Disaster Competence Literature review part 2 Ethical Issues by Gaynor Sheahan


editor’s note: part two of a review of disaster nursing by Gaynor Sheahan, RN, MS This is from a paper written for Monash University. reprinted with permission.

Ethical Issues in Disaster Nursing

Ethical issues and cultural competence are also significant issues considered important for inclusion in core competencies. Scarce resources in a disaster mean that nurses must make difficult choices, with the greater good of the many taking priority over the benefit of the individual, a foreign concept often for many nurses without disaster experience (International Council of Nurses, 2009). The ICN also highlights the need for nurses to be aware of such ethical dilemmas, and the importance of cultural competence (respect, dignity and knowledge of cultural norms) an important feature of any disaster education.

Code of Ethics? 

Karen Schroeter (2008) questioned whether the American Association of Nurses Code of Ethics applies in the same way during a disaster. Examples include: if a nurse should decide to evacuate along with their family; should a nurse be held accountable for their actions during a disaster; whether nurses can provide adequate care when supplies are gone; the reuse of supplies which would under normal circumstances be discarded; the refusal to care for patients if so doing might impact their own families; lack of personal protection equipment; provision of partial care due to scarce resources despite negative outcomes.

Triage

Ethical dilemmas of disaster triage pose particular problems due to limited resources and the large numbers of patients presenting during a disaster. A particular ethical dilemma is whether treatment priority should be given to frontline workers or their families to enable disaster workers to work more effectively (Schroeter, 2008).  The decision to evacuate families of key response workers first during Cyclone Tracy in Darwin in 1974 resulted in less distraction for the workers by worry about the care of their families, and in improved outcomes for the community (Fitzgerald, Aitken, Davis, & Daily, 2010).

This conflict between personal and professional obligations in a disaster is an important issue. Mary Caffee has made a comprehensive assessment on how to reconcile these conflicting obligations when making the decision to report to work in a disaster, with steps to be taken by both the nurse and the institution as part of disaster preparation (Chaffee, 2006). Schroeter (2008) concludes that every nurse should know their own personal line for professional integrity, and have some understanding of their own duty of care during a disaster when conditions are likely to be unsafe, advising nurses to decide before a disaster the level of risk they are prepared to accept, in consultation with colleagues and family.

A distinction has also been made between the ability to respond and the actual willingness to respond in a disaster (Qureshi et al., 2005). The most common inhibitors to respond in this study were transportation, obligations towards care of children and older family members, and personal health concerns. Fear and concern for family and self were the most frequently given reasons for actual willingness or personal decision (as opposed to ability) to respond.  The HCW is thus determining their personal ethical approach to a disaster response and assessing risk, prioritizing whether personal welfare or that of their family is more important than that of the community (Qureshi et al., 2005).

These findings were echoed by Australian research in the first phase of a national survey conducted of 450 Australian nurses from four different hospitals, into willingness to respond in a disaster (Arbon et al., 2011). The major concerns related to the nurses’ own personal safety or that of their families, with domestic living arrangements and elderly or disabled dependants significant factors influencing willingness to respond. Lack of knowledge or clinical confidence has also been suggested as an important factor involved in failure to respond in a disaster (International Council of Nurses, 2009).

The type of disaster would also seem to affect whether a HCW would respond or not according to the study by Qureshsi et al  (2005). Eighty-three percent of HCWs would respond to a mass casualty incident, 81% to an environmental disaster, and 71% to a chemical event, but least able to respond where personal or family risk was perceived to be high: smallpox epidemic (69%), radiological event (64%), sudden acute respiratory distress syndrome outbreak (64%). Of Australian nurses, 30% were unwilling to respond to a chemical or biochemical event, and were most likely to attend to natural disasters, pandemics, and terrorist attacks (Arbon et al., 2011).

Interventions such as a family emergency plan to ensure family will be cared for (Arbon et al., 2011; Gebbie & Qureshi, 2006; International Council of Nurses, 2009), and priority evacuation of the families of HCW if necessary such as happened in Cyclone Tracy may increase the likelihood that a HCW will respond in a disaster, with benefits for the entire community (Fitzgerald et al., 2010). Other issues could be addressed with appropriate planning and preparation, such as transportation solutions, personal protection equipment, environmental controls, and ensuring personal medication supply if needed (Qureshi et al., 2005).

Nurses need to be involved in disaster planning and preparation to ensure ethical considerations are taken into account (Schroeter, 2008) and it could be argued that  ability to respond and willingness to respond are as important as ethics and core competencies when considering disaster education and preparedness. Strangeland (2010) noted that 40% of HCWs in the studies she examined would not respond in a disaster and suggested that more research was needed in order to more fully understand nurses’ intent to respond to disasters, and their reasons for not responding, as the capacity of hospitals to cope in a disaster is directly related to nurse staffing levels.

