century in the United States and abroad (American Red Cross, 2009). Since that time, the role of nurses in disasters has evolved into a critical component of comprehensive response efforts and encompasses multiple areas including triage, transportation, and treatment of disaster survivors (Veenema, 2006). Nurses comprise one of the largest groups of healthcare professionals that can be mobilized in the event of a disaster. In particular, rehabilitation nurses play a vital role in planning, recovery efforts, and fostering disaster resilience because they are intimately involved in treating survivors adapting to disaster-related disabilities.
The type of disaster directly affects the type of demands placed on rehabilitation nurses. Survivors of disasters may experience psychological and physical injuries requiring medical and rehabilitation services. For example, fractures, punctures, and respiratory problems are common after earthquakes, hurricanes, and tornados and, in most cases, are readily treated. However, exposure to chemical agents, biological toxins, or pandemic illnesses may result in symptoms and acute conditions that worsen and eventually become chronic. Rehabilitation nurses are skilled in treating patients who have physical injuries and caring for those who may be facing prolonged recoveries.
To address the immediate and long-term needs of disaster survivors, rehabilitation nurses must hold core competencies related to disaster mitigation, preparedness, and response. Core competencies for rehabilitation nurses include familiarity with the disaster response plan of their workplace and community health system, understanding their specific role in response and recovery efforts, and the ability to evaluate the immediate situation and adapt as necessary. For example, knowledge of existing plans will permit first responders to be aware of locations for emergency medications and supplies, coordinate with other medical personnel, and reassure patients with factual information about how their current needs will be met.
For rehabilitation nurses to be sufficiently prepared to respond to disasters, continuing education in disaster training and response is essential. Multiple disaster training resources on the core competencies of disaster preparedness and response are readily available for rehabilitation nurses and other healthcare professionals. Table 2 lists sources available for disaster-related professional development.
Rehabilitation nurses base their practice on restorative principles that seek to maximize wellness and optimize long-term independence (Association of Rehabilitation Nurses, n.d.). This is particularly important and relevant when working with disaster survivors because emotional and mental health recovery, as well as long-term resilience, may be linked to physical recovery. Rehabilitation nurses provide a wide array of services to individuals, groups, and special populations to achieve this goal. Such activities include assessing the health and wellness of individuals and communities, developing plans to maximize recovery, addressing health prevention and promotion needs, and advocating for access and improvement of services to marginalized populations. By using core competencies in planning, response, assessment, and evaluation, rehabilitation nurses provide essential services to address immediate problems and provide long-term solutions in response to disasters.
Although each nursing specialty brings expertise to emergency and disaster situations, rehabilitation nurses are particularly suited to help at these times of complex, multifaceted medical and emotional responses. During medical interventions, rehabilitation nurses' ability to address practical, focused problems can be reassuring and extremely valued to injured survivors. Further, nurses who work in rehabilitation medicine services are more familiar and comfortable with the emotional reactions that accompany loss and injury, which is useful in times of disaster and emergencies. Rehabilitation nurses are a vital part of disaster preparedness, response, and recovery efforts and must continue to be sufficiently prepared through ongoing training and education to respond to healthcare needs in the event a disaster should occur.
About the Authors
Lisa M. Brown, PhD, is an associate professor at the University of South Florida, Aging and Mental Health Disparities in Tampa, FL. Address correspondence to her at email@example.com.
Edward J. Hickling, PsyD, is a clinical psychologist at James A. Haley VAMC-HSR&D/RR&D Research Center of Excellence in Tampa, FL.
Kathryn Frahm, PhD MSW, is a research postdocotoral fellow at University of South Florida, Aging and Mental Health Disparities in Tampa, FL.
American Red Cross. (2006). Prepare your family for disasters. Preparedness today. Retrieved January 27, 2010, from www.redcross.org/preparedness/cdc_english/evac-plan.html.
American Red Cross. (2009). Museum—Explore our history. Retrieved January 27, 2010, from www.redcross.org/museum/history/nursing.asp.
Association of Rehabilitation Nurses. (n.d.) Make a difference. Retrieved January 27, 2010, from www.rehabnurse.org/about/definition.html.
Below, R., Wirtz, A., & Guha-Sapir, D. (2009). Disaster category classification and peril terminology for operational purposes. Brussels, Belgium: Centre for Research on the Epidemiology of Disasters.
DeWolfe, D. (2000). Training manual for mental health and human service workers in major disasters: Section 2. Retrieved January 19, 2010, from http://mentalhealth.samhsa.gov/publications/allpubs/ADM90-538/tmsection2.asp
Federal Emergency Management Agency. (2009a). Introduction to incident command system (ICS-100). Retrieved January, 19, 2010, from http://emilms.fema.gov/IS100A/ICS0101000.htm
Federal Emergency Management Agency. (2009b). Make a plan. Ready America. Retrieved January 27, 2010, from www.ready.gov/america/makeaplan/index.html
Federal Emergency Management Agency. (2010). Declared disasters by year or state. Retrieved August 6, 2010, from www.fema.gov/news/disaster_totals_annual.fema.
Guha-Sapir, D. (2000). Disaster preparedness in schools of public health. In L. Y. Landesman (Ed.), Disaster preparedness in schools of public health: A curriculum for the new century. Washington, DC: Association of Schools of Public Health.
Homeland Security. (2008). U.S. Department of Homeland Security national response framework. Retrieved January 21, 2010, from www.fema.gov/pdf/emergency/nrf/nrf-core.pdf.
Karter, M. J. (2009). Fire loss in the United States 2008. Quincy, MA: National Fire Protection Association Fire Analysis and Research Division.
Medical Reserves Corps. (2008). Integration of the Medical Reserve Corps and the Emergency System for Advance Registration of Volunteer Health Professionals. Retrieved January 25, 2010, from www.medicalreservecorps.gov/File/ESAR_VHP/ESAR-VHPMRCIntegrationFactsheet.PDF.
Rodriguez, J., Vos, F., Below, R., & Guha-Sapir, D. (2009). Annual disaster statistical review 2008: The numbers and trends. Brussels, Belgium: Centre for Research on the Epidemiology of Disasters.
Veenema, T. G. (2006). Ready RN: Handbook for disaster nursing and emergency preparedness. St. Louis, MO: Mosby, Inc.
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