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Nurses as Leaders in Disaster Preparedness and Response—A Call to Action Tener Goodwin Veenema, PhD, MPH, MS, RN, FAAN1, Anne Griffin, MPH, BSN, RN, CNOR2, Alicia R. Gable, MPH3, Linda MacIntyre, PhD, RN4, RADM Nadine Simons, MS, RN5, Mary Pat Couig, PhD, MPH, RN, FAAN6, John J. Walsh Jr., MS7, Roberta Proffitt Lavin, PhD, APRN-BC8, Aram Dobalian, PhD, JD9, & Elaine Larson, PhD, RN, FAAN, CIC10

1 Nu Beta, Associate Professor, Johns Hopkins University School of Nursing, Department of Community and Public Health, Johns Hopkins School of Nursing, and Center for Refugee and Disaster Response, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 2 Clinical Investigator and Senior Program Manager, Veterans Emergency Management Evaluation Center, Office of Public Health, Veterans Health Administration, U.S. Department of Veterans Affairs, North Hills, CA, USA 3 Senior Project Director, Veterans Emergency Management Evaluation Center, Office of Public Health, Veterans Health Administration, U.S. Department of Veterans Affairs, North Hills, CA, USA 4 Alpha Eta and Beta Alpha, Chief Nurse, American Red Cross, Washington, DC, USA 5 Assistant Surgeon General and Regional Health Administrator, Region IX, Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services, San Francisco, CA, USA 6 Program Manager/Emergency Preparedness, U.S. Department of Veterans Affairs, Office of Nursing Services (ONS), Special Projects and Public Health Emergency Preparedness, Washington, DC, USA 7 Co-Director, Vanderbilt Program in Disaster Research and Training, Vanderbilt University School of Medicine, Nashville, TN, USA 8 Associate Dean for Academic Programs, University of Missouri-St. Louis College of Nursing, St. Louis, MO, USA 9 Director, Veterans Emergency Management Evaluation Center, Office of Public Health, Veterans Health Administration, U.S. Department of Veterans Affairs, Associate Adjunct Professor, Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, and School of Nursing, University of California, Los Angeles, North Hills, CA, USA 10 Alpha Zeta, Associate Dean for Research and Anna C. Maxwell Professor of Nursing Research, Columbia University School of Nursing and Professor of Epidemiology, Columbia University of Mailman School of Public Health, New York, NY, USA

Key words Competencies, curriculum, disaster, education,

nursing, policy, practice, preparedness, public

health emergency, research, scope of practice

Correspondence Dr. Tener Goodwin Veenema, Johns Hopkins

School of Nursing, 525 N. Wolfe Street Office,

Room 532, Baltimore, MD 21205. E-mail:

tveenem1@jhu.edu

Accepted: December 29, 2015

doi: 10.1111/jnu.12198

Abstract

Purpose: To develop a vision for the future of disaster nursing, identify barri- ers and facilitators to achieving the vision, and develop recommendations for nursing practice, education, policy, and research. Design and Methods: A series of semistructured conference calls were con- ducted with 14 national subject matter experts to generate relevant concepts regarding national nursing workforce preparedness. An invitational daylong workshop hosted by the Veterans Emergency Management Evaluation Center, U.S. Department of Veterans Affairs, was held in December 2014 to expand and refine these concepts. Workshop participants included 70 nurses, emer- gency managers, and a broad range of public health professionals. Conference call notes and audiotapes of the workshop were transcribed and thematic anal- ysis conducted to outline a vision for the future of nursing in disaster prepared- ness and response, and to articulate an agenda for nursing practice, education, policy, and research to achieve that vision. Findings: The group developed a vision for the future of disaster nursing, and identified current barriers and opportunities to advance professional disaster nursing. A broad array of recommendations for nursing practice, education, policy, and research, as well as implementation challenges, are summarized in this article. Conclusions: This project represents an important step toward enhancing nurses’ roles as leaders, educators, responders, policymakers, and researchers in disaster preparedness and response. Nurses and the health and human service organizations that employ them are encouraged to engage in an

A Call to Action Veenema et al.

expansive national dialogue regarding how to best incorporate the vision and recommendations into their individual lives and the organizations for which they work. Clinical Relevance: Nurses comprise the largest healthcare workforce, and opportunities exist to strengthen disaster readiness, enhance national surge capacity, and build community resiliency to disasters.

The past decade has shown a dramatic increase in the frequency and intensity of natural weather-related, technological, infectious disease, and human-caused dis- aster events (Hay & Mimura, 2010; U.S. Agency for International Development, 2015). With approximately 2.8 million registered nurses in the United States (Health Resources and Services Administration [HRSA], 2013), nurses represent the largest segment of the U.S. health- care workforce, and, accordingly, “the effectiveness of the healthcare system’s response to a public health emer- gency or disaster is largely dependent on the surge capacity of the nurse workforce” (National Advisory Council on Nurse Education and Practice [NACNEP], 2009, p. 2). Nurses must be prepared to respond to any disaster or public health emergency (NACNEP, 2009; Veenema, 2006, 2013). Employed across diverse settings, nurses collaborate on a daily basis with a broad range of public health or healthcare professionals and are well positioned to partner with health system leaders, indi- viduals, and families to significantly improve population health outcomes and build community resiliency to dis- asters across the nation. Nurses are consistently ranked by the public as trusted sources of health information (American Nurses Association [ANA], 2014) and there- fore have far-reaching influence.

