Page 1

E mergencies and disasters from, whether NAT

Ural or man-made, are difficult, to pre-
pare for. The September 11 terrorist
attacks in New York City, Pennsylvania,
and Washington, DC, and the subse-
quent bioterrorist attacks with anthrax, made this
abundantly clear. Although nurses may agree that
there's a need for basic competencies in disaster pre-
paredness and response in addition to the usual clin-
ical skills, such training is not part of the required
undergraduate curricula at most US schools of
nursing, and there is surprisingly little in the litera-
ture that addresses the role of nursing in this regard.
It is therefore imperative to identify what every nurse
needs to know to serve Effectively as a member of an
emergency and disaster response team.
Emergency or disaster? The term emergency
Refers to any extraordinary event or situation that
requires an intense, rapid response and that can be
addressed with existing community resources.
Disaster Refers to an event or situation that is of
greater magnitude than an emergency; disrupts
essential services such as housing, transportation,
communications, sanitation, water, and health care;
and that requires the response of people outside the
affected community. The term disaster par- ticularly
1

signifies an event that carries unforeseen, serious,

and immediate threats to public health.
Natural or man-made? The World Health
Organization defines natural disaster as the "result
of an ecological disruption or threat that exceeds
the adjustment capacity of the affected communicator
nity. Such disasters include large fires, extensive
"2

floods, hurricanes, and Earthquakes. As defined by

Guha-Sapir, man-made disasters Reviews those are the resulting
from events or situations that are the caused by Cleary
Humankind, such as war and armed conflict, over-
whelming environmental contamination, and signif-
icant technologic catastrophe.
1

As Landesman notes, "No two emergencies or

disasters are alike. But in each situation, regard-
"3

less of cause, the competencies nurses need to post-

sess in order to respond Effectively acre Essentially the
same. We use the term emergency preparedness
competencies to cover both emergency and disaster
preparedness and response skills.
mergency AND
E

ISASTER
D P

REPAREDNESS:
Kristine M. Gebbie is the Elizabeth S. Gill Associate Professor of
Clinical Nursing, director of the Center for Health Policy and Health
Services Research, and director of the doctoral program at the
Columbia University School of Nursing in New York City. Kristine
Qureshi, a certified emergency nurse with experience in emergency
and disaster planning, is a doctoral candidate at the Columbia
University School of Nursing and a research assistant at the Columbia
University Center for Public Health Preparedness. Contact author:
Kristine M. Gebbie: kmg24@columbia.edu.
By Kristine M. Gebbie, DrPH, RN, FAAN,
and Kristine Qureshi, MSN, RN, CEN
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Page 2
An outline for action. The first step toward emer-
gency preparedness is the identification of who
needs to know how to do what. Tus, in any set-
ting, one of the first questions a nurse may ask is,
"What's my role in an emergency?" Although there
is little in the nursing literature, specifically, that
addresses this subject, there are two Articles worth
mentioning. O'Brien found that nurses in Australia
play significant roles in all phases of emergency pre-
paredness and response, Including development of
disaster plans, hands-on treatment of casualties, and
evaluation of response activities. Shoaf and
4

Rottman, reporting on the 1999 University of

California-Los Angeles Conference on Public
Health and Disasters, cited four areas of focus in
emergency and disaster management: preparedness,
mitigation, response, and recovery. Along with a
5

fifth area, evaluation, Reviews These nurses offer an outline

for a plan of action to be taken when responding to
an emergency or disaster.
THE core competencies
Until now, emergency preparedness competencies
specific to nurses working in the United States
had not been identified. At the request of the Centers
for Disease Control and Prevention (CDC), one of
The authors of this article (Kristine Gebbie) has
developed a set of core emergency preparedness
competencies for public health workers. 6

this
served as the models for the core competencies for
nurses outlined below.
D ESCRIBE the agency's role in responding to a
range of emergencies that MIGHT Arise. During an
emergency or disaster, an organization, agency, or
units may continue functioning as usual, or it may
perform special services. You'll need to know if and
how the service line (the clinical unit or practice
area) will change or expand during an emergency.
For example, scheduled surgeries will be canceled
to create standby capacity (in terms of both unit
space and surgery time) for trauma Patients? Will a
long-term care center Become a shelter for displaced
seniors? Knowing in advance exactly what's
expected of the organization during an emergency
or disaster Gives the staff the opportunity to acquire
the pertinent knowledge and to practice Necessary
skills beforehand. Emergency department nurses
Generally know their roles through citywide trauma
plans for community disasters; nurses working in
other settings such as long-term care facilities or
home health care agencies may not have been
had instructed to prepare in the same way.
D ESCRIBE the chain of command in an emergency
response. Effective emergency response requires
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47

