Public Health Nursing and the Disaster Management Cycle

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1 CHAPTER 23 Public Health Nursing and the Disaster Management Cycle c0023 Susan B. Hassmiller, PhD, RN, FAAN Dr. Susan Hassmiller is the Senior Advisor for Nursing at the Robert Wood Johnson Foundation in Princeton, New Jersey, and Director of the RWJF Initiative on the Future of Nursing, at the Institute of Medicine in Washington, D.C. The Foundation provides support to improve the health and health care for all Americans. Dr. Hassmiller has taught public health nursing at the university level and has dedicated her career to the care and prevention of disease in vulnerable populations. She is a former member of the National Board of Governors for the American Red Cross, having served as the Chair of Chapter and Disaster Services. She is currently on the board of the Central New Jersey Chapter of the American Red Cross. She is a 2002 recipient of both the national American Red Cross Ann Magnussen Award and the regional American Red Cross Clara Barton Award, both recognizing her outstanding leadership in the field of nursing and disaster services. She is the 2009 recipient of the Florence Nightingale Medal of Honor, the highest award in nursing presented by the International Committee of Red Cross in Geneva, Switzerland. She oversees the annual Susan Hassmiller American Red Cross Award, which provides recognition to a Red Cross chapter that has made outstanding contributions in providing disaster health services involving nurses as leaders. p0100 Sharon A. R. Stanley, PhD, RN, RS Dr. Sharon Stanley is the Chief Nurse of the American Red Cross and the Director of Disaster Health Services and Mental Health. She has worked in the public health field for over 30 years, with experience as a county Health Commissioner and faculty member at private and public institutions. Her past positions in public health preparedness include Director of the Ohio Center for Public Health Preparedness, The Ohio State University, and Chief of Disaster Planning, Ohio Department of Health. Colonel Stanley retired from the U.S. Army Reserve in 2007 with 34 years of service, 12 of them active duty. Her military assignments include a three-state Brigade level command and Army Reserve Leadership Campaign Chief, assigned to the Pentagon. She is the recipient of numerous military awards, including the Order of Medical Military Merit. Dr. Stanley is a member of the Institute of Medicine Forum for Medical and Public Health Preparedness for Catastrophic Events, the Working Panel for Integration of Civilian and Military Domestic Disaster Medical Response, and the Federal Nursing Service Council, which includes the Chief Nurses of the Army, Navy, Air Force, Public Health Service, and Veterans Administration. She is a recent graduate of the Center for Homeland Security and Defense, Naval Postgraduate School, where she completed research in the field of mass fatality management. p0110 ADDITIONAL RESOURCES WEBSITE http: // /Stanhope Healthy People 2020 WebLinks Quiz Case Studies Glossary Answers to Practice Application OBJECTIVES After reading this chapter, the student should be able to do the following: 1. Discuss types of disasters, including natural and human made. 2. Assess how disasters affect people and their communities. 3. Differentiate disaster management cycle phases to include prevention, preparedness, response, and recovery. 4. Examine the nurse s role in the disaster management cycle. 5. List sources of competencies for public health nursing practice in disaster. 6. Explain how the community and its partners work together to prevent, prepare for, respond to, and recover from disasters. 7. Identify organizations in which nurses can volunteer to work in disasters. p0060 The authors wish to acknowledge the manuscript review and consultation of a review committee, which included Donna Jensen, PhD, RN, Professor Emeritus, Oregon Health and Science University and Disaster Health Services Manager, Oregon Trail Chapter, American Red Cross; Janice Springer, RN, PHN, MA, Nurse Manager and Recruiter for Concordia Language Villages and Disaster Health Services Advisor and State Nurse Liaison for Minnesota, American Red Cross; and Barbara J. Polivka, PhD, RN, Associate Professor, College of Nursing, The Ohio State University. 507 p0120

2 508 PART 4 Issues and Approaches in Population-Centered Nursing KEY TERMS American Red Cross, p. 516 BioSense, p. 520 bioterrorism, p. 509 BioWatch, p. 520 CBRNE threats: chemical, biological, radiological, nuclear, and explosive, p. 512 Cities Readiness Initiative, p. 520 Community Emergency Response Team (CERT), p. 516 community resilience, p. 518 Disaster Medical Assistance Team (DMAT), p. 516 Emergency Support Functions (ESFs), p. 518 general population shelters, p. 526 Homeland Security Act of 2002, p. 510 Homeland Security Exercise and Evaluation Program (HSEEP), p. 518 Homeland Security Presidential Directive-5 (HSPD-5), p. 510 Homeland Security Presidential Directive-8 (HSPD-8), p. 510 Homeland Security Presidential Directive-21 (HSPD-21): Public Health and Medical Preparedness, p. 511 human-made disaster, p. 509 human-made incident, p. 508 Medical Reserve Corps (MRC), p. 516 mitigation, p. 511 mutual aid agreements, p. 516 National Disaster Medical System (NDMS), p. 515 National Health Security Strategy (NHSS), p. 511 National Incident Management System (NIMS), p. 510 National Preparedness Guidelines (NPG), p. 510 National Response Framework (NRF), p. 510 pandemic, p. 509 Pandemic and All-Hazards Preparedness Act (PAHPA), p. 511 personal protective equipment (PPE), p. 514 Point of Dispensing (POD), p. 512 Project BioShield, p. 520 Public Health Nursing Intervention Wheel, p. 514 Public Health Security and Bioterrorism Preparedness and Response Act of 2002, p. 516 public health surge, p. 509 public health triage, p. 524 rapid needs assessment, p. 524 risk communication, p. 525 special needs shelters, p. 526 Strategic National Stockpile (SNS), p. 520 triage, p. 524 vicarious traumatization, p. 526 See Glossary for definitions OUTLINE u0010 u0015 u0020 u0025 Defining Disasters Disaster Facts Homeland Security: A Health-Focused Overview Healthy People 2020 Objectives The Disaster Management Cycle and Nursing Role Prevention (Mitigation) Preparedness Response Recovery Future of Disaster Management u0030 u0035 u0040 u0045 u0050 u0055 p0165 Wherever disaster calls there I shall go. I ask not for whom, but only where I am needed. From the Creed of the Red Cross Nurse by Lona L. Trott, RN, 1953 p0170 p0175 p0180 s0010 p0185 Around the world, people are experiencing unprecedented disasters from natural causes like hurricanes and earthquakes to human-made disasters such as oil spills and terrorism. Disasters, whether human-made or natural, are inevitable, but there are ways to help communities prepare for, respond to, and recover from disaster. This chapter describes disaster management approaches including phases of prevention, preparedness, response, and recovery. The public health nurse s role in these phases is described. DEFINING DISASTERS A disaster is any natural or human-made incident that causes disruption, destruction, and/or devastation requiring external assistance. Although natural incidents like earthquakes or hurricanes trigger many disasters, predictable and preventable human-made factors can further affect the disaster. On August 30, 2005, the day after Hurricane Katrina hit New Orleans, a breach in the Lake Pontchartrain levees created a disaster within a disaster as 75% of the city filled with up to 20 feet of water ( Reagan, 2005 ). The flooding of New Orleans has been called the largest civil engineering disaster in the history of the United States ( Marshall, 2005 ). Box 23-1 lists examples of natural and human-made disasters. From a health care standpoint, the disaster event type and timing predict subsequent injuries and illnesses. If there is prior warning (e.g., in hurricanes or slow-rising floods), the impact brings fewer injuries and deaths. Disasters with little or no advance notice such as terrorism events will often have more casualties because those affected have little time to make evacuation preparations. Disasters with warnings also carry their own dangers, because individuals can be injured attempting to prepare for the disaster or while evacuating. Public health disasters create pressing needs across a widespread region. In a p0190

3 CHAPTER 23 Public Health Nursing and the Disaster Management Cycle 509 s0015 p0195 b0070 pandemic, pressing and competing health needs occur within a close timeframe, producing a public health surge. In the recovery disaster phase, the immediate threat shifts to adjusting to a new normal in the affected community or region. DISASTER FACTS Disasters can affect one family at a time, as in a house fire, or they can kill thousands and result in economic losses in the millions, as with floods, earthquakes, tornadoes, hurricanes, tsunamis, and bioterrorism. The American Red Cross reports that BOX 23-1 TYPES OF DISASTERS Natural Hurricanes Tornadoes Hailstorms Cyclones Blizzards Drought Floods Mudslides Human-Made Conventional warfare Unconventional warfare (e.g., nuclear, chemical) Transportation accidents Structural collapse Explosions/bombing Fires Hazardous materials incident Pollution Avalanches Earthquakes Volcanic eruptions Pandemics and epidemics Lightning-induced forest fires Tsunamis Thunderstorms and lightning Extreme heat and cold Civil unrest (e.g., riots) Terrorism (chemical, biological, radiological, nuclear, explosives) Cyber attacks Airplane crash Radiological incident Nuclear power plant incident Critical infrastructure failure Water supply contamination From U.S. Department of Health and Human Services: Healthy People 2020: a roadmap to improve all Americans health, Washington, DC, 2010, USDHHS. it responds to a disaster in the United States every 8 minutes, resulting in response to over 70,000 incidents each year ( American Red Cross, 2009 ). The number of reported natural and human-made disasters continues to rise worldwide. Although the number of lives lost declined over the past 20 years 800,000 people died from natural disasters in the 1990s, compared with 2 million in the 1970s the number of people affected increased. In one decade, the number affected tripled to 2 billion (UN Office for the Coordination of Humanitarian Affairs, 2005 ). The increase in the number of lives saved may be explained by better forecasting and early warning systems ( International Federation of Red Cross and Red Crescent Societies, 2009 ). Within a 1-week period in the fall of 2009, three disasters a tsunami in the Samoa Islands, an earthquake in Indonesia, and a typhoon in the Philippines and Vietnam collectively left over 1000 dead, hundreds of thousands homeless, and caused millions of dollars in damages ( Thomson Reuters Foundation, 2009 ). Two disasters in 2008 accounted for 93% of all people dead or missing in disasters: Cyclone Nargis in Myanmar and the Sichuan earthquake in China took over 225,000 lives ( International Federation of Red Cross and Red Crescent Societies, 2009 ). The Centers for Disease Control and Prevention (CDC) estimates that between 41 million and 84 million cases of H1N1 occurred between April 2009 and January 16, 2010 in the United States, with 17,000 deaths, 1800 of them children ( Fox, 2010 ). The 2010 Haiti earthquake ( Figure 23-1 ) claimed an estimated 230,000 lives, left 1.5 million Haitians homeless, and destroyed the nation s capital ( American Red Cross, 2010d ). Disaster disproportionably strikes at-risk individuals, whether their day-to-day risk is physical, emotional, or economic. Disasters can also wipe out decades of progress in a matter of hours, in a manner that rarely happens in more developed countries. The poor, elderly, women, and children in developing communities are excessively affected and least able to rebound ( Duque, 2005 ). Unfortunately by 2050, the percentages of p0200 p0205 f0010 FIGURE 23-1 In the immediate aftermath of the 2010 Haiti earthquake, the American Red Cross provided thousands of Haitians with emergency supplies, food, and shelter. (Courtesy of The American Red Cross Disaster Online Newsroom, Washington, DC. Available at http: // newsroom. redcross. org. Accessed August 1, 2010.)

