Fluent Essays

1. What spiritual considerations surrounding a disaster can arise for individuals, communities, and health care providers? Explain your answer in the context of a natural or manmade disaster. How can a community health nurse assist in the spiritual care of the individual, community, self, and colleagues?  2.Watch the Diary of Medical Mission Trip videos dealing with the catastrophic earthquake in Haiti in 2010. Reflect on this natural disaster by answering the following questions: Propose one example of a nursing intervention related to the disaster from each of the following levels: primary prevention, secondary prevention, and tertiary prevention. Provide innovative examples that have not been discussed by previous students. Under which phase of the disaster do the three proposed interventions fall? Explain why you chose that phase. With what people or agencies would you work in facilitating the proposed interventions and why? By Angel Falkner Essential Questions · What responsibilities does the community/public health nurse have in disaster nursing? · What is the chain of command and communication process when a disaster occurs? · What is the nursing process in disaster management? · What are the different types of disasters? · Identify the common physical, psychological, and social effects on disaster victims and workers.  Introduction Over the past decade, the incidence of natural and man-made disasters has increased substantially, warranting the attention of federal and health care agencies. Public health nurses (PHNs) play a vital role in the disaster management process. PHNs are involved in the prevention, preparation, intervention, and aftermath-management processes involved in handling disasters; this is called  disaster nursing . PHNs are also actively involved in educating and preparing members of the community for disasters. In all cases, PHNs must demonstrate cultural competence when caring for victims of disaster. What is a Disaster? · According to the International Federation of Red Cross and Red Crescent Societies (IFRC) a disaster is “a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources,” (International Federation of Red Cross and Red Crescent Societies, n.d.). There are two major types of disasters,  man-made  and  natural . Man-made disasters include terrorism, transportation accidents, food and water contamination, and building collapse (see Figure 5.1). Natural disasters include forces of nature such as hurricanes, blizzards, mudslides, earthquakes, tsunamis, epidemics, and fires (see Figure 5.2). In either type of disaster, there is a  primary agent  and a  secondary agent  that cause damage. The agent is the cause of injury or insult during a disaster. During Hurricane Irma in 2017, the primary agent that caused damage was the flood waters from the storm. The secondary agents were the viruses and bacteria that cultivate in stagnant water and have the propensity to spread disease. When the outcomes of the event supersede the community’s ability to manage the effects on their own, involvement of federal agencies to provide assistance on multiple levels is warranted. Figure 5.1 Types of Natural Disasters Figure 5.2  Types of Man-Made Disasters Several terms define the severity of casualties associated with disasters.  Multiple casualty incident  occurs when the casualty toll is isolated to fewer than 100 people. A  mass casualty incident  involves larger numbers, typically more than 100 people, and has an apparent effect on local emergency medical services and resources. Mass casualties can occur in any type of disaster.  Many factors will impact the individuals directly affected by the event during a disaster. Individuals who typically require the care of another are often at the greatest degree of risk. These vulnerable population groups include young children, the geriatric community, persons with severe mental or physical handicaps, and those physically dependent upon medical equipment either in acute or long-term care facilities. Individuals who fall into the vulnerable population category may not be able to evacuate during a disaster event and may require high-priority assistance because of advanced medical needs. Dimensions of a Disaster · Disasters are made up of multiple dimensions. A disaster’s  predictability  is based upon the ability to foresee the impending event, such as with weather forecasting systems that have the ability to deliver a hurricane or tornado warnings. Man-made disasters, such as a terrorist attacks or vehicle accidents, are more difficult to predict as they can occur without warning and are often dependent on the behaviors and perceptions of specific individuals or groups. Geographic areas can help to determine the  frequency  of disasters. For instance, those living in the Midwest area of the United States known as “Tornado Alley” have a greater risk of experiencing a natural disaster from a tornado. People living in the state of Florida have a higher incidence of experiencing a hurricane because of their proximity to the coastline. Controllability  refers to the ability to plan ahead for the possibility of an event in the future. Though the event itself cannot be controlled or even predicted, people can prepare and plan for it. An example of this would be having an emergency kit in the house at all times in the event of a disaster such as a fire, tornado, or hurricane. These kits should include basic household items such as canned foods and bottled water. Such planning is described as  mitigation . The  Federal Emergency Management Agency (FEMA)  describes mitigation as the effort to reduce loss of life and property by lessening the impact of disasters (Federal Emergency Management Agency [FEMA], 2018).  Time is yet another uncontrollable factor. For instance, in the event of a hurricane, the developments in weather forecasting have made it possible for warnings to be issued days in advance, allowing time for people to evacuate and prepare for the upcoming event. Other events such as tornadoes, flash floods, or man-made events such as terrorist attacks, offer little to no warning.  Scope  and  intensity  refer to the scale of damage upon the community and the casualties that occur as a result of the event. Scope is more specific to the depletion of typical resources within the effected community, while intensity evaluates the effect on the community’s health and loss of life. The greater the scope and intensity, the larger the disaster and the more resources and support are required.  Disaster Phases · Phases during a disaster include preimpact, impact, and postimpact. See Table 5.1 for information on the disaster phases and the nursing process (Millet, 2013; Jakeway, LaRosa, Cary, & Schoenfisch, 2008; Association of Public Health Nurses, 2013). Preimpact  During the  preimpact  phase, preparation or mitigation occurs. This phase is optimal for planning and preparing for a disaster as individuals and as a community. Individuals may plan and prepare by gathering items for an emergency kit for the home or discussing where to meet family members in the event of an emergency. On a community level, planning and preparing may involve government agencies and health care facilities assessing inventories for resources and equipment necessary in the event of a disaster. This phase also provides emergency management services as well as health care facilities time to orchestrate drills and review policy and procedures that need to be followed in a disaster. When an impending disaster is predicted, PHNs may be called upon to set up shelters or emergency aid centers preemptively. Nurse managers and team leaders in health care facilities may help coordinate practice drills or meetings with staff for discussion of how to navigate the influx of patients expected during and after the event.  Impact  The  impact  phase occurs during the actual disaster event, which may last for minutes, days, or even weeks depending on the type of disaster. The priority for this phase is survival. The extent of predicted damage must be assessed in order to disseminate the appropriate resources. This assessment includes determining the appropriate number of health care workers and emergency first responders necessary to provide care to victims. The impact phase is also when search and rescue efforts are coordinated and executed. The PHN in this phase is a provider of physical and psychological care who helps to triage victims according to their injuries. Postimpact  The  postimpact  phase occurs once imminent danger has ceased. During this period, rescue and emergency medical care becomes the primary focus. Once victims are treated and transported to safety, the process of recovery can begin. This disaster phase can last months or years and, depending on the scope and intensity of the disaster, may even have lifelong effects. The postimpact phase includes debriefing and reevaluation of disaster and  emergency preparedness  and prevention strategies to improve outcomes should another disaster occur. Table 5.1 Disaster Phases and the Nursing Process Disaster Phase Prevention (Mitigation) Preparedness Response Recovery Definition · Planning for disasters or emergencies to reduce vulnerability/damage/injury should an event occur. · Develop capacity to respond swiftly, efficiently, and effectively to disasters and emergencies. · Provide support to populations affected by disasters and emergencies. · Restore support systems to functional levels. Assessment · Assess population groups for awareness of potential disasters. · Assess special needs of population groups in the event of a disaster.  · Conduct assessment of threats or hazards that pose the greatest risk to the population. · Use public health incident triages and teams to assess the impact of and health needs arising from the disaster. · Participate in the incident response assessment of postdisaster community needs for health care and health resources. Planning · Develop emergency awareness programs to increase awareness of potential emergency or disaster events. · Develop plans to address access to and needs of populations in the event of a disaster. · Plan for the needs of small or large populations to shelter in place, evacuate, and mass casualty surges. · Develop plans in collaboration with incident triages and teams to determine care and care logistics needed to serve the populations and reduce stress and burnout among responders. · Collaborate with community stakeholders and partnerships to plan long-term recovery priorities, resources, and care logistics. Implementation · Conduct community education programs to increase awareness with a variety of media approaches. · Conduct exercises and training drills to care for various size populations. · Include training scenarios involving persons with special needs and family separations. · Follow incident emergency response plans to deploy personnel to locations with affected populations such as emergency shelters. · Conduct ongoing assessment of needs. · Participate in restoration of health care services. Evaluation · Evaluate community education activities for effectiveness. · Evaluate exercises and training drills for gaps and remaining education and training needs. · Participate in incident emergency response evaluations, including gap analysis and planning for future events. · Participate in evaluation of the long-term consequences of the populations who experienced or responded to the disaster. Self-Protection In times of crisis, caregivers and health providers become first responders, providing aid to those in need; however, it is essential for providers to care for themselves first before rendering aid. FEMA reiterates the steps of initiating an emergency response in their  Community Emergency Response Team (CERT)  training, stating, a CERT member’s first job is to stay safe (PerformTech, Inc., 2011). One of the primary ways providers can ensure their own safety on the scene of a disaster is with the use of personal protective equipment (PPE). Nurses use PPE in practice on a regular basis, but there are some differences in PPE at the bedside in nursing versus during disaster relief efforts.  Figure 5.3 PPE Prior to assessing a scene, the first thing anyone responding to a disaster must do is to determine the level of safety risk. A firm awareness of one’s surroundings does not stop during rescue efforts. Disaster scenes often change quickly, and responders must remain vigilant.  During the Ebola epidemic, a series of transmissions among health care providers revealed gaps in infection prevention and control (IPC) procedures (Hageman et al., 2016). To address this gap, the CDC worked with facilities in the United States to provide new and improved IPC training in order to prevent further transmission of the Ebola epidemic (Hageman, et al., 2016).  Health care providers and volunteers responding to a disaster where the spread of infectious disease is a concern should be cautious, particularly when caring for victims, and use the appropriate protocol when handling patients and bodily fluids. Though nurses are familiar with universal precautions enforced in clinical settings, they must also follow protocols in the field to ensure their safety and the safety of colleagues, other volunteers, and effected persons.  Disaster Management Services There are multiple federal and local agencies involved in disaster management that contribute to safety and survival of citizens in the event of a disaster. Disaster response begins at a local level and then, if necessary, proceeds to a state and federal level. The PHN should be familiar with such systems and how they function. National Disaster Medical System (NDMS) The National Disaster Medical System is a division of the U.S. Department of Health and Human Services (HHS) and is composed of health professionals who are allocated to respond in the event of a disaster. These well-trained professionals are hired as intermittent federal employees and have an expected on-call deployment of a minimum of 2 weeks per year. They undergo a rigorous applicant screening process that ensures physical and psychological ability to fulfill expected duties. Once hired to be a part of this program, there are various teams that the health care professionals can be assigned to depending on background and expertise. These include Disaster Medical Assistance Teams (DMAT), Trauma and Critical Care Teams (TCCT), Victim Information Center Teams (VIC), Disaster Mortuary Operational Response Teams (DMORT), or and the National Veterinary Response Team (NVRT) (Public Health Emergency, 2018). Each of these respective teams are deployed to the sites of various natural and man-made disasters. Nurses typically serve on the DMAT or TCCT teams where their specialized skills can be best utilized. Nurses who are part of these teams have responsibilities similar to those within the area for which they are trained. For instance, a trauma critical care nurse would provide this type of nursing care to victims at the scene.  