Editor’s note: Gaynor Sheahan, RN is a nurse from Australia with long ties to Nepal, including work at Patan Hospital to set up their first triage system. She wrote this paper about disaster nursing as a graduate school assignment. It is reprinted here with permission, in two parts ( part two will be added in a day or two). I formatted the bolded headers as a means of making it easier on the eyes.
Assessment Task 3:
Review the literature and discuss the competing issues of competencies, expanded scope of practice, ethical practice and the ability to respond.
Attention towards identifying core competencies in disaster nursing intensified following what is now commonly called 9/11 in the USA in 2001 (Daily, Padjen, & Birnbaum, 2010; Gebbie & Qureshi, 2006; Veenema, 2007). The 2002 Bali bombing, in which many Australians were killed or injured, could be said to be the Australian equivalent of 9/11. The 24-hour news cycle and the speed with which news (and images) of disasters now travel around the world via the Internet, has increased awareness and, one could argue, fear of the likelihood of disaster striking closer to home than might have been perceived in the past. “A new level of urgency” has been described in teaching disaster nursing (Jennings-Sanders, 2004, p. 69) and heightened concerns about disaster events is evident amongst health care workers (HCWs) in recent years (Chapman & Arbon, 2008). An increase is also evident in the number of generalist as well as disaster specific peer reviewed journals publishing disaster health related material (Kelen & Sauer, 2008). The impact of disasters in humanitarian terms and on health care systems is immense and likely to worsen due to numerous factors including climate change, unplanned urban expansion, and technological events, with the risks worse for poorer populations. Yet according to Wynd (2006) there are few disaster nursing models with a global perspective, and the International Council of Nurses (ICN) states, “The global nature of disasters makes it imperative that nurses are equipped with similar competencies in order to work together in providing for the health needs of disaster populations” (2009, p. 15).
In this essay competence will be defined, and the difficulties of including within core competencies a myriad of skills and knowledge based competencies such as clinical task-based skills, personal abilities or attitudes such as creative thinking, and disaster specific knowledge. Research that there are too many core competencies, too much complexity, and confusion as a result of varying terminology will also be considered, and whether core competencies have been effectively evaluated in relation to disaster outcomes. The optimal timing and capacity for teaching core competencies is also an important factor when examining disaster education. The financial cost of disaster education to equip nurses with core competencies, especially in developing countries, will also be discussed. The ethical framework and scope of practice in relation to core competencies will be discussed, with the ability or willingness of nurses to respond in a disaster having an important impact on disaster outcomes, perhaps regardless of core competencies.
Components of Disaster Competence
Competence is described as an integration of knowledge, skill and judgment, with five main areas of competence: professional development; care management in disaster situations; care provision for vulnerable people and their families; systematic assessment and provision of disaster nursing care; fundamental attitudes towards disaster nursing (International Council of Nurses, 2009; University of Hyogo, 2006). Yet few nurses have disaster experience and most are inadequately prepared, especially in terms of workload, prioritizing patients, and using limited resources appropriately (International Council of Nurses, 2009; Jennings-Sanders, 2004).
Although the need for universal core competencies for disaster nursing is generally accepted, the research reflects the difficulties in identifying essential competencies and the necessary scope of these for generalist nurses. Disasters cover a range of situations: from earthquakes to tsunamis, from bombings to stampedes, from fires to biological or chemical accidents, from floods to random multiple shootings by one assailant. No two disasters can be considered the same (Landesman, 2001). One of the first research articles into core competencies suggested that trigger events for disasters can be difficult to anticipate and to prepare for, yet preparation through attainment of core competencies is vitally important (Gebbie & Qureshi, 2002).
Some have argued that in order to respond effectively, nurses need to have the same core competencies regardless of the type of disaster (Gebbie & Qureshi, 2002), and that it is unrealistic to expect nurses to be clinically skilled for all specific disaster conditions, recommending “just in time training” for less common specific injuries and illnesses (Gebbie & Qureshi, 2006, p. 6). A military model of nursing has been suggested, applicable to both military and civilian types of disasters, since military nurses already have many of the competencies required for a disaster situation such as setting up field hospitals and coping with large numbers of casualties (Wynd, 2006).
Specific Skills Needed
A commonly held perception is that critical care or emergency nurses, competent in clinical task based skills, are more appropriate HCWs in a disaster. The ICN (2009) acknowledges the need for generalist nurses to have basic skills such as airway, breathing, and circulation assessment skills, and management of pain, burns, hypovolaemia, fractures, crush injuries and other traumatic emergencies. Five essential clinical skills were identified in a small study following the Wenchuan earthquake in China with a larger skill list of 16 suggested as important to be included in disaster education (Yin, He, Arbon, & Jingei, 2011) (See Appendix 1). A pilot study of healthcare responders involved in Hurricane Katrina and Rita, found that not only were basic clinical care and triage the most commonly used skills but were also the skills responders felt least prepared to use (Lynn Slepski, 2007).