4 510 PART 4 Issues and Approaches in Population-Centered Nursing t0010 TABLE 23 1 TOTAL AMOUNT OF DISASTER ESTIMATED DAMAGE, BY CONTINENT AND BY YEAR ( ) IN MILLIONS OF U.S. DOLLARS (2009 PRICES) TOTAL Africa 173 1, ,455 1, ,947 Americas 13,337 6,800 15,946 15,386 25,085 74, ,370 7,226 16,625 64, ,616 Asia 15,449 27,108 15,687 15,855 27,630 75,332 30,494 24,873 35, , ,102 Europe 10,789 22,176 2,395 40,283 21,415 2,072 17,261 2,584 22,796 4, ,414 Oceania 1, , ,368 1,488 2,506 12,612 Very high 24,655 39,272 16,087 60,332 50, , ,144 11,694 46,461 64, ,865 development High human 2,412 2,259 3,952 3,328 2,907 7,058 14,607 2,041 11,564 6,360 56,488 development Medium human 14,234 8,370 15,421 10,842 27,178 24,878 30,641 22,557 18, , ,579 development Low human 173 8, ,760 development Total 41,474 57,995 35,528 74,561 81, , ,404 36,295 77, , ,691 From International Federation of Red Cross and Red Crescent Societies: World disasters report 2010: Focus on urban risk, Geneva, Switzerland, 2010, ATAR Roto Presse, p 167. n.a., no data available. For more information, see section on caveats in introductory text. Damage assessment is often unreliable. Even for existing data, the methodologies are not standardized and the financial coverage can vary significantly. Depending on where the disaster occurred and who reports it, estimations may vary from zero to billions of U.S. dollars. The total amount of damage reported in 2009 is the third lowest of the decade. p0210 s0020 p0215 p0220 p0225 population areas more vulnerable to disasters will increase. Eighty percent of the world s population will live in developing countries, while 46% will live in tornado and earthquake zones, near rivers, and on coastlines ( United Nations Development Programme, 2001 ; NASA, 2005 ). The monetary cost of disaster recovery efforts also rose sharply. The cost in more developed countries is higher because of the extent of material possessions and complex infrastructure, including technology. In the United States, increases in population and development in areas vulnerable to natural disasters, especially coastal areas, have led to major increases in insurance payouts (see Table 23-1 ). HOMELAND SECURITY: A HEALTH-FOCUSED OVERVIEW There is a concerted national effort to provide guidance to state and local planning regions to assist with the coordinated and successful responses and recovery efforts in all-hazard disasters and catastrophes. Many documents have been written at the national level, some of which will be reviewed in this overview and chapter. The reader may ask: Isn t this all beyond what an individual nurse should have to know? Actually, it matters greatly how the nation dials 911, and it matters to individuals as well as communities, regions, and the country as a whole. It also matters globally, beyond our own borders. Our national response is not just about the United States, but our international ability to assist other nations in their times of need. As the single largest profession within the health care network, nurses must understand the national disaster management cycle. Without nursing integration at every phase, communities and clients lose a critical part of the prevention network, and the multidisciplinary response team loses a firstrate partner. The U.S. Department of Homeland Security was created through the Homeland Security Act of 2002 (DHS, 2008b ), consolidating more than 20 separate agencies into one unified organization. Homeland Security Presidential Directive-8 (HSPD-8) was issued in December of It established national policies to strengthen the preparedness of the United States to prevent, protect against, respond to, and recover from threatened or actual terrorist attacks and major disasters, and it included a goal for national preparedness ( DHS, 2008c ). The national preparedness goal resulted in the National Preparedness Guidelines (NPG) and The National Response Plan (NRP), a national doctrine for preparedness to include Emergency Support Function (ESF) 8: Public Health and Medical ( DHS, 2008a ). ESF 8 provides coordinated federal assistance to supplement state, local, and tribal resources in response to public health and medical care needs. The 2004 NRP, an all-discipline, all-hazards comprehensive framework for managing domestic incidents, was updated to the National Response Framework (NRF) in January The NRF remains a guide for conducting a nationwide all-hazards response, built upon scalable, flexible, and adaptable coordinating structures to align key roles and responsibilities across the Nation, linking all levels of government, nongovernmental organizations, and the private sector ( DHS, 2008d, p i). Homeland Security Presidential Directive-5 (HSPD- 5) directed the Secretary of Homeland Security to develop and administer the National Incident Management System (NIMS), a unified, all-discipline, and all-hazards approach to domestic incident management ( DHS, 2008c ). The NIMS p0230 p0235 p0240

5 CHAPTER 23 Public Health Nursing and the Disaster Management Cycle 511 p0245 p0250 p0255 s0025 p0260 was established to provide a common language and structure enabling all those involved in disaster response the ability to communicate together more effectively and efficiently. Two national preparedness documents specifically guide disaster health preparedness, response, and recovery: HSPD 21: Public Health and Medical Preparedness and the National Health Security Strategy (NHSS). HSPD 21 established a national strategy that enables a level of public health and medical preparedness sufficient to address a range of possible disasters. It does so through four critical components of public health and medical preparedness: (1) biosurveillance, (2) countermeasure distribution, (3) mass casualty care, and (4) community resilience ( DHS, 2008c ). The NHSS focuses specifically on the national goals for protecting people s health in the case of disaster in any setting. National health security is achieved when the Nation and its people are prepared for, protected from, respond effectively to, and able to recover from incidents with potentially negative health consequences ( USD- HHS, 2009, p 2). The NHSS was directed by the Pandemic and All-Hazards Preparedness Act (PAHPA), which was enacted in 2006 to improve the nation s ability to detect, prepare for, and respond to a variety of public health emergencies ( Hodge, Gostin, and Vernick, 2007 ). In discussing community resiliency and impact of health care reform on public health preparedness, Vinter, Lieberman, and Levi (2010) state: Comprehensive health reform presents a rare opportunity to further strengthen our nation. However, even with health reform, there are still major gaps in our public health preparedness. Addressing these underlying weaknesses in our health system will not be easy or cheap, but failure to address these concerns could prove extremely costly (p 340). It should be apparent by this point that our national system of homeland security includes public health preparedness and response as a core part of its national strategies. Some of the strategy documents introduced in this section are covered in greater detail throughout the chapter. Every aspect of disaster management involves public health nursing. HEALTHY PEOPLE 2020 OBJECTIVES Because disaster affects the health of people in many ways, disaster incidents have an effect on almost every Healthy People 2020 objective. For example, although Access to Health Services and Public Health Infrastructure comprise two important Healthy People 2020 topic areas with subsequent objectives, they become even more significant when individual and community needs escalate in disaster ( USDHHS, 2010 ). Disasters also play a direct role in the objectives related to environmental health, food safety, immunization and infectious disease, and mental health and mental disorders. Public health professionals, such as those who work at the CDC, study the effect that disasters have on population health and continuously develop new prevention strategies. Other organizations, such as the American Psychological Association and the American Red Cross, work with communities in the preparedness, response, and recovery phases of a disaster and to revise and align the Healthy People 2020 objectives related to mental health. HEALTHY PEOPLE 2020 Examples of Objectives Related to Disaster Mitigation EH-21: Improve the utility, awareness, and use of existing information systems for environmental health. FS-1: Reduce infections caused by key pathogens transmitted commonly through food. HC/HIT-12: Increase the proportion of crisis and emergency risk messages, intended to protect the public s health, that demonstrate the use of best practices. IID-12: Increase the percentage of children and adults who are vaccinated annually against seasonal influenza. IID-13: Increase the percentage of adults who are vaccinated against pneumococcal disease. From Department of Health and Human Services (DHHS): Healthy people Available at http: // www. healthypeople. gov / 2020 / default. asp. Accessed February 3, THE DISASTER MANAGEMENT CYCLE AND NURSING ROLE Disaster management includes four stages: prevention (or mitigation ), preparedness, response, and recovery. Figure 23-2 shows the disaster emergency management cycle. Nurses have unique skills for all aspects of disaster to include assessment, priority setting, collaboration, and addressing of both preventive and acute care needs. In addition, public health nurses have a skill set that serves their community well in disaster to include health education and disease screening, mass clinic expertise, an ability to provide essential public health services, community resource referral and liaison work, population advocacy, psychological first aid, public health triage, and rapid needs assessment. Nurses have been serving in disasters for more than a century, and to this day, provide a significant resource to both the employee and the volunteer disaster management workforce, unmatched by any other profession. The World Association for Disaster and Emergency Medicine (WADEM) includes a nursing section. The Nursing Section of WADEM serves to welcome and represent nurses from all countries with an intent and desire to strengthen and improve the practice and knowledge of disaster nursing. The Nursing Section purposes are as follows ( WADEM, 2010 ): D e fine nursing issues for public health care and disaster health care Exchange scientific and professional information relevant to the practice of disaster nursing Encourage collaborative efforts enhancing and expanding the field of nursing disaster research Encourage collaboration with other nursing organizations Inform and advise WADEM of matters related to disaster nursing WADEM sponsored a text entitled International Disaster Nursing that was edited in 2010 by Robert Powers and Elaine Daily and is available from Cambridge University Press. b0015 s0030 p0295 p0300 u0115 u0120 u0125 u0130 u0135 p0330

