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Public Health Nursing and the Disaster Management Cycle

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 eld 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.



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 eld 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 eld of mass fatality management.


WEBSITE http://evolve.elsevier.com/Stanhope Healthy People 2020 WebLinks Quiz Case Studies Glossary Answers to Practice Application

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 nurses 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.





Issues and Approaches in Population-Centered Nursing

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 denitions

u0010 u0015 u0020 u0025 Dening 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


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


round the world, people are experiencing unprecedented disasters from natural causes like hurricanes and earthquakes to human-made disasters such as oil spills and terrorism. p0180 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 nurses role in these phases is described.

ruption, destruction, and/or devastation requiring external assistance. Although natural incidents like earthquakes or hurricanes trigger many disasters, predictable and preventable human-made

p0185 A disaster is any natural or human-made incident that causes dis-

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 lled with up to 20 feet of water (Reagan, 2005). The ooding 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 p0190 timing predict subsequent injuries and illnesses. If there is prior warning (e.g., in hurricanes or slow-rising oods), 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


CHAPTER 23 Public Health Nursing and the Disaster Management Cycle

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.


they can kill thousands and result in economic losses in the millions, as with oods, earthquakes, tornadoes, hurricanes, tsunamis, and bioterrorism. The American Red Cross reports that

p0195 Disasters can affect one family at a time, as in a house re, or



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 res 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 disas- p0200 ters continues to rise worldwide. Although the number of lives lost declined over the past 20 years800,000 people died from natural disasters in the 1990s, compared with 2 million in the 1970sthe number of people affected increased. In one decade, the number affected tripled to 2 billion (UN Ofce 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 disastersa tsunami in the Samoa Islands, an earthquake in Indonesia, and a typhoon in the Philippines and Vietnamcollectively 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 nations capital (American Red Cross, 2010d). Disaster disproportionably strikes at-risk individuals, p0205 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

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.)




Issues and Approaches in Population-Centered Nursing


2009 2000 1,243 6,800 27,108 22,176 668 39,272 2,259 8,370 8,094 57,995 2001 805 15,946 15,687 2,395 696 16,087 3,952 15,421 69 35,528 2002 436 15,386 15,855 40,283 2,601 60,332 3,328 10,842 60 74,561 2003 6,455 25,085 27,630 21,415 691 50,959 2,907 27,178 233 81,277 2004 1,908 74,679 75,332 2,072 627 122,083 7,058 24,878 600 154,619 2005 38 189,370 30,494 17,261 241 192,144 14,607 30,641 12 237,404 2006 244 7,226 24,873 2,584 1,368 11,694 2,041 22,557 3 36,295 2007 2008 TOTAL 12,947 428,616 386,102 146,414 12,612 627,865 56,488 292,579 9,760 986,691 173 13,337 15,449 10,789 1,726 24,655 2,412 14,234 173 41,474 782 863 16,625 64,162 35,747 117,927 22,796 4,644 1,488 2,506 46,461 64,178 11,564 6,360

Africa Americas Asia Europe Oceania Very high development High human development Medium human development Low human development Total

18,922 119,537 489 27

77,436 190,102

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 nancial coverage can vary signicantly. 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.

population areas more vulnerable to disasters will increase. Eighty percent of the worlds 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). p0210 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).


p0215 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: Isnt this all beyond what an individual p0220 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. p0225 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 rstrate partner. The U.S. Department of Homeland Security was created p0230 through the Homeland Security Act of 2002 (DHS, 2008b), consolidating more than 20 separate agencies into one unied organization. Homeland Security Presidential Directive-8 (HSPD-8) was p0235 issued in December of 2003. 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 2008. The NRF remains a guide for conducting a nationwide all-hazards response, built upon scalable, exible, 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- p0240 5) directed the Secretary of Homeland Security to develop and administer the National Incident Management System (NIMS), a unied, all-discipline, and all-hazards approach to domestic incident management (DHS, 2008c). The NIMS


CHAPTER 23 Public Health Nursing and the Disaster Management Cycle

was established to provide a common language and structure enabling all those involved in disaster response the ability to communicate together more effectively and efciently. p0245 Two national preparedness documents specically 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 sufcient 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 specically on the national goals for protecting peoples 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 (USDHHS, 2009, p 2). The NHSS was directed by the Pandemic and All-Hazards Preparedness Act (PAHPA), which was enacted in 2006 to improve the nations 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 p0250 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 p0255 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.



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 publics health, that demonstrate the use of best practices. IID-12: Increase the percentage of children and adults who are vaccinated annually against seasonal inuenza. IID-13: Increase the percentage of adults who are vaccinated against pneumococcal disease.
From Department of Health and Human Services (DHHS): Healthy people 2020. Available at http://www.healthypeople.gov/2020/default. asp. Accessed February 3, 2011.



