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Nurs Admin Q
Vol. 41, No. 2, pp. 118–127
Copyright c
2017 Wolters Kluwer Health, Inc. All rights reserved.
Education for Developing and
Sustaining a Health Care
Workforce for Disaster
Readiness
Joanne C. Langan, PhD, RN, CNE;
Roberta Lavin, PhD, FNP-BC, FAAN;
Kelly A. Wolgast, DNP, RN, FACHE, FAAN;
Tener Goodwin Veenema, PhD, MPH, MS, RN, FAAN
The United States needs a national health care and public health workforce with the knowledge,
skills, and abilities to respond to any disaster or public health emergency in a timely and ap-
propriate manner. This requires that all of our nation’s nurses and health care providers have
unrestrained access to high-quality, evidence-based, competency-driven education and training
programs. Programs of study for disaster readiness in both the academic and service sectors are
limited in number. Those that do exist may be based upon consensus rather than competency and
be price prohibitive. They may fail to fully capitalize on existing educational technologies and may
not be accessible to all providers. Nurse leaders are ideally positioned to recognize, advocate, and
support the need for a broad array of learning options to strengthen the readiness of the health
care workforce for disaster response. This article reviews current challenges and opportunities
for the expansion of evidence-based education and training opportunities for health care work-
force disaster readiness. Key words: competencies, disaster nursing, education, nurse leaders,
workforce readiness
THE IMPACTS of climate change, global
terrorism, and growing domestic civil
unrest, along with the emergence of new
infectious disease epidemics, suggest that the
Author Affiliations: Saint Louis University School
of Nursing, St. Louis, Missouri (Dr Langan);
University of Missouri—St. Louis (Dr Lavin); Online
Education and Outreach, Penn State University
College of Nursing, University Park, Pennsylvania
and COL (R), US Army (Dr Wolgast); and Johns
Hopkins University School of Nursing, Department
Community and Public Health Johns Hopkins School
of Nursing, Center for Humanitarian Health, Johns
Hopkins Bloomberg School of Public Health,
Baltimore, Maryland (Dr Veenema).
The authors declare no conflict of interest.
Correspondence: Joanne C. Langan, PhD, RN, CNE,
Saint Louis University School of Nursing, 3525 Caroline
St, St. Louis, MO 63104 (langanjc@slu.edu).
DOI: 10.1097/NAQ.0000000000000225
burden of caring for victims of disasters will
continue to increase for health care systems.
Unfortunately, many health care providers
lack the knowledge, skills, and abilities they
will need to respond to a disaster event.
Studies have shown that many nurses are
inexperienced with disaster situations and are
inadequately prepared to respond to the com-
plex demands of a disaster environment.1,2
While some progress has been made in devel-
oping and maintaining the workforce needed
during emergency events, there is much
more preparation that needs to be done.3
Health system readiness is now mandated by
The Joint Commission,4as a condition for
continued eligibility to receive Medicare and
Medicaid funding and is a critical component
of the National Health Security Strategy.5
Nurse leaders have a responsibility to ensure
that nurses, advanced practice nurses, and
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
118
Developing and Sustaining Disaster Readiness Education 119
allied health care workers are adequately
prepared to respond to a disaster event.
The role of nurses during all phases of a dis-
aster has a significant potential impact6on the
welfare of individuals and communities. The
nursing team’s disaster competence is critical
to the attainment of the best possible popu-
lation outcomes.7,8 A collective vision for the
future of disaster preparedness for health care
and public health providers9suggests that US
health care providers should possess disaster
and public health emergency (PHE) prepared-
ness skills in order to either respond directly
or to provide indirect support (such as shift
coverage for those who are deployed, or criti-
cal data collection). In addition, US nurses and
other health care providers should promote
preparedness among their families, commu-
nities, and the organizations they represent.
This dedication to professional preparedness
can be demonstrated by participating in disas-
ter planning, drills, and exercises within and
beyond their specialty environment.9This vi-
sion is deeply grounded in the belief that the
broader the range of leadership, skills, and
abilities that all licensed health care providers
bring to disaster planning and response, the
greater the chance of positive health out-
comes for more people.