6 512 PART 4 Issues and Approaches in Population-Centered Nursing Response Preparedness Recovery f0015 s0035 p0335 p0340 p0345 Mitigation FIGURE 23-2 Disaster management cycle. Prevention (Mitigation) All-hazards mitigation (prevention) is an emergency management term for reducing risks to people and property from natural hazards before they occur. Prevention can include structural measures, such as protecting buildings and infrastructure from the forces of wind and water, and non-structural measures, such as land development restrictions. These primary prevention measures implemented at the local government level achieve effectiveness, in an all-hazards approach to threats. Of course, prevention also includes human-made hazards and the ability to deter potential terrorists, detect terrorists before they strike, and take decisive action to eliminate the threat ( DHS, 2007b ). Prevention activities may include heightened inspections; improved surveillance and security operations; public health and agricultural surveillance; and testing, immunizations, isolation, or quarantine and halting of CBRNE threats: chemical, biological, radiological, nuclear, and explosive ( DHS, 2007b ). Within the community, the nurse may be involved in many roles in prevention of disaster. As community advocates, nurses partner for environmental health by identifying environmental hazards and serving on the public health team for mitigation purposes. Public health nurses in particular will be involved with organizing and participating in mass prophylaxis and vaccination campaigns to prevent, treat, or contain a disease. The nurse should be familiar with the region s local cache of pharmaceuticals and how the Strategic National Stockpile (SNS) (described later in the chapter) will be distributed. Once federal and local authorities agree that the SNS is needed, medicine delivery to any state in the United States occurs within 12 hours ( CDC, 2009b ). Then state and local emergency planners ensure Points of Dispensing (POD), to provide prophylaxis to the entire population within 48 hours (CDC, 2007). In terms of human-made disaster prevention, the nurse should be aware of high-risk targets and current vulnerabilities and what can be done to eliminate or mitigate the vulnerability. Targets may include military and civilian government facilities, FIGURE 23-3 Personal preparedness. Public health nurses need to develop their own disaster plan as a part of their community disaster activities. (Courtesy of the Wichita Falls Health District, Texas. Available at www. cwftx. net / index. aspx?nid=1301. Accessed August 1, 2010.) health care facilities, international airports and other transportation systems, large cities, and high-profile landmarks. Terrorists might also target large public gatherings, water and food supplies, banking and finance, information technology, postal and shipping services, utilities, and corporate centers. Preparedness Role of the Public Health Nurse in Personal and Professional Preparedness Public health nurses play a key role in community preparedness, but they must accomplish the critical elements of personal and professional preparedness first. Personal Preparedness Disasters by their nature require nurses to respond quickly. Public health nurses without plans in place to address their own needs, to include family and pets, will be unable to fully participate in their disaster obligations at work or in volunteer efforts (Figure 23-3 ). Many first responders left their jobs to care for their homes and their families when Hurricane Katrina occurred. In addition, the nurse assisting in disaster relief efforts must be as healthy as possible, both physically and mentally. A disaster worker who does not practice self-health is of little service to their family, clients, and community (see the How To box titled Be Red Cross Ready). Disaster kits should be made for the home, workplace, and car. The Nursing Tip lists emergency supplies specific to nursing that should be prepared and stored in a sturdy, easy-to-carry container. Important documents should always be in waterproof containers. Nurses should consider several contingencies for children and older adults with a plan to seek help from neighbors in the event of being called to a disaster. Many public shelters do not allow pets inside and other arrangements must be made. Currently, local emergency management agencies include pet management in the local disaster plans ( FEMA, 2009d ). During Hurricane f0020 s0040 s0045 p0350 s0050 p0355

7 CHAPTER 23 Public Health Nursing and the Disaster Management Cycle 513 b0020 Katrina, in Hattiesburg, MS, 2385 pets were rescued and subsequently sheltered (Reagan, 2005 ). HOW TO Be Red Cross Ready 1. Get a Kit Consider the following when assembling or restocking your kit to ensure that you and your family are prepared for any disaster: Store at least 3 days of food, water, and supplies in your family s easy-to-carry preparedness kit. Keep extra supplies on hand at home in case you cannot leave the affected area. Keep your kit where it is easily accessible. Remember to check your kit every 6 months and replace expired or outdated items. 2. Make a Plan When preparing for a disaster, always: Talk with your family. Plan. Learn how and when to turn off utilities and how to use lifesaving tools such as fire extinguishers. Tell everyone where emergency information and supplies are stored. Provide copies of the family s preparedness plan to each member of the family. Always ensure that information is up-to-date and practice evacuations, following the routes outlined in your plan. Don t forget to identify alternative routes. Include pets in your evacuation plans. 3. Get Informed There are three key parts to becoming informed: Get Info: Learn the ways you would get information during a disaster or an emergency. Know Your Region: Learn about the disasters that may occur in your area. Action Steps: Learn First Aid from your local Red Cross chapter. One way a nurse can feel assured about family member protection is by working with them to develop the skills and knowledge necessary for coping in disaster. For example, longterm benefits will occur by involving children and adolescents in activities such as writing preparedness plans, exercising the plan, preparing disaster kits, becoming familiar with their school emergency procedures and family reunification sites, and learning about the range of potential hazards in their vicinity to include evacuation routes. This strategy also offers children and adolescents an opportunity to express their feelings. THE CUTTING EDGE Federal Medical Stations State and local health resources can quickly become overwhelmed in the event of a disaster. The CDC s Division of Strategic National Stockpile (DSNS) can assist these communities by deploying Federal Medical Stations (FMSs). An FMS is a cache of medical supplies and equipment that can be used to set up a temporary non-acute medical care facility. Each FMS has beds, supplies, and medicine to treat 250 people for up to 3 days. The local community is expected to provide some operational support. A 250-bed FMS set consists of three modules: (1) Base Support: Administrative, food service, housekeeping, basic medical supplies, and personal protective equipment. There are five bed units, with 50 beds each. (2) Treatment: Medical/surgical items. (3) Pharmacy: Medications up to an additional 85 beds. The FMS debuted internationally to support the USNS Comfort in the 2010 Haiti earthquake. From Centers for Disease Control and Prevention: Federal medical station profile, Atlanta, 2009, Division of Strategic National Stockpile. Available at http: // www. texasjrac. org / documents / FMSfactsheetv3-1. pdf. Accessed February 6, p0530 b0030 b0025 Courtesy of the American National Red Cross. All rights reserved. NURSING TIP Emergency Supplies That Nurses Should Have Ready Identification badge and driver s license Proof of licensure and certification (e.g., RN, CPR/AED, First Aid) Pocket-size reference books (e.g., nursing protocols and intervention standards) Blood pressure cuff (adult and child) and stethoscope Gloves, mask, other personal protective equipment (PPE) for general care First aid kit with mouth-to-mouth CPR barrier Radio with batteries and cell phone charger Cash, credit card Important papers Sun protection Sturdy shoes with socks Medical identification of allergies, blood type Medications for self Weather-appropriate clothing to include rain gear Toiletries Watch, cell phone, PDA with pre-entered emergency numbers Flashlight, extra batteries Record-keeping materials to include pencil/pen Map of area Professional Preparedness Every state needs a qualified workforce of public health nurses for solutions for today s public health problems to include natural disasters and the threat of terrorism. Public health nurses, in turn, need dedicated, resourceful, and visionary leaders ( ASTDN, 2008, p 4). Chief public health nurse officers at the state level develop and maintain a strong public health nursing workforce ( ASTDN, 2008 ). Disaster management in the community is about population health: The core public health functions of assessment, policy development, and assurance hold as true in disaster as in day-to-day operations. Operating in the chaos of disaster surge, however, demands a flexible and proficient practice base in each of the core functions and 10 essential services. Just like the mission of public health and its core functions and essential services does not change in disaster, neither does the practice of public health nursing. The public health nurse must be prepared to advocate for the community in terms of a focus on population-based practice. The number of public health nurses available to get the job done is small compared with those with generic or other specialty nurse preparation. Also, disaster produces conditions that demand an aggregate care approach, increasing the need for public health nursing involvement in community service during disaster and catastrophe. s0055 p0540 p0545

8 514 PART 4 Issues and Approaches in Population-Centered Nursing p0550 p0555 The Public Health Nursing Intervention Wheel (Figure 23-4 ) is explained in detail in Chapter 9 and is a populationbased practice model that encompasses three levels of practice (community, systems, and individual/family) and 16 public health interventions. Each intervention and practice level contributes to improving population health, providing a practice foundation. This Wheel holds true to public health nursing interventions whether the nurse is working in day-to-day or in disaster operations. Disaster response teams need nurses with disaster and emergency management training, especially those who have served previously in disaster. Although the majority of disaster work is not high tech, the knowledge one needs for CBRNE disasters must be developed to include access to a ready cache of information related to nursing care. The following sites provide useful information: CDC: Emergency preparedness and response A to Z index (http: // /agent ) National Library of Medicine: Disaster information management research center (http: // / ) Unbound Medicine: Relief Central (http: //relief.unbound medicine. com / relief / ub / ) National Library of Medicine: WISER-Wireless information system for emergency responders (http: // / ) (See Box 23-2 for further information.) Depending on the job and possible volunteer assignments, it is also expected that nurses know how to use personal protective equipment (PPE), operate specialized equipment needed to perform specific activities, and safely perform duties in disaster environments. Professional preparedness also requires that nurses become aware of and understand the disaster plans at their workplace u0290 u0295 u0300 u0305 p0580 p0585 Social marketing Policy development and enforcement Surveillance Population - based Disease and health event investigation Outreach Advocacy Population - based Screening Case Finding Population - based organizing Community follow-up Referral and building Coalition Individual - focused Community - focused management Case Collaboration Systems - focused Delegateds function Consultation Counseling Health teaching f0025 FIGURE 23-4 Public Health Nursing Intervention Wheel. Sixteen public health nursing interventions that work in daily operations or disaster. (Courtesy of Minnesota Department of Health, St. Paul, MN. Available at http: // www. health. state. mn. us / divs / cfh / ophp / resources / docs / wheelbook2006. pdf. Accessed August 1, 2010.)

