CHAPTER

Disaster Nursing
Kristin Allyce Reed and Amelia Marie Nelson

Nurses, as an integral part and the largest component of the health care
team, must be prepared for disaster situations. Disasters occur all over
the world, sometimes with warning and sometimes without, making it
even more essential to have effective planning and preparedness training programs for nurses. As stated by Powers in International Disaster
Nursing, the goal of disaster nursing is ensuring that the highest
achievable level of care is delivered through identifying, advocating
and caring for all impacted populations throughout all phases of a
disaster event, including active participation in all levels of disaster
planning and preparedness.1 Many of these duties have fallen on public health nurses and emergency department nurses; however, all nurses
will be called upon when a catastrophic event occurs.
Historically, nurses have responded to the call for help when
needed. Starting with times of war, this desire and sense of duty to provide care for patients in need have placed the profession on the front
lines of disasters. Many of these events occurred in nurses own backyards; however, countless others have taken it upon themselves to volunteer and travel away from home to respond. Because nursing
professionals often desire to help those in need in an unconventional
setting, it is our duty to prepare those who respond to disasters.

HISTORICAL PERSPECTIVE
Florence Nightingale, the pioneer of modern nursing, functioned as a
disaster nurse during the Crimean War. Taking 38 other women with
her to Turkey, she assumed the management responsibilities of the barracks hospital.2 Wartime health care is similar to disaster health care in
that the needs far outweigh the resources. Nightingale worked tirelessly
to develop a rudimentary standard of care for the soldiers. This
required adaptation of previous knowledge and skills in order to provide care to these soldiers. This ability to adapt is one of the building
blocks required for disaster nurses.3
Clara Barton, another pioneering nurse, worked diligently during the
Civil War providing care to soldiers and then founded the American Red
Cross in 1881. Barton had a keen understanding of the needs of the
soldiers and what she could do to help. She came to be known as the
angel of the battlefield.4 By her example, and the establishment of the
American Red Cross, a new precedent for volunteerism was set.
In modern day medicine, nurses tend to focus on the refined medical skills learned in school and practiced in normal settings. During a
time of need, these innovators in disaster nursing focused on providing
food, water, and shelter. Although in the twenty-first century there have
been great advances in health care in disaster settings, nurses must not
forget the holistic approach and importance of basic human needs.
During a disaster situation, a nurse must be flexible and adaptable in

order to fill whatever role is necessary at the time, ensuring the best care
for all patients.
The flu pandemic of 1918-1919 affected millions of people worldwide; in all, 20 million people perished during this time. This incredible
number of people affected by flu required a large number of nurses and
doctors to care for them. The health care system was entirely overwhelmed, requiring the establishment of alternate care sites. In one
treatment facility in Camp Dodge, Iowa, nurses were able to adapt to
an exponentially rising patient population. In a twelve-day period,
the number of patients quickly rose from 1254 to 7863; however, the
initial nursing staff of 245 nurses only marginally increased to 442.5
The supply of nurses could not keep up with the exceptional demands
of the growing patient population, yet the nurses adaptability and flexibility allowed them to provide the best care possible with the resources
available. The ability to work outside of their normal duties and adapt
to the disaster at their feet was crucial.
Over the last century the specialty of emergency nursing has developed because the rapid evaluation and treatment of patients during
wartime was noted to save lives.6 Prior to this time it would have been
the responsibility of a nurse in the community to respond to a disaster.
The development of the specialty of emergency medicine, emergency
departments, and emergency medical systems has redirected small
disasters to be cared for directly in emergency departments.
These few examples chronicle the development of disaster medicine
and disaster nursing, both created out of necessity. Although these subspecialties are needed sporadically, when an event occurs they become
essential. It is important to explore the relatively new subspecialties and
develop the fundamental knowledge and the skill sets necessary for the
nursing personnel to function at the time of disaster.