BASIC EDUCATION FOR DISASTER
PREPAREDNESS
Nurses comprise the largest group of US
health care professionals.10 During disaster
situations, nurses may volunteer to respond
on their own volition, be asked to respond, or
may work nonscheduled shifts at their usual
place of work to assist in disaster relief ef-
forts. Frequently, nurses are responsible for
the supervision of volunteers in a disaster re-
sponse. Many nurses, however, may not know
how to respond effectively or what is ex-
pected of them as part of the health care team
response.11
The preparation for major PHE and disas-
ter events begins in the academic setting. The
literature supports access to evidence-based,
competency-driven disaster education for
health care and public health providers.12-15
The American Association of Colleges of Nurs-
ing includes disaster-related content as a re-
quirement within its published essentials for
doctoral, master’s, and baccalaureate educa-
tion (Table 1).14-16 However, there is little
guidance as to what, where, and when it
should be integrated into the curriculum. Pro-
fessional nursing organizations can advocate
for, and contribute content toward, nurse
preparedness. Most frequently, disaster con-
tent is embedded in public health courses in
schools of nursing. Some schools offer elec-
tive courses that address emergency response
for nurses, while others grant certificates or
continuing education modules that cover a
myriad of related topic areas.
Because nurses practice in a variety of set-
tings, education must be geared to the specific
areas or populations they serve. For example,
nurse leaders in both service and academic
settings need to know the essential disaster-
related content that their nurses or faculty
need in order to meet standards of regulatory
agencies or accrediting bodies. Faculty should
provide lessons on crisis nursing that will pre-
pare nursing students for state boards as well
as graduate nursing practice.
NURSING ROLES IN DISASTERS
If a mass casualty event is imminent or
threatening, all nurses will be asked to use
their expertise in the response and recov-
ery efforts. To prepare for this, nurses need
to study and be cognizant of the needs of
vulnerable populations. For example, disas-
ter survivors who are in compromised health
will require specialized care and instructions
when typical care patterns and routine re-
sources are not available. Nurses with spe-
cialized training, such as those with infection
control, emergency, and critical care skills,
will probably be in great demand. The nature
of the disaster or emergency will dictate the
most needed specialties.
All nurses can be of great help in mass ca-
sualty situations, whether or not they have
experience in these specialty areas. Student
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120 NURSING ADMINISTRATION QUARTERLY/APRIL–JUNE 2017
Table 1. AACN Essentials Applicable to Disaster Preparedness14-16
BSN Essentials MSN Essentials DNP Essentials
Essential VI: Interprofessional
Communication and
Collaboration for Improving
Patient Health Outcomes
(Sample content:
Participatory decision-
making—Critical to
delivering high-quality and
safe patient care in rapid
response)
Essential III: Quality
Improvement and Safety
Sample content: Simulation
training in a variety of
settings (eg, disasters, codes,
and other high-risk clinical
areas)
Essential VII: Clinical
Prevention and Population
Health (Sample content:
Health promotion and
disease prevention through
preparedness education to
minimize health
consequences of
emergencies including mass
casualty disasters.)
Essential VIII: Clinical
Prevention and Population
Health for Improving Health
Essential VII: Clinical
Prevention and Population
Health for Improving the
Nation’s Health
Essential VIII: Professionalism
and Professional Values
(Sample content: Value of
human dignity and social
justice in the allocation of
scarce resources at times of
disasters; accountability for
one’s self and nursing
practice through lifelong
learning)
Sample content: Disaster
preparedness and
management
Essential IX: Master’s Level
Nursing Practice
Clinical Practice Learning
Expectations: Simulated
mass casualty events
Emerging knowledge regarding
infectious diseases,
emergency/disaster
preparedness, and
intervention frame DNP
graduates’ knowledge of
clinical prevention and
population health
nurses may also be called upon to assist in
triaging victims in acute care or community
settings. Dispensing medications for mass pro-
phylaxis is a task that students, faculty, and
practicing nurses may all be asked to com-
plete. Inactive nurses might find themselves
called upon to help in community prepara-
tion or relief efforts. All nurses are much more
likely to respond to disasters if they and their
families are prepared and if they have the ed-
ucation and preparedness training to respond
with confidence.11 It can be complicated for
nurse leaders and educators to know what
content to teach that is evidence-based and
competency driven. This is just one of the
challenges in preparing for potential natural
disasters and man-made crises.
CHALLENGES IN PREPARING A HEALTH
CARE WORKFORCE FOR DISASTER
RESPONSE
Lack of national standards
What needs to be done to ensure the
provision of evidence-based, competency-
driven high-quality content in academic and
lifelong learning programs? Clear, concrete,
and widely shared guidance for the provi-
sion of disaster education would establish a
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Developing and Sustaining Disaster Readiness Education 121
foundation for educational programming, but
these are currently not in place. Current ed-
ucational programs vary greatly, and many
are not evidence-based.17 The absence of a
clearly articulated national framework for dis-
aster education is not without consequences.