9 CHAPTER 23 Public Health Nursing and the Disaster Management Cycle 515 b0075 and community. Nurses need to review the disaster history of the community, including how past disasters have affected the community s health care delivery system. Since September 11, 2001, there has been a national emphasis for emergency responding entities to further develop their disaster preparedness and response skills. It is important for nurses to BOX 23-2 NURSES AND TECHNOLOGY Hazardous Material Information Delivered via Wireless WISER (Wireless Intervention System for Emergency Responders) is a system designed to assist first responders in hazardous material incidents. By inputting a substance s physical properties and entering an individual s symptoms, WISER can help narrow the range of substances that may be involved. It provides detailed information about hazardous substances, health effects, treatment, personal protective equipment, toxicity, the emergency resources available, and the surrounding environmental conditions. As of August 2009, WebWISER, a web browser, could be used to access the same functionality of the stand-alone applications when the Internet is available. WebWISER supports both PC- and PDA-based browsers, including BlackBerry and iphone. From National Library of Medicine: WISER, Bethesda, MD, Available at http: // wiser. nlm. nih. gov /. Accessed February 6, understand and gain the competencies needed to respond in times of disasters before disaster strikes. Box 23-3 shows bioterrorism and emergency readiness competencies for those working in public health. Specific disaster competencies for public health nursing practice have been proposed in a set of 25 competencies categorized into preparedness, response, and recovery ( Polivka et al, 2008 ). The preparedness competencies focus on personal preparedness and on comprehending disaster preparedness terms, concepts, and roles. The competencies also focus on becoming familiar with the health department s disaster plan and its communication equipment suitable for disaster situations, as well as on the role of the PHN in a surge event. Response phase competencies include conducting a rapid needs assessment, outbreak investigation and surveillance, public health triage, risk communication, and technical skills such as mass dispensing. Recovery competencies include participating in after-action processes, contributing to disaster plan modifications, and coordinating efforts to address the psychosocial and public health impact of the event. See Box 23-4 for additional education and training opportunities. Nurses who seek increased participation or who seek an in-depth understanding of disaster management can become involved in any number of community organizations. The National Disaster Medical System (NDMS) provides nurses the p0590 p0595 b0080 BOX 23-3 BIOTERRORISM AND EMERGENCY READINESS COMPETENCIES FOR ALL PUBLIC HEALTH WORKERS CORE COMPETENCY 1. Describe the public heath role in emergency response in a range of emergencies that might arise (e.g., This department provides surveillance, investigation and public information in disease outbreaks and collaborates with other agencies in biological, environmental, and weather emergencies ). CORE COMPETENCY 2. Describe the chain of command in emergency response. CORE COMPETENCY 3. Identify and locate the agency emergency response plan (or the pertinent portion of the plan). CORE COMPETENCY 4. Describe functional role(s) in emergency response and demonstrate role(s) in regular drills. CORE COMPETENCY 5. Demonstrate correct use of all communication equipment used for emergency communication (phone, fax, radio, etc.). CORE COMPETENCY 6. Describe communication role(s) in emergency response: Within the agency using established communication systems With the media With the general public Personal (with family, neighbors) CORE COMPETENCY 7. Identify limits to own knowledge/skill/authority and identify key system resources for referring matters that exceed these limits. CORE COMPETENCY 8. Recognize unusual events that might indicate an emergency and describe appropriate action (e.g., communicate clearly within the chain of command). CORE COMPETENCY 9. Apply creative problem solving and fl exible thinking to unusual challenges within his or her functional responsibilities and evaluate effectiveness of all actions taken. From Centers for Disease Control and Prevention : Bioterrorism and emergency readiness: Competencies for all public health workers, Atlanta, Available at http: // www. nursing. columbia. edu / chp / pdfarchive / btcomps. pdf. Accessed February 6, b0085 BOX 23-4 WEBSITES PROVIDING EDUCATION AND TRAINING OPPORTUNITIES Public Health Workforce Development Centers Centers for Disease Control and Prevention: http: // /training / National Public Health Training Centers Network, ASPH: http: //www.asph. org /phtc /search-new.cfm Public Health Training Centers, CDC: http: // /phtrain / Government Training Facilities and Others National Nurse Emergency Preparedness Initiative: http: // / Emergency Management Institute: http: // / Federal Emergency Management Agency (FEMA) Training: http: //www.fema. gov /prepared /train.shtm Public Health Organizations American Nurses Association (ANA): http: // American Public Health Association (APHA): http: // Association of Schools of Public Health (ASPH): http: // Association of State and Territorial Directors of Nursing (ASTDN): http: // National Association of County and City Health Offi ces (NACCHO): http: // Public Health Foundation (PHF): http: //

10 516 PART 4 Issues and Approaches in Population-Centered Nursing b0090 p0600 b0035 BOX 23-5 VOLUNTEER OPPORTUNITIES IN DISASTER WORK American Red Cross (ARC): http: // Buddhist Compassion Relief (Tzu Chi): http: // / Certified Emergency Response Team (CERT): https: // / cert / Citizen Corps: http: // / Disaster Medical Assistance Team (DMAT): http: // / Medical Reserve Corps (MRC): http: // / HomePage National Baptists Convention, USA, Inc.: http: // / index.cfm?fuseaction=page&pageid= National Voluntary Organizations Active in Disaster (NVOAD): http: // www. The Salvation Army: http: // /usn /www _usn _2.nsf opportunity to work on specialized teams such as the Disaster Medical Assistance Team (DMAT). The Medical Reserve Corps (MRC) and the Community Emergency Response Team (CERT) provide opportunities for nurses to support emergency preparedness and response in their local jurisdictions. The American Red Cross offers training in disaster health services and disaster mental health for both response in local jurisdictions and national deployment opportunities. After participation in disaster training, nurses can take the following steps: join a local disaster action team (DAT); act as a liaison with local hospitals; determine health-services support for shelter sites; plan on a multidisciplinary team for optimal client service delivery; address the logistics of health and medical supplies; and teach disaster nursing in the community. A list of opportunities is shown in Box The importance of being adequately trained and properly associated with an official response organization to serve in a disaster cannot be overstated. In a disaster, many untrained and ill-equipped individuals rush in to help. Spontaneous volunteer overload creates added burden on an already tense situation to include role conflict, anger, frustration, and helplessness. The World Trade Center attacks of September 11, 2001 brought many qualified but unassociated responders to the site. Many well-intentioned local physicians in shirt sleeves and light footwear proceeded to the area and attempted to find victims, risking further injuries to themselves and getting in the way of structured rescue protocols. prohibited from participating in rescue operations within any area designated as a disaster by the Fire Department of New York ( Crippen, 2002 ). After the bombing of the Alfred P. Murrah building in Oklahoma City in 1995, a nurse who rushed into the building to rescue people became the only fatality who was not killed or injured in the initial blast and collapse ( Devlen, 2007 ). WHAT DO YOU THINK? Trust for America s Health (TFAH): Bioterrorism and Public Health Preparedness. Health emergencies pose some of the greatest threats to our nation, because they can be difficult to prepare for, detect, and contain. Important progress has been made to improve emergency preparedness since September 11, 2001, the subsequent anthrax attack, and Hurricane Katrina three events that put severe stress on our public health system. However, major problems still remain in our readiness to respond to large-scale emergencies and natural disasters. The country is still insufficiently prepared to protect people from disease outbreaks, natural disasters, or acts of bioterrorism, leaving Americans unnecessarily vulnerable to these threats. TFAH publishes an annual report on public health preparedness titled Ready or Not? Protecting the Public s Health from Diseases, Disasters and Bioterrorism, which examines America s ability to respond to health threats and help identify areas of vulnerability. TFAH also offers a series of recommendations to further strengthen America s emergency preparedness. What do you think of them, and how would you apply them to the role of the public health nurse? From Trust for America s Health : TFAH initiatives Bioterrorism and public health preparedness, Available at http: // healthyamericans. org / bioterrorism - and - public - health - preparedness /. Accessed February 7, Community Preparedness The Public Health Security and Bioterrorism Preparedness and Response Act of 2002 addressed the need to enhance public health and health care readiness and community health care infrastructures. It reaffirmed the public health department role on the front line of disaster prevention, preparedness, response, and recovery, to include a national need for emergency-ready public health and healthcare services in every community ( Office of Legislative Policy and Analysis, 2010 ). Public health departments throughout the country have been receiving federal government funding through the CDC, the Health Resources and Services Administration (HRSA), and the Department of Homeland Security (DHS). This funding is intended to upgrade and integrate the capacity of state and local public health jurisdictions to quickly and effectively prepare for and respond to bioterrorism, outbreaks of infectious disease, and other public health threats and emergencies. Planning and implementation require a coordinated response that involves a variety of stakeholders, including first and foremost the general public as well as all levels of government, public health agencies, hospitals, first responders, emergency management, health care providers within the community, schools and universities, the private sector, and business and non-governmental organizations (NGOs) such as the Red Cross. Mutual aid agreements establish relationships between partners prior to the incident at the local, regional, state, and national levels and ensure seamless service. Emergency management is responsible for developing and coordinating emergency response plans within their defined area, whether local, state, federal, or tribal. The Federal Emergency Management Agency (FEMA) is a coordination entity responsible for creating a comprehensive, all-hazard plan that incorporates scenarios that illustrate plausible major incidents that may affect their community. Plans incorporate all levels of disaster management including prevention (mitigation), preparedness, recovery, and response efforts. Agency personnel s0060 p0620 p0625