Yet despite significant federal funding for hospital and public health preparedness since the attacks of Septem- ber 11, 2001, efforts to prepare and mobilize nurses for disaster preparedness and response have been episodic and difficult to sustain. Assessments of professional readi- ness indicate that the nation’s nurses are inadequately prepared to respond to the complex demands of disas- ters (Baack & Alfred, 2013; Gebbie & Qureshi, 2006; NACNEP, 2009). While some disaster preparedness pro- grams have been developed across various government agencies, schools, and professional organizations, formal systems are not in place to provide pre- and postlicen- sure nurses with consistent, comprehensive, and updated education and training in emergency preparedness and disaster response. Although the American Association of Colleges of Nursing (AACN) requires disaster education (risk communication, emergency preparedness, and dis- aster response including self-protection) as part of their

essentials of baccalaureate education (AACN, 2008), re- sources and guidance for implementing this content is inadequate. As a result, educational programs vary gre- atly and many are not evidence based (Gebbie, Hutton, & Plummer, 2012). Training programs are more often de- veloped in “knee-jerk” response to specific disasters, as for the use of personal protective equipment (PPE) for nurses and other healthcare providers in U.S. hospitals during the Ebola scare (U.S. Department of Health and Human Services, 2014).

In addition, a host of practice, policy, and research challenges limit nurses’ effectiveness in response and re- covery. For example, healthcare organizations have not systematically adopted crisis standards of care or commu- nicated those to staff. Major policy issues include inade- quate integration of nursing into national disaster policy frameworks, the need to strengthen and improve coor- dination of existing volunteer health systems (Institute of Medicine [IOM], 2014b), inconsistencies in state-based li- censure reciprocity for volunteer health professionals, lia- bility concerns, and compensation for volunteers harmed while responding to disasters or public health emergen- cies (IOM, 2012). In the research arena, additional work is needed to identify nursing practices that are most effec- tive in improving population outcomes across the disaster life cycle, and to increase the overall number of doctorally prepared nurse scientists and specifically those trained in disaster nursing.

Worldwide, it is commonly acknowledged that nurses play an integral role in disaster response (Fritsch & Zang, 2009; Fung, Loke, & Lai, 2008; Usher & Mayner, 2011; Yamamoto 2013; Yan, Turale, Stone, & Petrini, 2015). Globally, disaster nurse readiness is a pressing concern (Chapman & Arbon, 2008) and nurse lead- ers from many countries have identified disaster nurs- ing education and training as a vital need (Chan et al., 2010; Kako, Mitani, & Arbon, 2012; Usher & Mayner, 2011; Yamamoto, 2013; Yan et al., 2015). Many are facing the challenge of identifying appropriate disas- ter nursing competencies and implementing effective education and training programs to prepare their nurs- ing workforce (Bahrami, Aliakbari, & Aein, 2014; Chan et al., 2010; Yamamoto, 2013; Yan et al., 2015).

Veenema et al. A Call to Action

Currently, no country stands apart from the rest as having satisfied the need that exists. However, activi- ties that followed the devastating 1995 Great Hanshin- Awaji Earthquake in Japan serve as a good example of how nursing professionals can collectively organize themselves to respond to need and generate enough mo- mentum to engage key stakeholders in order to estab- lish processes for response and ultimately influence their national response framework. Those efforts were evident when mechanisms were in place to immediately dispatch nurses to care for victims of the Niigata Cheutsu Earth- quake in 2004 (Yamamoto, 2013), and their momentum continues today.

The Veterans Emergency Management Evaluation Center (VEMEC), Office of Public Health, Veterans Health Administration (VHA), U.S. Department of Veterans Af- fairs (VA), with the support of the VA Office of Nursing Services and VHA Office of Emergency Management, initiated this call to action to identify challenges and determine the first action steps in systematically identi- fying relevant themes to improve the practice of disaster nursing. The aims of the project were to develop a vision for the future of disaster nursing, identify barriers and facilitators to achieving the vision, and develop recommendations for nursing practice, education, policy, and research. The project is targeted to a broad audience that includes nurses, employers, voluntary organizations, educators, policy makers, and researchers. As the largest employer of nurses in the United States (U.S. Department of Veterans Affairs, 2015) and with a mandate to support states and localities in times of a federally declared disaster (Public Law 97–174), the VA is well positioned to initiate this effort.

Methods

A list of subject matter experts in disaster nursing was generated based on a review of the literature. Ad- ditional experts were identified using a snowball tech- nique. Eighteen experts were invited to serve as steering committee members charged with informing the aims of the project, based on their subject matter expertise with respect to leadership, contributions, and publications in disaster nursing education, practice, policy, and research. A series of semistructured conference calls were held from September 2014 through December 2014 with the 14 experts who agreed to participate. Discussions in- cluded the following:

� What would an ideal vision for the future of disaster nursing look like?

� What factors related to practice, education, policy, and research currently impact disaster nursing?

� What opportunities exist to advance national nurse readiness?

� What actionable recommendations would support advancing national nurse readiness?

Through facilitated discussions, the members identified factors relevant to the practice of disaster nursing, ex- plored their individual and collective vision for the future of disaster nursing, and identified potential next steps in implementing that vision. They served as their own planning committee for a national workshop on disaster nursing in order to further refine their ideas by receiv- ing feedback from nurses working in a wide variety of settings.

The invitational workshop, “Call to Action: Nurses as Leaders in Disaster Preparedness and Response,” was convened on December 9, 2014, in Los Angeles by VEMEC. Audience invitations were sent to representa- tives at 117 relevant federal, state, and local agencies, foundations, hospitals, schools of nursing, and nonprofit organizations in California and across the nation. A to- tal of 70 individuals attended, with representation pre- dominantly from nursing; other participants were emer- gency management and a broad range of public health professionals.