An unprepared health care workforce has the
potential to limit the effectiveness of local,
state, and federal response plans; limit organi-
zational surge capacity; and negatively impact
health outcomes in populations impacted by
disasters.1While some government agencies,
schools, and professional organizations have
developed disaster preparedness programs,
formal systems are not in place to provide
pre- and postlicensure nurses with consis-
tent and comprehensive education and train-
ing in emergency preparedness and disaster
response.
Competing sets of disaster competencies
Nursing still lacks a research-based set of
workforce educational competencies specific
to disaster response, even though it has been
15 years since the tragedy of 9/11. Compet-
ing lists of disaster competencies for health
care providers have been published. Unfor-
tunately, these have resulted in confusion for
nurse leaders.18 These have been developed
primarily by consensus, and there is little ev-
idence that they have contributed to health
care workforce preparedness (Table 2).18
For the purposes of this article, a nursing
disaster competency is defined as a charac-
teristic of a nurse that enables an individual
professional to effectively perform the role of
nurse specific to a disaster situation. There
remains no consensus or empirical validation
of the majority of competencies.19 However,
researchers have identified 2 validated tools
that have undergone rigorous testing: the Dis-
aster Preparedness Evaluation Tool; and the
Emergency Preparedness Information Ques-
tionnaire. The Disaster Nursing Core Com-
petencies Scale was developed and tested
through utilization of these tools.
While the work of researchers on
these tools is helpful, the terminology
around competencies remains imprecise and
inconsistent.19, 20 The most common core
competencies referred to by various authors
are the detection of and response to an event,
the role of a nurse in incident command
[centers], triage, epidemiology and surveil-
lance, isolation, quarantine and decontami-
nation, communication, psychological issues
and care of special populations, accessing crit-
ical resources, reportage, and ethics.19
Academic and staff development adminis-
trators must ensure that a consistent and ap-
propriate set of competencies are identified
and then used to develop and revise curric-
ula. A starting point for this could include
those competencies that have a basic level
of evidence, such as those based on the ICN
Framework for Disaster Nursing Competen-
cies, built on generalist nursing competen-
cies. (It should be noted that these do not ad-
dress nurses in advanced practice.)21 Only the
Competencies for Clinical Nurse Specialists in
Emergency Care have validating research be-
yond the consensus work of expert panels.
Need for multiple portals to educational
programs
Disaster and large-scale PHEs are low-
frequency high-impact events. From an edu-
cator’s perspective, this creates a unique chal-
lenge for both students and lifelong learners
regarding learning transfer and retention of
content. Students must master the core con-
cepts and competencies for disaster response,
retain this information, retrieve it at the appro-
priate time, and utilize it in a manner that pro-
motes optimal health outcomes for victims.
Ideally, students should be able to access real-
time content and decision support wherever
and whenever they need it. For this reason,
nurse leaders should advocate for multiple
options where their staff can access quality
disaster education and training.
Need for greater emphasis on
psychiatric/mental health
Many disaster survivors experience psy-
chosocial symptoms such as stress, grief,
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122 NURSING ADMINISTRATION QUARTERLY/APRIL–JUNE 2017
Table 2. Table of Competencies Adapted From Disaster Education and the APRNa18
Competency
Documents Author Intended Audience
Method of
Development and
Evidence
Educational
Competencies for
Registered Nurses
Responding to
Mass Casualty
Incidents
International Nursing
Coalition for Mass
Casualty Education
Registered nurse
faculty
Consensus based
APRN Education for
Emergency
Preparedness and
All Hazards
Response:
Resources and
Suggested Content
National Panel for
APRN Emergency
Preparedness and
All Hazards
Response
Education
Nurse practitioner
faculty
Consensus based
ICN Framework of
Disaster Nursing
Competencies
World Health
Organization and
International
Council of Nurses
Generalist nurse Focus group
Written inquiry (Loke
and Fung) 11
Core Competencies
Required for
Disaster Nursing
University of Hyogo,
Graduate School of
Nursing
Nurse educators Training followed by
surveys
Disaster-Related
Competencies for
Healthcare
Providers
National Library of
Medicine
Collected
competencies for a
wide variety of
health professions
Primarily consensus
based, some
supported by
research of various
educational
offerings
The Contribution of
Nursing and
Midwifery in
Emergencies
World Health
Organization
Midwives Consensus based
Competencies for
Clinical Nurse
Specialists in
Emergency Care
Emergency Nurses
Association
Clinical Nurse
Specialists
Expert panel/
validation study
questionnaire to
national sample
Guidelines Regarding
theRoleofthe
CRNA in Mass
Casualty Incident
Preparedness and
Response
American Association
of Nurse
Anesthetists
Certified Registered
Nurse Anesthetists
Consensus based
Basic Essential
Curricular Content
for Public Health
Nursing Emergency
Preparedness
Association of
Community/Public
Health Nursing
Educators
Community/Public
Health Nurse
Educators
Consensus based
(continues)
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Developing and Sustaining Disaster Readiness Education 123
Table 2. Table of Competencies Adapted From Disaster Education and the APRNa18
(Continued)
Competency
Documents Author Intended Audience
Method of
Development and
Evidence
Public Health Nursing
Competencies for
Surge Events (PHN,
25(2) 159-165.