Federal Emergency Management Agency (FEMA) Established in 1979 by President Jimmy Carter, FEMA is a division of the Department of Homeland Security (DHS) and is the coordinating agency for allocation of assistance in the event of disasters in the United States. “FEMA’s mission is to support citizens and first responders to ensure that as a nation we work together to build, sustain and improve our capability to prepare for, protect against, respond to, recover from and mitigate all hazards” (FEMA, 2017). FEMA works with state and local governments to provide assistance, preparation, and training associated with disaster management. Since its inception, the department has been reformed several times to optimize its ability to provide necessary resources during disasters, with the most recent reformation occurring in 2006 following Hurricane Katrina. FEMA is responsible for formulating the National Response Framework (NRF), which is a guide that helps the nation understand how to respond to disasters and emergencies. FEMA outlines four primary phases regarding disaster management: mitigation, preparedness, response, and recovery (see Table 5.2) (FEMA, 2016).  It is important to note that in order for FEMA to provide aid during the recovery phase of disaster management, the disaster must be declared a major disaster by the acting President of the United States. This is a process that begins with the local governor of the affected area applying to FEMA to declare the affected region a major disaster area. Once this occurs, the allocation of resources, such as grant funding, is provided by FEMA.  · · Table 5.2 Elements of Disaster Management  Disaster/Emergency Management Phases Definition/Characteristics Role/Responsibilities of the Nurse and/or the PHN Mitigation · Any activity that prevents or reduces the impact of unavoidable emergencies · Acquiring insurance such as flood or fire protection · Takes place before and after events · Provide education to public regarding planning and reaction in the event of emergencies · Coordination of preparation drills, such as mass casualty drills Preparedness · Plans and preparation for life-saving efforts, including rescue and response · Evacuation plans, such as creating a disaster kit · Education of the public · Helping the public and families create disaster kits and plans of action in the event of an emergency · Helping coordinate and institute plans of action in facilities (e.g., hospitals, care homes, schools) Response · Safety is the priority · Activation of preparation plans made during mitigation and preparedness phases · Seeking shelter  · Helping citizens find appropriate shelter · Personal accountability for self and one’s own family Recovery · Medical assistance · Rescue and recovery of victims · Physical and psychological healing · Begin to rebuild · Mitigation continues · Provide medical attention to victims · Help provide emotional support · Begin planning for mitigation phase Note. Adapted from Infection Prevention Orientation Manual: Section 15: Emergency Preparedness, by K. Bryan & B. Wardle, 2014. Copyright 2014 by the Wyoming Department of Health.  National Response Framework (NRF) The NRF was developed by FEMA as a guide for preparedness in the event of a disaster or crisis situation. The framework recognizes the need for involvement beyond the federal government and incorporates the assistance of local, tribal, and state government agencies as well as assistance from the private sector and nonprofit organizations. Five key principles guide the framework (FEMA, 2016). 1. Engaged Partnership: All sectors of the community are involved and do not solely rely on governmental agencies. This involvement includes the private sector as well, including volunteer organizations such as the American Red Cross and Christian Disaster Response.  2. Tiered Response: Assistance begins at the local level where the event occurs and then branches outward as assistance is needed. 3. Scalable, Flexible, and Adaptable Operational Capabilities: The amount of allocated resources must expand to meet the needs the disaster has created.  4. Unity of Effort and Unified Command: The allocation of assigned roles during disaster management must be understood, meaning that each agency involved maintains its own respective authority, responsibility, and accountability.  5. Readiness to Act: Organizations’ members and volunteers must be adequately prepared prior to disaster events and understand the risk associated with responding to the needs of victims. It is important to follow regulated processes and procedures to operate effectively. Figure 5.4 National Response Framework Note. Adapted from National Response Framework (3rd ed.), by the Federal Emergency Management Agency, 2016. National Incident Management Systems (NIMS) National Incident Management Systems (NIMS) is a division of FEMA and DHS that helps provide prevention training and coordination between public and private entities in managing disaster incidents across the nation. They utilize the Incident Command System (ICS), which provides protocols and structure that helps coordinate various parts of disaster management, such as operations, planning, logistics, and finances (see Figure 5.5). The system has various leadership roles, such as the incident commander who helps oversee the various areas that need to be managed in an organized manner during disasters. While in use, the ICS works from an Emergency Operations Center (EOC) that can vary depending on the type of disaster. Figure 5.5 Incident Command System Note. Adapted from “Incident Management,” by Ready.gov. Emergency Operations Center (EOC) The Emergency Operations Center (EOC) serves as a command center where government agencies can manage the disaster response. According to FEMA, “EOC core functions include coordination; communications; resource allocation and tracking; and information collection, analysis, and dissemination,” (FEMA, n.d., para. 28). The EOC may be any type of building or structure, from a warehouse to a gymnasium, that provides ample space and is safe from the effects of the disaster. This is where coordination efforts occur, but it is also where emergency medical aid may be provided to the first survivors of the event.  Emergency Medical Services Traditionally, Emergency Medical Services (EMS) is thought of as the phone call to 9-1-1 in times of danger. From a young age, children are taught the importance of learning how to dial 9-1-1 in the event of a crisis in order to receive help from first responder medical personnel and law enforcement as quickly as possible. The Federal Interagency Committee on EMS (FICEMS) was established by Congress in order to streamline coordination between local EMS chapters and the federal government to improve the delivery of EMS to citizens across the country in times of crisis (Federal Interagency Committee on EMS, n.d.). In addition, the U.S. Department of Defense (DOD) provides specialized training to EMS workers in preparation for deployment to hostile or combat areas around the world. EMS also works with FICEMS to coordinate and institute casualty drills and provide preparedness education to the public. Courses such as pediatric and mass casualty triage training are available for free on their website. Nurses may be involved in the coordination and the execution of such training and drills throughout the community.  American Red Cross The American Red Cross (ARC) is an organization that provides aid during disasters and is composed of nearly 90\% specially trained volunteers. Founded by renowned nurse, Clara Barton, ARC’s mission is to provide assistance to those in dire need of emergency services related to any disaster occurrence. ARC works in conjunction with FEMA and other federal emergency response agencies and Community Emergency Response Teams (CERTs) to coordinate relief efforts for victims of disasters across the country. ARC assists with providing medical care, emergency supplies, and education and preparedness strategies as well as setting up and running emergency shelters among communities across the United States (American Red Cross, n.d.). Nurses can apply to volunteer for the ARC and will go through required volunteer training. After training, nurses will be utilized depending upon the need within the community and the volunteers’ availability.  Faith-Based Disaster Response Organizations There are a plethora of faith-based, nonprofit organizations that provide support during disaster relief throughout the United States. Each organization provides resources such as food, water, and basic necessities as well as volunteer relief workers who assist in many capacities and work in conjunction with government agencies to assist victims of disasters when they occur. In addition, many of these organizations provide training and assistance in the planning process to help improve efforts when the next disaster hits. These faith-based organizations provide support and assistance following their religious doctrines that speak largely of compassion, caring, and helping the less fortunate. Some commonly known faith-based disaster organizations include Catholic Charities USA, United Methodist Committee on Relief (UMCOR), and Lutheran Disaster Response. During recent events, such as Hurricane Irma in Florida, the United Methodist Committee on Relief provided a tremendous amount of support to relief efforts, including clean up following the hurricane and helping citizens with organization of aid and insurance to help them begin to rebuild their lives. Another organization, The Convoy of Hope, deployed several trailer trucks stocked with food and water prior to the impact of the hurricane to help prepare for the impending needs of the community (Rehwald, 2017). Community Emergency Response Teams (CERTs)  Community Emergency Response Teams (CERTs) are composed of community volunteers who work to prepare their communities against threats. Though they are not first responders to disaster events, they are well trained to assist first responders (Ready.gov, n.d.a). CERT volunteer teams are valued members of the community who provide aid to victims quickly and assist first responders in the management of disaster scenes. Nurses may volunteer for CERT teams, but they would be completing the duties as described in their CERT training for volunteers rather than providing nursing care to victims.  Some of the things CERT volunteers are trained to do include: · Prepare for the hazards that threaten their communities.  · Apply size-up and safety principles.  · Locate and turn off utilities.  · Extinguish small fires.  · Identify hazardous materials situations.  · Triage and treat victims.  · Set up a medical treatment area.  · Conduct search and rescue operations in lightly and moderately damaged structures.  · Understand the psychological impact of a disaster on themselves and others.  · Organize CERT members and spontaneous volunteers for an effective and safe response.  · Apply response skills in a disaster simulation.  Hospital Disaster Plans  · · · Hospitals play a critical role in responding to and preparing for disasters. Hospitals have policies and procedures in place in the event of a disaster that may vary slightly from facility to facility, but they cover the basics of disaster management and response. The Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), American Nurses Association (ANA), and FEMA provide advice on the components that should be incorporated into a hospital disaster plan. The Joint Commission requires every hospital to have a disaster plan in place. These plans should include management of internal and external disasters and are to be practiced several times a year. Nurse leaders will be involved in the planning, coordination, and incorporation of such drills to prepare employees. Internal disasters might include the rapid spread of an infectious disease process within the patient population inside the hospital. An external disaster would include any natural or man-made disaster that occurs within the nearby communities.  Nurses’ Duty to Respond · Nurses are licensed providers who have an obligation to respond in emergency situations. When disaster strikes, nurses are faced with numerous challenges, including the care of multiple stakeholders. According to the Provision 2 of the ANA Code of Ethics, the nurse retains a primary commitment to the patient at all times (American Nurses Association, 2015). However, this does not to negate Provision 5, which emphasizes self-care as equally important. Nurses have a moral obligation to uphold their fundamental duty to care, but this does not mean jeopardizing their own safety or the safety of others in times of crisis.  Social Justice  · · · The Agency for Healthcare Research and Quality (AHRQ) and the Institutes of Medicine (IOM) have developed a framework that includes six aims for the health care system. These aims indicate that patient care should be safe, effective, patient-centered, timely, efficient, and equitable. When discussing health equity, it is essential to underline the importance of providing disaster victims with equitable care despite social determinants of health (SDOH).  In areas that are impoverished or have a high number of immigrants or diverse cultures, special attention and care must be considered when providing support to victims following a disaster. This issue was highlighted in the aftermath of Hurricane Katrina in the Gulf Coast area. Many communities affected by the hurricane’s impact were impoverished, and it became evident very quickly that planning and response for these types of communities was not adequate. Victims did not receive the financial support, supplies, or medical attention they needed in a timely manner, extending their recovery time and leading to poor outcomes. The devastation that occurred in these areas gave rise to the development of more particular and critical response methods that addressed special issues such as poverty and culture (Lichtveld, 2018). This might include ensuring appropriate translation services are provided in order to communicate needs to communities that do not speak English.  