ORE
C C

OMPETENCIES
FOR N URSES

What every nurse should but may not know.

 Page 3
well-orchestrated teamwork in the which each member
knows what the lines of authority and Communication
tion are. The Incident Command System (ICS),
commonly used for defining the chain of command
during emergencies, Originated in the 1970s, when
local, state, and federal agencies in California
needed a well-coordinated procedure for fighting
wildfires; it has been developed further by the
Federal Emergency Management Agency (FEMA). 7

(See www.fema.gov/emi/is195.htm.)
The ICS designates common titles and roles to be
used in all responding organisasi and agencies.
For example, during an emergency, President Jones
of Organization A and Director of Agency B Smith
Become would "incident commanders" with spe-
spe- cific duties and responsibilities. The system Also
According organizes emergency response to five
major components: command, planning, opera-
tions, logistics, and finance and administration.
Depending on the scale of the emergency or disaster,
Incident commanders can appoint information and
interaction, safety officers and liaisons to manage
Reviews those channels. In affording diverse groups a com-
mon approach, the system facilitates communica-
tion and coordination of response Efforts.
In many organisasi, the nursing staff would
be deployed by the operations officer; Also they may
take part in planning, logistics, or finance and
administration.
I dentify and LOCATE the agency's emergency
response plan (or the pertinent portion of it). Every
nurse needs to know where the emergency response
plan can be found and to be familiar with its con-
tents before an emergency arises. If your agency fre-
quently responds to local emergencies, it may be
useful to outline the plan and your designated role
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Emergency Preparedness Information
US Department of Health and Human
Services, Office of Emergency
Preparedness (OEP)
http://ndms.dhhs.gov
The lead agency for disaster health and
medical services works in close
partnership with federal agencies and
directs the NDMS.
National Disaster Medical System
(NDMS)
http://ndms.dhhs.gov/NDMS/ndms.html
A cooperative program Among
government agencies and private and
organisasi voluntary, it works to
Ensure adequate distribution of
resources.
Federal Emergency Management Agency
(FEMA)
www.fema.gov
Works to build and support the national
emergency management system.
Centers for Disease Control and
Prevention (CDC)
www.cdc.gov
The lead federal agency for disease
prevention and control activities
Provides backup support to state and
local health departments.
Joint Commission on Accreditation of
Healthcare Organizations (JCAHO)
www.jcaho.org
(For revised standards, see
www.jcaho.org/standard/stds2001_mpfrm.html.)
According to Accredits facilities
established safety and quality
standards, and revised the emergency
management standards for health care
facilities in 2001.
Activities
Organization