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 rst 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 signicant 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): Dene nursing issues for public health care and disaster health care Exchange scientic and professional information relevant to the practice of disaster nursing Encourage collaborative efforts enhancing and expanding the eld 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.

s0030 p0295


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 signicant 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.


p0260 Because disaster affects the health of people in many ways,

u0115 u0120 u0125 u0130 u0135 p0330




Issues and Approaches in Population-Centered Nursing


paredness Pre



FIGURE 23-2 Disaster management cycle.


Prevention (Mitigation)

p0335 All-hazards mitigation (prevention) is an emergency man-

agement 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 p0340 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 regions 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 p0345 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-prole landmarks. Terrorists might also target large public gatherings, water and food supplies, banking and nance, information technology, postal and shipping services, utilities, and corporate centers.



Role of the Public Health Nurse in Personal s0045 and Professional Preparedness Public health nurses play a key role in community prepared- p0350 ness, but they must accomplish the critical elements of personal and professional preparedness rst. Personal Preparedness s0050 Disasters by their nature require nurses to respond quickly. p0355 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 rst 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 specic 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


CHAPTER 23 Public Health Nursing and the Disaster Management Cycle

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 familys 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 re extinguishers. Tell everyone where emergency information and supplies are stored. Provide copies of the familys 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. Dont 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.
Courtesy of the American National Red Cross. All rights reserved.

One way a nurse can feel assured about family member p0530 protection is by working with them to develop the skills and knowledge necessary for coping in disaster. For example, longterm benets 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 reunication 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.
b0030 THE CUTTING EDGE Federal Medical Stations State and local health resources can quickly become overwhelmed in the event of a disaster. The CDCs 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 ve 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 prole, Atlanta, 2009, Division of Strategic National Stockpile. Available at http://www.texasjrac.org/documents/FMSfactsheetv3-1.pdf. Accessed February 6, 2010.


NURSING TIP Emergency Supplies That Nurses Should Have Ready Identication badge and drivers license Proof of licensure and certication (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 identication 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

s0055 Professional Preparedness Every state needs a qualied workforce of public health nurses p0540 for solutions for todays 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 ofcers 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 exible and procient practice base in each of the core functions and 10 essential services. Just like the mission of public health and its core functions p0545 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.




Issues and Approaches in Population-Centered Nursing

CDC: Emergency preparedness and response A to Z index (http://www.bt.cdc.gov/agent) National Library of Medicine: Disaster information management research center (http://disaster.nlm.nih.gov/) Unbound Medicine: Relief Central (http://relief.unbound medicine.com/relief/ub/) National Library of Medicine: WISER-Wireless information system for emergency responders (http://wiser.nlm.nih.gov/) (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 specic 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

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. p0555 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:



icy Pol nt and e opm t vel cemen e d r o f en


Dise a hea se an lth eve d inve nt stig atio n

So m ar k

al ci ing et

Population - based

O ut r

ch ea

Population - based
Adv oca cy

ning ree Sc

Cas eF in

Population - based
Community organizing

Individual - focused
n litio Coa g din buil

Community - focused
te io ds n

ng di
Referral and follow-up
Cas e man a g em en t

bo lla Co

ra tio n

Systems - focused
Co nsu ltati on

ga le ct e D fun


lth Hea ing h c a e t

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.)

CHAPTER 23 Public Health Nursing and the Disaster Management Cycle

and community. Nurses need to review the disaster history of the community, including how past disasters have affected the communitys 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 rst responders in hazardous material incidents. By inputting a substances physical properties and entering an individuals 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, 2005. Available at http://wiser.nlm.nih.gov/. Accessed February 6, 2010.

understand and gain the competencies needed to respond in times of disasters before disaster strikes. Box 23-3 shows bioterrorism and emergency readiness com- p0590 petencies for those working in public health. Specic 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 departments 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 modications, 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 p0595 in-depth understanding of disaster management can become involved in any number of community organizations. The National Disaster Medical System (NDMS) provides nurses the



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 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, 2002. Available at http://www.nursing.columbia.edu/chp/pdfArchive/btcomps.pdf. Accessed February 6, 2010.