11 CHAPTER 23 Public Health Nursing and the Disaster Management Cycle 517 Region IX AK Seattle San Francisco OR American Samoa, Guam, HI U.S Trust Authority of The Pacific Islands WA CA Region X NV ID AZ UT Region VIII MT WY Denver CO NM Region VII ND MN SD NE IA KS Kansas city MO OK AR Austin TX LA Region V WI MI Chicago IL IN OH PA TN KY Atlanta MS AL GA SC FL WV VA NC CT Region NY New York II NJ PR US Virgin Islands Philadelphia DE MD Washington DC Region IV NH VT ME MA RI Region III Region I Boston f0030 Region FIGURE 23-5 Ten FEMA regions. (Courtesy of The Federal Emergency Management Agency [FEMA] Map Service Center, Washington, DC. Available at http: // msc. fema. gov / webapp / wcs / stores / servlet / FemaWelcomeView?storeId=10001&catalogId=10001&langId= - 1. Accessed August 1, 2010.) VI p0630 p0635 b0040 who work closely with their communities and community partners provide opportunities to train, exercise, evaluate, and update the plan. Stronger pre-disaster partnerships produce a more coordinated response. Respective FEMA assets are divided into regions across the nation ( Figure 23-5 ). Good disaster preparedness planning involves simplicity and realism with back-up contingencies because (1) plans never exactly fit the disaster as it occurs, and (2) all plans need implementation viability, no matter which key members are present at the time ( DHS, 2007a ). Finally, the community must have an adequate warning system and an evacuation plan that includes measures to remove those individuals from areas of danger who hesitate to leave. Some people refuse to leave their homes over fear that their possessions will be lost, destroyed, or looted. They also do not want to leave pets behind. Also, some people mistakenly believe that experience with a particular type of disaster is enough preparation for the next one. The nurse s visibility in the community helps develop the trust and credibility needed to help in contingency planning for evacuation. DID YOU KNOW? For the ninth consecutive year, nurses have been voted the most trusted profession in America according to Gallup s annual survey of professions for their honesty and ethical standards. Eighty-one percent of Americans believe nurses honesty and ethical standards are either high or very high. Nurses have received the highest rating every year except in 2001 when firefighters were noted as the most trusted. This very positive result brings with it a great deal of responsibility. Even if a nurse chooses not to formally participate in a disaster, neighbors and friends may still reach out for health guidance during a disaster. Participating in preparedness activities further supports the trust that the public puts in that service. From Advance for Nurses: Available at http: // nursing. advanceweb. com / news / national. news / nurses / rated - most - trusted - profession. Again. aspx. Accessed April 17, Nurses should be involved in identifying and educating these vulnerable populations about what impact the disaster might have on them, including helping them set up a personal preparedness plan. In addition to identifying high-risk individuals in neighborhoods, locations of concern include schools, college campuses, residential centers, prisons, and high-rise buildings ( Langan and James, 2005 ). Nurses can assist in community preparedness with their knowledge of the community s diversity such as non English-speaking groups, immunocompromised clients, children, and the physically challenged. The National Health Security Strategy (NHSS) The purpose of the NHSS is to reconnect public health and medical preparedness, response, and recovery strategies to ensure the nation s resilience in the face of health threats or incidents with potentially negative health consequences. Outcomes p0655 s0065 p0660

12 518 PART 4 Issues and Approaches in Population-Centered Nursing p0665 p0670 p0675 s0070 p0680 p0685 of the NHSS include community strengthening, integration of response and recovery systems, and seamless coordination between all levels of the public health and medical system (USDHHS, 2009 ). The 2006 PAHPA directed the Secretary of the Department of Health and Human Services (DHHS) to develop a National Health Security Strategy, presented to Congress in December 2009, with revision scheduled every 4 years afterward ( ASPR, 2007 ). Community resilience has become a central theme in disaster planning. The NHSS is built on the premise that healthy individuals, families, and communities with access to health care and knowledge become some of our nation s strongest assets in disaster incidents. In an open letter to the American people introducing the NHSS, Secretary Kathleen Sebelius stated: Community resilience is not possible without strong and sustainable public health, health care, and emergency response systems. This means that the health care infrastructure is capable of meeting anticipated needs and able to surge to meet unanticipated ones; ready to prevent or mitigate the spread of disease, morbidity and mortality; able to mobilize people and equipment to respond to emergencies; capable of accommodating large numbers of people in need during an emergency; and knowledgeable about its population including people s health needs, culture, literacy, and traditions and therefore able to communicate effectively with the full range of affected populations, including those most at risk, during an emergency ( DHS, 2009, p ii). Disaster and Mass Casualty Exercises Although practice will not ensure a perfect response to disaster, disaster and mass casualty drills and exercises are extremely valuable components of preparedness. After the exercise, the lessons learned through after-action reports are used to update disaster plans and subsequent operations. Exercise categories include discussion-based simulations or tabletops and operations-based events such as drills, functional, and full-scale exercises ( Gebbie and Valas, 2006 ). The latter operations-types involve escalating scope and scale testing of the disaster preparedness and response network using a specific plan. National Level Exercise 2009 (NLE09), conducted July 27-31, 2009, was the first major exercise conducted by the U.S. government that focused exclusively on terrorism prevention and protection, as opposed to incident response and recovery. NLE09 was designated as a Tier I National Level Exercise. Tier I exercises (formerly known as the Top Officials exercise series [TOPOFF]) occur annually in accordance with the National Exercise Program (NEP) ( FEMA, 2009b ). This program serves as the nation s over-arching exercise program for planning, organizing, conducting, and evaluating national level exercises and provides the opportunity to prepare for catastrophic crises ranging from terrorism to natural disasters. The NLE09 fullscale exercise began in the aftermath of a terrorism event outside the United States, with subsequent efforts by the terrorists to enter the United States and carry out additional attacks. The activities took place at command posts, emergency operation centers, intelligence centers, and potential field locations to include federal headquarters facilities in the Washington DC area, and in federal, regional, state, tribal, local, and private sector facilities in the states of Arkansas, California, Louisiana, New Mexico, Oklahoma, and Texas. Most exercises conducted in hospitals, communities, colleges, counties, or regions are much smaller in scope and scale than NLE09. The Homeland Security Exercise and Evaluation Program (HSEEP) was developed to help states and local jurisdictions improve overall preparedness with all natural and human-made disasters. It provides a standardized methodology and terminology for exercise design, development, conduct, evaluation, and improvement planning and assists communities to create exercises that will make a positive difference prior to a real incident ( FEMA, 2010 ). HSEEP is the national standard for all exercises. Whether conducted as drills, tabletops, functional, or fullscale scenarios, and whether the scope is local or national in nature, nurses and other health care providers must be included as a part of the exercise s planning, response, and after-action activities. Nurses, as client and community advocates, are essential players in the exercise and preparedness arena. Response The first level of disaster response occurs at the local level with the mobilization of responders such as the fire department, law enforcement, public health, and emergency services. If the disaster stretches local resources, the county or city emergency management agency (EMA) will coordinate activities through an emergency operations center (EOC). Generally, local responders within a county sign a regional or state-wide mutual aid agreement to allow the sharing of needed personnel, equipment, services, and supplies. The initial scope of disaster assessment is usually measured in dollars, health risk and injury, and/or lives lost. The more destruction and lives at risk, the greater the degree of attention and resources provided at the local, regional, and state levels. When state resources and capabilities are overwhelmed, governors may request federal assistance under a Presidential disaster or emergency declaration. If the event is considered an incident of national significance (a potential or high-impact disaster), appropriate response personnel and resources are provided. National Response Framework (NRF) The NRF was written to approach a domestic incident in a unified, well-coordinated manner, enabling all emergency responding entities the ability to work together more effectively and efficiently. The on-line component, the NRF Resource Center (http: // /emergency /nrf / ), contains supplemental materials including annexes, partner guides, and other supporting documents and learning resources. This information is dynamic and is designed to change with lessons learned from real-world events ( DHS, 2008d ). The second part of the NRF includes Emergency Support Functions (ESFs). The 15 ESFs provide a mechanism to bundle federal resources/capabilities to support the nation. Examples of functions include transportation, communications, and energy. p0690 p0695 s0075 p0700 p0705 s0080 p0710 p0715

13 CHAPTER 23 Public Health Nursing and the Disaster Management Cycle 519 p0720 p0725 s0085 p0730 Each ESF includes a coordinator function, and both primary and support agencies that work together to coordinate and deliver the full breadth of federal capabilities. Specifically, the ESFs provide the structure for coordinating federal interagency support for a federal response to an incident. The NRFs also include support annexes, incident specific annexes, and partner guides. ESF 8 (described previously) is Public Health and Medical Services. It provides guidance for medical and mental health personnel, medical equipment and supplies, assessment of the status of the public health infrastructure, and monitoring for potential disease outbreaks. The ESF 8 primary agency is the DHHS; supporting agencies include the DHS, the American Red Cross, the Department of Defense, and the Department of Veterans Affairs. The NDMS is part of ESF 8 and includes the DMATs. These teams of specially trained civilian physicians, nurses, and other health care personnel can be sent to a disaster site within hours of activation ( USDHHS, n.d.). National Incident Management System (NIMS) The NIMS is the nation s common platform for disaster response, to include universal protocols and language. The [NIMS] provides a systematic, proactive approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector to work seamlessly to reduce the loss of life and property and harm to the environment ( FEMA, 2009c ). No matter what type of nursing practice or which agency a nurse chooses, they will most likely come into direct contact with NIMS, to include the Incident Command System (ICS). Figure 23-6 lays out how ICS operates at the basic level. The NIMS includes varying levels of education and training, with many organizations requiring a base level of familiarization to comply with federal funding requirements. A well-developed training program promotes nation-wide NIMS implementation. The training program also grows the number of adequately trained and qualified emergency management/response personnel. The How To Be Incident Command Ready box demonstrates a basic NIMS training plan for nurse responders. HOW TO Be Incident Command Ready Five-Year NIMS Training Plan A critical tool in promoting the nationwide implementation of NIMS is a well-developed training program that facilitates NIMS training throughout the nation, growing the number of adequately trained and qualified emergency management/response personnel. The Five-Year NIMS Training Plan compiles the existing and ongoing development of NIMS training and guidance for personnel qualification. The National Training Program for the NIMS will develop and maintain a common national foundation for training and qualifying emergency management/response personnel. To accomplish this, the Five-Year NIMS Training Plan describes a sequence of goals, objectives, and action items that translates the functional capabilities defined in the NIMS into positions, core competencies, training, and personnel qualifications. Emergency Management Institute The Emergency Management Institute (EMI), located at the National Emergency Training Center in Emmitsburg, MD, offers a broad range of NIMS-related training, including the following online courses: IS-100.HC Introduction to the Incident Command System for Healthcare/Hospitals IS-200.HC Applying ICS to Healthcare Organizations b0045 Command Defines the incident goals and operational period objectives Includes an incident commander, safety officer, public information officer, senior liaison, and senior advisors f0035 Operations Establishes strategy Supports Command (approach methodology, and Operations in etc.) and spe- their use of personnel, cific tactics (actions) supplies, and to accomplish the equipment goals and objectives set by Command Coordinates and executes strategy and tactics to achieve response objectives Logistics Performs technical activities required to maintain the function of operational facilities and processes Planning Coordinates support Supports Command activities for incident and Operations planning as well as with administrative contingency, long-range, issues as well as and demobilization tracking and processing planning incident expenses Supports Command and Operations in processing incident information Coordinates information activities across the response system Admin/Finance Includes such issues as licensure requirements, regulatory compliance, and financial accounting FIGURE 23-6 Incident Command System (ICS). (Courtesy of U.S. Department of Health and Human Services, Washington, DC. Available at http: // www. phe. gov / Preparedness / planning / mscc / handbook / chapter1 / Pages / emergencymanagement. aspx. Accessed August 1, 2010.)