CURRENT PRACTICE
Education and Principles of Disaster Nursing
Many of the key skills that nurses perform in their day-to-day roles
make for exceptional providers in disaster settings. Some of the key
skills that nurses embody are the ability to prioritize and delegate tasks,
think critically, be adaptable and flexible, and advocate for themselves
and the patients that they care for. With these skills and further training
nurses are well equipped to handle disaster situations. Each nurse
maintains his or her own specialty and scope of practice, but without
the combined efforts of all members of the health care team the patients
suffer. This becomes even more important during disasters. Responding to disasters requires a cohesive team of individuals with comprehensive understanding of their skill sets and how to function within
the team. As noted by the International Council of Nurses, Nurses,

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SECTION I

Introduction

as team members, can play a strategic role cooperating with health and
social disciplines, government bodies, community groups, and nongovernmental agencies, including humanitarian organizations.7
Nurses, as an integral part of this team, require training and education
in order to function successfully in these roles.
Disaster preparedness is not just being prepared and knowing what
to expect when responding to a disaster but also assisting in the formulation and execution of a response plan for ones own community and
workplace. Nurses should have at least a basic understanding of the following principles:
The Incident Command System (ICS): In the United States the ICS is
used as a standardized framework for chain of command. To function during a disaster, nurses should be well versed in the principles
of ICS.
The local and regional disaster response plan: Nurses must have an
understanding of preexisting disaster plans in their communities
and facilities. This would include knowing where and when to
report during times of disaster and what role they are expected to
fill within the response system.
Self-preparedness: It is necessary to discuss and develop an individual and family preparedness plan. The nurse, as a responder, will be
away from his or her family for an uncertain period of time, so it is
essential that a well-developed family plan is devised ahead of time.
One should also be mentally prepared for this separation.
Community resources: Understanding of available resources allows
for more effective care of those in need (i.e., available alternate care
sites, blood bank capabilities, pharmacy stockpiles, and shelters).
Personal abilities and shortcomings: While working in an unfamiliar
setting with unfamiliar people, it is necessary to stand firm in ones
knowledge base and skill sets. Being able to communicate this to the
team will allow for proper delegation of tasks, therefore providing
safe and effective care to patients. Prior to the occurrence of a disaster, nurses should consider and understand their emergency skill set.
Participation in disaster drills: Often hospitals will run disaster drills
simulating a variety of scenarios, from biological, mass casualty, and
internal disasters. Nurses must be involved during these drills
because they will be integral parts of a real-world disaster response.

Nursing Within the Disaster Cycle

When one thinks of disaster nursing or disaster medicine as a whole, it
is often the response phase that gets most of the attention. Without mitigation and preparation, however, the response to a disaster would be
disorganized at best. As defined by the World Health Organization
(WHO), a disaster is A serious disruption of the functioning of a community or a society causing widespread human, material, economic, or
environmental losses which exceed the ability of the affected community
or society to cope using its own resources.8 Although many nurses
have neither the desire nor the ability to travel domestically or internationally to all disasters, this does not exclude them from potentially needing to respond to a nearby event. Disasters happen every day and often in
our own backyards; therefore nurses of all skills and specialties should
have a basic knowledge of the four phases of the disaster cycle.

Mitigation
During mitigation it is imperative to complete accurate vulnerability
assessments. It is this phase in which providers can assess a situation
and make changes in order to decrease the likelihood that events,
human-made or natural, will become disasters. Nurses, with a firm
grasp on the abilities and resources within their communities and facilities, should be involved in the assessment and then planning of this
stage. This requires close evaluation and analysis of the risks that exist

and the resources required. It is during this time that a disaster plan
should be developed after a thorough hazard vulnerability analysis
(HVA). Nurses should assist with the HVA in this phase.
Throughout history, and in modern day disaster settings, there are
often secondary disease processes that infiltrate a disaster zone, particularly in events that occur in developing countries. As nurses, one of the
interventions that should be implemented is that of vaccination. When
a disaster causes gross displacement of a population and results in
large-scale sheltering, there is greater risk of disease. Vaccinations
not only play important roles in disease management in such settings
but also help prevent pandemic events, such as influenza. Vaccinations
are not the only nursing practice that can mitigate disease in a disaster.
Basic knowledge of good hygiene practices, such as hand washing and
use of antiseptic solutions, are important in postdisaster settings
because they help to prevent the outbreak of communicable diseases.
During this phase nurses are highly involved in teaching the community and fellow health care practitioners.