The workshop was organized into four sessions (Table 1). The first session included a series of presen- tations to orient the audience and provide the necessary background and history of disaster nursing. The second session focused on developing a vision for the future of disaster nursing using the “focus prompt” developed by the planning committee in order to provide a launch- ing point for participants to respond (Jackson & Trochim, 2002). There was also an interactive visioning exercise in which all participants in small groups wrote and shared their vision and then discussed with the audience. The third session included four panel discussions focused on disaster nursing practice, education, policy, and research. Each panel had three to four experts speak, followed by audience discussion. The fourth session served as a re- cap of the discussions that took place during the day and an overview of the identified barriers and facilitators and the broad range of potential recommendations in the four areas needed to achieve the overall vision for the fu- ture of disaster nursing. All sessions were facilitated by a qualified moderator, who was selected for her experience moderating large group discussions and broad expertise in nursing research, education, policy, and practice.

Sessions were audio-recorded and transcribed. Tran- scripts and written feedback from the participants (vision statements, written questions for panelists) were themat- ically coded by two of the authors who came to collective agreement, and then the themes were analyzed by the

A Call to Action Veenema et al.

Table 1. Speakers or Panelists and Topics

Speaker or panelist Presentation or panel title

Donna Gage, PhD, RN, NE-BC Welcome and opening remarks

Chief Nursing Officer, Office of Nursing Services, Veterans Health Administration, U.S.

Department of Veterans Affairs

Tener Goodwin Veenema, PhD, MPH, MS, RN, FAAN

Associate Professor, Department of Community and Public Health, Johns Hopkins School of

Nursing

Keynote address and Painting the future landscape

Center for Refugee and Disaster Response Johns Hopkins Bloomberg School of Public Health

Anne Griffin, MPH, BSN, RN, CNOR Historical timeline of disaster nursing

Clinical Investigator and Senior Program Manager

Veterans Emergency Management Evaluation Center, Office of Public Health

U.S. Department of Veterans Affairs

Cheryl Peterson, MSN, RN Practice panel

Senior Director, Nursing Programs, American Nurses Association

Linda MacIntyre, PhD, RN

Chief Nurse, American Red Cross

Carole Snyder, MS, RN

California State Council President, Emergency Nurses Association

CDR Derrick Gooch

U.S. Public Health Service

Tener Goodwin Veenema, PhD, MPH, MS, RN, FAAN Education panel

Associate Professor, Department of Community and Public Health, Johns Hopkins School of

Nursing

Center for Refugee and Disaster Response Johns Hopkins Bloomberg School of Public Health

Joan Stanley, PhD, CRNP, FAAN, FAANP

Senior Director of Education Policy, American Association of Colleges of Nursing

Beverly Malone, PhD, RN, FAAN

CEO, National League for Nursing

RADM Nadine Simons, MS, RN (Ret.) Policy panel

Assistant Surgeon General and Regional Health Administrator, Region IX

Office of the Assistant Secretary for Health, U.S. Department of Health and Human Services

John J. Walsh, Jr., MS

Co-Director, Vanderbilt Program in Disaster Research and Training

Vanderbilt University School of Medicine

Roberta Proffitt Lavin, PhD, APRN-BC

Associate Dean for Academic Programs

University of Missouri-St. Louis College of Nursing

Mary Pat Couig, PhD, MPH, RN, FAAN Research panel

Program Manager/Emergency Preparedness, Office of Nursing Services, Veterans Health

Administration, U.S. Department of Veterans Affairs

John J. Walsh, Jr., MS

Co-Director, Vanderbilt Program in Disaster Research and Training

Vanderbilt University School of Medicine

Roberta Proffitt Lavin, PhD, APRN-BC

Associate Dean for Academic Programs

University of Missouri-St. Louis College of Nursing

Elaine Larson, PhD, RN, FAAN, CIC Moderator for panels

Associate Dean for Research and Anna C. Maxwell Professor of Nursing Research, Columbia

University School of Nursing and Professor of Epidemiology, Columbia University of

Mailman School of Public Health

Veenema et al. A Call to Action

larger author group to identify gaps and additional ideas for consideration.

Results

Vision

To create a national nursing workforce with the knowl- edge, skills, and abilities to respond to disasters and public health emergencies in a timely and effective manner.

Ideally, nurses would:

� Possess the minimum knowledge base, skills, and abil- ities regarding disaster response and public health emergency preparedness;

� respond directly or provide indirect support (e.g., shift coverage for those deploying or critical data collection) during a disaster event or public health emergency;

� promote preparedness amongst individuals in their care, families, and communities and within the orga- nizations they represent; and

� demonstrate a commitment to professional prepared- ness by participating in disaster planning, drills, and exercises within and beyond their specialty environment.

This vision is predicated upon the belief that nurses who possess at least a minimum knowledge base and skill set are better able to keep themselves and their patients and families safe or at least to minimize the harm that may occur. It provides recognition of the broad range of leadership and other skills that nurses bring to disasters. Such a workforce would include all licensed nurses who provide care to individuals, families, and communities, and their efforts would be grounded in a culture of preparedness that would enhance national disaster preparedness and response as well as community resiliency.