Public Health Workforce Development Centers Centers for Disease Control and Prevention: http://www.bt.cdc.gov/training/ National Public Health Training Centers Network, ASPH: http://www.asph. org/phtc/search-new.cfm Public Health Training Centers, CDC: http://www.cdc.gov/phtrain/ Government Training Facilities and Others National Nurse Emergency Preparedness Initiative: http://www.nnepi.org/ Emergency Management Institute: http://training.fema.gov/ Federal Emergency Management Agency (FEMA) Training: http://www.fema. gov/prepared/train.shtm Public Health Organizations American Nurses Association (ANA): http://www.ana.org American Public Health Association (APHA): http://www.apha.org Association of Schools of Public Health (ASPH): http://www.asph.org Association of State and Territorial Directors of Nursing (ASTDN): http:// www.astdn.org National Association of County and City Health Ofces (NACCHO): http:// www.naccho.org Public Health Foundation (PHF): http://www.phf.org




Issues and Approaches in Population-Centered Nursing

preparedness since September 11, 2001, the subsequent anthrax attack, and Hurricane Katrinathree 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 insufciently 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 Publics Health from Diseases, Disasters and Bioterrorism, which examines Americas ability to respond to health threats and help identify areas of vulnerability. TFAH also offers a series of recommendations to further strengthen Americas 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 Americas Health: TFAH initiativesBioterrorism and public health preparedness, 2010. Available at http://healthyamericans. org/bioterrorism-and-public-health-preparedness/. Accessed February 7, 2010.


American Red Cross (ARC): http://www.redcross.org Buddhist Compassion Relief (Tzu Chi): http://www.tzuchi.org/ Certied Emergency Response Team (CERT): https://www.citizencorps.gov/ cert/ Citizen Corps: http://www.citizencorps.gov/ Disaster Medical Assistance Team (DMAT): http://www.dmat.org/ Medical Reserve Corps (MRC): http://www.medicalreservecorps.gov/ HomePage National Baptists Convention, USA, Inc.: http://www.nationalbaptist.com/ index.cfm?FuseAction=Page&PageID=1000000 National Voluntary Organizations Active in Disaster (NVOAD): http://www. nvoad.org The Salvation Army: http://www.salvationarmyusa.org/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 23-5. p0600 The importance of being adequately trained and properly associated with an ofcial 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 conict, anger, frustration, and helplessness. The World Trade Center attacks of September 11, 2001 brought many qualied but unassociated responders to the site. Many well-intentioned local physicians in shirt sleeves and light footwear proceeded to the area and attempted to nd 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 Americas Health (TFAH): Bioterrorism and Public Health Preparedness. Health emergencies pose some of the greatest threats to our nation, because they can be difcult to prepare for, detect, and contain. Important progress has been made to improve emergency

Community Preparedness s0060 The Public Health Security and Bioterrorism Preparedness p0620 and Response Act of 2002 addressed the need to enhance public health and health care readiness and community health care infrastructures. It reafrmed 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 (Ofce 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 rst and foremost the general public as well as all levels of government, public health agencies, hospitals, rst 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 p0625 coordinating emergency response plans within their dened 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


CHAPTER 23 Public Health Nursing and the Disaster Management Cycle

Region Region AK



Region Region

NH ME VT CT RI Region Boston MA

Seattle MT


MN WI MI Chicago IN OH WV KY TN Atlanta NC SC Region PA


NY New York NJ PR

WY San Francisco Region CA NV UT Denver CO

US Virgin Islands




Philadelphia DE MD Washington DC Region

AZ American Samoa, Guam, HI U.S Trust Authority of The Pacific Islands NM

KS Kansas city MO OK Austin TX LA








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.)

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). p0630 Good disaster preparedness planning involves simplicity and realism with back-up contingencies because (1) plans never exactly t 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 sysp0635 tem 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 nurses 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 Gallups 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 reghters 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, 2011.

Nurses should be involved in identifying and educating p0655 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 communitys diversity such as nonEnglish-speaking groups, immunocompromised clients, children, and the physically challenged. The National Health Security Strategy (NHSS) s0065 The purpose of the NHSS is to reconnect public health and p0660 medical preparedness, response, and recovery strategies to ensure the nations resilience in the face of health threats or incidents with potentially negative health consequences. Outcomes




Issues and Approaches in Population-Centered Nursing

centers, intelligence centers, and potential eld 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, col- p0690 leges, 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 full- p0695 scale 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 exercises planning, response, and after-action activities. Nurses, as client and community advocates, are essential players in the exercise and preparedness arena.