Preparedness
During the preparedness phase, nurses should help develop the disaster
plan for their hospitals or working facilities. It is of utmost importance
that nurses during this phase are involved in the discussion of surge
capacity and patient care aspects of the developing disaster plan. In this
phase nurses should also develop plans for their own families and
encourage other medical personnel to do the same. Knowing that when
a disaster strikes, health care workers will be needed to provide medical
care, it is exceptionally important that all have a plan for their own families during this time.
The plans developed during the preparedness phase should be exercised regularly and include all parties that would be involved in a real
disaster. It is important that the first time response plans are enacted
not be during an actual disaster. Nurses should have a chance to practice their roles during drills in order to be competent in the tasks that
may be outside of their normal responsibilities.

Response
Nurses are vital during the response phase. Due to the number of nurses
in the health care field, they will carry out the majority of the care delivered to the injured or ill. To be successful in this phase, nurses must
have a basic understanding of the disaster plan, as well as the pathophysiology of the unique diseases and injuries they may encounter.
Nurses will be responsible not only for direct patient care, but also
for patient flow, surge capacity operations, and the utilization of
resources. The available supplies may be limited and require careful distribution and rationing. With potentially limited resources, nurses will
need to be flexible and adaptable in order to optimize the quality of care
delivered to the affected masses. Having a firm understanding of
expected disaster operations and the ICS system within the facility
or community will allow nurses to be more efficient and effective in
their individual roles.
Another important role nurses may be asked to perform during this
time is that of disaster triage. Triage is a skill set that nurses routinely
exercise and therefore they are well suited to take on this role in a disaster. Disaster triage using the simple triage and rapid treatment
(START) technique and the traditional nursing emergency severity
index (ESI) triage used in the United States looks to prioritize patients
based on acuity. However, in disaster triage there is the addition of the
deceased/expectant category, where an individual has either expired or
will likely die despite medical interventions. During a disaster it is
necessary to sort the overwhelming patient population by acuity and
prioritize their medical care. The WHO defines disaster triage as a

CHAPTER 5 Disaster Nursing

process designed to prioritize casualty care to ensure care is available to
those who need it most urgently and that the greatest number of casualties survive.9 During disaster triage, nurses must prioritize care to
optimize resource utilization and ensure that the greatest number of
patients survive.

Recovery
After a disaster occurs communities must return to their normal state.
This process may overlap with the response phase. During this phase
communities start to heal and rebuild. The length of this phase can vary
considerably based on the type of disaster. The recovery process will
include significantly more than the rebuilding of structures and reestablishment of the physical appearance of the community. Nurses
should be aware and in tune with the needs of their patients during this
phase. The immediate drama and high profile of the relief responses
can absorb and exhaust compassion and support, leaving the ongoing
recovery phase without the required critical attention and funding.
Thus long-term health and socioeconomic consequences are not
reduced and may even result in a secondary disaster.10 While the
community rebuilds physically it is essential for nurses to closely
observe how their communities heal mentally, emotionally, and physically and assist in this process. Although usually not the primary
victims of disaster, health care workers must be vigilant about stress
debriefing and their own personal recovery.
The disaster cycle is a continuum. Part of the recovery phase is personal reflection in order to function successfully at home, at work, and
in future disasters. We must not forget, but we must also look back and
learn. Shortcomings in prior disaster preparation and response should
be looked at as the framework for developing an ever-growing skill set
and improvement in future responses.