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49
in a card or small notebook; Necessary include con-
tact information and update it regularly.
D ESCRIBE emergency response functions or roles
and demonstrate them in regularly performed drills.
Effective emergency response requires that each
Team members know what to do and how to do it.
The nurse's role may be Essentially unchanged or it
may entail different duties-for example, working
as backup staff member in the intensive care unit,
supporting families in the emergency department,
being on call at home, or reporting for duty at the
local health department. To Ensure competence dur-
ing an emergency or disaster, it is important that
tasks be practiced. Know the which types of emergen-
cies are Likely to occur in your area and roomates
health conditions are Likely to result from them.
Some occurrences, such as terrorist attacks, are less
predictable; still, by possessing and practicing com-
petencies, you'll be better prepared to handle all
types of emergencies.
D EMONSTRATE the use of equipment (including PER
sonal protective equipment) and the skills required
in during regular emergency response drills. All
nurses know how to safely operate and equipment that
they use daily. But during an emergency, they may
be required to use unfamiliar equipment. knowing
the setting to the which you're Likely to be dispatched
affords the opportunity to learn how to use such
equipment in advance. You also need to know how
to protect yourself. This requires awareness of the post-
sible contaminants and knowledge of Appropriate
methods of protection. Some emergency response
activities require simple universal precautions while
others require more sophisticated protections.
D EMONSTRATE the correct operation of all equip-
ment used for emergency communication. team-
work and communication are essential during
emergency response. For example, a nurse may
serve as a communication link between the hospital
and health department. Professional staff members
Often do not know how to use common communica-
tion equipment, and the simplest task Becomes cum-
bersome and consumes too much time. Practicing
with the equipment beforehand can Eliminate this.
D ESCRIBE communication roles in emergency
response
• within your agency.
• with news media.
• with the general public (including Patients and
families).
• with personal contacts (one's own family, friends,
and neighbors).
Every organization or agency should delineate
specific roles and responsibilities that apply to both
internal and external communication. You'll need
to know the communication roles of others, in addi-
tion to your own, to refer information requests
appropriately. During emergency response, communicator
In the Eye of the Storm
A Brooklyn hospital puts its emergency and disaster
preparedness plan to the test.
O n September 11, 2001, core competencies for nursing emer-
gency response were tested throughout my hospital. Eighty
eight Patients (mostly self-Referred) from the site of the attacks on
the World Trade Center were seen that day. We found that our
hospitalwide quarterly drills of the emergency plan prepared the
staff to respond appropriately.
After Several laboratory and administrative staff members saw
the first plane strike the south tower, the emergency response plan
went into immediate effect. Patient care rounds Began at once. to
space ready for new admissions, an effort was made to expedite
patient discharges and transfers to long-term care and rehabilita-
tion facilities (for example, by contacting a private car and ambu-
lance services for early patient pick-up), and case managers
contacted community-based skilled nursing facilities and adult
homes to find additional beds. In each department, managers
reassigned patient care activities and released staff members to
the emergency labor pool.
Department heads and Reviews those assigned to the pool met in the
executive boardroom, where, as defined by the emergency plan, a
command post was established. Run by two senior administrators,
the command post deployed staff to Necessary outposts, and man-
aged communication throughout the institution. Portable phones
with walkie-talkie components helped staff to berkomunikasi, as did
video conferencing technology, the which the command post used to
contact another hospital in the network.
Meanwhile, emergency department personnel accessed a disaster
supplies and equipment located in central supply. while clinicians
Patients were preparing for incoming, housekeeping, clerical, and
other nonclinical staff did their best to Ensure that adequate food,
water, and other supplies were available if needed. Psychiatric
and other mental health services and pastoral care were offered
Directly to staff members affected by the tragedy.
Afterward, evaluations of the emergency response plan by
administrators and staff members were Generally positive, yet they
revealed a few weaknesses. For example, in a revised plan to be
released within the next six months, an ambulatory presurgical
site testing will replace labor and delivery as an alternate treat-
and-release site. A location in the long-term care facility will
Become the designated command post, and a conference room in
a nearby assisted living program will be assigned as head-media
