Preparedness
& Response
Association of State and Territorial Directors of Nursing
Public Health Nurses’ Vital Role in Emergency Preparedness & Response
April 2002Introduction
Over the past 100 years, public health nurses have been actively involved in disaster planning and response. The terrorism events of September 11th, 2001 have created an opportunity to articulate public health nurses’ past, present and future role in preparing for and responding to disasters and terrorist events. The Association of State and Territorial Directors of Nursing has developed this document to present an overview of public health nurses’ contributions in times of disaster, the core skills which public health nurses bring to emergency preparedness and response, and areas for further development. Public health nurses are a vital part of the public health work force and as such will continue to need to be well prepared to respond to the public health issues in times of catastrophes.Public health nursing is defined as the practice of protecting and promoting the health of populations using knowledge from nursing, social, and public health sciences. (1) In the United States, public health nurses make up an estimated 15 to 20 percent of the public health workforce. Historically public health nurses have provided a broad array of health services to individuals, groups and special populations. These have included such activities as: assessment of the community’s health; leading groups to develop health action plans; developing health initiatives to address disease prevention and health promotion; advocating for policies to improve the health of special populations; and assuring access to health care for special populations. Utilizing skills in assessment, analysis, planning and evaluation, public health nurses provide population –focused nursing practice, in which problems are defined and solutions are proposed.
Past History of Responding to Emergencies and Disasters
Public health nurses have long been an integral part of the communities in which they work, being widely accepted and trusted health care providers in homes, schools and other community settings. Over the past decades, public health nurses have been called on to respond to numerous emergencies and disasters. The term emergency refers to any extraordinary event or situation that requires an intense, rapid response and that can be addressed with existing community resources. Disaster refers to an event or situation that is of greater magnitude than an emergency; disrupts essential services such as housing, transportation, communication, sanitation, water and health care; and that requires the response of people outside the community affected (2). The following are just a few examples of the wide variety of emergencies and disasters, in which public health nurses have been involved.In 1998 the Northeast was struck by a severe ice storm, which raged throughout NewYork, Vermont, Maine and the Quebec Providence of Canada. People were without electricity for as long as three weeks, roads were inaccessible, water sources were limited and heat was at a premium. Emergency shelters were in full operation through out rural areas. Public health nurses responding as part of the local and state emergency response teams assisted in locating home bound persons needing special assistance and connecting persons with needed resources such as safe drinking water, mental health services, and food supplies for infants. Working closely with state epidemiologists, they also coordinated with local health care providers to assess populations at increased risk for gastrointestinal infections and influenza.
In 1999 North Carolina was hit by Hurricane Floyd, which resulted in major flooding in most of the eastern one-third of the state. Thousands of homes were fully or partially under water and remained that way for several weeks. The usual hurricane shelter system, of remaining open for 48 hours until people could return to their homes, would not work. Likewise the public health nurses who staff those shelters could not continue to work 24 hours a day for several weeks. Each day, the Director of Public Health Nursing recruited and deployed several teams of 3 – 8 nurses from the unaffected parts of the state to provide relief for those nurses and to open additional shelters as people literally fled their homes with nothing but the clothes on their backs. These nurses had to develop systems to identify those at risk for health problems in the absence of medical records, prioritize needs for health care services, locate, administer and track needed medications and other supplies for managing existing illnesses, establish systems for tracking individuals and for crowd control and to assure a safe and healthy environment in the shelter.
In 1998 Minnesota experienced extensive damage from spring floods. Public health nurses became critical members of local emergency response teams. One key contribution was their familiarity with the local communities. They were able to identify and mobilize a variety of community resources, especially as it became apparent that people were going to be displaced from their homes. They knew the members of the community who were home bound and either needed shelter, food, and other supplies. They assisted in identifying pharmacists and physicians who could help those who were dependent on pharmaceuticals. They were critical in helping to establish safe mass shelters and feeding sites. They trained site staff and then assisted in monitoring for health risks associated with large group living situations. These public health nurses were able to collaborate with other health, public health, and community professionals. For example, some volunteered in shelters established as relocation sites for nursing home residents. Others assisted in the development and distribution of health education brochures about cleaning up homes after a flood. Some nurses worked with local housing inspectors to assess homes and recommend needed clean up before inhabiting the dwelling. Public health nurses also assisted with the administration of vaccines. Even though tetanus infection was a remote possibility for many affected by the flood, immunization provided both some peace of mind for the individual and an opportunity for the nurse to assess overall health status and make referrals as necessary. At a state level, public health nurses organized statewide conference calls to link local public health staff with state experts in epidemiology, environmental health, and risk communications. These calls served both surveillance and communication functions and assured optimum informed communication. As a result of their extensive contributions during these floods, public health nurses have become integral members of and participants in emergency response teams, in these communities.