Evacuation · In the event of an impending disaster, the best-case scenario would allow a few days to coordinate evacuationefforts. In events when early warnings are not possible, evacuation efforts may prove to be more chaotic. Properly planning ahead helps to ensure safe and prompt escape from the area of threat. Planning involves identifying the types of disasters that could occur in the surrounding area, identifying where to go when evacuation is necessary, preparing a safe places for pets, and being familiar with escape routes and alternate routes out of the area. Families should also determine a location where they should meet if they become separated for any reason. Keeping a bag containing household essentials, including nonperishable food, bottled water, flashlights, batteries, and a first-aid kit, is another necessary item to have in the home at all times. Before returning home, always check with local authorities to make sure it is safe to do so. Nurses should be careful when reporting for duty in response to a disaster; they should ensure their families’ safety first and that the route and available transportation to the hospital is safe before embarking on the journey.  Rescue and Recovery Once the imminent threat of the disaster’s effects are over, the rescue and recovery process begins. This process is commonly referred to as search and rescue (SAR). The rescue process begins at the local level, with first responders from the local fire and police departments as well as emergency management personnel being on the scene. The largest SAR system was established under FEMA and includes 28 urban rescue task forces that are deployed in the event of disasters around the nation. The local emergency manager may request assistance from the state and, if necessary, FEMA will deploy its three closest SAR task forces to intervene. The scene is assessed for safety before the search and rescue crew is sent in, and heavy equipment is used to clear away large pieces of debris that may be trapping survivors. Emergency health care workers are on scene to provide stabilizing medical treatment once survivors are extricated. During the process, hazardous material specialists are also on scene to evaluate for possible contamination that could pose a threat to the rescue team (FEMA, 2017).  Principles of Disaster Management  Disaster Preparedness · · The concepts of primary, secondary, and tertiary prevention have been described in detail throughout the baccalaureate-nursing program. These concepts can also be applied to disaster preparation as well. Prevention is a key component in the NRF for disaster management that warrants further discussion and elaboration. Though true prevention of disasters is not possible, prevention in disaster preparation is described in terms of management versus total aversion of disaster occurrence.  Preventable Versus Nonpreventable Disasters cause destruction in part because of their unpredictable nature, which warrants proper preparation versus true prevention. Prevention measures, such as mitigation efforts, are the best ways that the impact of disaster can be lessened. The major difference between mitigation and preparedness is that mitigation looks at long-term solutions that help to reduce risk instead of merely reacting to consequences of disaster events once they have occurred (FEMA, 2018). Though impossible to stop disasters altogether, it is possible to educate, plan, and collaborate efforts to prepare communities to withstand, survive, and recover from events that are not in anyone’s control.  Primary Primary prevention in disaster management involves planning prior to the occurrence or onset of a disaster event. The PHN assists in educating the community and families about having plans in place in the event of a disaster and being aware of the local resources families may need during a disaster. This is particularly important for families with small children and those in care of persons who are severely disabled or in need of continual medical care and treatment.  Ready.gov is a government website that provides a wide range of information regarding preparation for common emergencies and disaster events. The website is a resource the PHN can recommend to people for assistance in creating a plan that includes evacuation, safety skills, and financial concerns (Ready.gov, n.d.c). Another tool this website provides is a list of supplies recommended for preparing an emergency supply kit (see Figure 5.6). Preparedness is essential, yet is often overlooked as a necessity in American society. A recent national survey conducted by Columbia University determined that two-thirds of American households do not have adequate plans for disasters (Petkova et al., 2016).  Figure 5.6 Emergency Supply List Note. Adapted from “Emergency Supply List,” by the Federal Emergency Management Agency, 2014. · · Mitigation  Mitigation refers to the specific measures taken prior to the onset of a disaster event that help to decrease or eliminate the disaster’s associated risks. Though the levee system in Louisiana failed during Hurricane Katrina in 2005, their original construction and institution is an example of mitigation. The levees were meant to help diminish the floodwaters associated with massive storms such as Katrina, thereby decreasing the damage. According to FEMA the following are also examples of mitigation: · Complying with or exceeding National Flood Insurance Program floodplain management regulations · Enforcing stringent building codes, flood-proofing requirements, seismic design standards, and wind-bracing requirements for new construction or repairing existing buildings  · Adopting zoning ordinances that steer development away from areas subject to flooding, storm surge, or coastal erosion  · Retrofitting public buildings to withstand ground shaking or hurricane-strength winds · Acquiring damaged homes or businesses in flood-prone areas, relocating the structures, and returning the property to open space, wetlands, or recreational uses  · Building community shelters and tornado-safe rooms to help protect people in their homes, public buildings, and schools in hurricane- and tornado-prone areas (FEMA, 2018). Secondary Secondary prevention may occur when the onset of the disaster has occurred or within hours of its impact; this is when  response  occurs during a disaster. Response in disaster management indicates the period of time for emergency assistance with the goal of maintaining and saving lives, improving health, surviving the disaster event, and supporting victims (National Disaster Recovery Framework, 2016). The priority is safety and survival during the response phase and occurs when it is necessary to evacuate or, if more appropriate, find and take shelter. Families and individuals can prepare for this phase by having a designated safe area or location in which they plan to take refuge. PHNs educate families on possible evacuation and alternative routes as well as locating places of refuge when evacuation is not an option.  Tertiary Tertiary prevention occurs after the offending event has ceased and the focus is on  recovery . The tertiary and recovery phases may last weeks, months, or even years and involves property damage recuperation, physical rehabilitation of those injured, mental illness evaluation and treatment, planning for future disasters, and financial recuperation. While the focus is on recovering from the event, thought should be given to how well the first two prevention phases went and what can be done to improve them. PHNs can help to evaluate the process and devise and implement changes in the prevention plan that may help to avoid devastating results in the next disaster event.  Community Reaction · · · The effects of a disaster can be longstanding and life changing for individuals and communities. Effects can be on many levels, from the psychological to spiritual. All varying needs must be taken into consideration when caring for those affected following a disaster event.  Psychological Impact Following disasters, individuals within the affected community may have varying emotional reactions. It is normal to see a degree of panic within the community when the disaster is occurring. Panic is the sudden onset of excited feelings brought on by the fear of impending danger; this is what causes people to run franticly from buildings or the scene of a disaster in search of refuge.  Shock is defined as a period of disbelief that may render a person incapable of typical thought processes or role function; this usually sets in once the imminent danger of the disaster has ended. This is a very typical reaction following a disastrous event and, while usually temporary, may have a profound impact on a person’s sense of normalcy and control. If the initial shock of the event does not dissipate, the emotional strain may lead to long-term mental disorders such as depression or  post-traumatic stress disorder (PTSD) .  There are a wide range of psychological effects following a disaster. Some level of distress is considered typical; however longstanding depression, anxiety, and PTSD may affect individuals for years following the disaster event itself (Martin, 2015). The psychological effects can last years and have a devastating effect on the daily lifestyle, personal relationships, and return of typical daily functions in individuals struggling with such diagnoses. There are also correlations between exposure to a disaster and increased incidence of drug and alcohol abuse as a means of coping with the stress of the experience (Maclean, Popovici, & French, 2016). Nurses within the community must take this into account when caring for survivors of such events, remembering to consider that the event may have occurred many years ago and still have an impact on the patient. Nurses should refer patients to case management, chaplain services, and social work as well as coordinate counseling services or other appropriate resources for mental health when indicated. The Disaster Distress Hotline, a free telephone hotline offered by the Substance Abuse and Mental Health Services Administration (SAMHSA), is available for people seeking help following a disaster event (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). People can call or text 365 days a year, 24 hours a day to receive free emotional support related to being involved in a disaster; these services are provided in English, Spanish and accommodations are made for the hearing impaired (SAMHSA, 2012).  Under normal, controlled circumstances, the business of caring for the sick is emotionally draining; therefore, doing so in the midst of total chaos adds additional strain and may have an impact on health care professionals that warrants attention. Nurses should stay aware of their own emotional health during these times and reach out for support when needed. Nurses may fall victim to the psychological affects following a disaster and should be supported by their managers, peers, and other health care professionals to provide them with the care they may need.  Spiritual and Cultural Considerations As previously discussed, disasters take a significant toll on mental health, causing short and long-term distress. During these times, the need for spiritual care may become dire. Regardless of religious affiliation, chaplains play an important role in supporting the communities’ emotional needs during and after a devastating event (Graham, 2014). Nurses working with the victims can advocate for the spiritual needs of patients by locating the chaplain whenever possible and facilitating the incorporation of spiritual practices that do not interfere with patient safety or the course of treatment to provide comfort. Reaching beyond spiritual guidance, chaplains are trained to provide psychological support. Chaplains are valuable members of society, providing counsel and comfort to the shocked, grieving, and emotionally devastated victims in disasters.  Cultural needs must also be considered when preparing for disasters and caring for survivors. Different cultures may respond to a traumatic event differently, whether it be with prayer, crying, or stoic affect. The PHN should be aware of cultural differences and approach each patient with sensitivity and respect, allowing them to grieve, react, and respond the way that is appropriate for them, as long as they are not causing self-harm or harming others. In areas where populations are extremely vulnerable, such as areas of high poverty, their ability to cope and recover financially as well as psychosocially following a disaster may be severely impaired (Knox & Haupt, 2015). These individuals will require more support from local and federal agencies to move forward with the recovery process. PHNs are valuable advocates helping to allocate resources for those with limited capacity to do so on their own. In preparing a community for disaster, the community’s culture should be examined, and appropriate adjustments should be made to account for cultural differences. This may mean PHNs must adjust how they educate community members about disaster preparations or utilizing translation services if needed.  Physical Impacts Beyond the short-term injuries that may be sustained during a disaster event, some survivors may experience life-long effects on their health. These effects stem from a number of things, including severe injuries or exposure to carcinogenic, toxic, or radioactive substances during or after the event.  Fertility  One major longstanding physical impact seen in disaster survivors is a decrease in fertility. This is due to a variety of reasons associated with the disaster, including exposure to toxic agents, psychological trauma, and general exposure to the traumatic event (Zotti, Williams, Robertson, Horney & Hsia, 2013). Along with decreased rates of fertility, studies have shown an impact on pregnancy loss, birth defects, low-birth weights, and preterm births (Zotti et al., 2013). Studies point to the stress of the disaster event having profound negative effects on women in their child-bearing years. These negative effects may inhibit women from conceiving or carrying to term, which may cause an increase in emotional strain on the woman and her partner. While there are promising infertility treatments that can be offered to a struggling couple, their mental health and coping must be of concern as well. Nurses must consider offering services that will address the issue of fertility and childbearing as well as mental well-being.  