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). p0665 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 disasp0670 ter 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 nations 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 peoples health needs, culture, literacy, and traditionsand therefore able to communicate effectively with the full range of affected populations, including those most at risk, during an emergency (DHS, 2009, p ii).



s0070 Disaster and Mass Casualty Exercises p0680 Although practice will not ensure a perfect response to disas-

ter, 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 specic plan. p0685 National Level Exercise 2009 (NLE09), conducted July 27-31, 2009, was the rst 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 Ofcials exercise series [TOPOFF]) occur annually in accordance with the National Exercise Program (NEP) (FEMA, 2009b). This program serves as the nations 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

The rst level of disaster response occurs at the local level with p0700 the mobilization of responders such as the re 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 p0705 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 signicance (a potential or high-impact disaster), appropriate response personnel and resources are provided. National Response Framework (NRF) s0080 The NRF was written to approach a domestic incident in a uni- p0710 ed, well-coordinated manner, enabling all emergency responding entities the ability to work together more effectively and efciently. The on-line component, the NRF Resource Center (http://www.fema.gov/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 p0715 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.


CHAPTER 23 Public Health Nursing and the Disaster Management Cycle

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. Specically, the ESFs provide the structure for coordinating federal interagency support for a federal response to an incident. The NRFs also include support annexes, incident specic annexes, and partner guides. p0720 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 p0725 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.).
s0085 National Incident Management System (NIMS) p0730 The NIMS is the nations common platform for disaster response,


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 qualied 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 qualied emergency management/response personnel. The Five-Year NIMS Training Plan compiles the existing and ongoing development of NIMS training and guidance for personnel qualication. 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 dened in the NIMS into positions, core competencies, training, and personnel qualications. 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.HCIntroduction to the Incident Command System for Healthcare/Hospitals IS-200.HCApplying ICS to Healthcare Organizations


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 seamlesslyto 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

Command Defines the incident goals and operational period objectives Includes an incident commander, safety officer, public information officer, senior liaison, and senior advisors

Operations Establishes strategy (approach methodology, etc.) and specific tactics (actions) to accomplish the goals and objectives set by Command Coordinates and executes strategy and tactics to achieve response objectives f0035



Admin/Finance Supports Command and Operations with administrative issues as well as tracking and processing incident expenses Includes such issues as licensure requirements, regulatory compliance, and financial accounting

Supports Command Coordinates support activities for incident and Operations in planning as well as their use of personnel, contingency, long-range, supplies, and and demobilization equipment planning Performs technical Supports Command and activities required Operations in processing to maintain the incident information function of operational facilities Coordinates information and processes activities across the response system

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.)



Issues and Approaches in Population-Centered Nursing

use of standards and dening 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 rst 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. Difcult 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 ag 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 unied 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 ooding from levee failure. Later joined by Hurricane Rita, Hurricane Katrina
s0095 p0805

IS-700.ANational Incident Management System (NIMS), An Introduction IS-701NIMS Multiagency Coordination System IS-800.BNational Response Framework, An Introduction

From Federal Emergency Management Agency, NIMS Resource Center, 2010. Available at http://www.fema.gov/emergency/nims/NIMS TrainingCourses.shtm and www.training.fema.gov. Accessed August 1, 2010.

s0090 Response to Bioterrorism p0770 The twenty-rst 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 difcult to recognize because many biological agent symptoms mimic inuenza 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






CHAPTER 23 Public Health Nursing and the Disaster Management Cycle



TABLE 23-2
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) COUNTERMEASURE PARTNER AND RESPONSE COMMUNICATION ADMINISTRATION AND ALERTING Health Alert Network (HAN) enables secure, high-speed, two-way communication among the federal agencies, states, local public health ofcials, 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: e-mail; voice mail; texting; faxing; Web capability. CROSSFUNCTIONAL 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

Enables partners to Connects a wide meet the needs variety of laboraof managing the tories to detect administration of biological and countermeasures chemical terrorand response activiism and other ties. public health It includes such emergencies, capabilities as single including: and multiple dose State and local delivery of counterpublic health measure, adverse Agriculture events monitoring, Water and food follow-up of clients, testing isolation and quaran Veterinary tine management, Federal and links to distribu Military tion vehicles such International as the Strategic (The CDC has National Stockpile to set the standard provide traceability for development between distributed of secure comand administered munication netproducts. works between laboratories and establishment of a standard way of naming/sharing laboratory test results.)

Modied from Centers for Disease Control and Prevention: Public health information network, 2010. Available at http://www.cdc.gov/phin/resources/ phin-facts.html. Accessed February 27, 2010.

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, oods, and more than 1800 conrmed 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 s0100 moderate to severe stress reactions. Individuals react to the p0830 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 23-3.




