A nurse is volunteering on a disaster medical assistant team as a first responder

The increasing frequency of natural and environmental disasters, along with public health emergencies such as the COVID-19 pandemic, highlights the critical importance of having a national nursing workforce prepared with the knowledge, skills, and abilities to respond. COVID-19 has revealed deep chasms within a fragmented U.S. health care system that have resulted in significant excess mortality and morbidity, glaring health inequities, and an inability to contain a rapidly escalating pandemic. Most severely affected by these systemic flaws are individuals and communities of color that suffer disproportionately from the compound disadvantages of racism, poverty, workplace hazards, limited health care access, and preexisting health conditions that reflect the role of social determinants of health (SDOH) and inequities in access to health and health care that are a primary focus of this report. As natural disasters and public health emergencies continue to threaten population health in the decades ahead, articulation of the roles and responsibilities of nurses in disaster preparedness and public health emergency response will be critical to the nation’s capacity to plan for and respond to such events.

As described in the conceptual model framework developed by the committee to guide this study (see in Chapter 1), strengthening nurses’ capacity to aid in disaster preparedness and public health emergency response is one of the key ways to enhance nursing’s role in addressing SDOH and improving health and health care equity. This chapter explores the contribution of nurses during the COVID-19 pandemic and across sentinel historical events and describes the impact of natural disasters and public health emergencies on SDOH and health and health care equity. It also illuminates the multiple and systemic challenges encountered by nurses in these past events, and identifies bold and essential changes needed in nursing education, practice, and policy across health care and public health systems and organizations to strengthen and protect the nursing profession during and after such events. Only when equipped with the salient knowledge, skills, and abilities can nurses be fully effective in helping to protect the well-being of underserved populations, striving for health equity, and advocating for themselves and other health care workers.

NURSES’ PREPAREDNESS FOR DISASTER RESPONSE

Critical lessons learned during the response to prior infectious disease outbreaks, such as the 2003 severe acute respiratory syndrome (SARS) coronavirus outbreak, the 2009 H1N1 influenza pandemic, and the Ebola virus outbreak in West Africa, were not applied to workforce planning for future infectious disease outbreaks such as COVID-19 (Hick et al., 2020). These prior public health emergencies illuminated glaring gaps in emergency preparedness and workforce development and the harmful effects on nurses, and multiple calls to improve nurse readiness for pandemic response have been issued (Catrambone and Vlasich, 2017; Corless et al., 2018; Veenema et al., 2016a).

Basic knowledge about health system emergency preparedness is generally lacking among nurses, including school nurses, who, as discussed above, are expected to play key roles during public health emergencies (Baack and Alfred, 2013; Labrague et al., 2018; Rebmann et al., 2012; Usher et al., 2015). For example, in a survey of more than 5,000 nurses across the Spectrum Health system, 78 percent of respondents said they had little or no familiarity with emergency preparedness and disaster response (ASPR, 2019). Similarly, studies evaluating curricular content in U.S. schools of nursing (Charney et al., 2019; Veenema et al., 2019) and globally (Grochtdreis et al., 2016) disclose a notable absence of health care emergency preparedness content and little evidence that the few students who receive instruction in this context achieve competency in these skills. Furthermore, the willingness of individual nurses and other health care providers to respond to disasters is variable, and research suggests that many feel unequipped to respond (Connor, 2014; Veenema et al., 2008) or to keep themselves safe (Subbotina and Agrawal, 2018).

This educational gap is striking given that studies have shown that the more knowledgeable nurses are about infectious disease manifestation, transmission, and protection, the more confident and successful they will be when working during an outbreak (Liu and Liehr, 2009; Shih et al., 2009). Moreover, nurses who have previous experience working with an infectious disease outbreak are more confident and better prepared during a subsequent outbreak (Koh et al., 2012; Lam and Hung, 2013; Liu and Liehr, 2009), more knowledgeable about infection control and prevention measures, and more skilled in treating those with such infectious diseases. Nurses with a strong sense of their professional value—those who believe their role as a nurse is not just a job but a responsibility to serve and protect the public—are more likely to work during an infectious disease outbreak (Koh et al., 2012). Their outlook often causes them to struggle in balancing their duty as a nurse to provide care with their personal safety and health during an outbreak (Chung et al., 2005).