Toxic Exposure Regardless of the type of disaster, there is always risk of exposure to toxic substances or carcinogens that have the potential to impact health throughout one’s lifetime. A prime example of this type of exposure that is still being researched and studied is the exposure to various toxic inhalants during the September 11, 2001 terrorist attack on the World Trade Center in New York City. During this terrorist attack, high concentrations of dense dust particles were inhaled and swallowed by survivors and first responders in the surrounding area, causing a host of respiratory and digestive issues that continue to cause these individuals health problems, such as gastroesophageal reflux (GERD) and lung cancer (Lippman, Cohen & Chen, 2015).  Nurses must understand that the health effects following a disaster can have lifelong impacts that cause a multitude of issues long after the disaster occurrence. The skill of history taking is essential in these instances. The patient may not mention being a survivor of a disaster, especially if it was many years ago, and they see no reason to bring it up. Discovering that a patient is a survivor of a disaster event and was exposed to toxic agents may indicate a need for different diagnostic procedures, which highlights the importance of detailed and thorough health history taking. In addition, the patient may be suffering from other effects of surviving a disaster as well, such as PTSD or other mental health issues, and may require appropriate referral and support from other members of the health care team, such as social work and case management.  Population Health Considerations Post Disaster There are a great number of considerations to be made during the recovery phase to help the affected community fully recover. Beyond the physical injuries and loss of lives, there is damage to buildings and property, loss of housing, lack of running water and electricity, overwhelmed emergency services and local hospitals, and inadequate financial resources to provide the necessary items for relief and recuperation. Each of these issues warrants time, resources, collaborative planning, and efforts in order to restore balance to a community that has suffered immeasurable losses. PHNs are instrumental to this process by evaluating patients in the community, assessing their needs, and providing necessary education for health promotion measures and/or preparation for the next disaster that may occur.  Economic Impact  The economic impact on communities after a disaster can vary depending on various elements of the disaster itself and the severity of its impact. According to FEMA, in the 1990s more than $25 billion was allocated to provide disaster assistance in the United States, and money sent to assist after disasters worldwide skyrocketed to over $608 billion (FEMA, 2009). While the costs and lives lost are seemingly unavoidable, proper preparation and improvement of preparation processes are essential to decreasing cost as well as saving lives. PHNs can contribute to this by being involved in the mitigation and preparation processes in disaster management, as well as the evaluation postdisaster to help improve preparation plans before the next disaster strikes. Table 5.3 provides information on the five costliest hurricanes on record to strike the United States (Office for Coastal Management, n.d.). Table 5.3 Economic Impact  Name Year Cost Katrina 2005 $161 billion Harvey 2017 $125 billion Maria 2017 $90 billion Sandy  2012 $71 billion Irma 2017 $50 billion Nurse’s Role in Disaster Management  · · · PHNs play an integral role in the community as trusted and esteemed caregivers. PHNs not only have a responsibility to their patients, but also to their community as a whole. Whether natural or man-made, disasters are inevitable, and nurses must be prepared to respond. Nurses have a long and proud history of caring for the sick and injured in tumultuous times, most notably in the days of Florence Nightingale during the Crimean War. These roots remain a driving force that inspires nurses to dutifully and skillfully care for patients. PHNs take this care a step further by helping to plan for the sustainability of their communities, especially during times of disaster. According to the Association for Public Health Nurses (APHN), the role of public health nurses in disaster management includes “population based practice like rapid needs assessments of communities impacted by the incident, population based triage, mass dispensing of preventive or curative therapies, community education, and providing care or managing shelters for displaced populations” (Association of Public Health Nurses, 2013, p. 4). The basic steps of the traditional nursing process—assessment, planning, implementation, and evaluation— is the same process utilized for nursing during disaster management with some modification necessary to address public health (see Table 5.4).  Table 5.4 Nursing Process in Disaster Management Nursing Process Step Description Assessment · PHNs are responsible for assessment of the local population for risks and needs during times of disaster · PHN may also conduct a hazard vulnerability assessment, which involves identifying threats and hazards in the area that pose the greatest amount of risk.  Planning · PHNs formulate plans of care that address functional needs of the population during a disaster.  · PHNs then work with key stakeholders within the community to address these needs, which might include sheltering, evacuation planning, and mass casualty capabilities. Implementation · PHNs participate in training for community health care providers, including forming and conducting casualty drills and education regarding protocol during a disaster Evaluation · PHNs evaluate training, drills, and education · PHNs evaluate operational plans and protocols to make improvements in the future Note. Adapted from The Role of the Public Health Nurse, by the Association of Public Health Nurses, 2014. Disaster Management in Years to Come · · · · With political shifts, climate changes, and increasing populations worldwide, both natural and man-made disasters have and will continue to change. The threat of impending disasters will continue to warrant appropriate action and planning. PHNs need to remain aware of these changes to prepare themselves and their communities adequately. Mass Shootings Over the past few decades, there has been an increase in mass shootings in the United States. Such events often result in multiple casualties, many more injuries, and often a lifetime of devastation for the victims and victims’ loved ones (Terrades, 2017). Because of this, it is essential that PHNs and all health care professionals take steps to prepare for such an event in their local communities. This involves education regarding response and survival during an active shooter event in every setting, from schools to churches to businesses. This also involves preparing acute care facilities, emergency management plans and processes, and drills to practice proper response efforts in advance. Educating parents and caregivers regarding gun safety and the importance of keeping guns unloaded and in a locked safe at all times should be reiterated and stressed at every opportunity. Mandatory survival training and education is often being implemented in many workplaces that help employees to understand how to respond in case of an active shooter event in their place of business (U.S. Department of Homeland Security [DHS] 2017). The DHS offers several training handouts and videos that are free for use in educating the public regarding surviving active shooter situations (see Figure 5.7).  Figure 5.7 Active Shooter Response Note. Adapted from “Active Shooter Pocket Card,” by the U.S. Department of Homeland Security. Terrorism After the events of September 11, the thought process regarding mitigation and preparedness for terrorist events shifted. In 2002, President George W. Bush enacted the Homeland Security Act with the goal of reducing the nation’s vulnerability to terrorism, protecting the United States from future attacks, and minimizing the damage in the event of terrorist and disaster attacks (FEMA, 2008). Mitigation strategies, such as enhanced security procedures, were elevated and continue to be the gold standard in the effort to prevent terrorist attacks. The DHS also started a campaign called “See Something, Say Something” that emphasizes public awareness and involvement in reporting suspicious activity of any kind in order to assist in prevention measures (DHS, n.d.). PHNs can be actively involved in educating members of the community about safety and reporting suspicious activity to help keep their community safe.  Bioterrorism  In recent years, the threat of impending terrorist attacks has warranted the attention of health care professionals in collaboration with federal agencies to help prevent and respond to an act of bioterrorism. The act of  bioterrorism , or chemical terrorism, is defined as the use of biological or chemical agents as a weapon to cause injury, death, and disruption (Centers for Disease Control and Prevention [CDC], 2017). In response to the impending threat of anthrax attacks, the CDC (1999) published the National Bioterrorism Preparedness and Response Initiative, which is a guide for prevention and response to bioterrorism attacks. The CDC’s five primary focus areas are preparedness, detection, diagnosis, response, and communication (CDC, 2016).  Health care facilities have their own protocols to follow when dealing with bioterrorism threats. The protocol is largely directed by recommendations from the CDC. Nurse leaders are an important part of the process of understanding the protocol and knowing how to properly educate their staff regarding procedures in the event of a bioterrorist attack. The protocol details procedures such as isolation precautions, handling of patient specimens, decontamination following exposure, patient placement, and postmortem care of infected patients. In addition, it provides an overview of a handful of bioterrorism agents, their expected clinical features, and recommendations for treatment and care for agents such as botulism, anthrax, and plague (CDC, 2018).  Within hospital settings, the Occupational Safety and Health Administration (OSHA) has published guidelines to assist hospitals with response to an attack of this nature. These guidelines discuss preplanning, care of the victims, and avoidance of cross contamination (Occupational Safety & Health Administration, 1997). Health care personnel must be familiarized and educated on bioterrorism agents and how to protect themselves and the victims of the event. Because nurses have a great deal of contact with patients, providing them with the education necessary to work in these conditions is crucial. PHNs can be advocates for such education in order to protect their own health, the health of their colleagues, and the health of their patients. Nurses working at the bedside or in leadership roles can help to establish and implement education plans that would inform nurses of proper protocol in a bioterrorism event.  Nuclear Threats and Response In light of political tension around the globe, it behooves any well-organized government to be well prepared for any disaster, including one as devastating as a nuclear detonation. FEMA and the CDC have plans in place to respond in the event that nuclear war were to become aa reality. PHNs serve as educators of the community, helping to institute plans for survival and safety in the event of a nuclear detonation. The website Ready.gov also provides numerous tips and advice regarding surviving a nuclear blast and necessary steps to survive after detonation.  Three of the primary factors reiterated in survival of a nuclear blast are distance, shielding, and time. Individuals should be instructed to put as much distance and protection between themselves and the fallout particles as possible, this means immediately heading indoors and staying there. The thicker the walls of the structure or the deeper underground the individuals can go, the safer they are from the nuclear fallout materials. Time is the final factor; following a nuclear detonation, the first few weeks pose the greatest amount of risk. People are advised to stay indoors for a minimum of two weeks, as the nuclear materials can cause the greatest degree of damage in this time period (Ready.gov, n.d.b). PHNs can be valuable in providing education regarding these important survival guidelines to the communities they serve. The RN to BSN program at Grand Canyon University meets the requirements for clinical competencies as defined by the Commission on Collegiate Nursing Education (CCNE) and the American Association of Colleges of Nursing (AACN), using nontraditional experiences for practicing nurses. These experiences come in the form of direct and indirect care experiences in which licensed nursing students engage in learning within the context of their hospital organization, specific care discipline, and local communities. Note: This is an individual assignment. In 1,500-2,000 words, describe the teaching experience and discuss your observations. The written portion of this assignment should include: 1. Summary of teaching plan 2. Epidemiological rationale for topic 3. Evaluation of teaching experience 4. Community response to teaching 5. Areas of strengths and areas of improvement Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. The RN to BSN program at Grand Canyon University meets the requirements for clinical competencies as defined by the Commission on Collegiate Nursing Education (CCNE) and the American Association of Colleges of Nursing (AACN), using nontraditional experiences for practicing nurses. These experiences come in the form of direct and indirect care experiences in which licensed nursing students engage in learning within the context of their hospital organization, specific care discipline, and local communities. Based on the feedback offered by the provider, identify the best approach for teaching. Prepare a presentation based on the Teaching Work Plan and present the information to your community. Options for Delivery  Select one of the following options for delivery and prepare the applicable presentation: 1. PowerPoint presentation – no more than 30 minutes 2. Pamphlet presentation – 1 to 2 pages 3. Audio presentation 4. Poster presentation Selection of Community Setting These are considered appropriate community settings. Choose one of the following: 1. Public health clinic 2. Community health center 3. Long-term care facility 4. Transitional care facility 5. Home health center 6. University/School health center 7. Church community 8. Adult/Child care center Community Teaching Experience Approval Form  Before presenting information to the community, seek approval from an agency administrator or representative using the Community Teaching Experience Approval Form. Submit this form as directed in the Community Teaching Experience Approval assignment drop box. General Requirements While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.  