Issues and Approaches in Population-Centered Nursing

TABLE 23-3


EMOTIONAL 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 PHYSICAL Nausea Lightheadedness Dizziness Gastrointestinal problems Rapid heart rate Tremors Headaches Grinding of teeth Fatigue Poor sleep Pain Hyperarousal Jumpiness BEHAVIORAL 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

Poor concentration Confusion Disorientation Indecisiveness Shortened attention span Memory loss Unwanted memories Difculty making decisions

From Centers for Disease Control and Prevention: Coping with a traumatic event: information for health professionals, 2005. Available at http:// www.bt.cdc.gov/masscasualties/copingpro.asp. Accessed March 6, 2010.




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 difcult 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 bodys ight-or-ght 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 difculty 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 inuences 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.ickr.com/photos/americanredcross/ page4/. Accessed October 7, 2010.)


CHAPTER 23 Public Health Nursing and the Disaster Management Cycle



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. s0105 Stress Reactions in the Community. Communities reect the p0855 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 rst 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. p0860 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



Seniors Vision and/or hearing impaired Women Children Individuals with chronic disease Individuals with chronic mental illness NonEnglish-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, 2010. Available at http://sis.nlm.nih.gov/outreach/specialpopulationsand disasters.html. Accessed January 25, 2011.

hours on end with no thought of their own personal or health needs. They may ght 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 p0865 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 p0870 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, p0875 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.

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.ickr.com/ph otos/americanredcross/sets/72157622497666858/. Accessed August 1, 2010.)



Emotional highs

Issues and Approaches in Population-Centered Nursing

Community cohesion

A new beginning

Heroic Pre-Disaster
Warning Threat

Disillusionment Impact


Working through grief

Coming to terms Anniversary reactions

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. Available at http://mentalhealth.samhsa.gov/dtac/CCPtoolkit/Phases_of_disaster.htm. Accessed August 1, 2010.)

s0110 Role of the Public Health Nurse in Disaster Response p0880 The role of the public health nurse during a disaster depends

a great deal on the nurses 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 exibility in disaster, especially during the response (Stanley et al, 2008). Nursing Role in First Responder. Although valued for their s0115 p0885 expertise in community assessment, case nding and referring, prevention, health education, and surveillance, there may be times when the nurse is the rst 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 p0890 is a population-based approach for use in an incident undened by a geographical location. Public health triage involves the sorting or identication 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 ofcers are the rst line of defense. A comprehensive public health response to outbreaks of illness consists of ve components. These components do not vary from normal operations in epidemiological investigation; they simply become eld 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 regions population, social systems, and geophysical features. Elements of a rapid needs assessment include: determining the magnitude of the incident, dening the specic 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


s0125 p0905


CHAPTER 23 Public Health Nursing and the Disaster Management Cycle

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 rst 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 inux 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):244-247, March 2006. Available at http://www.cdc.gov/mmwr/preview/mmwr html/mm5509a7.htm. Accessed March 13, 2010.


for formal communication. The Public Information Ofcer (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 ofcial spokespersons in all major p0935 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 conicts; and coordinate between stakeholders so that the necessary messages can be received, understood, accepted and acted on (AHRQ, 2005, p 55).

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 identied 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. Specically, 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 identied 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.
Modied 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, 2009.


s0130 Nursing Role in Disaster Communication. Nurses working as p0925 members of an assessment team need to return accurate infor-

mation 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. p0930 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




Issues and Approaches in Population-Centered Nursing

general population shelter level but do not require inpatient care. Nurses need awareness of the surrounding medical facilities p0970 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 communitys 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 nished; denying needed rest and recovery time; feelings of overriding stress and fatigue; engaging in unnecessary risk-taking activities; difculty 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 u-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,
s0140 p0975

s0135 Nursing Role in Sheltering. General population shelters are p0955 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 stafng 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), rst 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. p0960 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). p0965 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





CHAPTER 23 Public Health Nursing and the Disaster Management Cycle

disasters bring forth strong thoughts and emotions, both positive and negative. Other workers may experience mild reactions or hardly any reaction at all. There are some common strategies that will help individuals returning from the incident: rest and recovery time, focusing on accomplishments, using calming strategies such as relaxation techniques or working on hobbies, and concentrating on self-care to include healthy food and drink, exercise, and sleep (American Red Cross, 2010b).