Barriers and Facilitators to Achieving the Vision

Panelists and participants highlighted a number of in- dividual, organizational, and environmental barriers and facilitators to achieving this vision (Table 2). The iden- tification of these factors helped inform the vision state- ment and recommended strategies for advancing disaster nursing. While many factors were identified during this process, the recommendations in this article target a se- lect group as being important for the initial steps toward achieving the stated vision.

Table 2. Barriers and Facilitators to Achieving the Vision

Level Factors

Individual factors

for nurses 1. Level of personal disaster preparedness

2. Levels of knowledge, skills, and abilities

regarding disasters and public health

emergencies

3. Willingness to respond

4. Capacity to educate individuals, families, and/or

communities on disaster preparedness and

response

Organizational

factors 1. Level of institutional commitment to

preparedness (e.g., planning, training, PPE,

adoption of crisis standards of care, logistics,

and effective communications)

2. Presence and influence of nurses in leadership

positions in disaster and public health

emergency management

3. Empowerment of nurses to lead and report

issues/problems

4. Adoption of an interprofessional team approach

to disasters

Environmental or

systemic

factors

1. Authority and degree of coordination,

communication, and collaboration among

federal-state-local partners

2. Ability to produce and distribute adequate PPE,

pharmaceutical supplies, and logistical support

3. Impact of regulations or guidelines requiring

disaster preparedness (e.g., Centers for

Medicare & Medicaid Services, accrediting

bodies)

4. Influence of reimbursement and financial

incentives for preparedness and response

5. Need for a national nursing workforce plan for

preparedness and disaster response

6. Capacity and constraints of educational

systems, employers, and volunteer agencies to

prepare nurses for disasters

7. Lack of metrics for evaluation

8. State-based licensure constraints on the ability

of nurses to respond to disasters across state

lines or outside their practice area (RNs, APRNs)

9. Degree of coordination of multiple volunteer

emergency response teams (e.g., ESAR-VHP,

MRC, NDMS, American Red Cross)

10. Comprehensiveness of liability protection for

nurses and other responders to disasters

11. Prioritization and funding of disaster nursing

research

12. Suitability of current research approaches and

infrastructure to assess need and inform nursing

practice during the disaster cycle

13. Degree of community engagement in disaster

planning, ethical considerations, and response

Note. APRN = advanced practice registered nurse; ESAR-VHP = Emergency System for Advance Registration of Volunteer Health Pro-

fessionals; MRC = Medical Research Council; NDMS = National Disaster Medical System; PPE = personal protective equipment; RN = registered nurse.

A Call to Action Veenema et al.

Recommendations

1. Practice

Recommendation 1.1. Health care and related or- ganizations support clinical nursing practice during disas- ters to reflect crisis standards of care and address common barriers to willingness of nurses to respond to a disaster.

Disasters and public health emergencies may require nurses to shift slowly or abruptly from care as usual where the focus is on individual outcomes to a crisis stan- dard of care where the focus is on population outcomes. This shift represents a stark contrast in the way nursing is practiced daily. Training for unique disaster nursing skills such as reverse triage and allocation of scarce resources as well as guidance on triggers for when transitions happen is required in order to provide the best possible care for as long as possible.

Organizations should adopt their own crisis standards of care using a framework such as described in the 2012 IOM Report, Crisis Standards of Care: A Systems Frame- work for Catastrophic Disaster Response. Dissemination ef- forts should provide clarity to nurses on specific triggers and the impact on disaster nursing scope of practice. As part of the process for adopting crisis standards of care, nursing representation should be evident on all emer- gency preparedness and disaster-related planning com- mittees and nurses should be provided with regular, ongoing interprofessional disaster education, training, and drills.

Organizations should also recognize factors within their control that influence willingness to respond. In theory, the implementation of crisis standards of care that provide a framework for disaster response may ultimately impact willingness to respond. A systematic literature re- view identified work environment and climate as one of the major factors either facilitating or hindering the will- ingness of healthcare personnel to respond to an event (Connor, 2014). Organizations can consider strategies supported by research that could increase response, such as promoting pre-event plans for dependents at home; ensuring the supply of PPE, vaccines, and antiviral drugs for all employees; ensuring nursing representa- tion on all disaster preparedness planning committees; assigning specific roles to nurses; and providing regular ongoing interprofessional disaster education, train- ing, and drills (Balicer et al., 2010; Balicer, Omer, Barnett, & Everly, 2006; Connor, 2014; Goodhue et al., 2012; Irvin, Cindrich, Patterson, & Southall, 2008).

Recommendation 1.2. Establish a collective effort among nurse leaders to advance the practice of disaster nursing and public health emergency preparedness and response.

A collective effort such as a society or association with sufficient policy and operational expertise would be dedicated to advancing the practice of disaster nurs- ing and public health preparedness. This focused initia- tive might include, for example, a national advisory board of disaster nursing and subject matter experts and legal experts who could author a model scope of practice spe- cific to the specialty of disaster nursing that could be adopted by organizations. They could work with national nursing organizations to promote nurses as leaders in disaster preparedness by issuing position statements and participating in a range of initiatives to advance the prac- tice of disaster nursing. Such collective efforts could lead to a nationwide campaign to engage nurses from all spe- cialty areas.

2. Education

Recommendation 2.1. Develop a national set of disaster nursing competencies to be integrated into the AACN Essentials of Nursing and National League for Nursing (NLN) Guidelines for Nursing Education.