You are not required to submit this assignment to LopesWrite. Benchmark Information Registered Nurse to Bachelor of Science in Nursing The benchmark assesses the following competencies: 3.3 Provide individualized education to diverse patient populations in a variety of health care settings. By Angel Falkner Essential Questions · What responsibilities does the community/public health nurse have in disaster nursing? · What is the chain of command and communication process when a disaster occurs? · What is the nursing process in disaster management? · What are the different types of disasters? · Identify the common physical, psychological, and social effects on disaster victims and workers.  Introduction Over the past decade, the incidence of natural and man-made disasters has increased substantially, warranting the attention of federal and health care agencies. Public health nurses (PHNs) play a vital role in the disaster management process. PHNs are involved in the prevention, preparation, intervention, and aftermath-management processes involved in handling disasters; this is called  disaster nursing . PHNs are also actively involved in educating and preparing members of the community for disasters. In all cases, PHNs must demonstrate cultural competence when caring for victims of disaster. What is a Disaster? · According to the International Federation of Red Cross and Red Crescent Societies (IFRC) a disaster is “a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources,” (International Federation of Red Cross and Red Crescent Societies, n.d.). There are two major types of disasters,  man-made  and  natural . Man-made disasters include terrorism, transportation accidents, food and water contamination, and building collapse (see Figure 5.1). Natural disasters include forces of nature such as hurricanes, blizzards, mudslides, earthquakes, tsunamis, epidemics, and fires (see Figure 5.2). In either type of disaster, there is a  primary agent  and a  secondary agent  that cause damage. The agent is the cause of injury or insult during a disaster. During Hurricane Irma in 2017, the primary agent that caused damage was the flood waters from the storm. The secondary agents were the viruses and bacteria that cultivate in stagnant water and have the propensity to spread disease. When the outcomes of the event supersede the community’s ability to manage the effects on their own, involvement of federal agencies to provide assistance on multiple levels is warranted. Figure 5.1 Types of Natural Disasters Figure 5.2  Types of Man-Made Disasters Several terms define the severity of casualties associated with disasters.  Multiple casualty incident  occurs when the casualty toll is isolated to fewer than 100 people. A  mass casualty incident  involves larger numbers, typically more than 100 people, and has an apparent effect on local emergency medical services and resources. Mass casualties can occur in any type of disaster.  Many factors will impact the individuals directly affected by the event during a disaster. Individuals who typically require the care of another are often at the greatest degree of risk. These vulnerable population groups include young children, the geriatric community, persons with severe mental or physical handicaps, and those physically dependent upon medical equipment either in acute or long-term care facilities. Individuals who fall into the vulnerable population category may not be able to evacuate during a disaster event and may require high-priority assistance because of advanced medical needs. Dimensions of a Disaster · Disasters are made up of multiple dimensions. A disaster’s  predictability  is based upon the ability to foresee the impending event, such as with weather forecasting systems that have the ability to deliver a hurricane or tornado warnings. Man-made disasters, such as a terrorist attacks or vehicle accidents, are more difficult to predict as they can occur without warning and are often dependent on the behaviors and perceptions of specific individuals or groups. Geographic areas can help to determine the  frequency  of disasters. For instance, those living in the Midwest area of the United States known as “Tornado Alley” have a greater risk of experiencing a natural disaster from a tornado. People living in the state of Florida have a higher incidence of experiencing a hurricane because of their proximity to the coastline. Controllability  refers to the ability to plan ahead for the possibility of an event in the future. Though the event itself cannot be controlled or even predicted, people can prepare and plan for it. An example of this would be having an emergency kit in the house at all times in the event of a disaster such as a fire, tornado, or hurricane. These kits should include basic household items such as canned foods and bottled water. Such planning is described as  mitigation . The  Federal Emergency Management Agency (FEMA)  describes mitigation as the effort to reduce loss of life and property by lessening the impact of disasters (Federal Emergency Management Agency [FEMA], 2018).  Time is yet another uncontrollable factor. For instance, in the event of a hurricane, the developments in weather forecasting have made it possible for warnings to be issued days in advance, allowing time for people to evacuate and prepare for the upcoming event. Other events such as tornadoes, flash floods, or man-made events such as terrorist attacks, offer little to no warning.  Scope  and  intensity  refer to the scale of damage upon the community and the casualties that occur as a result of the event. Scope is more specific to the depletion of typical resources within the effected community, while intensity evaluates the effect on the community’s health and loss of life. The greater the scope and intensity, the larger the disaster and the more resources and support are required.  Disaster Phases · Phases during a disaster include preimpact, impact, and postimpact. See Table 5.1 for information on the disaster phases and the nursing process (Millet, 2013; Jakeway, LaRosa, Cary, & Schoenfisch, 2008; Association of Public Health Nurses, 2013). Preimpact  During the  preimpact  phase, preparation or mitigation occurs. This phase is optimal for planning and preparing for a disaster as individuals and as a community. Individuals may plan and prepare by gathering items for an emergency kit for the home or discussing where to meet family members in the event of an emergency. On a community level, planning and preparing may involve government agencies and health care facilities assessing inventories for resources and equipment necessary in the event of a disaster. This phase also provides emergency management services as well as health care facilities time to orchestrate drills and review policy and procedures that need to be followed in a disaster. When an impending disaster is predicted, PHNs may be called upon to set up shelters or emergency aid centers preemptively. Nurse managers and team leaders in health care facilities may help coordinate practice drills or meetings with staff for discussion of how to navigate the influx of patients expected during and after the event.  Impact  The  impact  phase occurs during the actual disaster event, which may last for minutes, days, or even weeks depending on the type of disaster. The priority for this phase is survival. The extent of predicted damage must be assessed in order to disseminate the appropriate resources. This assessment includes determining the appropriate number of health care workers and emergency first responders necessary to provide care to victims. The impact phase is also when search and rescue efforts are coordinated and executed. The PHN in this phase is a provider of physical and psychological care who helps to triage victims according to their injuries. Postimpact  The  postimpact  phase occurs once imminent danger has ceased. During this period, rescue and emergency medical care becomes the primary focus. Once victims are treated and transported to safety, the process of recovery can begin. This disaster phase can last months or years and, depending on the scope and intensity of the disaster, may even have lifelong effects. The postimpact phase includes debriefing and reevaluation of disaster and  emergency preparedness  and prevention strategies to improve outcomes should another disaster occur. Table 5.1 Disaster Phases and the Nursing Process Disaster Phase Prevention (Mitigation) Preparedness Response Recovery Definition · Planning for disasters or emergencies to reduce vulnerability/damage/injury should an event occur. · Develop capacity to respond swiftly, efficiently, and effectively to disasters and emergencies. · Provide support to populations affected by disasters and emergencies. · Restore support systems to functional levels. Assessment · Assess population groups for awareness of potential disasters. · Assess special needs of population groups in the event of a disaster.  · Conduct assessment of threats or hazards that pose the greatest risk to the population. · Use public health incident triages and teams to assess the impact of and health needs arising from the disaster. · Participate in the incident response assessment of postdisaster community needs for health care and health resources. Planning · Develop emergency awareness programs to increase awareness of potential emergency or disaster events. · Develop plans to address access to and needs of populations in the event of a disaster. · Plan for the needs of small or large populations to shelter in place, evacuate, and mass casualty surges. · Develop plans in collaboration with incident triages and teams to determine care and care logistics needed to serve the populations and reduce stress and burnout among responders. · Collaborate with community stakeholders and partnerships to plan long-term recovery priorities, resources, and care logistics. Implementation · Conduct community education programs to increase awareness with a variety of media approaches. · Conduct exercises and training drills to care for various size populations. · Include training scenarios involving persons with special needs and family separations. · Follow incident emergency response plans to deploy personnel to locations with affected populations such as emergency shelters. · Conduct ongoing assessment of needs. · Participate in restoration of health care services. Evaluation · Evaluate community education activities for effectiveness. · Evaluate exercises and training drills for gaps and remaining education and training needs. · Participate in incident emergency response evaluations, including gap analysis and planning for future events. · Participate in evaluation of the long-term consequences of the populations who experienced or responded to the disaster. Self-Protection In times of crisis, caregivers and health providers become first responders, providing aid to those in need; however, it is essential for providers to care for themselves first before rendering aid. FEMA reiterates the steps of initiating an emergency response in their  Community Emergency Response Team (CERT)  training, stating, a CERT member’s first job is to stay safe (PerformTech, Inc., 2011). One of the primary ways providers can ensure their own safety on the scene of a disaster is with the use of personal protective equipment (PPE). Nurses use PPE in practice on a regular basis, but there are some differences in PPE at the bedside in nursing versus during disaster relief efforts.  Figure 5.3 PPE Prior to assessing a scene, the first thing anyone responding to a disaster must do is to determine the level of safety risk. A firm awareness of one’s surroundings does not stop during rescue efforts. Disaster scenes often change quickly, and responders must remain vigilant.  During the Ebola epidemic, a series of transmissions among health care providers revealed gaps in infection prevention and control (IPC) procedures (Hageman et al., 2016). To address this gap, the CDC worked with facilities in the United States to provide new and improved IPC training in order to prevent further transmission of the Ebola epidemic (Hageman, et al., 2016).  Health care providers and volunteers responding to a disaster where the spread of infectious disease is a concern should be cautious, particularly when caring for victims, and use the appropriate protocol when handling patients and bodily fluids. Though nurses are familiar with universal precautions enforced in clinical settings, they must also follow protocols in the field to ensure their safety and the safety of colleagues, other volunteers, and effected persons.  Disaster Management Services There are multiple federal and local agencies involved in disaster management that contribute to safety and survival of citizens in the event of a disaster. Disaster response begins at a local level and then, if necessary, proceeds to a state and federal level. The PHN should be familiar with such systems and how they function. National Disaster Medical System (NDMS) The National Disaster Medical System is a division of the U.S. Department of Health and Human Services (HHS) and is composed of health professionals who are allocated to respond in the event of a disaster. These well-trained professionals are hired as intermittent federal employees and have an expected on-call deployment of a minimum of 2 weeks per year. They undergo a rigorous applicant screening process that ensures physical and psychological ability to fulfill expected duties. Once hired to be a part of this program, there are various teams that the health care professionals can be assigned to depending on background and expertise. These include Disaster Medical Assistance Teams (DMAT), Trauma and Critical Care Teams (TCCT), Victim Information Center Teams (VIC), Disaster Mortuary Operational Response Teams (DMORT), or and the National Veterinary Response Team (NVRT) (Public Health Emergency, 2018). Each of these respective teams are deployed to the sites of various natural and man-made disasters. Nurses typically serve on the DMAT or TCCT teams where their specialized skills can be best utilized. Nurses who are part of these teams have responsibilities similar to those within the area for which they are trained. For instance, a trauma critical care nurse would provide this type of nursing care to victims at the scene.  