p0995 In recovery, the immediate response actions to address initial

consequences subside. Recovery is about returning to the new normal, a community balance of infrastructure and social welfare that is near the level that it would have had if the event had not occurred (Leonard and Howitt, 2010). The recovery phase is often the hardest part of a disaster. It involves ongoing work beyond the preparedness and the rush to response. Although the initial response phase to a disaster generally provides an onslaught of relief aid, impatience and the loss of momentum toward seeking normalcy is soon felt (see Figure 23-9). During the recovery phase for a large-scale incident, the federal government provides assistance with rebuilding property, restoring lifelines, and restoring economic institutions with the assistance of individuals, the private sector, and non-governmental entities. An incident that creates a need for a public health surge p1000 response is not a transitory event. Recovery involves a shift from short-term aid to long-term support for communities: sustainment of effort. Long-term support should include the disasteraffected population representation in the recovery effort, using local knowledge and skills to prioritize use of resources, personnel, and surviving systems and infrastructure. Assisting relief organizations incorporate and build on the existing community resilience.
s0150 Role of the Public Health Nurse in Disaster Recovery p1005 The role of the public health nurse in the recovery phase of a

disaster is as varied as in the preparedness and response phases. Flexibility remains important for a successful recovery operation. Community clean-up and rebuilding efforts can cause many physical and psychological problems. Nurses need awareness of the potential public health challenges specic to the disaster area and should monitor the physical and psychosocial environment. Disruption of the public health infrastructure water and food supply, sanitation system, vector control programs, and access to primary and mental health carecan lead to increased disease and community dysfunction. Nursing Role in Ongoing Community Assessment. The reals0155 p1010 ity of the recovery effort is that the rapid needs assessment continues into an ongoing community needs assessment. To determine effective interventions to ensure the best possible outcomes, it is essential to have ongoing accurate data about the population. Some conditions are manifest only after time elapses. A major advantage of the recovery community assessment efforts is that they can be more in-depth, with a better sense and condence in the result. Some examples of community data points in the recovery phase include: ongoing

illnesses and injuries related to the disaster; disease and acute respiratory infections related to disruption of environmental or health services; health facility infrastructure in terms of adequate personnel, beds, medical and pharmaceutical supplies; and environmental health assessment to include water quantity and quality, sanitation, shelter, solid waste disposal, and vector populations (Landesman, 2006). A realistic perspective is most useful to the community recovery effort. It will take months or perhaps years to achieve the new sense of normalcy, which may be signicantly different from the normal pre-disaster state. The health care system and related resources will continue to be taxed, probably beyond abilities for adequate response. Nurses should also be aware that post-disaster cleanup creates opportunities for unintentional injury and hazards, including those occurring from falls, contact with live wires, accidents with cutting devices, heart attacks from overexertion and stress, and auto accidents resulting from road conditions and missing trafc controls (e.g., stoplights). Nurses should also educate the public of the hazards related to carbon monoxide poisoning stemming from using lanterns, gas ranges, or generators or from burning charcoal for a heat source in enclosed areas. The Nursing Role in Psychosocial Support. Acute and chronic illnesses can become worse by the prolonged effects of disaster. The psychological stress of cleanup and/or moving can cause feelings of severe hopelessness, depression, and grief in the disillusionment phase (see Figure 23-9). Recovery can be impeded by short-term psychological effects that eventually merge with the long-term results of living in adverse circumstances (Bryce, 2001). Although the majority of individuals will eventually recover from disasters, mental distress may persist for months to come. Especially at risk are the members of vulnerable populations who continue to live in chronic adversity. Shehab, Anastario, and Lawry (2008) describe a community assessment of a Mississippi manufactured-home population conducted 2 years after Katrina. The researchers surveyed the displaced population for health care needs and access to care as well as identied barriers to and gaps in health care services. At the time of the study, there were about 17,800 trailers in 20 Mississippi counties. Manufactured home parks were included in the survey if they contained 10 or more trailers. There were 69 parks sampled, and homes were selected using random sampling methods. Data gathered included demographic data, displacement information, self-reported health status, types of health services needed and accessed during displacement, depression, suicidal ideation and attempts, and reproductive child health. Key ndings from the 610 respondents included: 80% of households had at least one adult with a chronic condition, and 58% of households had a child with a chronic condition. Sixty-two percent (62%) of respondents indicated their health was fair or poor since displacement. Fifty-seven percent (57%) of respondents were clinically depressed, 72% had depressive symptoms, 24% had suicidal ideation, and 5% had attempted suicide. Ninety-four percent (94%) noted that health care services were not available in their community, and 75% reported no access to counseling or support services since displacement (Shehab et al, 2008).



s0160 p1025






Issues and Approaches in Population-Centered Nursing

every step of the disaster management cycle. To fully participate in this mission, nurses must continue to plan and train in an all-hazards environment, regardless of their specialty practice. Public health nurses are especially critical members of the multidisciplinary disaster health team given their population-based focus and specialty knowledge in epidemiology and community assessment. Although sophisticated technology and surveillance will continue to advance in response to both human-made and natural disasters, the nature of disasters will retain the element of unpredictability. That unpredictability and the medical and public health surge requirements in disaster makes prevention and preparedness activities on the part of individuals and communities even more important. Disaster information changes rapidly because of the learning that occurs during and after each incident, producing progressive best practices. Staying current in disaster training requires the public health nurses commitment in community planning activities, exercise participation, and actual disaster work.