In conclusion, many questions remain concerning core competencies in disaster education for nurses. A lack of consensus in regard to the clinical skills, knowledge, abilities, ethical framework, and scope of practice, is reflected in the number and variety of core competences developed by a myriad of organisations and countries, unsupported by universal terminology. The optimal timing for disaster education, evaluation of the effectiveness of core competencies in relation to improved outcomes in a disaster, as well as the financial cost involved, especially for developing countries, is yet to be addressed fully. There is little literature to identify the necessary qualifications and experience of nurses attending disasters, their scope of practice, and the most effective nurse-patient ratios (International Council of Nurses, 2009). Little research exists addressing whether current training is effective and achieves competency aims, with few research tools having been established in the field of disaster health (Lynn Slepski, 2007). The ability and willingness of nurses to respond in a disaster are also issues that need further research (Strangeland, 2010). Empirical evidence supporting disaster nursing is lacking due to the difficulties involved in conducting research under disaster conditions (Veenema, 2007). This lack of empirical data could be overcome by further studies based on health professionals with previous or current experience of disaster health (Daily et al., 2010) to assist identification of the critical issues in disaster health, and from that, establishment of a common framework for competencies. (See Appendix 3)

REFERENCES 

Arbon, P., Cusack, L., Ranse, J., Shaban, R., Considine, J., Mitchell, B., . . . Bahnisch, L. (2011). Understanding the willingness of Australian emergency nurses to respond to a disaster. Adelaide, Australia: Flinders University.

Asian Disaster Reduction Centre. (2011). Natural Disasters Data Book 2011: An analytic overview Retrieved 11th September, 2012, from http://www.adrc.asia/publications/databook/DB2011_e.html

Chaffee, M. (2006). Disaster Care: Making the decision to report to work in a disaster. American Journal of Nursing, 106(9), 54 – 57.

Chapman, K., & Arbon, P. (2008). Are nurses ready? Disaster preparedness in the acute setting. Australasian Emergency Nursing Journal, 11, 135-144.

Daily, E., Padjen, P., & Birnbaum, M. (2010). A Review of Competencies Developed for Disaster Healthcare Providers: Limitations of Current Processes and Applicability. Prehospital and Disaster Medicine, 25(5), 387-395.

Fitzgerald, G., Aitken, P., Davis, E., & Daily, E. (2010). Disaster Recover. In R. Powers & E. Daily (Eds.), International Disaster Nursing. New York, United States of America: Cambridge University Press.

Gebbie, K., & Qureshi, K. (2002). Emergency and Disaster Preparedness. American Journal of Nursing, 102(1), 46-51.

Gebbie, K., & Qureshi, K. (2006). A Historical Challenge: Nurses and Emergencies. The Online Journal of Issues in Nursing, 11(3).

Hein, K. (2010). The Competency of Competencies. Prehospital and Disaster Medicine, 25(5), 396-397.

Hsu, E. B., W, J. M., Catlett, C. L., Robinson, K. L., Feuerstein, C., Cosgrove, S. E., . . . Bass, E. B. (2004). Effectiveness of hospital staff mass-casualty incident training methods: a systematic literature review. Prehospital & Disaster Medicine, 19(3), 191-199.

International Council of Nurses. (2009). International Council of Nurses Framework of Disaster Nursing Competencies (W. P. Region, Trans.): World Health Organisation.

Jennings-Sanders, A. (2004). Teaching disaster nursing by utilizing the Jennings Disaster Nursing Management Model. Nurse Education in Practice, 4, 69-76.

Jennings-Sanders, A., Frisch, N., & Wing, S. (2005). Nursing Students’ Perceptions About Disaster Nursing. Disaster Management & Response, 3(3), 80-85.

Kako, M., & Mitani, S. (2010). A literature review of disaster nursing competencies in Japanes nursing journals. Science Direct, 17, 161-173.

Kelen, G., & Sauer, L. (2008). Trend analysis of disaster health articles in peer-reviewed publications pre- and post 9/11. American Journal of Disaster Medicine 3(6), 369 – 376.

Kingma, M. (2010). Foreword II. In R. Powers & E. Daily (Eds.), Introduction to Disasters and Disaster Nursing. New York, United States of America: Cambridge University Press.

Landesman, L. (2001). Public Health management of disasters: the practice guide 2001. Washington DC, USA: American Public Health Association.

McMahon, M. M. (2010). Hospital Impact: Emergency Department. In R. Powers & E. Daily (Eds.), International Disaster Nursing. New York, United States of America: Cambridge University Press.

Nair, M., & Webster, P. (2010). Education for health professionals in the emerging market economies: a literature review. Medical Education, 44, 856-863.

Qureshi, K., Gershon, R. R. M., Sherman, M. F., Straub, T., Gebbie, E., McCollum, M., . . . Morse, S. S. (2005). Health Care Workers’ Ability and Willingness to Report to Duty During Catastrophic Disasters. Journal of Urban Health, 82(3), 378-388.

Ranse, J., Arbon, P., Ramon, S., Considine, J., Mitchell, B., & Lenson, S. (2010). Exploring the disaster content in Australian postgraduate emergency nursing programs Retrieved October 5th, 2012, from http://www.jamieranse.com/2010/10/exploring-disaster-content-in.html

Regmi, K. (2008). Adult learning opportunities in Nepal. Journal of Adult and Continuing Education, 14(1), 85-94.