Nurses were the preferred first responders according to the Wenchuan earthquake study, with the following optimal qualifications: emergency rescue training or emergency department experience, and with at least three years clinical experience (Yin et al., 2011). The criteria for non-emergency trained staff caring for patients during a disaster has been summarised as a largely clinical skill based list (1 – 5) but with some personal competencies included (5 – 9) (McMahon, 2010, p. 89). (See Appendix 2)
The question of the optimal balance between including clinical task-based skills, as well as personal abilities or attitudes, and disaster specific knowledge in core competencies is raised in the research. A comprehensive set of core competencies for disaster nursing developed following the terrorist attacks in USA in 2001 covered not only specific practical skills, but also specific disaster relevant knowledge competencies (Gebbie & Qureshi, 2002). Some have argued however that too great an emphasis has been put on clinical role competencies at the expense of personal competencies (Daily et al., 2010). Gebbie & Qureshi (2006) suggested that it was necessary for a “balance between knowledge of how emergency response works as a system, in contrast with knowledge of signs, symptoms, and clinical management of the injuries and illnesses caused by the many specific agents of disasters” (Gebbie & Qureshi, 2006, p. 9). Tener Goodwin Veenema highlights the need to provide nurses with both “a solid foundation of knowledge (educational competencies) and a toolbox of skills (occupational competencies) to respond in a timely and appropriate manner” in a disaster situation (Veenema, 2007, p. v).
Characteristics of Nepali educational system that inhibit development of competence
Creative problem solving, flexible thinking, communication skills, and ability to evaluate effectiveness have also been recommended as core competencies (Gebbie & Qureshi, 2002, pp. 49-50; Stanley & Veenema, 2007). However, core competencies such as these may be difficult to foster in developing countries. Nepali nurses for example, have often experienced only a rote learning, didactic, teacher led educational system prior to entering nursing school (Regmi, 2008), and generally follow set routines and procedures with a task orientated focus. Critical thinking and problem-solving skills are not well developed (Regmi, Regmi, & Shahi, 2009). This is not uncommon in developing countries, where there is often an outdated nursing curriculum and teaching methods, a shortage of nurse educators, and the need for a standardized accreditation system (Nair & Webster, 2010).
It has been suggested that core competencies in disaster nursing may be too complex, too numerous, and that the lack of standardized terminology impedes comparison for best practice. A literature review of disaster nursing competencies in forty three Japanese nursing journals, concluded it was difficult to provide an overview due to the wide definitions of competencies, with disaster nursing itself covering a broad area, and competencies largely focused on the acute phase of a disaster, and less so on other phases such as recovery (Kako & Mitani, 2010). Elaine Daily (2009) is cited in the same article as stating that there exists a “complexity of competencies” due to the numerous agencies involved in a disaster event, with no commonly accepted standard of education (Kako & Mitani, 2010, p. 11). In addition, the review suggested too many competencies, with various organisations creating their own competencies.
Similarly, Daily, Padjen and Birnbaum (2010) evaluated commonalities and their universal applicability in their review of published disaster health competencies, and discovered hundreds had been developed by a variety of organisations, including governments. Comparison was made difficult by imprecise and inconsistent terminology, and use of various terms such as competency, domain and sub-competency. In 2010, Karen Kein commented that humanitarian professionals working in disaster health “do not know what they do not know. Much of the education and training remains outdated” with no agreement on domains or specific core competencies for response and preparedness (Hein, 2010, p. 396).
Education and training programmes are key to effective disaster preparedness, yet the multitude of programmes lack a common standard for best practice, despite core competencies comprised of knowledge and skills considered essential, and a lack of universal acceptance (Daily et al., 2010). A literature review of 16 research articles also concluded that implementation and standardization of education in disaster response, disaster plans and surge capacity was not done well in the acute setting, and that more focused research would only be possible once gaps were properly identified (Chapman & Arbon, 2008).
An important question is whether there is sufficient evidence that current core competencies are effective in relation to satisfactory disaster outcomes. A literature review conducted in 2004 examined training methods used in mass-casualty incidents and concluded there was a lack of strongly evidence-based competencies in disaster health response (Hsu et al., 2004). More recently, Daily et al (2010) state that there is little evidence relating disaster health competencies to outcomes, due to the infancy stage of disaster health as a discipline, with none of the competencies they reviewed having been validated, and no evidence one set of competencies is any better than another; a similar result was found by Slepski (2007). The best method of training, and the frequency of training for optimal preparation of nurses for disasters has not yet been identified, with tabletop exercises, disaster drills, computer simulation, conferences, satellite broadcasts and continuing education the most commonly used (Lynn Slepski & Littleton-Kearney, 2010).