Gaps in education and training are evident in nursing leadership as well (Knebel et al., 2012; Langan et al., 2017; Veenema et al., 2016b, 2017). Nurse leadership, an important component of nurses’ roles (see Chapter 9), is essential in any organization experiencing a disaster (Samuel et al., 2018). Thus, greater effort to develop and evaluate training programs for nurse leaders is warranted. Such programs can cultivate communication, business, and leadership competencies, and these nurse leaders, in turn, can improve health care’s response, outcomes for patients, staff well-being, and the financial stability of hospitals (Shuman and Costa, 2020). Results of the April 2020 ANA survey indicated gaps in crisis leadership resulting in a lack of trust between nursing and hospital leadership and front-line nursing staff.

Areas in which action needs to be taken to advance national nurse readiness for responding to disasters, including pandemics, are detailed below. First, however, it is critical to identify and understand the gaps in the U.S. health care system both within and outside of the nursing workforce that have contributed to an ongoing lack of disaster readiness (Veenema et al., 2020). A range of factors that influence nursing workforce development and nurses’ safety and support during disasters extend across the governmental, system (e.g., large regional health systems), and organizational (e.g., individual hospitals, clinics, and other types of health care settings) levels. Aggressive actions taken now to transform nursing education, practice, and policy across health care and public health systems and organizations can improve the readiness, safety, and support of the national nursing workforce for COVID-19 as well as future disasters. The factors reviewed below that affect nurse preparedness include government strategies, research funding, education and accreditation, responsibilities of hospitals and health care organizations, and the role of professional nursing organizations. The interactions among nurses, health care institutions, and government have been identified as crucial to an effective pandemic response (Lam et al., 2018).

Government Strategies

The federal government has wide-ranging responsibilities for disaster preparedness and response across various agencies. The Office of the Assistant Secretary for Preparedness and Response (ASPR) within the U.S. Department of Health and Human Services (HHS) “leads the nation’s medical and public health preparedness for, response to, and recovery from disasters and public health emergencies” (HHS, 2019). ASPR’s many roles during these events include coordinating the HHS Emergency Support Functions, overseeing the National Disaster Medical System, supporting the Hospital Preparedness Program, and maintaining and distributing the Strategic National Stockpile.6 ASPR’s strategies for identifying risks and informing preparedness and response efforts also include the National Biodefense Strategy and the National Health Security Strategy. Federal response strategies and frameworks beyond those of ASPR include FEMA’s National Response Framework and CDC’s Public Health Emergency Preparedness and Response Capabilities.

Concern has been expressed that the above federal strategies may not accurately reflect and incorporate the capacity of the nursing workforce to respond to disasters. Veenema and colleagues (2016a) identify the need for a systematic review of national policies and planning documents addressing disasters to ensure that they elevate, prioritize, and address the practice of disaster nursing in federal, state, and local emergency management operations. For instance, the 2017–2022 Health Care Preparedness and Response Capabilities provides a framework for health care coalition capabilities, including health care and medical readiness, health care and medical response coordination, continuity of health care service delivery, and medical surge (ASPR, 2016). Noteworthy, however, is that many of the capabilities outlined in this framework depend on a trained nursing workforce.

Ensuring that nurses are educationally prepared and available will be instrumental to success in mass vaccination and other disaster-related efforts. In terms of local government decisions, for example, school nurses are responsible for safe reentry of children to K–12 education during disasters. Lessons learned from the reopening of schools in other jurisdictions and other countries, as well as CDC guidance, can inform the incorporation of such practices as pandemic public health interventions into schools. The roles and responsibilities expected of nurses within existing local, state, and federal preparedness and response strategies need to be clarified to equip nurses with the knowledge, skills, and abilities needed to execute those roles safely and to build and maintain them across the nursing workforce. Additionally, nursing expertise that draws on both clinical and public health nursing knowledge can actively inform policy makers from the local to the federal levels to ensure nurses’ robust preparation for and response to disasters.

Research Funding

Scientific evidence is foundational to the delivery of safe, high-quality nursing care to individuals and communities affected by a disaster, yet data suggest that this evidence base is underdeveloped (Veenema et al., 2020). Research gaps have been identified (Stangeland, 2010), and priorities related to disaster nursing have been articulated (Ranse et al., 2014). A 2016 consensus report articulates specific recommendations for advancing research on disaster nursing, including the articulation of a research agenda based on a needs assessment to document gaps in the literature, nursing knowledge and skills, and available resources; expansion of research methods to include interventional studies and use both quantitative and qualitative designs; and an effort to increase the number of PhD-prepared nurse scientists serving as principal investigators on disaster research projects (Veenema et al., 2016a).