The best way to increase and maintain response capacities and to ensure the sustainability of this capacity is through workforce development. Competency-based disaster nursing programs, standardized disaster curric- ula, training guidelines, and performance measures are needed across all levels of nursing personnel. The panel proposed that the first step in developing a framework for expanding educational opportunities for nurses would be to identify a minimum set of competencies with respect to disaster preparedness and response. These competen- cies would ensure that every nurse had the foundational ability to respond at a basic level and could keep him- or herself and patients safe. The panel recognized the broad scope and spectrum of nursing care rendered during disaster events and that not all nurses need to be prepared for all roles. For example, nurses participate as valued members of the disaster response team as first responders, hospital-based first receivers, and those who bring realistic calm to families and communities impacted by catastrophic events. The AACN essentials of baccalaureate education (AACN, 2008) include several statements regarding emergency preparedness, and these competencies could be expanded and made more explicit.

Existing published competencies for nursing or health- care workforce development have been identified based on retrospective evaluation of disaster response lessons learned or proposed via a systematic consensus-building approach (Daily, Padjen, & Birnbaum, 2010; Hsu et. al., 2006; International Council of Nurses, 2009; Loke & Fung, 2014; Schultz, Koenig, Whiteside, & Murray, 2012;

Veenema et al. A Call to Action

Walsh et al., 2012). To date, there is no single set of disaster practice competencies accepted for curriculum guidance, either in nursing or in other health professions. Nor are published data available to validate any of the published disaster-related healthcare competencies (Daily et al., 2010). Only scant data support or identify specific knowledge, skills, and abilities that relate to improved outcomes associated with a disaster (Stanley & Bennecoff Wolanski, 2015; Williams, Nocera, & Casteel, 2008).

A national workgroup could review existing published competencies in disaster nursing to develop a limited set of competencies needed by all nurses and worthy of in- clusion in national nursing curricular guidelines. Ideally, this work would be in collaboration with the AACN, NLN, National Association for Associate Degree Nursing, and National Council of State Boards of Nursing.

Recommendation 2.2. Establish coalitions of schools of nursing to develop evidence-based and competency-driven didactic and clinical learning op- portunities using multiple delivery platforms that can be integrated into the undergraduate and/or graduate nursing curricula.

Different approaches to integrating disaster content into the nursing curriculum exist. Disaster nursing could be presented as a core course with didactic and clinical components, or the content could be woven through ex- isting course work as appropriate. Many important com- petencies not specific to disasters (e.g., infection control, epidemiology, and risk assessment) could be presented in a disaster context. In addition to establishing mini- mum knowledge and competencies for all U.S. nurses, it is important to have consistent metrics for evaluation. Members of the education panel questioned whether the current number or types of questions on the National Council Licensure Examination (NCLEX) provided suf- ficient incentive to drive the inclusion of increased content into the nursing curricula or for evaluating the competence of newly graduated registered nurses. Some options to explore include revising the NCLEX to include a larger number of questions pertaining to disas- ter nursing, or adding a state-based examination or ad- dendum to the NCLEX. Discussions should be pursued with the National Council of State Boards of Nursing to determine the best way to include this material in stan- dardized testing.

Recommendation 2.3. Broaden life-long, contin- uing educational opportunities in disaster nursing and public health emergency preparedness and response for nurses through healthcare and related organizations across all healthcare settings.

The panel voiced strong consensus for the nursing edu- cation community at large to expand educational oppor- tunities in disaster response and emergency preparedness to accommodate nurses at all levels in their career from prelicensure students to staff and advanced practice reg- istered nurses currently in the workforce. A possible ap- proach would be to establish employer requirements for training and testing (e.g., in conjunction with the Center for Medicare & Medicaid Services regulations or accredi- tation standards).

The unique learning needs of nurse executives and nursing faculty would need to be addressed as well. The panel proposed that a national framework for the expansion of education and training opportunities be established. This could be accomplished through a national workgroup composed of key stakeholders in dis- aster nursing education working in collaboration with State Boards of Nursing.

Recommendation 2.4. Establish a national clear- inghouse of information to provide guidance and re- sources on disaster nursing.

The panel endorsed use of a centralized clearinghouse to provide access to timely and updated resources re- lated to disaster nursing. While the primary focus would be to provide resources for nurses and nursing faculty, other audiences might include policymakers, health care organizations, researchers, funders, or emergency man- agers. Resources might include case studies, research studies, policy issues, interprofessional training tools, ex- emplars of didactic and clinical learning experiences, an outline of how and where the competencies might be in- tegrated into current nursing curricula, and a directory of media and online resources. The panel also recognized the critical need to develop competencies and resources specific to nurse administrators or executives and others in leadership positions to prepare them for crisis condi- tions resulting from disasters and emergencies and facili- tate decision making in highly ambiguous situations (e.g., regarding allocation of scarce resources, evacuation, and patient transfers).

These resources for disaster nursing could be incor- porated as part of an existing clearinghouse (e.g., the Technical Resources Assistance Center and Information Exchange, developed by the U.S. Department of Health and Human Service’s Assistant Secretary for Preparedness and Response) or in a new repository, as appropriate. The panel members acknowledged that the success of clear- inghouses, however, is dependent on the availability of resources to assure that they are regularly updated and managed to maintain their accuracy. Hence, if such re- sources are established, they must include management plans to assure feasibility and sustainability.

A Call to Action Veenema et al.

3. Policy

Recommendation 3.1. Conduct a thorough review of national policies and planning documents addressing disasters and public health emergencies to ensure that they elevate, prioritize, and address the practice of dis- aster nursing in federal, state, and local emergency man- agement operations.