14 520 PART 4 Issues and Approaches in Population-Centered Nursing s0090 p0770 u0345 u0350 u0355 u0360 u0365 p0800 IS-700.A National Incident Management System (NIMS), An Introduction IS-701 NIMS Multiagency Coordination System IS-800.B National Response Framework, An Introduction From Federal Emergency Management Agency, NIMS Resource Center, Available at http: // www. fema. gov / emergency / nims / NIMS TrainingCourses. shtm and www. training. fema. gov. Accessed August 1, Response to Bioterrorism The twenty-first century has experienced threats not addressed by the public health philosophy of the twentieth century, where adversaries may use biological weapons agents as part of a long-term campaign of aggression and terror (The White House, 2004, p 2). Results of a biological release can be difficult to recognize because many biological agent symptoms mimic influenza or other viral syndromes. Pathogens such as bacteria, viruses, and toxins can be used to create biological weapons. While an aerosol release may be a likely vehicle for dissemination, certain biological agents could also be released through the water and food supply. Only about a dozen pathogens pose a major threat, even though there are thousands of pathogens, some highly contagious. Quarantine of those exposed to contagious agents may be considered in some instances. A few vaccines have been developed to combat bacterial pathogens. The CDC provides an excellent source of biological agent information to include the latest agent fact sheets for health practitioners ( CDC, n.d.). Biodefense programs help public health professionals mount a proactive response ( TFAH/RWJF, 2009 ): BioWatch is an early warning system for biothreats that uses an environmental sensor system to test the air for biological agents in several major metropolitan areas. BioSense is a data-sharing program to facilitate surveillance of unusual patterns or clusters of diseases in the United States. It shares data with local and state health departments and is a part of the BioWatch system. Project BioShield is a program to develop and produce new drugs and vaccines as countermeasures against potential bioweapons and deadly pathogens. Cities Readiness Initiative is a program to aid cities in increasing their capacity to deliver medicines and medical supplies during a large-scale public health emergency such as a bioterrorism attack or a nuclear accident. Strategic National Stockpile (SNS) is a CDC-managed program with the capacity to provide large quantities of medicine and medical supplies to protect the American public in a public health emergency to include bioterrorism. The SNS is deployed through a combination of state level request and the public health system. Some of the most common lessons from exercises as well as live incidents involve communication. In an effort to keep the public health community informed, CDC developed the Public Health Information Network (PHIN). The PHIN is is a national initiative to improve the capacity of public health to use and exchange information electronically by promoting the use of standards and defining functional and technical requirements (CDC, 2010a, p 530). The PHIN focuses on six components that help ensure information access and sharing: early event detection, outbreak management, connecting laboratory systems, countermeasure and response administration, partner communications and alerting, and cross-functional components. Table 23-2 describes the components. How Disasters Affect Communities When things are lost, disasters are measured in dollars. When people are killed, distant observers rate the toll in numbers of lives ( Pigott, 2005, p 1). Although both benchmarks make for easy comparisons, the pain and suffering of those in and on the fringes of the impact zone cannot be dismissed. People in a community will be affected physically and emotionally, depending on the type, cause, and location of the disaster; its magnitude and extent of damage; the duration; and the amount of pre-warning provided. The first goal of any disaster response is to re-establish sanitary barriers as quickly as possible ( Veenema, 2009 ). Water, food, waste removal, vector control, shelter, and safety are basic needs. Difficult weather conditions such as extreme heat or cold can hamper efforts, especially if electricity is affected. Continuous monitoring of the environment proactively addresses potential hazards. Disease prevention is an ongoing goal, especially if there is an interruption in the public health infrastructure. Infectious disease outbreaks occur in the recovery phase of disasters, and occasionally disaster workers introduce new organisms into the area. Although the immediate response to a disaster by civilians may be unpredictable, the response is not always a negative one. For example, the terrorist attacks of September 11, 2001, created extreme anger and grief but also led to a huge increase in compassion and patriotism. Thousands of people helped, from donating blood and money to rescuing individuals from the buildings. Four days after the attack, buying an American flag was nearly impossible, as most stores had sold out ( Associated Press, 2001 ). Within 1 month of the attack, an estimated $757 million in cash contributions and hundreds of truckloads of goods had been donated to help the families of victims and rescue workers ( Yates, 2001 ). This was the worst human-made disaster in American history, killing more than 2500 civilians and 460 emergency responders. Yet, the terrorist attacks of September 11 will also be remembered for how they unified the country ( Rand Corporation, 2004 ). The psychological effects of September 11 were different from those of more contained, single-event disasters. The attack was totally unexpected and of great magnitude, with much uncertainty and fear about what might happen next. Not knowing when or if a subsequent attack will occur may prevent individuals from moving beyond their fear and anger ( American Red Cross, 2002 ). Another recent U.S. disaster raises similar issues. At 7:10 am EDT on August 29, 2005, Hurricane Katrina made landfall in southern Plaquemines Parish, Louisiana, as a Category 3 hurricane. Starting as a natural disaster, its consequences were compounded by a human-made disaster caused by flooding from levee failure. Later joined by Hurricane Rita, Hurricane Katrina s0095 p0805 p0810 p0815 p0820 p0825

15 CHAPTER 23 Public Health Nursing and the Disaster Management Cycle 521 t0015 TABLE 23-2 PUBLIC HEALTH INFORMATION NETWORK (PHIN) COMPONENTS EARLY EVENT DETECTION Creates a national health surveillance system that signals a public health emergency. Provides a consistent manner in which data are collected, managed, transmitted, analyzed, retrieved, and disseminated. Detects subsequent cases of the health event. Localizes the population affected and tracks the health changes over time. Evaluates the effectiveness of the response activities. Provides ongoing investigation and management of the event. OUTBREAK MANAGEMENT Provides consistency in the capture and management of activities associated with the investigation and containment of a disease outbreak or public health emergency, including: Case investigation Tracing and monitoring Exposure source investigation and linking of cases and contacts to exposure sources Data collection, packaging, and shipment of clinical and environmental specimens Integration with early detection and countermeasure administration capabilities; ability to link laboratory test results with outbreak information LABORATORY RESPONSE NETWORK (LRN) Connects a wide variety of laboratories to detect biological and chemical terrorism and other public health emergencies, including: State and local public health Agriculture Water and food testing Veterinary Federal Military International (The CDC has set the standard for development of secure communication networks between laboratories and establishment of a standard way of naming/sharing laboratory test results.) COUNTERMEASURE AND RESPONSE ADMINISTRATION Enables partners to meet the needs of managing the administration of countermeasures and response activities. It includes such capabilities as single and multiple dose delivery of countermeasure, adverse events monitoring, follow-up of clients, isolation and quarantine management, and links to distribution vehicles such as the Strategic National Stockpile to provide traceability between distributed and administered products. PARTNER COMMUNICATION AND ALERTING Health Alert Network (HAN) enables secure, high-speed, two-way communication among the federal agencies, states, local public health officials, and health-related institutions to reference new and emerging infectious diseases, chronic disease epidemics, environmental health dangers, bioterrorist attacks, and other epidemiological and laboratory data. It provides: Health alerts/ updates Advisories Secure collaboration among designated public health professionals involved in an outbreak or event Sharing of information with the public The network also includes a redundancy of communication devices to include: ; voice mail; texting; faxing; Web capability. CROSS- FUNCTIONAL COMPONENTS Provides the infrastructure for all other components to ensure that systems can remain available and dependable, exchange data, protect private information, and support national standards. Components include: Secure message transport Public health directory and directory exchange Message addressing Vocabulary standards Operational policies and procedures System security and availability Privacy requirements Modified from Centers for Disease Control and Prevention: Public health information network, Available at http: // www. cdc. gov / phin / resources / phin - facts. html. Accessed February 27, affected the Gulf Coast and the nation in ways that will be felt for generations to come. It is the costliest U.S. disaster ever, with economic estimates of more than $125 billion ( NOAA, 2007 ). The hurricane, floods, and more than 1800 confirmed deaths created traumatic stress that rose to unbearable levels in New Orleans, resulting in a tense and sometimes violent aftermath ( Reagan, 2005 ). New Orleans was typically described as a warzone in the weeks following the disaster, as was the Gulfport-Biloxi coastline in Mississippi where 90% of the buildings were demolished. Hundreds of thousands of people lost access to their homes and their jobs as a result of Hurricane Katrina. Although the response and recovery efforts eventually superseded any natural recovery efforts in the history of the country, many residents of both Louisiana and Mississippi believed that the help was too little, too late. Despite the enormous efforts of people and the vast amounts of money spent to help the area recover, there is much work to be done and more funds will be needed in order to restore the area ( ISS, 2009 ). Stress Reactions in Individuals. A traumatic event can cause moderate to severe stress reactions. Individuals react to the same disaster in different ways depending on their age, cultural background, health status, social support structure, and general ability to adapt to crisis. Symptoms that may require assistance are listed in Table s0100 p0830