Referrals to mental health professionals should continue throughout the recovery phase and as long as the need exists. The role of the nurse in case nding and referral remains critical during this phase. In the end, it is the concept of community resilience that will return the community back to its new normal. The public health nurse is the community and client advocate that ensures resilience is enabled in partnership with the population.

Primary Prevention Participate in community disaster exercises; assist in development of the disaster management plan for the agency/community; pre-identify vulnerable populations. Secondary Prevention Assess disaster survivors; conduct rapid needs assessment; use individual and population-based triage for care. Tertiary Prevention Ensure that community service linkages are available to individuals and families; conduct community outreach; participate in planning efforts for the communitys new normal.


Throughout this chapter, how nurses work in disaster management is applied to standards of public health nursing, core competencies of health professionals in disaster work, and the public health nursing intervention wheel. Other applicable areas include discussion about the continuous processes of assessment, planning, implementation, evaluation, collaboration and cooperation. The role of the nurse in disaster management relates to both standards of nursing and public health practice. Specically, the nurse must rst assess, then plan, implement, and evaluate while simultaneously working with a variety of other concerned and involved agencies and individuals.




Katrina, the H1N1 pandemic, and the Haiti earthquake of 2010 continued to underscore the need for nursing involvement at

p1060 In the last several years, the terrorist events of 9/11, Hurricane

s0170 PRACTICE APPLICATION p1070 You are a public health nurse working at the local health department when a level 7.4 earthquake strikes with the epicenter 40 miles away. You have two children in grade school across town, a husband downtown at his place of business, and older parents who live 10 miles out of town, toward the epicenter. You are not hurt and the health department is not extensively p1075 damaged, although neither cell phone nor landline phones are working. Emergency auxiliary electricity is activated, but the computer system is down. A rapid damage assessment and visual survey within the immediate neighborhood reveals some structural damage, and 18 individuals with injuries have already approached the health department clinic for assistance. Three of the clients injuries

are serious but not life threatening, with the remainder of the clients experiencing minor injuries and varying stress levels. An hour passes and there is no word about damage outside of p1080 the immediate health department area. Health department workers are very worried and concerned about their homes and family. Two staff members have already left on foot to check on their homes, which are within 3 miles of the department. What are your priorities in this situation? List them in order and p1085 defend your position. Discuss the concepts of prevention and preparedness and how they relate to this disaster situation to include home, community, and workplace. Answer is in the back of the book. p1090


CHAPTER 23 Public Health Nursing and the Disaster Management Cycle

s0175 KEY POINTS u0380 The number of disasters, both human made and natural, continu0385 u0390
ues to increase, as do the number of people affected by them. Professional preparedness involves personal planning as well as an understanding of the disaster plan at work and in the community. Healthy People 2020 objectives are linked in many ways to the disaster management cycle, since a disaster incident affects the health of a community in many areas. For effectiveness in disaster prevention, preparedness, response, and recovery, nurses must get involved in their communitys disaster plan, preferably through their workplace and partnering community agencies. Nurses must be adequately trained and properly associated with an ofcial response organization to serve communities during a disaster. Becoming knowledgeable about available community resources prior to a disaster incident, to include vulnerable population assets, ensures a more coordinated response and recovery. Flexibility is a key attribute in providing nursing care during disaster. The Public Health Intervention Wheel is appropriate for daily operations as well as during disaster chaos. With any disaster it is always best to use the resources, personnel, and infrastructure of the community itself to promote selfreliance and resilience. The National Response Framework and National Incident Management System work together to ensure a unied, wellcoordinated national response by public and private entities.





u0410 u0415 u0420


The public health nursing role in the disaster management cycle includes helping clients maintain a safe environment and advocating for environmental safety measures in the community; risk communication and client education; community assessment to include rapid needs assessment; public health triage; and surveillance and eld epidemiology. Triage in a disaster setting involves both individual and population-based approaches. People in a community react differently to a disaster depending on the type, cause, and location of the disaster; its magnitude and extent of damage; its duration; and the amount of warning that was provided. Individual variables that cause people to react differently include their age, cultural background, health status, social support structure, and general adaptability to crisis. The affected community experiences four stages of stress during disaster: honeymoon, heroic, disillusionment, and reconstruction. The nurse assisting in disaster relief efforts must maintain selfhealth, both physically and mentally, to be of service to his or her family and clients. Ongoing community assessment is just as important as initial rapid needs assessment. Surveillance reports indicate the continuing status of the affected population and the effectiveness of ongoing relief efforts.