Despite substantial progress in the development of a coordinated national strategy regarding disasters and public health emergencies, panelists agreed that these policies may not fully capitalize on the untapped po- tential of the nursing workforce. As a result, panelists strongly supported a broad-based evaluation of national disaster policy and planning documents to identify gaps and ensure that potential roles for nurses and their contributions are fully realized in federal, state, and local disaster operations.

As a starting point, they recommended that the role of nurses be reexamined within the context of the National Response Framework (U.S. Department of Homeland Security [DHS], 2013), the guide to how the United States responds to all types of disasters and emergencies. The panel strongly endorsed the placement of nursing professionals in leadership roles in management of disaster functions related to command and control, coordination of medical services, and decision making regarding patient care and population healthcare needs. For example, embed nurse leaders into response oper- ation leadership roles as a distinct part of the decision- making and management processes within the National Response Framework itself, especially in Emergency Support Function 8—public health and medical services. Most often, emergency situations and disaster events are managed by nonhealth or medical personnel and agencies. As highlighted in the Medical Surge Capac- ity and Capability Management System (Barbera & Macintyre, 2007), placing trained nurses within the operational response framework can provide distinct advantages, including:

� Timely input by public health and medical managers at decision-making levels regarding life and safety issues for nonhealth responders;

� ability to define medical response priorities across all aspects of an incident and incorporate them into a sin- gle cohesive strategy;

� promotion of a proactive rather than a reactive re- sponse by healthcare organizations, helping to ensure the continuity of medical operations during an inci- dent; and

� hands-on instruction for public health and medical managers by jurisdictional managers who have exten- sive incident management experience.

Examples of other priority national policy documents which could benefit from enhanced nursing roles in- clude the Target Capabilities List (DHS, 2007) and the re- lated Universal Task List (DHS, 2005), which collectively outline the capabilities and a framework for planning, priority setting, and program implementation across all government levels in prevention, protection, response, and recovery in events of national significance. Given the complexity of these policies and the numerous stakehold- ers involved in the public and private sectors, panelists advocated for a review of these policy issues by the Na- tional Academy of Medicine or similar body.

Recommendation 3.2. Encourage a culture of vol- unteerism through national nursing professional or- ganizations by engaging their members to align with volunteer agencies and participate in disaster response.

Volunteer health professionals are essential in meet- ing surge capacity needs during times of disaster and emergencies (NACNEP, 2009). Given that nurses are the largest component of the U.S. healthcare workforce and play a critical role in surge capacity, panelists strongly recommended that national nursing organizations en- courage their membership to volunteer with response teams organized by the government (e.g., the Medical Reserve Corps, Emergency Systems for the Advance Reg- istration of Volunteer Health Professionals) or private organizations such as the American Red Cross. Advance registration through established systems can help ensure that nurses and other professionals are fully prepared to respond during disasters. In contrast, “spontaneous” or unaffiliated volunteers who arrive on a disaster scene may actually impede response efforts (Hodge, Gable, & Cálves, 2005).

The panel also recognized the importance of hav- ing policies in place to strengthen and coordinate ex- isting volunteer systems. One of the major challenges is coordination and duplication of volunteers across numerous state and private-based systems (NACNEP, 2009). To that end, the panel endorsed exploration of a national registry or database that could link to the multiple existing systems to improve coordination. The panel acknowledged, however, that the utility of such a registry would be dependent on commitment and re- sources to maintain updated and accurate information over time.

Faculty and students of schools of nursing are an important untapped source of potential volunteers (Cu- sack, Arbon, & Ranse, 2010) and have played important roles in response to disasters in other countries such as China (Yang, Xiao, Cheng, Zhu, & Arbon, 2010), Japan (Okumura et al., 1998), and Hong Kong (Fung et al., 2008). While the idea of involving prelicensed nurses in

Veenema et al. A Call to Action

disaster response prompts prudent concern, there have been successful collaborations in the United States between schools of nursing and community stakeholders that have yielded positive outcomes for students in need of real-life learning experiences as well as the commu- nities in need of service following a disaster (Pattillo & O’Day, 2009; Richards, Novak, & Davis, 2009). A next step could build on these successful experiences, and potentially a network of schools could be established pre-event through a coordinated national registry. Partic- ipating schools would be prepared to respond by meeting nationally established standards for disaster preparedness prior to an event. The panel proposed further exploration regarding the responsibilities and opportunities for schools of nursing in responding to disasters.

Recommendation 3.3. Facilitate timely and effi- cient deployment of nurses and other healthcare work- ers to disaster areas by expanding liability protections for volunteers and providing coverage for volunteers harmed while responding.

A variety of legal, regulatory, and policy issues can impede the ability of nurses and other healthcare work- ers to respond to and meet surge capacity needs during times of disaster or public health emergencies. Recurrent challenges for volunteer health professionals include timely and efficient reciprocity of state-based licenses, as well as gaps in liability coverage and compensation for harm incurred during response (Hodge, 2006; Hodge et al., 2005; Hodge, Gable, & Vernick, 2008; IOM, 2012, 2014b). The panel also recognized the need to protect volunteers from loss of employment while responding to disasters. While progress has been made to address these challenges through the development of model legislation, expansion of volunteer protection acts (e.g., the Emergency Management Assistance Compact, Model State Emergency Health Powers Act [Gostin et al., 2002], Uniform Emergency Volunteer Health Practitioners Act [2007]), and employment rights legislation (e.g., Uniformed Services Employment and Reemployment Rights Act), important gaps still remain (IOM, 2012). The panel advocated for increased efforts by lawmakers, pol- icymakers, emergency managers, public health officials, and the private sector to address these issues in advance, before disasters and emergencies occur.