In May 2000, the US Forest Service started a “controlled burn” yet winds up to 80 miles per hour caused fires with 400 homes destroyed in Los Alamos, New Mexico. Nearly 20,000 Los Alamos residents were initially evacuated to the city of White Rock; within a short period of time the town of White Rock was also evacuated. Many residents arrived at Red Cross evacuation sites without identification and often in need of medications. The New Mexico Department of Health core team, including public health nursing leaders, met daily to exchange information, plan, and problem solve. Public health nurses assisted in a broad range of activities from helping displaced residents, distributing supplies, and funneling volunteers from other parts of the state to disaster areas in need. The disaster presented many challenges including the need for rapidly changing plans, communication with multiple partners disbursed over a broad area, assessment of when it was safe for residents to return home, assessment of mental health needs and consideration of the public health risks created by unmanaged domestic animals.
Core skills, which Public Health Nurses bring to Emergency Preparedness and Response
The Centers for Disease Control and Prevention has recently described the emergency preparedness, core competencies for all public health workers (3). Public health nurses have already demonstrated competencies in several of these areas, including the following: a) readiness to apply professional nursing skills to a range of emergency situations; b) ongoing ability to maintain regular communication with partner professionals in other agencies involved in emergency response; and c) an eagerness to participate in continuing education to maintain up to date knowledge in areas relevant to emergency response. As public health nurses continue to prepare for emergency response in their communities, it will be essential that they persist in developing and enhancing their expertise in these competencies.Public health nurses bring a broad range of skills and knowledge to emergency planning and response. As noted in Public Health Nursing, A Partner for Healthy Populations, "The services provided by public health nurses have focused on preserving, protecting, and improving the health of populations through activities that improve the environment, encourage lifestyle and behavior changes, and assure access to care. (4) Applying knowledge of the sciences of nursing and public health and the social sciences, they address health protection and disease prevention with a system minded approach. This systems thinking, combined with a holistic point of view, provides a very valuable approach to problem identification and analysis, thus creating opportunities for quick solutions and inclusion of many community resources and partners.
Key to the work of public health nurses is their community assessment skills. The assessment process includes a review of the needs, strengths, and expectations of all the people and is guided by epidemiological methods. (5) Working throughout the community, public health nurses are constantly gathering information, which helps them remain attuned to the changing complexities of these communities, such as changing demographics, environmental factors, and economic factors. With a population focus and skills in data analysis, public health nurses have a unique awareness of the vulnerable populations in the community, who may be at particular risk in times of disaster. They are also aware of the diverse community resources and gaps in community services. These community assessment skills can be quickly applied in emergency planning, by utilizing knowledge of the community's resources and potentially vulnerable populations. The nurse is able to identify both physical and social factors within the community, which may decrease the effectiveness of the community's response to a disaster. (6) These community assessment skills are particularly valuable in assessing the emerging needs of the community in both planning and responding to events of disaster. As noted by Kristine Gebbie, "Because nurses are so familiar with normal patterns of health and illness in the communities and organizations they serve, they're well positioned to recognize deviations in them. (7)
As active members of the communities, they move through diverse and challenging areas of the community, which may include multiple environmental threats. They are welcomed into the homes of a broad cross section of the population, using expert skills in interviewing, evaluation and problem solving. "Public health nurses are known and trusted by community members as advocates for their health." (4) At times of disaster public health nurses' acceptance and trust by the community is extremely valuable.
Education of the public on health risks and disease prevention approaches is a cornerstone of the work which public health nurses have done for decades. These expert skills in public health education have addressed a broad range of areas from smoking cessation, optimum prenatal and infant care, injury prevention, assuring safe drinking water and prevention of HIV transmission. These expert skills in educating the public can be applied directly to emergency preparedness and response.
