Disaster veteran and nurse leader Frances Hughes shares the findings of her Fulbright research into post-disaster responses and building resilient RNs.
We know that disasters may occur with little or no warning, in unexpected locations and are not always a single event.
But there are several key issues that emerged from my Fulbright study that, if addressed appropriately, could significantly enhance how we develop and deliver a psychosocial response to disaster and build resiliency in our staff.
During my Fulbright Senior Scholarship, which I started in 2012 and finished this year, I visited and met with health professionals, agencies and organisations across the United States and then analysed the literature I gathered from those visits and online research.
Along the way I experienced two historic natural disasters – Hurricane Sandy in October 2012 and the blizzard known as Nemo in February 2013 – providing me with some first-hand experience of services and systems on the United States’ east coast.
There are considerable lessons to be learnt from the USA about the need to ensure that health professionals are skilled, qualified, and supported to respond during emergencies. The challenge is around developing and keeping such systems ‘active’ – knowing they may rarely be used – and balancing that with the need to respond to existing pressures.
Key lessons include that disasters can occur at unexpected times and locations and crises may also reoccur, precipitating further events (for example, hurricane winds, storm surges, and floods) resulting in people living in disaster conditions like facing a severe lack of rental housing; and damage from damp leading to mould and exacerbating respiratory illness. This means we should consider changing our paradigm of disaster response planning to encompass a longer-term situation.
Furthermore, while there is usually an outpouring of national and international support following a disaster, this support diminishes over time and may in some cases be replaced with a sense of compassion fatigue.
The emotional impact of struggling with insurers, losing critical landmarks and being unable to access services that have previously been taken for granted, all contribute to the longer term impact of the disaster and must be factored into planning for psychosocial response.
Lesson 1: Understanding disasters – preparing for the unlikely and the unknown
One of the defining features of disasters is that they are often difficult to predict. We may have some warning that a particular event is likely to occur in a defined area (e.g. hurricane) but other disasters may occur without warning (e.g. terrorist attacks, earthquakes). Even when we are able to predict and prepare for disaster, aspects of the event may remain unknown.
The response to disaster is also influenced by a wide range of factors, including resources, geography, communications and socio-political factors such as civil unrest or conflict. The emergency management principles of preparedness, response, recovery and mitigation might occur sequentially, in differing order or may repeat themselves. Despite the unanticipated elements of disasters, we are able to develop and deliver a considered response. If services regard disasters as unlikely, one-off events, impacting primarily on buildings and able to be responded to within a defined timeframe, the ability of services – and more importantly the people they serve – to be part of an effective psychosocial recovery process will be compromised.
By improving our understanding of the nature, impact, and responses to disaster, we are able to become part of a psychosocial response system that is timely, effective, and results in stronger communities.
Lesson 2: Recognise and celebrate the positive
In evaluating disaster responses, it is tempting to focus on negative outcomes in order to learn from experience. However, it is equally as important to learn from positive experiences, and to endeavour to replicate the conditions under which they occurred. Disasters can lead to positive responses, and it is important that we not only recognise and celebrate those responses, but learn from them.
For example, Coney Island Hospital had previously been evacuated with Hurricane Irene in August 2011 so they were better prepared than some other facilities to respond to Hurricane Sandy. At Bellevue Hospital, in New York city, beds could not be accessed so in order to continue providing a service, the hospital opened walk-in clinics, laboratories, a pharmacy and x-ray clinic. As the hospital makes money from inpatients, this was a significant altruistic move on their part.
Lesson 3: Engage nurses in response planning
Effective psychosocial response planning must not only involve health professionals, but must also engage them in the planning process. In short, there must be a sense of ownership.
Many of the nurses with whom I met during my visits to the USA expressed frustration at their lack of involvement in disaster planning. Not only do nurses have a good understanding of the needs of particular client/patient groups, but they often have local knowledge about barriers to accessing assistance during an emergency (e.g. lack of transport).
Planning is an active process and needs to be supported with role play, simulation exercises and information flow. Planners must also recognise the challenges in talking about disasters during periods of normalcy – e.g. it is difficult to plan for blizzards during hot weather.
All health services staff, including those in critical roles, should be asked to identify their own needs and possible solutions. Staff must have the time to participate in disaster planning, and issues such as industrial relations need to be addressed. A well-supported workforce is able to respond more rapidly and function in difficult circumstances, for longer periods.
Disaster preparation should also include discussion of professional boundaries and professional liability. It is almost inevitable that at least some will find themselves operating outside their usual scope of practice. So have these discussions with staff before they are put in situations which may find them exposed. Although liability and industrial/union issues vary between jurisdictions, health professionals need to be aware of the very different parameters that apply in emergencies. Professional nursing associations play a key role in providing guidance to nurses.
Lesson 4: Deploying staff in a disaster
Staff deployment is a crucial part of emergency response. Nurses and other health professionals may be deployed into an affected area, and staff from within the area may be redeployed to other locations or hospitals. Both scenarios present particular challenges.