4. Research

Recommendation 4.1. Establish a research agenda based on a thorough needs assessment to document gaps in literature, nursing knowledge and skills, and available resources.

To understand what information is needed to fulfill the vision for a national disaster nursing workforce, the pan- elists endorsed the development of a focused research agenda. As with any research program, this would neces- sitate a methodical and systematic approach to disaster nursing research that would include:

� Conducting a thorough needs assessment to document gaps in literature, gaps in nursing knowledge and skills, and the available resources;

� partnering with nurses and other healthcare profes- sionals working in the field, nurse scientists, and com- munity members to establish research priorities and a collective commitment to carry the research agenda forward; and

� finalizing a comprehensive research agenda to engage policy makers and funders.

Over the previous several decades, research in public health emergency preparedness has advanced the field in several ways, including the development of standard terminology, healthcare and public health systems as- sessments, and enhanced healthcare worker willingness, ability, and intention to respond. A recent IOM report (2014a) also highlighted strategies to enable rapid and sustainable research during disasters. Nevertheless, the focus in disaster research remains broadly based, and gaps in the literature have not been systematically addressed. After a thorough review of the disaster nursing literature, specific attention should be given to identifying pertinent gaps and essential areas of emphasis for disaster nursing research.

It is particularly important to assure that nursing research in disaster preparedness and response comple- ments and supplements what is already available and in particular contributes new information for nursing practice and policy. This requires a close relationship with other agencies and disciplines also conducting research. As such, a crosswalk with other national public health emergency preparedness research agendas (e.g., National Academy of Medicine, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention) should be developed. Additionally, in order to have an informed research agenda that will have a sustainable impact on practice, it is essential to interface with nurses in practice, including engagement through professional organizations such as the Emergency Nurses Association, ANA, and Association of Public Health Nurses.

Since all disasters are local, partnerships through community-based participatory research should be devel- oped to help define research priorities and address regula- tory (e.g., institutional review board) and other issues in advance (Minkler, 2005). Preplanning will help ensure

A Call to Action Veenema et al.

that when a disaster strikes the necessary mechanisms will be in place to expedite the research.

Recommendation 4.2. Expand research methods to include interventional studies and use both quantita- tive and qualitative designs.

Currently the research related to disaster nursing is primarily descriptive. A move toward interventional research is needed to identify what works based on current and potentially new frameworks, and how those affected by disasters and the healthcare professionals who respond can achieve improvements in outcomes and safety. Analytic approaches such as data mining with social media and electronic text and idea mapping to visualize scenarios, ideas, and concepts may uncover new approaches and areas for research consideration (Chen, 1988; Weiner, 2011; Weiner & Bartoo, 2014). Interventional research could help in determining methods to create a culture of preparedness; identifying skills and approaches across four phases of disasters— mitigation, preparedness, response, and recovery—each requiring different strategies and approaches; and the effective roles of nurses in preparedness, response, and recovery.

Recommendation 4.3. Increase the number of doc- torally prepared nurse scientists serving as principal in- vestigators on disaster research projects.

To our knowledge, there are no formal training pro- grams for nurse scientists interested in research related to disaster preparedness and response, but a number of resources are available for planning and enhancing such training programs. The major challenge, however, may be to develop a cadre of nurse scientists with a sustained interest in the field. The response following natural and human-made disasters has been immediate public con- cern, which often quickly wanes. Creating a culture of awareness and preparedness among nurse scholars will involve collaboration with educators, practitioners, and policy makers or funders. One effective means to build a body of research is through priorities set by funding agen- cies. The National Institute of Nursing Research (NINR) is the primary federal funder of training programs for nurse scientists, and although their strategic plan does not currently include disaster preparedness and response as one of their priorities, the panel identified their active involvement and support of such training as being vital. As the NINR and influential professional nursing organi- zations articulate disaster nursing as a priority, the need for and interest among nurse scholars to focus on disas- ter nursing research will grow. Other agencies within the National Institutes of Health, HRSA, and private funders

such as the Robert Wood Johnson Foundation could also support programs that advance disaster nursing science.

Discussion

In this project, we have proposed a vision for the future of disaster nursing and recommendations for nurs- ing practice, education, policy, and research to achieve of that vision. Unfortunately, previous calls to educate the national nursing workforce for emergency and dis- aster preparedness (e.g., International Nursing Coalition for Mass Casualty Education Educational Competencies for Registered Nurses Responding to Mass Casualty In- cidents, 2003; NACNEP, 2009) were not sustained. Un- like prior efforts, this call to action highlights the need for a more coordinated, interdisciplinary, and structured approach to assuring that the nursing workforce is well prepared for disaster response, and makes specific recom- mendations for how this might be accomplished. Ongoing assessments of progress toward these ends, with a focus on adapting implementation strategies to address areas where progress is limited, will be essential to the success of this effort.