quarters.
Emergency preparedness and disaster response planning have
always been an important aspect of emergency nursing practice.
Yet today's JCAHO accreditation standards-which call for monitor around
mentoring of the level of staff participation in preparation for emer-
gencies or disasters-reflect the need for organization-wide
involvement. The preparedness of our staff enabled them to PER
form well, despite the fact that many were personally affected by
the loss of family and friends. -Cathy Norton Lind, MSN, RN,
CEN, FN, Director of Emergency Services, The Brookdale
University Hospital and Medical Center, Brooklyn, NY
 Page 5
nication within an agency gen-
erally follows the usual chain
of command. Communication
with the news media is usually
delegated to a single office or
person.
Communication with the
public Occurs at various levels
of formality. For example, dis-
cussion with Patients and their
families tends to be conversa-
tional and informal; a some-
what more formal, scripted
exchange would take place
over a telephone hotline. Each
nurse must be prepared to PER
form a role in communication
at this level. For example, stay-
ing current with CDC (see
www.cdc.gov) or health de-
partment information regard-
ing anthrax will help the Ensure
that the information you dis-
pense is accurate.
Personal communications
Also must be considered.
Because the nurse will not be
Able to focus on emergency
response duties if worried
about the safety of family
members, significant others,
friends, and pets, provisions
for them should be planned in advance. An overall
family emergency plan can be useful and is Easily
developed using the suggestions developed by
the American Red Cross (ARC) and FEMA
(Www.fema.gov/library/yfdp.pdf).
I dentify the limits of your own knowledge, skills,
and authority, and identify key system resources for
referring matters that exceed Reviews These limits. During an
emergency, Often nurses perform tasks outside Reviews their
usual domain. But Because nurses are Generally seen
as being exceptionally versatile, they're Likely to Be
asked to perform tasks or to assume roles that are
far beyond that domain. For example, a nurse who
ordinarily works with adults may be asked to work
with children, Although she may not be familiar
with pediatric medication concerns. It's important
both to Recognize when one is past the limit of one's
knowledge, skills, or authority and to know where
to direct the request or need so that Appropriate
answers or services can be provided. In other words,
Be clear with yourself and others about what you
know and what you do not know.
A nurse working in a disaster shelter should be
Able to Recognize the presence of an acute illness or
injury and know how to arrange the patient's trans-
fer to a facility that can provide the Appropriate
level of care. For example, in
the case of a patient with
crushing chest pain, you would
arrange his immediate transfer
by ambulance to the ED.
A PPLY creative problem-solv-
ing skills and flexible thinking
to the situation, within the con-
fines of your role, and Evaluate
the effectiveness of all actions
taken. No matter how well pre-
pared in the core competencies
you are, there will be times
when you'll need to think on
your feet. Situations will not nec-
essarily Arise and develop
exactly as the preparedness
plan describes. Systems, equip-
ment, or plans may fail. Crea-
tive problem solving entails
addressing a situation with
whatever resources are avail-
Able at the moment; nurses tend range
to be good at this Because It's a
Also used under ordinary skill
circumstances. Once you take
action, you should Evaluate its
effectiveness on an ongoing
base. If you refer a problem
elsewhere, follow up to see that
it was appropriately addressed.
For example, suppose an
emergency plan calls for the use of mobile tele-
phones for internal communication, but when a dis-
Occurs aster, reception may be interrupted. The
nurse manager decides to assign a runner to handouts
carry messages to and from the facility's command
post until the reception problem is corrected. She
Also checks regularly on the status of the mobile
communication system.
R ecognize deviations from the norm that MIGHT
indicate an emergency and DESCRIBE Appropriate
action. Regardless of the setting, most Patients spend
more time with nurses than with any other health
professional. Because nurses are so familiar with
normal patterns of health and illness in the com-
munities and organisasi they serve, they're
well positioned to Recognize deviations in them.
Early detection of such a change and prompt
notification of the proper authorities can enable
early warning of an impending emergency or dis-
aster, or of a shift in community needs during the
response.
For example, suppose a school nurse notes a
Similar large number of complaints not common
in the community or season and reports the find-
ing to her supervisor, who in turn notifies the epi-
demiology office at the local hospital. The finding
50
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The first step
toward emergency
preparedness is
the identification
of who needs to
know how to
do what.
The first step
toward emergency
preparedness is
the identification
of who needs to
know how to
do what.