However, funding for this work has been insufficient. Support for public health emergency preparedness and response (PHEPR) research in general has repeatedly stopped and restarted, resulting in an evidence base comprising one-off studies. There has been little funding for academic public health emergency programs since 2015, with the exception of CDC’s Center for Preparedness and Response’s Broad Agency Announcement for Public Health Emergency Preparedness and Response Applied Research, and no funding for academic disaster nursing. Overall funding for disaster research has declined since 2009 (NASEM, 2020). A report recently released by the National Academies (NASEM, 2020) concludes,

A report recently released by the National Academies concludes the public health emergency preparedness and response (PHEPR) response field is currently “relying on fragmented and largely uncoordinated efforts,” (NASEM, 2020, p. 7) often with no clear linkage to overall system goals. Collectively, these deficiencies have contributed to a field based on long-standing practice not evidence-based practices (NASEM, 2020). To address these deficiencies, the PHEPR field needs a coordinated intergovernmental, multidisciplinary effort with defined objectives to prioritize and align research efforts and investments in a research infrastructure to strengthen the capacity to conduct research before, during, and following public health emergencies (NASEM, 2020).

Education and Accreditation

In 2017, the Centers for Medicare & Medicaid Services (CMS) enacted the Emergency Preparedness Rule, which established requirements for planning, preparing, and training for emergencies (CMS, 2016, 2019). The rule was intended to advance health care preparedness, but it did not address the preparedness of the nursing workforce. The rule was designed to promote preparedness at the health care organization level, allowing the organization flexibility in testing and training for staff, including nurses. Accreditors are required to ensure that the criteria for the rule are met, but they do not evaluate the level of knowledge among staff or require additional training or workforce development. Gaps in nursing’s emergency preparedness within these organizations can occur even if they have met the CMS emergency preparedness criteria.

Maintaining adequate and safe staffing levels during a disaster needs to be a key consideration in the development of a workforce emergency strategy. The Joint Commission has a vested interest in nursing workforce issues, viewing nursing as part of its mission to support high-quality and safe care for the public. The Joint Commission has produced recommendations designed to increase the professionalism of nursing and diversify the nursing workforce, and it has implemented measures to improve the safety and quality of nursing care practices. While The Joint Commission does not specifically require reporting of nurse-to-patient ratios, it does have some related metrics around patient outcomes (The Joint Commission, 2020). The lack of metrics that specifically measure whether facilities have the plans, procedures, and human resources needed to surge the workforce during a disaster leaves them vulnerable to staffing shortages and increases the likelihood that they will need to turn to a crisis standards of care staffing model.

Fundamental and seismic change also is required in nursing education if the profession is to keep pace with the increasing numbers of natural disasters and public health emergencies. The major threats to global human health (climate change, air pollution, influenza, emerging infectious diseases, vaccine hesitancy) (WHO, 2019) receive minimal coverage in most nursing school curricula. COVID-19 represents a harbinger of public health emergencies to come, highlighting the vital role of disaster response education and training for nurses. Yet, repeatedly, empirical evidence shows that nurses are ill prepared to respond to these events (Charney et al., 2019; Labrague et al., 2018; Veenema, 2018). Overall, the preparedness of the nursing workforce is a factor in prelicensure education and lifelong learning inclusive of training (e.g., regular drills and exercises). Nursing preparedness requires that all organizations employing nurses, from schools of nursing to hospitals to other health-related organizations, engage in this agenda. To equip nurses to respond to future disaster events, schools of nursing need to produce nurses capable of providing culturally meaningful care, using data to drive health decisions, and addressing SDOH to optimize population health outcomes (Duke Margolis Center for Health Policy, 2020). And as noted earlier, PhD-prepared nurse scientists are essential to conduct disaster research and educate a cadre of future nurse researchers and educators to sustain and advance the field. Nursing curricula need to be updated to reflect the realities of these increasing threats to human health.