Multiple reports highlight the nursing profession’s breadth and untapped potential during disasters. In 2011, the IOM published The Future of Nursing: Leading Change, Advancing Health, which proposed recommendations designed to advance health in the U.S. population by transforming the role of the nurse in the delivery of care. The Future of American Red Cross Nursing: A Blueprint for Ac-

tion (American Red Cross National Nursing Committee, 2012) outlined recommendations for how nurses can and should be actively engaged as full contributors in achiev- ing such priorities during disaster preparedness and mobi- lization. The Association of Public Health Nurses’ (APHN) The Role of the Public Health Nurses in Disaster Preparedness,

Response, and Recovery (APHN, 2013) recognized that pub- lic health nurses possess a broad range of population- based knowledge, skills, and nursing expertise when it comes to disaster preparedness, response, and recovery. Other organizations that have issued reports, briefs, or white papers on the role of nursing in disasters include the Association for Community Health Nursing Educa- tors, ANA, ICN, and World Health Organization (Stan- ley & Bennecoff Wolanski, 2015). Most recently, the ICN has called for increased support of and safer working environments for nurses as frontline healthcare work- ers following large numbers of nurses who died during the 2014 Ebola outbreak (ICN, 2015). Taken collectively, these documents provide a foundation for nurses to en- gage in an expansive national dialogue regarding the fu- ture for disaster nursing in the US, with implications for global nursing as well.

Veenema et al. A Call to Action

Globally, disaster nurse readiness is a pressing concern (Chapman & Arbon, 2008). China, Japan, Taiwan, Iran, and many other countries have identified similar issues related to the identification of appropriate disaster nursing competencies and the challenges with imple- mentation of effective education and training programs to prepare their nursing workforce (Bahrami et al., 2014; Chan et al., 2010; Yamamoto, 2013; Yan et al, 2015). Ca- pacity for crisis nursing leadership during U.S. and inter- national disaster events (Danna, Bernard, Schaubhut, & Matthews, 2010; Johnson, 2002; Samuel, Griffin, White, & Fitzpatrick, 2015) and evidence-based disaster manage- ment (Usher et al., 2015) warrants further exploration.

The recommendations presented in this article consti- tute a point of departure for addressing the barriers and facilitators (see Table 1) to preparing a national nurs- ing workforce with the knowledge, skills, and abilities to respond to disasters and public health emergencies in a timely and effective manner. We recognize that these recommendations range in complexity and some may be more challenging to implement than others. For exam- ple, successful implementation of the practice and policy recommendations will require the nursing profession to establish or expand partnerships with other healthcare professionals, emergency managers, policymakers, and healthcare organizations. Despite such challenges, we be- lieve these recommendations are critical to enhancing na- tional nurse preparedness, which can ultimately increase the resiliency of healthcare organizations and communi- ties more broadly.

Conclusions

At a time when disasters and public health emer- gencies are occurring with increasing frequency, it is essential that the breadth and untapped potential of the nursing profession be fully understood and deployed. De- spite considerable funding for hospital and public health preparedness since the attacks of September 11, 2001, ef- forts to prepare and mobilize nurses for disaster prepared- ness and response have been episodic and difficult to sustain. This article presents a vision for the future of dis- aster nursing, identifies barriers and facilitators to achiev- ing that vision, and offers recommendations in nursing practice, education, policy, and research. This project represents an important step toward enhancing nurses’ roles as leaders, educators, responders, policymakers, and researchers in disaster preparedness and response. Further exploration of these ideas and a commitment to expand the national dialogue within the nursing profes- sion and beyond is needed to truly achieve national nurse readiness.

Acknowledgments

The Nursing Call to Action was initiated, directed, and supported by the Veterans Emergency Management Eval- uation Center (VEMEC) of the U.S. Department of Vet- erans Affairs, Veterans Health Administration, Office of Public Health. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government.

The authors wish to thank the following individu- als who also participated in the planning committee or December 2014 workshop: Donna Gage, PhD, RN, NE-BC (Office of Nursing Services, Veterans Health Administra- tion, U.S. Department of Veterans Affairs), CDR Derrick Gooch (U.S. Public Health Service), Beverly Malone, PhD, RN, FAAN (National League for Nursing), Cheryl Peterson, MSN, RN (American Nurses Association), Kris- tine Qureshi, DNSc, RN, FAAN (University of Hawai’i at Manoa), Carole Snyder, MS, RN (Emergency Nurses Association), and Joan Stanley, PhD, CRNP, FAAN, FAANP (American Association of Colleges of Nursing).

The authors also wish to thank the following indi- viduals for their early work in developing this call to action: Colleen Conway-Welch, PhD, CNM, RN, FAAN, FACN (Vanderbilt University), Karen La Scala, RN, BSN, MBA (Office of Emergency Management, Veterans Health Administration, U.S. Department of Veterans Af- fairs [retired]), Karen Ricci MPH, RN (formerly with the Veterans Emergency Management Evaluation Center, Veterans Health Administration, U.S. Department of Vet- erans Affairs), and Sharon Stanley, PhD, RN, RS, FAAN and COL (ret), U.S. Army (Association of Public Health Nurses).

Clinical Resources � American Red Cross Disaster Nursing: http://www.

redcross.org/support/volunteer/nurses/students � ANA Nursing World Resources for Disaster Pre-

paredness & Response: http://www.nursingworld. org/MainMenuCategories/WorkplaceSafety/DPR

� Emergency Nurses Association Emergency Prepar- edness Resources: https://www.ena.org/practice- research/Practice/Safety/EmergencyPrepared/ Pages/Default.aspx

� Technical Resources Assistance Center and In- formation Exchange (TRACIE): https://asprtracie. hhs.gov/

http://www.redcross.org/support/volunteer/nurses/students

http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/DPR

https://www.ena.org/practice-research/Practice/Safety/EmergencyPrepared/Pages/Default.aspx

https://asprtracie.hhs.gov/

A Call to Action Veenema et al.

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http://www.va.gov/nursing/workforce/workforce.asp

http://www.ijbhtnet.com/journals/Vol_4_No_4_July_2014/4.pdf

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September 8, 2022

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