Regmi, K., Regmi, S., & Shahi, M. (2009). Tibhuvan University certificate nursing curriculum. Journal of Institute of Medicine, 31(3).

Schroeter, K. (2008). Nurses, Ethics, and Times of Disaster. Perioperative Nursing Clinics, 3, 245-251.

Slepski, L. (2007). Emergency Preparedness and Professional Competency Among Health Care Providers During Hurricanes Katrina and Rita: Pilot Study Results. Disaster Management and Response, 5(4), 99-110.

Slepski, L., & Littleton-Kearney, M. (2010). Disaster Nursing Educational Competencies. In R. Powers & E. Daily (Eds.), International Disaster Nursing. New York, United States of America: Cambridge University Press.

Stanley, J. M., & Veenema, T. G. (2007). Directions for Nursing Education. In T. G. Veenema (Ed.), Disaster Nursing and Emergency Preparedness for Chemical, Biological, and Radiological Terrorism and Other Hazards (Second ed., pp. 545-554). New York, United States of America: Springer Publishing Company.

Strangeland, P. A. (2010). Disaster Nursing: A Retrospective Review. Critical Care Nursing Clinics of North America, 22(4), 421-436.

University of Hyogo. (2006). Core competencies Required for Disaster Nursing Retrieved September 14th, 2012, from http://www.coe-cnas.jp/english/group_education/core_competencies_list.html

Usher, K., & Mayner, L. (2011). Disaster nursing: A descriptive survey of Australian undergraduate nursing curricula Australasian Emergency Nursing Journal 14, 75-80.

Veenema, T. G. (Ed.). (2007). Disaster Nursing and Emergency Preparedness for Chemical, Biological, and Radiological Terrorism and Other Hazards (Second ed.). New York, United States of America: Springer Publishing Company.

Wynd, C. A. (2006). A Proposed Model for Military Disaster Nursing. Online Journal of Issues in Nursing, 11(3).

Yin, H., He, H., Arbon, P., & Jingei, Z. (2011). A survey of the practice of nurses’ skills in Wenchuan earthquake disaster sited: implications for disaster training. Journal of Advanced Nursing 

Appendix 1:  

Yin, H., He, H., Arbon, P., & Jingei, Z. (2011). A survey of the practice of nurses’ skills in Wenchuan earthquake disaster sited: implications for disaster training. Journal of Advanced Nursing.

 Essential skills for core competencies
1.      First aid

2.      Basic life support

3.      Advanced cardiac life support

4.      Infection control

5.      Field triage

 Additional Skills
1.      Mass casualty transportation

2.      Emergency management

3.      Haemostasis,

4.      Bandaging

5.      Fixation

6.      Manual handling

7.      Observation

8.      Monitoring

9.      Mass casualty triage

10.  Controlling specific infection

11.  Psychological crisis intervention

12.  Cardiopulmonary resuscitation

13.  Debridement

14.  Dressings

15.  Central venous catheter insertion

16.  Patient care recording

 

 Appendix 2:

 

McMahon, M. M. (2010, p89). Hospital Impact: Emergency Department. In R. Powers & E. Daily (Eds.), International Disaster Nursing. New York, United States of America: Cambridge University Press.

 Criteria for non-ED staff caring for patients in ED

during a disaster

1.      Rapid assessment

2.      Advanced Cardiac Life Support

3.      Airway management

4.      Intravenous access skills

5.      Resuscitation & stabilization

6.      Managing several critically injured/ill patients simultaneously

7.      Critical thinking

8.      Knowledge of disaster principles and Incident Command

9.      Ability to function independently

 

Appendix 3:

Daily, E., Padjen, P., & Birnbaum, M. (2010). A Review of Competencies Developed for Disaster Healthcare Providers: Limitations of Current Processes and Applicability. Prehospital and Disaster Medicine, 25(5), 387-395.

 

 Suggestions for future research
·         Collect information from all disaster responders post event to identify competencies for job roles and establish framework for competency modeling

·         Agreement on terminology

·         Precise, well articulated competency statements to enable consistency, proper assessment and standardized education

·         Regulatory bodies to set standards for practice certification and accreditation for educational programmes

·         Inclusion of input from international communities to promote more universally applicable and adaptable competencies

 

 

 

About Joe Niemczura, RN, MS

Experienced nursing educator and problem-solver. I have fifteen years of USA nursing faculty background. Add it with fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. I travel outside of Kathmandu Valley as well. When the recent violence happened, I knew the cities - I had trained people in those locations. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011. Global Health Nursing is not all sweetness and light; not solely milk & honey and happy moms and babies.
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3 Responses to Disaster Competence Literature review part 2 Ethical Issues by Gaynor Sheahan

  1. Yagya says:

    Thanks for sharing…

  2. sani adhikari says:

    Hello

    Namaskar how are you

    Sent from my Windows Phone ________________________________

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