The American Association of Colleges of Nursing (AACN) establishes the standards for curriculum for academic nursing programs through a series of Essentials documents that are currently being revised and are targeted to be released in early 2021 (see Chapter 7 for more detailed information). Population health competencies that specifically address disaster response are included in the revised Essentials, and their addition has the potential to drive transformational change across academic programs. Greater emphasis on disaster and public health emergency response competencies and skills should have beneficial effects for nurses during disasters, including greater resilience, increased practical and theoretical knowledge, a broader view of the “clinical and organizational big picture,” and reduced psychological impact in case of sudden reassignment to a different clinical setting (Bambi et al., 2020). While all schools need to increase content in general disaster preparedness, it is also worth considering incorporating additional hazard-specific content to build capacity for nurses to respond to the kinds of emergencies that are most likely in the geographic area where they will live and practice. Schools of nursing can expand their use of educational technology, including telenursing and virtual simulations to increase interprofessional disaster training opportunities in partnership with community disaster response agencies.

The Commission on Collegiate Nursing Education (CCNE) Standards and Professional Nursing Guidelines Standards for Accreditation of Baccalaureate and Graduate Nursing Programs are applied at accreditation site visits to schools of nursing (AACN, 2011) to confirm that academic programs align with Essentials. CCNE evaluators’ confirmation of the adoption of the new Essentials standards on incorporating disaster response content into education and training programs could produce evidence of graduates’ related clinical competence (Veenema et al., 2020).

Disasters, including such events as the COVID-19 pandemic, interrupt academic progression and student mastery of clinical competencies and can delay graduations. Schools of nursing and state boards of nursing would be well served to establish options for supporting clinical rotations in the health care setting, such as expanding the role of virtual or simulated learning and alternative, nontraditional sites for clinical placements. Working with clinical and community partners, schools of nursing would benefit from establishing back-up plans to ensure that academic programs continue during public health emergencies. A particular emphasis on addressing health care equity in the face of disaster would be of prime importance.

Responsibilities of Hospitals and Health Care Organizations

The COVID-19 pandemic has revealed profound problems with the financing and delivery of American health care, presenting both challenges and opportunities for nursing, and has exposed systemic vulnerabilities that afflict the well-being and resilience of nurses and other health professionals. Hospitals and other organizations employing nurses, nurse leaders, physicians, and others have a responsibility to create a safe working environment for nurses, ensuring adequate staffing levels, access to appropriate levels of PPE, and physical and mental health support services for protracted disaster events. Hospital administrators and nursing and medical executives need to be held accountable for having policies in place to ensure a safe working environment for nurses during disaster response. Hospital disaster plans need to accommodate changes in clinical duties and nurse staffing to meet demand, and identify alternative nurse staffing resources to aid in the response. Long-term care facilities, home care agencies, and community health clinics need to include the same accommodations.

Nurse executives in various health and health care organizations across communities can work together to plan for circumstances that may require surging nurses across settings to meet emerging health care needs. Nurses well educated in addressing SDOH would be of particular value in contributing to the development and implementation of preparedness and response strategies that meet the needs of diverse high-risk, high-vulnerability populations. Stockpiling and procurement of adequate supplies (e.g., testing supplies, PPE, medical gases) are critical for keeping nurses safe at work. Health system leaders, mandated to have emergency management response plans in place, can ensure that all disaster and pandemic response plans address training content, including issues of health equity and communication with and protection of their workforce.

The Role of Professional Nursing Organizations

Professional nursing organizations have an important role in ensuring that their members and the profession at large have the expertise and support to respond to unanticipated events that threaten the health of the public. These organizations have advocated for the support and protection of nurses during past disasters and continue to do so today. The Tri-Council for Nursing (Tri-Council) is an alliance of five nursing organizations focused on leadership for education, practice, and research. Working with specialty nursing organizations, such as the Emergency Nurses Association and the Council of Public Health Nursing Organizations, the Tri-Council could advocate for a broad and forward-thinking national plan to advance disaster nursing and PHEPR. A special emphasis should be the care of individuals, families, and communities that are disproportionally affected by disasters. Nursing organizations uniting around the COVID-19 response can use this experience to establish a foundation for preparing the profession to meet future disaster-related challenges.

What is the role as a nurse in disaster preparedness and response?

Which organizations offer volunteer opportunities in disaster work for nurses select all that apply?

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What are the three main duties of disaster management response team?