Feedback from the New York Nurses Association indicates that the redeployment of nurses, following the closure of key New York hospitals, encountered a range of problems. Some hospitals welcomed the new nurses and took time to ensure they were oriented to how its services worked. Other hospitals were less prepared for the incoming nurses, and did not appear to have processes to ensure that deployed staff were able to start work without undue delay or disruption. Issues as small as ensuring newly deployed nurses were given codes to glucometers resulted in delays in them being able to start work.
Delays in re-opening some hospitals have resulted in some redeployed staff either taking up positions elsewhere or resigning.
In the second scenario, managing deployment within an affected area, it must also be recognised that many staff will have their own homes and families affected. The orientation role for incoming staff generally fell to permanent staff, all of whom were impacted themselves. Incoming staff sometimes needed support with their own reactions to their city and a working environment that had changed, as well as coping with stressed co-workers and patients, and working in an environment under severe restrictions. Resources are required to ensure incoming staff are briefed about systems, processes, the disaster impact (damaged buildings, resources) and how to access and give support without being intrusive. These resources are needed both internally and from the ‘donor’ service indicating the need for a co-ordinated system for deploying staff in response to a disaster.
Incorrectly managed deployment may result in services affected by disasters finding it difficult to attract staff once the immediate crisis phase has passed and is exacerbated if recruitment and retention was already difficult prior to a disaster.
Medical reservists is an exciting scheme I witnessed in Florida’s public health system. Reservists are people – many are nurses – and other clinicians who apply to become trained and credentialed to be deployed at times of disaster to places around the state. What this means is, at any given time, you can tell who is available if they need extra staff for surge and also ongoing support. It systematises support and deployment. But more importantly, services know they are getting people who meet professional and security requirements (credentialed) and know their systems and not just someone who wants to volunteer.
Lesson 5: Support your own staff
In an emergency, health professionals often find themselves operating outside their usual role. This may involve dealing with an influx of uncommon injuries (like crush injuries) or undertaking surgery in disaster conditions without appropriate equipment. Some health professionals are unskilled in working with people who have difficulty in communicating, or who have no accessible health records.
Health professionals are not immune from disasters impacting on their communities. Fears about family, possessions, and personal safety are the same but a nurse on duty cannot choose to walk across town to check whether his or her partner or children are safe, or to visit vulnerable clients living at home.
Actively involving health professionals in the disaster planning assists in psychosocial recovery and enables us to be more effective in working towards recovery as part of a community. Relatively simple initiatives can assist health professionals in focusing on the tasks they need to fulfil in the event of say a blizzard. One of the centres I visited had developed a staff support plan for emergencies that included: arranging continuity of care for elderly relatives or children of staff, staff being able to drop off pets at local vet services, access to emergency funds, four-wheel drive collection of critical staff and a special memorandum of understanding with hotels near hospital to allow staff to use empty rooms.
Poorly prepared staff, particularly those with little experience in working with vulnerable people, can contribute to the negative impacts of disasters, and delay recovery for individuals. Moreover, frontline nurses need to be supported to take up more advanced training at postgraduate level.
It should be noted that the response of the local government/state can contribute to a disaster and to delays in effective psychosocial response. Delays or poorly coordinated services contribute to increased damage to individuals and communities – from physical (access to medical care, lack of food and clean water, living in unsafe buildings) to psychological damage (including depression, prolonged trauma, and unsafe behaviours such as increased alcohol or drug use).
Lesson 6: Using science to model disaster impacts on mental health
One of the most exciting and stimulating engagements I had was with the Disaster Epidemiology Emergency Preparedness (DEEP) centre at the University of Miami. They have developed a disaster ecology model using science to develop a disaster planning process that reduces vulnerability and identifies hazards.
The discussion of timing, duration and frequency are also key in our improved understanding and response to disasters. An example is pandemic influenza with influenza pandemics occurring approximately three times each century. The cascading effects of disasters are also noted, with, for example, a hurricane that can start with strong winds and be followed by tidal or river surge, flood, fire, and displacement. I have been invited to participate with the team from DEEP and feel incredibly honoured to work with director Dr James Shultz in an ongoing manner.
Conclusion: building resiliency
To build resiliency (or ability to bounce back from adversity) and mental health in our nurses, the following are the key lessons from my scholarship:
- Involvement of clinicians in planning, developing scenarios and logistical management and communications
- Provide ongoing educational processes for clinicians including role plays and simulation exercises
- Planning for staff protection following a disaster
- Institutional support for employee wellness in all dimensions of human functioning
- Family support strategies for staff members
- Institutional support for stress management training and practice across the workforce
- Develop capacity to build teams and “buddy” systems with new members in response to surge demands
- Improve our ability to have credentialed reservist clinicians to be “called up” when services need extra staff
- Become involved to increase the research and science on impact of disasters on the psychological/ mental health of our communities.
*The author: Dr Frances Hughes, RN, DNurs ONZM. Former Minister of Health Chief Nurse , mental health clinican and currently Queensland Chief Nurse.
The mental health nurse’s interest in post-disaster response was first triggered by being in Manhattan for 9/11. She went on to be commissioned by WHO, with Australian colleague Margaret Grigg, to write international guidelines for nurses on coping with post-disaster mental health issues.