Planning and operating immunization clinics is another area of skills frequently provided by public health nurses. These clinics have historically been conducted both for regularly scheduled vaccinations and in outbreak situations (e.g. with measles). Beyond basic nursing skills such as physical assessment and immunization technique, public health nurses also have expert skills in clinic management, thus assuring optimum access and quality of services. These skills can be applied directly in the emergency preparedness work of public health, such as planning and operating mass clinics to administer anthrax prophylaxis or small pox vaccine.
In their ongoing efforts to improve the public's health, public health nurses have expert skills in collaborating with multidisciplinary teams. With the knowledge and respect for the strengths and uniqueness each partner brings to a health initiative, public health nurses strive to collaborate effectively for the optimum outcomes. With a background in program planning and group dynamics, nurses can help ensure that planning is a systematic process, which takes into consideration the needs of vulnerable populations. ( 6) Effective emergency preparedness and response greatly depends on collaboration with multiple partners. For public health nurses this is an opportunity to work with new partners such as local police, fire response personnel and HAZMAT teams.
Public Health Nurses Preparedness and Response to Recent Acts of Terrorism
In the past five years, public health nurses in numerous states have been part of their state and local emergency preparedness teams. Community emergency response teams have focused on identifying local resources, other community partners and community assessment information. Public health nurses have assisted in gathering community preparedness information for the Department of Justice and the Centers for Disease Control. Through the Health Alert Network grants in several states, public health nurses are now linked with statewide emergency response networks. These improved linkages have created computer and Internet access in more local health departments, the capability to send broadcast faxes and cells phone connections in remote areas. In addition, public health nurses in several states have had education on Incident Command Systems and Red Cross Emergency Response courses.In the Oklahoma City bombing, public health nurses responded immediately by assisting with the triage of the victims and rescue workers. They assured that volunteers were qualified to assist in areas of emergency care and assisted in assuring that needed volunteer services were directed to appropriate areas. In addition they assessed the health risk exposures of emergency responders to mental health stress, air quality and other disaster-related stresses.
Most recently public health nurses have been involved in New York City, Washington DC and Florida in conducting mass clinics to assess anthrax exposure. They have provided health risk assessments to identify persons at risk of exposure to anthrax, assisted in identifying the possible sources of the outbreaks and provided prophylactic treatment when indicated.
As noted previously, public health nurses have provided a critical link with the state epidemiologist in infectious disease investigation and surveillance. Now this epidemiological knowledge and skills are being applied to increase surveillance for potential agents of bioterrorism such as anthrax, small pox, or viral hemorrhagic fever. Public health nurses have long utilized their skills in comprehensive assessment and history taking to identify persons at risk, assist in identifying the source of an infectious disease outbreak, and provide prophylactic treatment e.g. meningitis outbreaks.
Conclusion
Public health nurses bring a broad range of knowledge and skills to emergency planning and response. Based on the practice of protecting and promoting the health of populations, public health nurses combine knowledge from nursing, social, and public health sciences, to provide a distinctive contribution to the emergency planning team.For the future, public health nurses have many responsibilities if they are to continue to contribute as vital members of the community’s emergency response team. It will be essential that they continue to develop and enhance their competencies in emergency preparedness. Additional education in many areas should include, for example, the following: a) knowledge of agents of mass destruction; b) thorough understanding of their role in an incident command system; c) enhanced skills in the epidemiological surveillance and investigation of infectious diseases; and d) expert knowledge of methods to rapidly procure, distribute and administer medications and vaccines in mass clinic settings. Expertise in communication of health risks to community members will be essential to assure optimum information and trust. There will be increased opportunities for public health nurses to work with new partners as they prepare for emergencies, including the local, state and federal law enforcement, the National Guard and HAZMAT teams. Opportunities to enhance connections with nurses in other settings will be important as mutual aide agreements are made, bringing nurses from a variety of settings to the scene of a disaster. As public health nurses are called on to respond to disasters and as the nursing shortage continues to loom, planning must include initiatives to retain and recruit nurses into public health to address existing and future gaps in the public health nursing infrastructure.
REFERENCES