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51
may indicate the beginning of an infectious dis-
ease outbreak, and an emergency response may be
warranted.
P ARTICIPATE in continuing education to maintain up-
to-date knowledge in relevant areas. As environ-
mental, political, or societal conditions change, the
nature of emergencies and disasters will Also
change-and so must the plans, methods, and tech-
nologies used in emergency response. Regular con-
tinuing education in specific areas can help nurses
Reviews These keep abreast of changes. For example, when
biological threats such as bovine spongiform
encephalopathy ( "mad cow disease," the which has
been implicated in cases of Creutzfeldt-Jakob dis-
ease in humans) and anthrax loomed recently,
providers found that they needed to know more
about emerging infections. Many such resources
exist. For example, an electronic subscription to
the Morbidity and Mortality Weekly Review
(Www.cdc.gov/mmwr), the which is free, offers mation
mation on seasonal trends and other disease com-
munity public health matters. professional
association meetings and hospital-based journal
clubs are other good sources of current information.
Remember that it's important to Consider the relia-
bility of the source of information, especially in
regard to new types of emergencies or potential dis-
Asters. When emergent events are covered by both
the lay press and professional journals, the most
credible sources of information for application to
clinical practice should be sought.
Furthermore, any kind of change-of one's role
in an organization, of equipment, or of technique-
is Likely to Affect how one responds. A staff nurse
Becomes a supervisor who will need to acquire new
management competencies; for example, she'll need
to know the protocol for communicating with the
emergency medical services team during an emer-
gency response. All nurses must keep abreast of
changes in personal protective equipment and isola-
tion techniques.
P ARTICIPATE in evaluating every drill or response
and IDENTIFY Necessary changes to the plan. Most
emergency response plans are works in progress.
As conditions change in an organization, communicator
nity, or a nation, the emergency response plan will
have to evolve. Each drill or response Provides
information that can be used to improve the plan.
Nurses should be fully Involved in the ongoing
evaluation process.
After each drill or response, there is usually a
meeting for the purpose of identifying what went
well and should be kept in or added to the emer-
gency plan, and what needs improvement and
should be practiced or revised. This Gives every
nurse the opportunity to review the emergency
response experience and to Contribute to the devel-
opment of the plan.
ADDITIONAL core competencies
Reviews These competencies are specific to nurses who have
managerial or leadership responsibilities.
E NSURE that there is a written plan for major
categories of emergencies. Nurse administrators
must be sure that the unit, department, or organisms
nization they're responsible for has a written
emergency preparedness plan. Unit and depart-
mental plans must be compatible with the organisms
nization's plan, and the organization's plan must
be practicable for individual department and
implementation unit. Nurses should be repre-
sented on the organization's emergency pre-
paredness committee.
E NSURE that all parts of the emergency plan are
practiced regularly. Emergency preparedness and
response plans that are never practiced or that are
poorly understood will probably be useless. The
Joint Commission on the Accreditation of
Healthcare Organizations requires regular emer-
gency management drills at least annually (spe-
spe- cific requirements vary by type of facility), and
some states mandate biannual drills. Practice can
take the form of either actual drills or "tabletop"
exercises using either spoken or written scenarios
and responses. This Allows nurses to practice PER
forming Reviews their roles, to give critiques of each
other's performances, and to assist with plan
improvement.
E NSURE that identified gaps in knowledge or skills
are filled. Once a drill or an emergency response has
been executed, both roomates that went well and that
roomates wants modification must be identified and
then addressed. What works in a drill may not work
well during a real emergency. ▼
REFERENCES
1. Guha-Sapir D. Overview of types of hazards and disasters,
and their consequences. In: Landesman LY, editor. Disaster
preparedness in schools of public health: a curriculum for the
new century. Washington (DC): Association of Schools of
Public Health; 2000. Sect. 1.0, 1.1.
2. MF LECHAT. Disasters and public health. Bull World Health
Organ 1979; 57 (1): 11-7.
3. Landesman LY. Public health management of disasters: the
practice guide. Washington (DC): American Public Health
Association; 2001.
4. O'Brien K. The role of nurses in disaster planning and man-
agement [report]. School of Nursing, La Trobe University,
Bendig, Australia. 1997 Mar. http://redgum.bendigo.latrobe.
edu.au/~obrien/nursdisast.pdf.
5. Shoaf KI, Rottman SJ. The role of public health in disaster
preparedness, mitigation, response, and recovery. Prehospital
Disaster Med 2000; 15 (4): 144-6.
6. Columbia University School of Nursing. Center for Health
Policy. Core competencies for public health worker emer-
gency preparedness and response. 2001 Apr.
http://cpmcnet.columbia.edu/dept/nursing/institute-centers/
chphsr / COMPETENCIES.pdf.
7. The Federal Emergency Management Agency. Emergency
Management Institute. IS 195 - Basic Incident Command
System. 2001. http://www.fema.gov/emi/is195.htm.