16 522 PART 4 Issues and Approaches in Population-Centered Nursing t0020 TABLE 23-3 COMMON RESPONSES TO A TRAUMATIC EVENT COGNITIVE EMOTIONAL PHYSICAL BEHAVIORAL Poor concentration Confusion Disorientation Indecisiveness Shortened attention span Memory loss Unwanted memories Difficulty making decisions Shock Numbness Feeling overwhelmed Depression Feeling lost Fear of harm to self and/or loved ones Feeling nothing Feeling abandoned Uncertainty of feelings Volatile emotions Nausea Lightheadedness Dizziness Gastrointestinal problems Rapid heart rate Tremors Headaches Grinding of teeth Fatigue Poor sleep Pain Hyperarousal Jumpiness Suspicion Irritability Arguments with friends and loved ones Withdrawal Excessive silence Inappropriate humor Increased/decreased eating Change in sexual desire or functioning Increased smoking Increased substance use or abuse From Centers for Disease Control and Prevention: Coping with a traumatic event: information for health professionals, Available at http: // www. bt. cdc. gov / masscasualties / copingpro. asp. Accessed March 6, p0835 p0840 p0845 People who are affected by a disaster often have an exacerbation of an existing chronic disease. For example, the emotional stress of the disaster may make it difficult for people with diabetes to control their blood glucose levels. Grief results in harmful effects on the immune system. It reduces the function of cells that protect against viral infections and tumors. Hormones produced by the body s flight-or-fight mechanism also play a role in mediating the effects of grief. Older adults reactions to disaster depend a great deal on their physical health, strength, mobility, independence, and income ( Ellen, 2001 ) ( Figure 23-7 ). They can react deeply to the loss of personal possessions because of the high sentimental value attached to the items and their irreplaceable value. Their need for relocation depends on the extent of damage to their home or their compromised health. They may try and conceal the seriousness of their health conditions or losses if they fear loss of independence. Box 23-6 lists other populations at higher risk for serious disruption post-disaster, many of them the same populations at risk for adverse health affects pre-disaster as well. The effect of disasters on young children can be especially disruptive ( FEMA, 2009a ) ( Figure 23-8 ). Regressive behaviors such as thumb sucking, bedwetting, crying, and clinging to parents can occur. Children tend to re-experience images of the traumatic event or have recurring thoughts or sensations, or they may intentionally avoid reminders, thoughts, and feelings related to disaster events. Children may have arousal or heightened sensitivity to sights, sounds, or smells and may experience exaggerated responses or difficulty with usual activities. Children not immediately impacted by a disaster can also be affected by it. The constant bombardment of disaster stories on television can cause fear in children. They may believe that the event could happen to them or their family, to believe someone will be injured or killed, or to think they will be left alone. It is best to turn off the television news and engage in activities with family, friends, and neighbors ( FEMA, 2009a ). The parents reaction to a disaster greatly influences children. FIGURE 23-7 Older adults and disaster. Older adults reactions to a disaster depend on a variety of pre-disaster factors. (Courtesy of the American Red Cross Disaster Online Newsroom, Washington, DC. Available at http: // www. flickr. com / photos / americanredcross / page4 /. Accessed October 7, 2010.) f0040

17 CHAPTER 23 Public Health Nursing and the Disaster Management Cycle 523 p0850 s0105 p0855 p0860 b0095 Public health nurses should help those in the affected community talk about their feelings, including anger, sorrow, guilt, and perceived blame for the disaster or the outcomes of the disaster. Community members should be encouraged to engage in healthy eating, exercise, rest, daily routine maintenance, limited demanding responsibilities, and time with family and friends. Stress Reactions in the Community. Communities reflect the individuals and families living in them, both during and after a disaster incident ( Figure 23-9 ). Four community phases are commonly recognized: (1) Heroic, (2) Honeymoon, (3) Disillusionment, and (4) Reconstruction ( USDHHS, 2000 ). The first two phases, the Heroic and Honeymoon phases, are most often associated with response efforts. The latter two phases, Disillusionment and Reconstruction, are most often linked with recovery. For purposes of continuity, all phases will be discussed in this Response section. During the Heroic phase, there is overwhelming need for people to do whatever they can to help others survive the disaster. First responders, who include health and medical personal, will work BOX 23-6 POPULATIONS AT GREATEST RISK FOR DISRUPTION AFTER DISASTER Seniors Vision and/or hearing impaired Women Children Individuals with chronic disease Individuals with chronic mental illness Non English-speaking Low income Homeless Tourists; persons new to an area Persons with disabilities Single-parent families Substance abusers Undocumented residents From National Institutes of Health, National Library of Medicine: Special populations: emergency and disaster preparedness, Available at http: // sis. nlm. nih. gov / outreach / specialpopulationsand disasters. html. Accessed January 25, hours on end with no thought of their own personal or health needs. They may fight needed sleep and refuse rest breaks in their drive to save others. Moreover, imported responders may be unfamiliar with the terrain and inherent dangers. Those with oversight responsibilities may need to order helpers to take necessary breaks and attend to their health needs. Exhausted, overworked responders present a danger to themselves and the community served. In the Honeymoon phase, survivors may be rejoicing in that their lives and the lives of loved ones have been spared. Survivors will gather to share experiences and stories. The repeated telling to others creates bonds among the survivors. A sense of thankfulness over having survived the disaster is inherent in their stories. The Disillusionment phase occurs after time elapses and people begin to notice that additional help and reinforcement may not be immediately forthcoming. A sense of despair results and exhaustion starts to takes its toll on volunteers, rescuers, and medical personnel. The community begins to realize that a return to the previous normal is unlikely and that they must make major changes and adjustments. Nurses need to consider the psychosocial impact and the consequent emotional, cognitive, and spiritual implications. Public health nurses should identify groups/population segments particularly at risk for burn out and exhaustion, to include responders and volunteers involved in rescue efforts. They may need breaks and reminders for nourishment. In addition, those in shock and those consumed by grief related to loss of loved ones will need compassionate care, with possible referrals to mental health counseling resources. The last phase, Reconstruction, is the longest. Homes, schools, churches, and other community elements need to be rebuilt and reestablished. The goal is to return to a new state of normalcy. Because the scope of human need may still be extensive, the nurse will continue to function as a member of the interprofessional team to provide and assure provision of the best possible coordinated care to the population. p0865 p0870 p0875 f0045 FIGURE 23-8 Children and disaster. The effects of a disaster on young children can be especially disruptive. (Courtesy of the American Red Cross Disaster Online Newsroom, American Samoa, 2009, credit to Talia Frenkel. Available at http: // www. flickr. com / ph otos / americanredcross / sets / /. Accessed August 1, 2010.)

18 524 PART 4 Issues and Approaches in Population-Centered Nursing Emotional highs Honeymoon Community cohesion Heroic Reconstruction A new beginning Pre-Disaster Warning Threat Impact Disillusionment Setback Inventory Working through grief Coming to terms Anniversary reactions f0050 Emotional lows Trigger events Up to 1 yr after anniversary FIGURE 23-9 Community phases of disaster. (Courtesy of U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration [SAMHSA]: Training manual for mental health and human services workers in major disasters, ed 2, Washington, DC, 2000, SAMHSA. Avail able at http: // mentalhealth. samhsa. gov / dtac / CCPtoolkit / Phases _ of _ disaster. htm. Accessed August 1, 2010.) s0110 p0880 s0115 p0885 p0890 Role of the Public Health Nurse in Disaster Response The role of the public health nurse during a disaster depends a great deal on the nurse s experience, professional role in a community disaster plan, and prior disaster knowledge to include personal readiness. Public health nurses bring leadership, policy, planning, and practice expertise to disaster preparedness and response ( ASTDN, 2008 ). One thing is certain about disasters: continuing change. Public health nursing roles in disaster are generally consistent with the scope of public health nursing practice, but the nurses provide that practice in chaotic surge. That said, there is ongoing demand for flexibility in disaster, especially during the response ( Stanley et al, 2008 ). Nursing Role in First Responder. Although valued for their expertise in community assessment, case finding and referring, prevention, health education, and surveillance, there may be times when the nurse is the first to arrive on the scene. In this situation, it is important to remember that life-threatening problems take priority. Once rescue workers begin to arrive at the scene, plans for triage should begin immediately. Triage at the individual level is the process of separating casualties and allocating treatment on the basis of the individuals potentials for survival. Highest priority is always given to those who have life-threatening injuries but who have a high probability of survival once stabilized ( Chames, 2007 ). A type of triage called public health triage also exists, which is a population-based approach for use in an incident undefined by a geographical location. Public health triage involves the sorting or identification of populations for priority interventions ( Stanley et al, 2008 ). In epidemics, for example, the public health triage focus becomes the prevention of secondary infection ( Burkle, 2006 ). Nursing Role in Epidemiology and Ongoing Surveillance. Health care providers and public health officers are the first line of defense. A comprehensive public health response to outbreaks of illness consists of five components. These components do not vary from normal operations in epidemiological investigation; they simply become field expedient ( Polivka et al, 2008 ). They include detecting the outbreak, determining the cause, identifying factors that place people at risk, implementing measures to control the outbreak, and informing the medical and public communities about treatments, health consequences, and preventive measures ( Rotz et al, 2000 ). Ongoing assessments or surveillance reports are just as important as initial assessments. Surveillance reports indicate the continuing status of the affected population and the effectiveness of ongoing relief efforts. Surveillance continues into the recovery phase of a disaster. Nursing Role in Rapid Needs Assessment. The traditional model of community assessment presents the foundation for the rapid community assessment process. The acute needs of populations in disaster turn the community assessment into rapid appraisal of a sector or region s population, social systems, and geophysical features. Elements of a rapid needs assessment include: determining the magnitude of the incident, defining the specific health needs of the affected population, establishing priorities and objectives for action, identifying existing and potential public health problems, evaluating the capacity of the local response including resources and logistics, and determining the external resource needs for priority actions ( Stanley s0120 p0895 p0900 s0125 p0905