Federal Emergency Management Agency (FEMA) Established in 1979 by President Jimmy Carter, FEMA is a division of the Department of Homeland Security (DHS) and is the coordinating agency for allocation of assistance in the event of disasters in the United States. “FEMA’s mission is to support citizens and first responders to ensure that as a nation we work together to build, sustain and improve our capability to prepare for, protect against, respond to, recover from and mitigate all hazards” (FEMA, 2017). FEMA works with state and local governments to provide assistance, preparation, and training associated with disaster management. Since its inception, the department has been reformed several times to optimize its ability to provide necessary resources during disasters, with the most recent reformation occurring in 2006 following Hurricane Katrina. FEMA is responsible for formulating the National Response Framework (NRF), which is a guide that helps the nation understand how to respond to disasters and emergencies. FEMA outlines four primary phases regarding disaster management: mitigation, preparedness, response, and recovery (see Table 5.2) (FEMA, 2016).  It is important to note that in order for FEMA to provide aid during the recovery phase of disaster management, the disaster must be declared a major disaster by the acting President of the United States. This is a process that begins with the local governor of the affected area applying to FEMA to declare the affected region a major disaster area. Once this occurs, the allocation of resources, such as grant funding, is provided by FEMA.  · · Table 5.2 Elements of Disaster Management  Disaster/Emergency Management Phases Definition/Characteristics Role/Responsibilities of the Nurse and/or the PHN Mitigation · Any activity that prevents or reduces the impact of unavoidable emergencies · Acquiring insurance such as flood or fire protection · Takes place before and after events · Provide education to public regarding planning and reaction in the event of emergencies · Coordination of preparation drills, such as mass casualty drills Preparedness · Plans and preparation for life-saving efforts, including rescue and response · Evacuation plans, such as creating a disaster kit · Education of the public · Helping the public and families create disaster kits and plans of action in the event of an emergency · Helping coordinate and institute plans of action in facilities (e.g., hospitals, care homes, schools) Response · Safety is the priority · Activation of preparation plans made during mitigation and preparedness phases · Seeking shelter  · Helping citizens find appropriate shelter · Personal accountability for self and one’s own family Recovery · Medical assistance · Rescue and recovery of victims · Physical and psychological healing · Begin to rebuild · Mitigation continues · Provide medical attention to victims · Help provide emotional support · Begin planning for mitigation phase Note. Adapted from Infection Prevention Orientation Manual: Section 15: Emergency Preparedness, by K. Bryan & B. Wardle, 2014. Copyright 2014 by the Wyoming Department of Health.  National Response Framework (NRF) The NRF was developed by FEMA as a guide for preparedness in the event of a disaster or crisis situation. The framework recognizes the need for involvement beyond the federal government and incorporates the assistance of local, tribal, and state government agencies as well as assistance from the private sector and nonprofit organizations. Five key principles guide the framework (FEMA, 2016). 1. Engaged Partnership: All sectors of the community are involved and do not solely rely on governmental agencies. This involvement includes the private sector as well, including volunteer organizations such as the American Red Cross and Christian Disaster Response.  2. Tiered Response: Assistance begins at the local level where the event occurs and then branches outward as assistance is needed. 3. Scalable, Flexible, and Adaptable Operational Capabilities: The amount of allocated resources must expand to meet the needs the disaster has created.  4. Unity of Effort and Unified Command: The allocation of assigned roles during disaster management must be understood, meaning that each agency involved maintains its own respective authority, responsibility, and accountability.  5. Readiness to Act: Organizations’ members and volunteers must be adequately prepared prior to disaster events and understand the risk associated with responding to the needs of victims. It is important to follow regulated processes and procedures to operate effectively. Figure 5.4 National Response Framework Note. Adapted from National Response Framework (3rd ed.), by the Federal Emergency Management Agency, 2016. National Incident Management Systems (NIMS) National Incident Management Systems (NIMS) is a division of FEMA and DHS that helps provide prevention training and coordination between public and private entities in managing disaster incidents across the nation. They utilize the Incident Command System (ICS), which provides protocols and structure that helps coordinate various parts of disaster management, such as operations, planning, logistics, and finances (see Figure 5.5). The system has various leadership roles, such as the incident commander who helps oversee the various areas that need to be managed in an organized manner during disasters. While in use, the ICS works from an Emergency Operations Center (EOC) that can vary depending on the type of disaster. Figure 5.5 Incident Command System Note. Adapted from “Incident Management,” by Ready.gov. Emergency Operations Center (EOC) The Emergency Operations Center (EOC) serves as a command center where government agencies can manage the disaster response. According to FEMA, “EOC core functions include coordination; communications; resource allocation and tracking; and information collection, analysis, and dissemination,” (FEMA, n.d., para. 28). The EOC may be any type of building or structure, from a warehouse to a gymnasium, that provides ample space and is safe from the effects of the disaster. This is where coordination efforts occur, but it is also where emergency medical aid may be provided to the first survivors of the event.  Emergency Medical Services Traditionally, Emergency Medical Services (EMS) is thought of as the phone call to 9-1-1 in times of danger. From a young age, children are taught the importance of learning how to dial 9-1-1 in the event of a crisis in order to receive help from first responder medical personnel and law enforcement as quickly as possible. The Federal Interagency Committee on EMS (FICEMS) was established by Congress in order to streamline coordination between local EMS chapters and the federal government to improve the delivery of EMS to citizens across the country in times of crisis (Federal Interagency Committee on EMS, n.d.). In addition, the U.S. Department of Defense (DOD) provides specialized training to EMS workers in preparation for deployment to hostile or combat areas around the world. EMS also works with FICEMS to coordinate and institute casualty drills and provide preparedness education to the public. Courses such as pediatric and mass casualty triage training are available for free on their website. Nurses may be involved in the coordination and the execution of such training and drills throughout the community.  American Red Cross The American Red Cross (ARC) is an organization that provides aid during disasters and is composed of nearly 90\% specially trained volunteers. Founded by renowned nurse, Clara Barton, ARC’s mission is to provide assistance to those in dire need of emergency services related to any disaster occurrence. ARC works in conjunction with FEMA and other federal emergency response agencies and Community Emergency Response Teams (CERTs) to coordinate relief efforts for victims of disasters across the country. ARC assists with providing medical care, emergency supplies, and education and preparedness strategies as well as setting up and running emergency shelters among communities across the United States (American Red Cross, n.d.). Nurses can apply to volunteer for the ARC and will go through required volunteer training. After training, nurses will be utilized depending upon the need within the community and the volunteers’ availability.  Faith-Based Disaster Response Organizations There are a plethora of faith-based, nonprofit organizations that provide support during disaster relief throughout the United States. Each organization provides resources such as food, water, and basic necessities as well as volunteer relief workers who assist in many capacities and work in conjunction with government agencies to assist victims of disasters when they occur. In addition, many of these organizations provide training and assistance in the planning process to help improve efforts when the next disaster hits. These faith-based organizations provide support and assistance following their religious doctrines that speak largely of compassion, caring, and helping the less fortunate. Some commonly known faith-based disaster organizations include Catholic Charities USA, United Methodist Committee on Relief (UMCOR), and Lutheran Disaster Response. During recent events, such as Hurricane Irma in Florida, the United Methodist Committee on Relief provided a tremendous amount of support to relief efforts, including clean up following the hurricane and helping citizens with organization of aid and insurance to help them begin to rebuild their lives. Another organization, The Convoy of Hope, deployed several trailer trucks stocked with food and water prior to the impact of the hurricane to help prepare for the impending needs of the community (Rehwald, 2017). Community Emergency Response Teams (CERTs)  Community Emergency Response Teams (CERTs) are composed of community volunteers who work to prepare their communities against threats. Though they are not first responders to disaster events, they are well trained to assist first responders (Ready.gov, n.d.a). CERT volunteer teams are valued members of the community who provide aid to victims quickly and assist first responders in the management of disaster scenes. Nurses may volunteer for CERT teams, but they would be completing the duties as described in their CERT training for volunteers rather than providing nursing care to victims.  Some of the things CERT volunteers are trained to do include: · Prepare for the hazards that threaten their communities.  · Apply size-up and safety principles.  · Locate and turn off utilities.  · Extinguish small fires.  · Identify hazardous materials situations.  · Triage and treat victims.  · Set up a medical treatment area.  · Conduct search and rescue operations in lightly and moderately damaged structures.  · Understand the psychological impact of a disaster on themselves and others.  · Organize CERT members and spontaneous volunteers for an effective and safe response.  · Apply response skills in a disaster simulation.  Hospital Disaster Plans  · · · Hospitals play a critical role in responding to and preparing for disasters. Hospitals have policies and procedures in place in the event of a disaster that may vary slightly from facility to facility, but they cover the basics of disaster management and response. The Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), American Nurses Association (ANA), and FEMA provide advice on the components that should be incorporated into a hospital disaster plan. The Joint Commission requires every hospital to have a disaster plan in place. These plans should include management of internal and external disasters and are to be practiced several times a year. Nurse leaders will be involved in the planning, coordination, and incorporation of such drills to prepare employees. Internal disasters might include the rapid spread of an infectious disease process within the patient population inside the hospital. An external disaster would include any natural or man-made disaster that occurs within the nearby communities.  Nurses’ Duty to Respond · Nurses are licensed providers who have an obligation to respond in emergency situations. When disaster strikes, nurses are faced with numerous challenges, including the care of multiple stakeholders. According to the Provision 2 of the ANA Code of Ethics, the nurse retains a primary commitment to the patient at all times (American Nurses Association, 2015). However, this does not to negate Provision 5, which emphasizes self-care as equally important. Nurses have a moral obligation to uphold their fundamental duty to care, but this does not mean jeopardizing their own safety or the safety of others in times of crisis.  Social Justice  · · · The Agency for Healthcare Research and Quality (AHRQ) and the Institutes of Medicine (IOM) have developed a framework that includes six aims for the health care system. These aims indicate that patient care should be safe, effective, patient-centered, timely, efficient, and equitable. When discussing health equity, it is essential to underline the importance of providing disaster victims with equitable care despite social determinants of health (SDOH).  In areas that are impoverished or have a high number of immigrants or diverse cultures, special attention and care must be considered when providing support to victims following a disaster. This issue was highlighted in the aftermath of Hurricane Katrina in the Gulf Coast area. Many communities affected by the hurricane’s impact were impoverished, and it became evident very quickly that planning and response for these types of communities was not adequate. Victims did not receive the financial support, supplies, or medical attention they needed in a timely manner, extending their recovery time and leading to poor outcomes. The devastation that occurred in these areas gave rise to the development of more particular and critical response methods that addressed special issues such as poverty and culture (Lichtveld, 2018). This might include ensuring appropriate translation services are provided in order to communicate needs to communities that do not speak English.  