u0435 u0440





s0180 CLINICAL DECISION-MAKING ACTIVITIES 5. Discuss the advantages and disadvantages of serving on a o0065 o0045 1. Select a vulnerable population within your community and determine what special needs the group would have in time of disaster. What community resources are currently available to help this group? Where is the gap in services? o0050 2. Describe the role of the public health nurse across the disaster management cycle: prevention (mitigation), preparedness, response, and recovery. How do you sustain your nursing practice across these stages? o0055 3. Interview a nurse who has responded to a disaster. What role did the nurse play? Were his or her interventions provided at the individual or aggregate level or both? Ask the nurse to give you specic examples. o0060 4. Conduct an interview with an ofcial from the Emergency Management Agency, American Red Cross, Medical Reserve Corps, or other agency involved with disaster management. What is your communitys plan for response to a disaster? What agencies are involved? disaster team in your own community. Are you a good candidate to serve on a disaster team? Have you examined your ability to be exible? What about your personal preparedness? 6. Contact your local public health department to determine its role o0070 in a local disaster, including the role of the nurses who work there. How could you determine a specic nurses role in disaster management? 7. Determine what the disaster plan is where you work; get spe- o0075 cic details. 8. Identify community response mechanisms and facilities with o0080 the capacity to provide medical care for trauma, burns, and chemical, biological, nuclear, and radiological exposure.




Issues and Approaches in Population-Centered Nursing

Agency for Healthcare Research and Quality: Health emergency assistance line and triage hub (HEALTH) model, Rockville, MD, 2005. Available at http://www.ahrq. gov/research/health. Accessed January 25, 2011. Advance for Nurses: Available at http://nursing.advanceweb.com/ news/national.news/nurses/ratedmost-trusted-profession.Again. aspx. Accessed April 17, 2011. American Red Cross: Disaster mental health services: an overview, ARC Publication No. 3077-2A, Washington, DC, 2002, Disaster Mental Health. American Red Cross: About us, 2009. Available at http://www.redcross. org/en/aboutus. Accessed January 25, 2011. American Red Cross: Coping with disasterpreparing for deployment, Washington, DC, 2010a, Disaster Mental Health. American Red Cross: Coping with disasterreturning home from a disaster assignment, Washington DC, 2010b, Disaster Mental Health. American Red Cross: Disaster health services guidance, Washington, DC, 2010c, Disaster Health Services. American Red Cross: Haiti assistance program disaster response report 17, Washington, DC, 2010d. Assistant Secretary for Preparedness and Response: Pandemic and AllHazards Preparedness Act (PAHPA) progress report, Washington, DC, 2007, USDHHS. Available at http:// www.hhs.gov/aspr/conference/ pahpa/2007/pahpa-progressreport-102907.pdf. Accessed February 7, 2010. Associated Press: As patriotism soars, ags are hard to come by, USA Today, September 16, 2001. Association of State and Territorial Directors of Nursing: The role of public health nurses in emergency preparedness and response, Washington, DC, 2007, ASTDN. Available at http://www.astdn.org/ downloadableles/ASTDN%20 EP%20Paper%20nal%2010%20 29%2007.pdf. Accessed January 25, 2011. Association of State and Territorial Directors of Nursing: Every state health department needs a public health nursing leader, 2008. Available at http://www.astdn.org/down loadableles/2008_ASTDN_Bro_ web.pdf. Accessed February 3, 2011. Bryce CP: Stress management in disasters, Washington, DC, 2001, Pan American Health Organization. Available at http://www/paho. org/English/ped/stressmgn1.pdf. Accessed April 17, 2011. Burkle FM: Population-based triage management in response to surgecapacity requirements during a large-scale bioevent disaster, Acad Emerg Med 13(11):11181129, 2006. Centers for Disease Control and Prevention: Bioterrorism, Atlanta, n.d. Available at http://www.bt.cdc. gov/bioterrorism/. Accessed February 27, 2010. Centers for Disease Control and Prevention: Bioterrorism and emergency readiness: Competencies for all public health workers, Atlanta, 2002. Available at http://www. nursing.columbia.edu/chp/pdfArchi ve/btcomps.pdf. Accessed January 25, 2011. Centers for Disease Control and Prevention: Coping with a traumatic event: information for health professionals, 2005a. Available at http://www.bt.cdc.gov/masscasual ties/copingpro.asp. Accessed January 25, 2011. 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CHAPTER 23 Public Health Nursing and the Disaster Management Cycle

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