DOI: 10.1111/j.
1525-1446.2008.
00692.x.)
Polivka, Stanley,
Gordon, Tolbee,
Kieffer, and
McCorkle
Public Health Nursing Delphi study
Emergency
Preparedness and
Response Core
Competency Set
for Perinatal and
Neonatal Nurses
(Obstet Gynecol
Neonatal Nurs.
2010;39(4):450-
465, quiz
465-467.)
Jorgensen, Mendoza,
and Henderson
Obstetrical and
Neonatal Nurses
Consensus based
aAdapted with permission. CThe Honor Society of Nursing, Sigma Theta Tau International.
depression, and anxiety. Because the disrup-
tion caused by the disaster may continue for
many weeks or months, chronic psychologi-
cal conditions such as posttraumatic stress dis-
order, substance abuse, and major depression
may require long-term management. Triage
for physical injuries is often implemented in
the early stages of disaster response. Less vis-
ible adverse mental health effects of disas-
ters need identification and triage as well. As-
pects of psychological treatment that need
implementation include psychological first
aid, psychological debriefing, crisis counsel-
ing, and psychoeducation for individuals with
distress.22 Nurse leaders can be strong voices
for the inclusion of mental health content in
disaster education programs. This education
can help prepare the workforce to anticipate
and respond to the psychiatric and mental
health needs of individuals and families im-
pacted by disasters.
Victims who have suffered debilitating in-
juries and loss are not the only individuals
in need of mental health care. Those who
have witnessed the effects of disaster events,
such as friends, families, community mem-
bers, first responders, and the health care
workers themselves need assessment and may
need nursing intervention. Education is a key
to preparing health care providers for this
type of readiness and response. Debriefings
and care for the health care providers should
be a nurse leader’s priority as he or she plans
to try to return a health care system to some
type of normalcy. Counselors, mental health
nurses, social workers, chaplains, or other
grief counselors may be needed to support
those efforts.
INCREASING NURSE LEADER
AWARENESS
Nurse leaders are in a powerful position
to advocate for, lead, and support institu-
tional initiatives designed to improve nurs-
ing and other health care provider disaster
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124 NURSING ADMINISTRATION QUARTERLY/APRIL–JUNE 2017
readiness. Nurse leaders can work with their
state and local office of emergency prepared-
ness as well as their organization’s emergency
management committees to increase aware-
ness among hospital administration and staff
of the importance of disaster education. They
can craft policies that provide staff with time,
funding, and incentives to access disaster ed-
ucation. Administrators can support training
exercises of all types to ensure that compe-
tence is established and sustained. They can
also form academic practice partnerships in
which training is planned together.
In early 2016, the American Organiza-
tion of Nurse Executives published a guid-
ing principle related to crisis management
as an exemplar of lessons learned from re-
cent disasters and the threat associated with
Ebola transmission. The principle addresses
the need for nurse leaders to be effective
communicators; critical thinkers; and col-
laborative members of the leadership team,
while being comfortable with uncertainty;
savvy in media relations; and able to demon-
strate empathy (“calm, confidence and au-
thority in all situations”).23 American Orga-
nization of Nurse Executives also advocates
that nurse leaders at all levels possess com-
petencies in developing and implementing
bioterrorist, biohazard, and disaster readiness
plans.23
In 2013, a policy position statement on
health care executives’ roles in emergency
preparedness was published. The statement
provides relevant information while guiding
health care leaders to maintain a current disas-
ter plan, assess resource availability, develop
an incident command system, develop pro-
tocols and policies for patient and employee
safety, develop communication plans, and en-
sure ongoing surveillance programs for the
most likely disaster scenarios. Frequent or-
ganization drills, which include community
involvement to test disaster plans, are one
way for leaders to assess effectiveness of the
plans.24 The expectation is clearly established
for nurse leaders and health care leadership
teams to be proactive in addressing disaster
preparedness.