Evacuation · In the event of an impending disaster, the best-case scenario would allow a few days to coordinate evacuationefforts. In events when early warnings are not possible, evacuation efforts may prove to be more chaotic. Properly planning ahead helps to ensure safe and prompt escape from the area of threat. Planning involves identifying the types of disasters that could occur in the surrounding area, identifying where to go when evacuation is necessary, preparing a safe places for pets, and being familiar with escape routes and alternate routes out of the area. Families should also determine a location where they should meet if they become separated for any reason. Keeping a bag containing household essentials, including nonperishable food, bottled water, flashlights, batteries, and a first-aid kit, is another necessary item to have in the home at all times. Before returning home, always check with local authorities to make sure it is safe to do so. Nurses should be careful when reporting for duty in response to a disaster; they should ensure their families’ safety first and that the route and available transportation to the hospital is safe before embarking on the journey.  Rescue and Recovery Once the imminent threat of the disaster’s effects are over, the rescue and recovery process begins. This process is commonly referred to as search and rescue (SAR). The rescue process begins at the local level, with first responders from the local fire and police departments as well as emergency management personnel being on the scene. The largest SAR system was established under FEMA and includes 28 urban rescue task forces that are deployed in the event of disasters around the nation. The local emergency manager may request assistance from the state and, if necessary, FEMA will deploy its three closest SAR task forces to intervene. The scene is assessed for safety before the search and rescue crew is sent in, and heavy equipment is used to clear away large pieces of debris that may be trapping survivors. Emergency health care workers are on scene to provide stabilizing medical treatment once survivors are extricated. During the process, hazardous material specialists are also on scene to evaluate for possible contamination that could pose a threat to the rescue team (FEMA, 2017).  Principles of Disaster Management  Disaster Preparedness · · The concepts of primary, secondary, and tertiary prevention have been described in detail throughout the baccalaureate-nursing program. These concepts can also be applied to disaster preparation as well. Prevention is a key component in the NRF for disaster management that warrants further discussion and elaboration. Though true prevention of disasters is not possible, prevention in disaster preparation is described in terms of management versus total aversion of disaster occurrence.  Preventable Versus Nonpreventable Disasters cause destruction in part because of their unpredictable nature, which warrants proper preparation versus true prevention. Prevention measures, such as mitigation efforts, are the best ways that the impact of disaster can be lessened. The major difference between mitigation and preparedness is that mitigation looks at long-term solutions that help to reduce risk instead of merely reacting to consequences of disaster events once they have occurred (FEMA, 2018). Though impossible to stop disasters altogether, it is possible to educate, plan, and collaborate efforts to prepare communities to withstand, survive, and recover from events that are not in anyone’s control.  Primary Primary prevention in disaster management involves planning prior to the occurrence or onset of a disaster event. The PHN assists in educating the community and families about having plans in place in the event of a disaster and being aware of the local resources families may need during a disaster. This is particularly important for families with small children and those in care of persons who are severely disabled or in need of continual medical care and treatment.  Ready.gov is a government website that provides a wide range of information regarding preparation for common emergencies and disaster events. The website is a resource the PHN can recommend to people for assistance in creating a plan that includes evacuation, safety skills, and financial concerns (Ready.gov, n.d.c). Another tool this website provides is a list of supplies recommended for preparing an emergency supply kit (see Figure 5.6). Preparedness is essential, yet is often overlooked as a necessity in American society. A recent national survey conducted by Columbia University determined that two-thirds of American households do not have adequate plans for disasters (Petkova et al., 2016).  Figure 5.6 Emergency Supply List Note. Adapted from “Emergency Supply List,” by the Federal Emergency Management Agency, 2014. · · Mitigation  Mitigation refers to the specific measures taken prior to the onset of a disaster event that help to decrease or eliminate the disaster’s associated risks. Though the levee system in Louisiana failed during Hurricane Katrina in 2005, their original construction and institution is an example of mitigation. The levees were meant to help diminish the floodwaters associated with massive storms such as Katrina, thereby decreasing the damage. According to FEMA the following are also examples of mitigation: · Complying with or exceeding National Flood Insurance Program floodplain management regulations · Enforcing stringent building codes, flood-proofing requirements, seismic design standards, and wind-bracing requirements for new construction or repairing existing buildings  · Adopting zoning ordinances that steer development away from areas subject to flooding, storm surge, or coastal erosion  · Retrofitting public buildings to withstand ground shaking or hurricane-strength winds · Acquiring damaged homes or businesses in flood-prone areas, relocating the structures, and returning the property to open space, wetlands, or recreational uses  · Building community shelters and tornado-safe rooms to help protect people in their homes, public buildings, and schools in hurricane- and tornado-prone areas (FEMA, 2018). Secondary Secondary prevention may occur when the onset of the disaster has occurred or within hours of its impact; this is when  response  occurs during a disaster. Response in disaster management indicates the period of time for emergency assistance with the goal of maintaining and saving lives, improving health, surviving the disaster event, and supporting victims (National Disaster Recovery Framework, 2016). The priority is safety and survival during the response phase and occurs when it is necessary to evacuate or, if more appropriate, find and take shelter. Families and individuals can prepare for this phase by having a designated safe area or location in which they plan to take refuge. PHNs educate families on possible evacuation and alternative routes as well as locating places of refuge when evacuation is not an option.  Tertiary Tertiary prevention occurs after the offending event has ceased and the focus is on  recovery . The tertiary and recovery phases may last weeks, months, or even years and involves property damage recuperation, physical rehabilitation of those injured, mental illness evaluation and treatment, planning for future disasters, and financial recuperation. While the focus is on recovering from the event, thought should be given to how well the first two prevention phases went and what can be done to improve them. PHNs can help to evaluate the process and devise and implement changes in the prevention plan that may help to avoid devastating results in the next disaster event.  Community Reaction · · · The effects of a disaster can be longstanding and life changing for individuals and communities. Effects can be on many levels, from the psychological to spiritual. All varying needs must be taken into consideration when caring for those affected following a disaster event.  Psychological Impact Following disasters, individuals within the affected community may have varying emotional reactions. It is normal to see a degree of panic within the community when the disaster is occurring. Panic is the sudden onset of excited feelings brought on by the fear of impending danger; this is what causes people to run franticly from buildings or the scene of a disaster in search of refuge.  Shock is defined as a period of disbelief that may render a person incapable of typical thought processes or role function; this usually sets in once the imminent danger of the disaster has ended. This is a very typical reaction following a disastrous event and, while usually temporary, may have a profound impact on a person’s sense of normalcy and control. If the initial shock of the event does not dissipate, the emotional strain may lead to long-term mental disorders such as depression or  post-traumatic stress disorder (PTSD) .  There are a wide range of psychological effects following a disaster. Some level of distress is considered typical; however longstanding depression, anxiety, and PTSD may affect individuals for years following the disaster event itself (Martin, 2015). The psychological effects can last years and have a devastating effect on the daily lifestyle, personal relationships, and return of typical daily functions in individuals struggling with such diagnoses. There are also correlations between exposure to a disaster and increased incidence of drug and alcohol abuse as a means of coping with the stress of the experience (Maclean, Popovici, & French, 2016). Nurses within the community must take this into account when caring for survivors of such events, remembering to consider that the event may have occurred many years ago and still have an impact on the patient. Nurses should refer patients to case management, chaplain services, and social work as well as coordinate counseling services or other appropriate resources for mental health when indicated. The Disaster Distress Hotline, a free telephone hotline offered by the Substance Abuse and Mental Health Services Administration (SAMHSA), is available for people seeking help following a disaster event (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). People can call or text 365 days a year, 24 hours a day to receive free emotional support related to being involved in a disaster; these services are provided in English, Spanish and accommodations are made for the hearing impaired (SAMHSA, 2012).  Under normal, controlled circumstances, the business of caring for the sick is emotionally draining; therefore, doing so in the midst of total chaos adds additional strain and may have an impact on health care professionals that warrants attention. Nurses should stay aware of their own emotional health during these times and reach out for support when needed. Nurses may fall victim to the psychological affects following a disaster and should be supported by their managers, peers, and other health care professionals to provide them with the care they may need.  Spiritual and Cultural Considerations As previously discussed, disasters take a significant toll on mental health, causing short and long-term distress. During these times, the need for spiritual care may become dire. Regardless of religious affiliation, chaplains play an important role in supporting the communities’ emotional needs during and after a devastating event (Graham, 2014). Nurses working with the victims can advocate for the spiritual needs of patients by locating the chaplain whenever possible and facilitating the incorporation of spiritual practices that do not interfere with patient safety or the course of treatment to provide comfort. Reaching beyond spiritual guidance, chaplains are trained to provide psychological support. Chaplains are valuable members of society, providing counsel and comfort to the shocked, grieving, and emotionally devastated victims in disasters.  Cultural needs must also be considered when preparing for disasters and caring for survivors. Different cultures may respond to a traumatic event differently, whether it be with prayer, crying, or stoic affect. The PHN should be aware of cultural differences and approach each patient with sensitivity and respect, allowing them to grieve, react, and respond the way that is appropriate for them, as long as they are not causing self-harm or harming others. In areas where populations are extremely vulnerable, such as areas of high poverty, their ability to cope and recover financially as well as psychosocially following a disaster may be severely impaired (Knox & Haupt, 2015). These individuals will require more support from local and federal agencies to move forward with the recovery process. PHNs are valuable advocates helping to allocate resources for those with limited capacity to do so on their own. In preparing a community for disaster, the community’s culture should be examined, and appropriate adjustments should be made to account for cultural differences. This may mean PHNs must adjust how they educate community members about disaster preparations or utilizing translation services if needed.  Physical Impacts Beyond the short-term injuries that may be sustained during a disaster event, some survivors may experience life-long effects on their health. These effects stem from a number of things, including severe injuries or exposure to carcinogenic, toxic, or radioactive substances during or after the event.  Fertility  One major longstanding physical impact seen in disaster survivors is a decrease in fertility. This is due to a variety of reasons associated with the disaster, including exposure to toxic agents, psychological trauma, and general exposure to the traumatic event (Zotti, Williams, Robertson, Horney & Hsia, 2013). Along with decreased rates of fertility, studies have shown an impact on pregnancy loss, birth defects, low-birth weights, and preterm births (Zotti et al., 2013). Studies point to the stress of the disaster event having profound negative effects on women in their child-bearing years. These negative effects may inhibit women from conceiving or carrying to term, which may cause an increase in emotional strain on the woman and her partner. While there are promising infertility treatments that can be offered to a struggling couple, their mental health and coping must be of concern as well. Nurses must consider offering services that will address the issue of fertility and childbearing as well as mental well-being.  