NURSING ROLES WITHIN DISASTER RESPONSE

Nurses who wish to participate in disaster response have a number of
different organizations where they would be welcomed and their work
would be beneficial. Local programs such as the Medical Reserve Corps
and the American Red Cross take volunteers to assist in domestic
responses. These organizations are exceptionally important when
disasters occur locally. Nurses are more effective when responding
as part of an organization, due to the clear direction and support
provided.11 By having nurses and other medical professionals precredentialed, there is an additional workforce that can be called upon to
assist in disaster responses.
Another opportunity for nurses who wish to be involved in disaster
response is through the National Disaster Medical System (NDMS).
NDMS is a federally run program that responds during peacetime to
disasters that occur nationally and occasionally internationally.12
Within NDMS there are two agencies that utilize nurses in their disaster
response: the Disaster Medical Assistance Team (DMAT) and the
International Medical Surgical Response Team (IMSURT). These
teams are regionally or state based, with most states having at least
one DMAT. These teams will deploy within the United States when
called up by federal orders.
For nurses with the desire to expand their skills beyond the border
of the United States there are many organizations that provide disaster
and humanitarian aid internationally. These organizations provide
medical care, relief, and recovery during times of need in foreign countries. Most of these organizations provide information, training, and
education prior to deployment. They deploy to areas with long-term
needs as well as areas in crisis. Volunteering on an international level
takes nurses further outside their comfort zones and stresses their

29

ability to adapt to unfamiliar and often austere conditions. The sharp

learning curve required to be successful in such an environment allows
nurses to return strengthened in their routine roles. Such experiences
provide nurses the opportunity to grow further as practitioners and
exercise their critical thinking skills, even more so than perhaps they
do in their day-to-day jobs.
As described above, for those with an interest there are a multitude
of organizations and opportunities for nurses to volunteer their time in
the arena of disaster medicine. Nurses play an important role in all
aspects of the disaster cycle and therefore play an integral role in the
responding agencies.

PITFALLS
At present, the major pitfalls for nurses in disaster are the lack of overall
disaster-related education and the absence of nurse involvement in the
planning and drilling stages. The increased number of terrorist attacks
combined with the ongoing occurrences of natural disasters brings to
light the need for more training and education of nurses, so that they
might assist in all phases of the disaster cycle. Incidents such as the
Oklahoma City Bombing, 9/11, Hurricane Katrina, the Haiti earthquake, the Boston Marathon Bombing, and Typhoon Haiyan in the
Philippines required nurses with emergency and critical training to step
out of their normal roles. Nurses were on the front line of the 2014
Ebola outbreak and will continue to be on the front line in similar disasters long into the future. It is therefore important that nurses who
respond and deploy to areas affected by disaster have the required
training to be successful in caring for their patients. This training
should include how to respond medically to injuries or disease processes that may be encountered, as well as having an understanding
of how the ICS operates. Having nurses involved in the mitigation
and planning phases allows them to have an understanding of the roles
they may be asked to fill and the resources required to face disaster.
The ever-rising number of disasters makes it even more apparent
that the education routinely provided to nurses is grossly inadequate.
As identified in a study conducted in the 2000-2001 academic year,
which looked at 348 nursing programs in the United States, 32.7% of
the programs included a disaster nursing curriculum. In the post-9/11
world of nursing and disaster education, this number rose only marginally to 53%.13 As shown in this study, the basic education surrounding
disaster nursing is lacking. Although some would argue that the topic
of disaster nursing is very specific and does not have a place in the fundamentals of nursing, experts in disaster nursing would disagree. It is
necessary for all nurses to have a basic awareness of disaster mitigation,
preparedness, response, and recovery. While this information will provide a rudimentary understanding of disasters, one must have a more
in-depth competence surrounding the practices of disaster nursing.

CONCLUSION
All levels of medical providers practice disaster medicine, including
physicians, nurse practitioners, physician assistants, nurses, paramedics, and emergency medical technicians (EMTs); therefore an integrated, multidisciplinary response is imperative. This can only be
accomplished by education at all levels, including nursing, and the
inclusion of nurse education and participation in all phases of the disaster cycle. Because nurses make up the majority of the health care workforce worldwide, they will most assuredly play a pivotal role in future
disasters. Whether due to volunteer deployment to a region recently
affected or a mass casualty incident in their hometown, nurses will need
a fundamental knowledge of disaster preparedness and response.

30

SECTION I

Introduction

REFERENCES
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