19 CHAPTER 23 Public Health Nursing and the Disaster Management Cycle 525 b0050 s0130 p0925 p0930 et al, 2008 ). Noji (1997) points out that disaster assessment priorities relate to the type of disaster. Sudden-impact disasters such as tornadoes and earthquakes involve ongoing hazards, injuries and deaths, shelter requirements, and clean water. Gradual-onset disasters such as famines produce concerns with mortality rates, nutritional status, immunization status, and environmental health. THE CUTTING EDGE Illness Surveillance and Rapid Needs Assessment Among Hurricane Katrina Evacuees: Colorado, September 1-23, 2005 After Hurricane Katrina struck the U.S. Gulf Coast on August 29, 2005, approximately 200,000 evacuees were sent to shelters in 18 states ( CDC, 2006 ). On September 3, 2005, Colorado was asked to assist in sheltering some of the evacuees; the next day the first evacuees were airlifted into the Denver area, where they were housed at the former Lowry Air Force Base. During the next 4 weeks, 3600 evacuees registered at Lowry, with an average of 400 persons in residence per day. Other persons self-evacuated to other parts of the state, including approximately 2000 who went to Colorado Springs. In all, an estimated 6000 evacuees were living throughout Colorado in the weeks after Hurricane Katrina. As a result of the influx of evacuees, the Colorado Department of Public Health and Environment (CDPHE) and the Tri-County Health Department (TCHD) established surveillance systems to provide early detection of outbreaks and determine the scope of medical conditions of evacuees. A rapid needs assessment was also conducted at the local level to assess acute medical and other needs of evacuees. Results indicated that many evacuees had chronic conditions and approximately half planned to remain in the area, suggesting a long-term need for increased health-related and other services. In addition, the most common acute symptoms were related to altitude sickness, requiring education of incoming Gulf Coast evacuees regarding the effects of the mile-high altitude in Denver. From Centers for Disease Control and Prevention: Illness Surveillance and Rapid Needs Assessment Among Hurricane Katrina Evacuees Colorado, September 1-23, 2005; MMWR Weekly 55(9): , March Available at http: // www. cdc. gov / mmwr / preview / mmwr html / mm5509a7. htm. Accessed March 13, Nursing Role in Disaster Communication. Nurses working as members of an assessment team need to return accurate information to relief managers to facilitate rapid rescue and recovery. A part of that communication is involved with the rapid and ongoing needs assessment just described. Lack of or inaccurate information regarding the scope of the disaster and its initial effects can contribute to a mismatched resource supply. After Hurricane Andrew in 1992, a well-meaning public continued to ship thousands of pounds of clothing to South Florida. Much of the clothing eventually was burned because there were inadequate on-site personnel to sort and distribute the clothing, and the piles eventually became a public health nuisance. Times of crisis or great uncertainty call for great skills in communication. The community needs accurate information transmitted in a timely manner. Health care personnel are the best sources for essential health information that is technical in nature. Disaster incidents also use public affairs spokespersons for formal communication. The Public Information Officer (PIO) is an individual with the authority and responsibility to communicate information to the public at large. Still, nurses are considered trustworthy sources of information and may be approached for an interview. The nurse should refer the media to the PIO representing the agency. If the public approaches the nurse for information, however, that health information should be conveyed. It is entirely within public health nursing scope of practice to provide health education. Finally, although there are official spokespersons in all major disasters, there may be an occasion for the nurse to serve as a member of the risk communications team. Risk communication is the science of communicating critical information to the public in situations of high concern. The objectives in emergency communication are to identify and respond to the barriers of fear, panic, distrust, and anger: build or re-establish trust; resolve conflicts; and coordinate between stakeholders so that the necessary messages can be received, understood, accepted and acted on ( AHRQ, 2005, p 55). EVIDENCE-BASED PRACTICE A variety of ethical challenges are presented at the time of public health emergencies due to the fact that the stakes are often high since many people may be affected at once; there is little time to deliberate and problem solve; and the emergency may have affected essential resources such as roads, electrical power and so forth. Thomas, MacDonald, and Wenink (2009) interviewed 13 responders in the Epidemiology Section of the North Carolina Division of Public Health to learn how they identified and addressed ethical issues in public health emergencies. What they learned is that the responders were aware of the issues and able to address them in a group interaction. However, few of the study participants had any training in public health ethics. The researchers found in their interviews with the 13 responders that they were able to describe the types of ethical issues they had experienced, the patterns of decision making they engaged in and possible improvements that could be made to improve their skills in these areas. The potential improvements can be applied to the use that nurses could make to them. Specifically, this study concluded that potential improvements could be made in the areas of identifying a wider range of ethical issues to consider; by discussion and training, developing a deeper understanding of the ethical issues; identifying and using resources to aid in identifying the issues and making decisions about them; assigning roles to designated persons and providing training for these people; reducing the vulnerability of the ethics environment when leadership turnover occurred and evaluating action taken in public health emergencies after they are over. Nurse Use The potential improvements that these authors identified for their epidemiology section responders could easily be applied to the work of public health nurses. For example, nurses could have training including role playing, case studies and scenario development in order to identify the ethical dilemmas and work through possible solutions prior to a disaster. Nurses could also identify issues and possible responses, assign roles, design a care path that is not vulnerable to leadership changes and evaluate their actions in the face of a real or mock disaster so they would be better prepared to deal with the actual ethical challenges as they might arise. Modified from Thomas, JC, MacDonald PDM, and Wenink E: Ethical decision making in a crisis: a case study of ethics in public health emergencies, J Pub Health Manag Pract 15(2):E16-E21, p0935 b0055

20 526 PART 4 Issues and Approaches in Population-Centered Nursing s0135 p0955 p0960 p0965 Nursing Role in Sheltering. General population shelters are often the responsibility of the local Red Cross chapter under the ESF 6 partner function. In massive disasters, however, mega shelters with the capability to house thousands may be initiated in partnership with the local, regional, or state government for the masses needing temporary shelter. ESF 6 provides both short- and long-term care. This responsibility includes the plan for structure, operations, management, and staffing of mass care sites. Each person arriving at a shelter is assessed by a nurse to determine the type of facility that is appropriate. Nurses, because of their comfort with delivering aggregate health promotion, disease prevention, and emotional support, make ideal shelter managers and team members. Nurses in shelter functions are involved in providing assessment and referral, health care needs (e.g., prescription glasses, medications), first aid, and appropriate dietary adjustment; keeping client records; ensuring emergency communications; and providing a safe environment ( American Red Cross, 2010c ). The Red Cross provides training for shelter support and use of appropriate protocols and partners with other agencies such as the Medical Reserve Corps (MRC) and local public health agencies to ensure adequate health delivery capacity to the shelter community. Common-sense approaches work best when dealing with the shelter community. Basic measures that can be taken by the shelter nurse include the following: listen to shelter residents tell and retell their disaster story and current situation; encourage residents to share their feelings with one another if it seems appropriate to do so, especially those suffering from similar circumstances; help residents make decisions; delegate tasks (e.g., reading, crafts, and playing games with children) to teenagers and others to help combat boredom; provide the basic necessities (e.g., food, clothing, rest); attempt to recover or gain needed items (e.g., prescription glasses or medication); provide basic compassion and dignity (e.g., privacy when appropriate and if possible); and refer to a mental health counselor or other sources of help as the situation warrants ( American Red Cross, 2010c ). Although general population shelters can accommodate a variety of functional needs for individuals (e.g., assistance with activities of daily living), there may be circumstances where another type of shelter can provide a more supportive environment for the individual. President Bush marked the anniversary of the Americans with Disabilities Act in 2004 with an executive order that charged federal agencies to fully integrate people with disabilities into the national emergency preparedness effort ( DHS, 2006 ). Based on lessons learned from Hurricanes Katrina and Rita, the DHS charged emergency planners to ensure that the needs of special populations are being addressed through the provision of appropriate information and assistance. The updated DHS plan established the emergency planning category of special needs shelters. These shelters are designed for those individuals who have pre-existing conditions resulting in medical impairments and who have been able to maintain activities of daily living in a home environment prior to the disaster or emergency situation. Special medical needs shelters provide special/supervised housing to individuals whose physical or mental condition exceeds the general population shelter level but do not require inpatient care. Nurses need awareness of the surrounding medical facilities and services provided in their area, including alternate care sites and medical shelters. The federal government provides assistance to medical needs shelters through ESF 8 by assessing public health and medical needs, offering health surveillance, and supplying health care personnel. Special needs shelters reduce the surge demands on hospitals and long-term care facilities that generally occur during disasters. Although helpful in reducing surge, too many referrals can create tension between the special needs shelters, the general population shelters, and the health care facilities as roles and responsibilities become blurred and overall resources are drained. Careful preplanning for a community s special needs populations is essential. Psychological Stress of Disaster Workers Disaster relief work can be rewarding because it provides an opportunity to have a profound and positive impact on the lives of those who may be experiencing their greatest time of need. However, the work can also be challenging and stressful. During an assignment, responders may be exposed to chaotic environments, long hours, rapidly changing information and directives, long wait times before getting to work, noisy environments, and living quarters that are less than ideal ( American Red Cross, 2010a ). Nurses who work with survivors of disasters may be at risk for vicarious traumatization. Vicarious traumatization occurs in response to listening to survivors stories of the traumatic event ( McLaughlin, Murray, and Benbenishty, 2005, p 73). The degree of workers stress depends on the nature of the disaster, their role in the disaster, individual stamina, and other environmental factors. Environmental factors include noise, inadequate workspace, physical danger, and stimulus overload, especially exposure to death and trauma. Other sources of stress may emerge when workers do not think that they are doing enough to help, from the burden of making life-and-death decisions, and from the overall change in living patterns ( Bryce, 2001 ). Disaster nurses who live in the community where disaster strikes and who are also directly affected by the disaster will experience additional stress. Anger and resentment may occur since their disaster work demands time away from their own personal situations created by the disaster. Symptoms that may signal a need for stress management assistance include the following: being reluctant or refusing to leave the scene until the work is finished; denying needed rest and recovery time; feelings of overriding stress and fatigue; engaging in unnecessary risk-taking activities; difficulty communicating thoughts, remembering instructions, making decisions, or concentrating; engaging in unnecessary arguments; having a limited attention span; and refusing to follow orders ( Bryce, 2001 ). Physical symptoms such as tremors, headaches, nausea, and colds or flu-like symptoms can also occur. The nurse should understand that everyone reacts differently following a disaster assignment. Most reactions are considered normal and are temporary, resolving in days to a few weeks ( American Red Cross, 2010b ). For some workers, p0970 s0140 p0975 p0980 p0985 p0990

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