Toxic Exposure Regardless of the type of disaster, there is always risk of exposure to toxic substances or carcinogens that have the potential to impact health throughout one’s lifetime. A prime example of this type of exposure that is still being researched and studied is the exposure to various toxic inhalants during the September 11, 2001 terrorist attack on the World Trade Center in New York City. During this terrorist attack, high concentrations of dense dust particles were inhaled and swallowed by survivors and first responders in the surrounding area, causing a host of respiratory and digestive issues that continue to cause these individuals health problems, such as gastroesophageal reflux (GERD) and lung cancer (Lippman, Cohen & Chen, 2015).  Nurses must understand that the health effects following a disaster can have lifelong impacts that cause a multitude of issues long after the disaster occurrence. The skill of history taking is essential in these instances. The patient may not mention being a survivor of a disaster, especially if it was many years ago, and they see no reason to bring it up. Discovering that a patient is a survivor of a disaster event and was exposed to toxic agents may indicate a need for different diagnostic procedures, which highlights the importance of detailed and thorough health history taking. In addition, the patient may be suffering from other effects of surviving a disaster as well, such as PTSD or other mental health issues, and may require appropriate referral and support from other members of the health care team, such as social work and case management.  Population Health Considerations Post Disaster There are a great number of considerations to be made during the recovery phase to help the affected community fully recover. Beyond the physical injuries and loss of lives, there is damage to buildings and property, loss of housing, lack of running water and electricity, overwhelmed emergency services and local hospitals, and inadequate financial resources to provide the necessary items for relief and recuperation. Each of these issues warrants time, resources, collaborative planning, and efforts in order to restore balance to a community that has suffered immeasurable losses. PHNs are instrumental to this process by evaluating patients in the community, assessing their needs, and providing necessary education for health promotion measures and/or preparation for the next disaster that may occur.  Economic Impact  The economic impact on communities after a disaster can vary depending on various elements of the disaster itself and the severity of its impact. According to FEMA, in the 1990s more than $25 billion was allocated to provide disaster assistance in the United States, and money sent to assist after disasters worldwide skyrocketed to over $608 billion (FEMA, 2009). While the costs and lives lost are seemingly unavoidable, proper preparation and improvement of preparation processes are essential to decreasing cost as well as saving lives. PHNs can contribute to this by being involved in the mitigation and preparation processes in disaster management, as well as the evaluation postdisaster to help improve preparation plans before the next disaster strikes. Table 5.3 provides information on the five costliest hurricanes on record to strike the United States (Office for Coastal Management, n.d.). Table 5.3 Economic Impact  Name Year Cost Katrina 2005 $161 billion Harvey 2017 $125 billion Maria 2017 $90 billion Sandy  2012 $71 billion Irma 2017 $50 billion Nurse’s Role in Disaster Management  · · · PHNs play an integral role in the community as trusted and esteemed caregivers. PHNs not only have a responsibility to their patients, but also to their community as a whole. Whether natural or man-made, disasters are inevitable, and nurses must be prepared to respond. Nurses have a long and proud history of caring for the sick and injured in tumultuous times, most notably in the days of Florence Nightingale during the Crimean War. These roots remain a driving force that inspires nurses to dutifully and skillfully care for patients. PHNs take this care a step further by helping to plan for the sustainability of their communities, especially during times of disaster. According to the Association for Public Health Nurses (APHN), the role of public health nurses in disaster management includes “population based practice like rapid needs assessments of communities impacted by the incident, population based triage, mass dispensing of preventive or curative therapies, community education, and providing care or managing shelters for displaced populations” (Association of Public Health Nurses, 2013, p. 4). The basic steps of the traditional nursing process—assessment, planning, implementation, and evaluation— is the same process utilized for nursing during disaster management with some modification necessary to address public health (see Table 5.4).  Table 5.4 Nursing Process in Disaster Management Nursing Process Step Description Assessment · PHNs are responsible for assessment of the local population for risks and needs during times of disaster · PHN may also conduct a hazard vulnerability assessment, which involves identifying threats and hazards in the area that pose the greatest amount of risk.  Planning · PHNs formulate plans of care that address functional needs of the population during a disaster.  · PHNs then work with key stakeholders within the community to address these needs, which might include sheltering, evacuation planning, and mass casualty capabilities. Implementation · PHNs participate in training for community health care providers, including forming and conducting casualty drills and education regarding protocol during a disaster Evaluation · PHNs evaluate training, drills, and education · PHNs evaluate operational plans and protocols to make improvements in the future Note. Adapted from The Role of the Public Health Nurse, by the Association of Public Health Nurses, 2014. Disaster Management in Years to Come · · · · With political shifts, climate changes, and increasing populations worldwide, both natural and man-made disasters have and will continue to change. The threat of impending disasters will continue to warrant appropriate action and planning. PHNs need to remain aware of these changes to prepare themselves and their communities adequately. Mass Shootings Over the past few decades, there has been an increase in mass shootings in the United States. Such events often result in multiple casualties, many more injuries, and often a lifetime of devastation for the victims and victims’ loved ones (Terrades, 2017). Because of this, it is essential that PHNs and all health care professionals take steps to prepare for such an event in their local communities. This involves education regarding response and survival during an active shooter event in every setting, from schools to churches to businesses. This also involves preparing acute care facilities, emergency management plans and processes, and drills to practice proper response efforts in advance. Educating parents and caregivers regarding gun safety and the importance of keeping guns unloaded and in a locked safe at all times should be reiterated and stressed at every opportunity. Mandatory survival training and education is often being implemented in many workplaces that help employees to understand how to respond in case of an active shooter event in their place of business (U.S. Department of Homeland Security [DHS] 2017). The DHS offers several training handouts and videos that are free for use in educating the public regarding surviving active shooter situations (see Figure 5.7).  Figure 5.7 Active Shooter Response Note. Adapted from “Active Shooter Pocket Card,” by the U.S. Department of Homeland Security. Terrorism After the events of September 11, the thought process regarding mitigation and preparedness for terrorist events shifted. In 2002, President George W. Bush enacted the Homeland Security Act with the goal of reducing the nation’s vulnerability to terrorism, protecting the United States from future attacks, and minimizing the damage in the event of terrorist and disaster attacks (FEMA, 2008). Mitigation strategies, such as enhanced security procedures, were elevated and continue to be the gold standard in the effort to prevent terrorist attacks. The DHS also started a campaign called “See Something, Say Something” that emphasizes public awareness and involvement in reporting suspicious activity of any kind in order to assist in prevention measures (DHS, n.d.). PHNs can be actively involved in educating members of the community about safety and reporting suspicious activity to help keep their community safe.  Bioterrorism  In recent years, the threat of impending terrorist attacks has warranted the attention of health care professionals in collaboration with federal agencies to help prevent and respond to an act of bioterrorism. The act of  bioterrorism , or chemical terrorism, is defined as the use of biological or chemical agents as a weapon to cause injury, death, and disruption (Centers for Disease Control and Prevention [CDC], 2017). In response to the impending threat of anthrax attacks, the CDC (1999) published the National Bioterrorism Preparedness and Response Initiative, which is a guide for prevention and response to bioterrorism attacks. The CDC’s five primary focus areas are preparedness, detection, diagnosis, response, and communication (CDC, 2016).  Health care facilities have their own protocols to follow when dealing with bioterrorism threats. The protocol is largely directed by recommendations from the CDC. Nurse leaders are an important part of the process of understanding the protocol and knowing how to properly educate their staff regarding procedures in the event of a bioterrorist attack. The protocol details procedures such as isolation precautions, handling of patient specimens, decontamination following exposure, patient placement, and postmortem care of infected patients. In addition, it provides an overview of a handful of bioterrorism agents, their expected clinical features, and recommendations for treatment and care for agents such as botulism, anthrax, and plague (CDC, 2018).  Within hospital settings, the Occupational Safety and Health Administration (OSHA) has published guidelines to assist hospitals with response to an attack of this nature. These guidelines discuss preplanning, care of the victims, and avoidance of cross contamination (Occupational Safety & Health Administration, 1997). Health care personnel must be familiarized and educated on bioterrorism agents and how to protect themselves and the victims of the event. Because nurses have a great deal of contact with patients, providing them with the education necessary to work in these conditions is crucial. PHNs can be advocates for such education in order to protect their own health, the health of their colleagues, and the health of their patients. Nurses working at the bedside or in leadership roles can help to establish and implement education plans that would inform nurses of proper protocol in a bioterrorism event.  Nuclear Threats and Response In light of political tension around the globe, it behooves any well-organized government to be well prepared for any disaster, including one as devastating as a nuclear detonation. FEMA and the CDC have plans in place to respond in the event that nuclear war were to become aa reality. PHNs serve as educators of the community, helping to institute plans for survival and safety in the event of a nuclear detonation. The website Ready.gov also provides numerous tips and advice regarding surviving a nuclear blast and necessary steps to survive after detonation.  Three of the primary factors reiterated in survival of a nuclear blast are distance, shielding, and time. Individuals should be instructed to put as much distance and protection between themselves and the fallout particles as possible, this means immediately heading indoors and staying there. The thicker the walls of the structure or the deeper underground the individuals can go, the safer they are from the nuclear fallout materials. Time is the final factor; following a nuclear detonation, the first few weeks pose the greatest amount of risk. People are advised to stay indoors for a minimum of two weeks, as the nuclear materials can cause the greatest degree of damage in this time period (Ready.gov, n.d.b). PHNs can be valuable in providing education regarding these important survival guidelines to the communities they serve. NRS-428VN: Clinical Practice Hours: Teaching Project The RN to BSN program at Grand Canyon University meets the requirements for clinical competencies as defined by the Commission on Collegiate Nursing Education (CCNE) and the American Association of Colleges of Nursing (AACN), using both direct and indirect clinical experiences for practicing nurses. This course requires students to complete a clinical experience involving the development and implementation of a teaching plan at a community /public health location in their local community. Specific criteria regarding the selection of an appropriate site is found in the Guidelines for Undergraduate Field Experience Manual located here: https://students.gcu.edu/academics/college-of-nursing-and-health-care-professions.php Complete the table below by indicating the date each required activity was completed and submit in the online classroom. Date Completed Hours Clinical Experiences and Activities 4 hours Perform Needs Assessment which Includes Assessment of Environmental Factors, Socio-Economic / Cultural / Political Disparities, Beliefs, Attitudes, Practices, and Health Literacy 6 hours Research Evidence for the Chosen Teaching Topic, Including Behavioral Change Theories and Techniques to Promote Health Management 6 hours Create Teaching Plan for Chosen Population Based on Needs Assessment and Applying Knowledge of Social Cultural Factors of the Population 2 hours Obtain Feedback and Approval from Community Site Representative 1 hours Review Feedback and Adjust the Teaching Plan Accordingly 4 hours Develop Presentation 2 hours Evaluate Teaching Effectiveness and Discuss with Community Site Representative Submit Required Form Signed by Community Site Representative in the Online Classroom Total 25 I ____________________have completed the clinical hours required to meet the learning objectives of the course. Student Signature: __________________________________________ Date: ___________________________________ Faculty Signature: __________________________________________ Date: ___________________________________