J. Englebright, PhD, a chief nurse executive
stated,
As a large system, all HCA facilities benefit from the
after action reports from each disaster response.
For instance, in our latest hospital evacuation,
we learned that our quarterly drills did not have
enough emphasis on command and communica-
tion protocols. We plan to use this information to
design future drills for all hospitals, to evaluate dif-
ferent communication technology options, and to
develop specific training modules. My primary con-
cern is that disaster preparedness is often skimmed
over in the business of the clinical work environ-
ment. Training can be concentrated on specific
roles such as ED or perinatal staff, leaving much
of the nursing workforce unprepared. (E-mail com-
munication, September 2016.)
RELEVANCE TO CLINICAL PRACTICE
Nurses across a broad array of settings will
play a variety of roles before, during, and af-
ter disasters. Prior to a disaster or PHE, nurses
can work on efforts to increase prepared-
ness and resilience in schools, churches, and
other community organizations. The empha-
sis on interprofessional learning is an impor-
tant element in disaster preparedness educa-
tion because preparation and response efforts
require the assistance of a number of profes-
sions. Nurse leaders are urged to support a
collegial approach to learning with other dis-
ciplines and experts. As with any initiative,
evaluation is a key aspect in the cycle of as-
sessment, planning, implementation, and im-
proving the approach. Evaluation is also key
in choosing the types of disaster content and
programs to choose.
MAKING DECISIONS ON THE
COST/BENEFIT OF DISASTER
PROGRAMS AND CONTENT
The cost of disaster programming must be
considered in designing curriculum to ensure
disaster competencies. Two major consider-
ations are as follows: (1) What content and
practices are essential at each level of nursing
education for nurses to respond adequately
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Developing and Sustaining Disaster Readiness Education 125
during a disaster? (2) How do faculty and
nurse leaders make allocation decisions re-
garding education with available funding?
Faculty working in schools of nursing can
begin by using Rescher’s system25 for the al-
location of scarce resources, as adapted in the
Figure. Rescher’s criteria for inclusion and ex-
clusion can be applied in a manner that is
easily understood and fair. Include courses
that meet the desired criteria. Key elements
of this system include the consideration of
population and geographic location served;
greatest likelihood of meeting essential stu-
dent learning outcomes; faculty prepared-
ness based on teaching expertise; and future
relevance.25
Completion of this process will help en-
sure that the courses and/or methods selected
will have the greatest positive impact on so-
ciety and the preparedness of the students.
Rescher’s factors include principles of utili-
tarianism and justice to analyze the value and
benefit of various approaches to teaching dis-
aster content.25 His model allows flexibility
for schools to make decisions that best meet
the needs of their constituency and address
their local risk assessment. The cost/benefit
considerations of adding disaster-specific con-
tent cannot be overlooked as all schools have
limited resources. The best outcome requires
a thoughtful approach based on community
risk assessment, faculty competencies, and
available funding.
CONCLUSION
All nurses and health care providers, across
all types of health care settings, would ben-
efit by having unrestrained access to high-
quality, evidence-based, competency-driven
education and training programs. The goal
of this would be to improve health care out-
comes for individuals and families impacted
by disaster or major PHEs. Nurse leaders are
well-positioned in both academia and service
settings to advocate for and influence the pro-
cess of selecting, developing, and sustaining
education for a health care workforce. They
have a responsibility to prepare a team that
Figure. Ethical analysis for APRN disaster curriculum inclusion. Copyright Roberta Lavin. Used with
permission from Rescher.25
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126 NURSING ADMINISTRATION QUARTERLY/APRIL–JUNE 2017
is knowledgeable of all aspects of disaster,
response, and recovery. The authors of this
article acknowledge the difficulty in choosing
appropriate curricula and the effort it takes to
sustain readiness. However, evidence-based
content is available in a variety of media to
assist in the development, implementation,
and evaluation of curricula. Opportunities
exist to establish academic and workplace
partnerships to create and share disaster edu-
cation content. The process is dynamic, and
we all need to be vigilant in updating content
and sharing lessons learned. In this way, our
health care workforce will be better prepared
to serve our communities, both now and in
the future.
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