Where to place disaster training in the curriculum
Optimal timing for teaching disaster core competencies is also yet to be determined: whether as an essential part of undergraduate nursing curricula or as postgraduate education. A descriptive study by Jennings-Sanders and Frisch in 2005 examined nursing students perceptions about disaster nursing and found that nursing students had significant gaps of knowledge of disaster nursing (Jennings-Sanders, Frisch, & Wing, 2005). The authors concluded that disaster nursing should be taught as a specialty in undergraduate nursing programs. Veenema (2007) argues that competencies could be integrated into a number of already established units of study in the nursing curriculum in the USA. Kako and Mitani (2010) suggested that the basic core competencies be added to the nursing education curriculum, with the development of advanced competencies in the future with a broader perspective to include disaster areas other than the acute phase. A retrospective review conducted in USA however found that despite nursing schools including disaster nursing in curricula nursing faculty was not prepared nor confident to teach it (Strangeland, 2010).
A similar picture has emerged in Australia. A descriptive survey of Australian undergraduate nursing curricula found that there was negligible disaster nursing content and practice, limited interest in future inclusion of disaster nursing, with little importance given to it as an undergraduate issue, despite nurses being the major professional group to be called upon to respond when a disaster occurs. The authors recommended that a major impetus from registration boards would be required in order for disaster nursing to be included into future undergraduate nursing curricula (Usher & Mayner, 2011). In a paper presented at the 8th International Conference for Emergency Nurses, Canberra, Australia, in 2010, Jamie Ranse discussed research conducted into the disaster content in postgraduate emergency nursing programmes in Australia in 2009. The researchers concluded a national framework was needed for greater consistency as there was great variation in postgraduate courses, with disaster content not included in all postgraduate programmes (Ranse et al., 2010).
International Council of Nurses (ICN)
The ICN (2009) considers inclusion of disaster nursing education in basic nursing programmes to be essential, as well as post-basic, and continuing in-service education. The optimal timing for disaster nursing education is a possible area for future research but the number of annual competencies already expected of the average nurse in Australia may be a significant inhibiting factor if included as continuing in-service education.
The financial cost of disaster education to equip nurses with core competencies must also be considered. In the USA especially, as a direct result of 9/11 and Hurricane Katrina, there has been a greater awareness of the lack of disaster preparedness and vulnerability to future disaster and terrorist events (Daily et al., 2010; Gebbie & Qureshi, 2006; Veenema, 2007). Much of the literature on competencies is published by US organisations, despite the majority of disasters occurring outside the US (Daily et al., 2010). By region Asia had the highest disaster occurrences in 2011 (over 44%) with 82% of people killed, 94% of people affected, and over 88% of the economic damage (Asian Disaster Reduction Centre, 2011). Disasters have catastrophic impact on development on poorer, developing nations with funds needing to be diverted from essential health programmes to deal with the impact (International Council of Nurses, 2009; Kingma, 2010). The cost of disaster education and disaster research is such that it is important that core competencies are effective in relation to good disaster outcomes, particularly in those countries with fewer resources, where a disaster may cancel out years of development (International Council of Nurses, 2009).
The scope of practice of nurses in a disaster is also an important issue when considering core competencies. Gebbie and Qureshi, (2002) considered the importance of personal attitudes such as a nurse’s response to their own limitations when asked to perform tasks outside of their normal scope of practice (for example, adult care nurses being asked to care for paediatric patients) and willingness to communicate this to others in more senior roles. Slepski (2007) found that many HCWs involved in Hurricanes Katrina and/or Rita were asked to work outside of their normal roles or with patients groups they were unfamiliar with, such as paediatric or geriatric patients.
As nurses frequently have to work outside of their normal scope of practice in a disaster some of the difficulties of using competencies as the basis for development have been identified (Daily et al., 2010, p. 392):
(1) Disasters occur infrequently and can result from numerous and varied events in disparate settings and conditions
(2) Multiple professions and disciplines are involved in healthcare management during a disaster
(3) Many unique roles and tasks are required during a disaster
(4) Different levels of performance of some competencies may be acceptable and/or necessary.
Following the Wenchuan earthquake, Yin et al (2011) concluded that the scope of practice for nurses in a disaster needed to be expanded. Fitzgerald, Aitken, Davis and Daily (2010, p. 110) have stated, “Conditions during disaster mandate that practice restrictions be altered. While it is not the time to learn to be a neurosurgeon, it is a time when flexibility about who does what and when is paramount”. In a pilot study of HCWs involved in Hurricanes Katrina and/or Rita a notable finding was not lack of disaster related knowledge or skills but the need to change from normal work practices to ones necessary to practice effectively in a disaster. This “transition process” was recommended as an area for future research (Lynn Slepski, 2007, p. 110).
soon – part two!