Nurse Education in Practice xxx (2014) 1e5

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

“Skip the infection, get the injection”: A case study IN emergency

preparedness education
Lavonne M. Adams*, Sharon B. Canclini, Pamela Jean Frable
Texas Christian University, Harris College of Nursing & Health Sciences, TCU Box 298620, Fort Worth, TX 76129, USA

a r t i c l e i n f o a b s t r a c t

Article history:
Accepted 27 December 2013
Keywords:
Emergency preparedness education
Disaster preparedness education
Public health preparedness
Emergency preparedness competencies
Disaster preparedness competencies
The frequency of natural and manmade disasters along with increasing potential for public health
emergencies emphasizes the need for emergency preparedness education. Because nurses are the largest
group of health professionals to meet the needs of those affected by disasters and public health emer-
gencies, schools of nursing need to prepare graduates who are knowledgeable about disaster and public
health emergency management. The use of core competencies may be a means to ensure consistent
application of best practices in disaster health care. The next step in competency development involves
validation through evidence. Through documentation and dissemination of their experiences with
emergency preparedness education, schools of nursing can provide supportive evidence to aid in com-
petency development. The purpose of this paper is present a case study of an ongoing and evolving
public health nursing education project consistent with disaster health care and emergency prepared-
ness competencies.
Ó 2014 Elsevier Ltd. All rights reserved.

Introduction
The frequency of natural and manmade disasters along with
increasing potential for public health emergencies emphasizes the
need for emergency preparedness. A disaster may be described as a
“destructive event that disrupts the normal functioning of the
community” (Veenema and Wooley, 2013, p. 3) and can be caused
by natural or environmental forces or by man-made forces
including disease (Veenema and Wooley, 2013). Emergency pre-
paredness has been described as “the comprehensive knowledge,
skills, abilities, and actions needed to prepare for and respond to
threatened, actual, or suspected chemical, biological, radiological,
nuclear or explosive incidents, man-made incidents, natural di-
sasters, or other related events” (Slepski, 2005, p. 426). Prior
planning and coordination among knowledgeable health pro-
fessionals are essential to effective disaster response, particularly
for large-scale events, and require emergency preparedness edu-
cation. Nurses comprise the largest group of health professionals to
meet needs of those affected by disasters and public health emer-
gencies, so it is crucial for schools of nursing to prepare graduates
who are knowledgeable about disaster and public health emer-
gency management. Curricula are crowded, however, and the
essential content for disaster nursing education has yet to be clearly
delineated (Gebbie et al., 2012; LittletoneKearney and Slepski,
2008). The use of core competencies has been suggested as a
means to ensure consistent application of best practices in disaster
health care and significant progress has been made in competency
identification (Gebbie et al., 2012; Walsh et al., 2012; James et al.,
2010; Jakeway et al., 2008). The next step in competency devel-
opment involves validation through evidence and schools of
nursing can provide supportive evidence through documentation
and dissemination of their experiences with emergency pre-
paredness education. The educational approach described in this
paper was designed within a public health nursing framework;
upon additional examination, the project is consistent with
recently proposed, broad-based disaster medicine and emergency
preparedness competencies (Walsh et al., 2012) and can lend
support for their relevance to disaster health care. The purpose of
this paper is to present a case study of an ongoing and evolving
public health nursing education project that is consistent with
disaster health care and public health preparedness competencies.
Literature review
Nursing students and emergency preparedness

* Corresponding author. Tel.: þ1 817 257 6805; fax: þ1 817 257 7944.
For nurses to be proficient in providing care during disasters and
E-mail addresses: L.adams2@tcu.edu (L.M. Adams), S.canclini@tcu.edu public health emergencies, schools of nursing must include
(S.B. Canclini), P.frable@tcu.edu (P.J. Frable). educational opportunities that introduce students to concepts of

1471-5953/$ e see front matter Ó 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.nepr.2013.12.004

Please cite this article in press as: Adams, L.M., et al., “Skip the infection, get the injection”: A case study IN emergency preparedness education,
Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2013.12.004
2 L.M. Adams et al. / Nurse Education in Practice xxx (2014) 1e5
preparedness and disaster nursing. Despite crowded curricula,
nurse educators can strategically develop emergency preparedness
exercises for students that will help achieve competence in these
areas, as well as evidence based practice, role socialization, and
clinical reasoning. Ultimately, nursing students should be prepared
to think about how they, as professional nurses, will one day fit into
the larger community during a disaster event and how they can
serve as valuable assets within that community.
Many schools of nursing participate in immunization clinics
(Schutt and Parker 2006; Evenson et al., 2005; Kemsley and Riegle,
2004), conduct health fairs for the community (Adams and
Canclini, 2008; Maltby, 2006), or teach disaster nursing through
the use of drills and simulations (Kako et al., 2012; Warland et al.,
2012; Hutchinson et al., 2011; Kaplan et al., 2011; Morrison and
Catanzaro, 2010). Some schools develop elective disaster health
care training courses, which may be nursing-specific or interpro-
fessional. Nursing students from a variety of nursing programs in
China participated in a pilot training program that included role
play and skill training (Chan et al., 2010; Pang et al., 2009). In Tor-
onto, Canada, five different educational institutions with nursing,
medicine, paramedicine, police, media, and health administration
programs offered a voluntary online training program culminating
in a high-fidelity mass casualty simulation (Atack et al., 2009).
In yet another approach, other schools have gone so far as to
incorporate disaster preparedness and response participation as
part of ongoing serving learning. Nursing students from Purdue
have partnered with family health clinics over a three year period
to provide care to survivors of Hurricane Katrina (Richards et al.,
2009). The University of South Carolina College of Nursing
formed a Medical Reserve Corps in collaboration with the Uni-
versity’s health services (Culley, 2010). The University of Texas
School of Nursing formalized its disaster preparedness and
response program by creating a Memorandum of Cooperation be-
tween the city of Austin and The University of Texas at Austin to
provide trained volunteers to meet community health care needs
during a disaster (Pattillo and O’Day, 2009). Regardless of the
approach, it is crucial to align emergency preparedness education
with appropriate competencies.
Competencies for emergency preparedness
As emergency preparedness planning has become a greater
priority for communities, health care professionals have begun to
identify core competencies essential to the delivery of care during
disasters or public health emergencies (Gebbie et al., 2012; Walsh
et al., 2012; Jakeway et al., 2008). Because various subsets of
health professionals have differentiated skills essential for delivery
of care during disaster events, it is important to identify compe-
tencies specific to these professionals (James et al., 2010). An
example of this is a position paper in which the Association of State
and Territorial Directors of Nursing (ASTDN) offers guidance in how
the expertise public health nurses can contribute to community
health and safety during disasters by describing how selected
emergency preparedness competencies apply specifically to public
health nurses (Jakeway et al., 2008).
Experts advocate for disaster medicine and public health pre-
paredness becoming recognized as a “discipline for all health pro-
fessionals” (James et al., 2010, p.102). Thus, broadly-based
competencies applicable to a variety of health professionals have
been proposed (Walsh et al., 2012). Not all nursing students will
become public health nurses; however, all of them will be part of a
profession that must respond to disasters. Therefore, even when
the focus of a specific course or project is on the use of the public
health framework and interventions, the emphasis for their future
practice must be broad and should include awareness both of
Please cite this article in press as: Adams, L.M., et al., “Skip the infection, get the injection”: A case study IN emergency preparedness education,
Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2013.12.004
discipline-specific and cross-professional competencies. The
recently-proposed disaster medicine and public health prepared-
ness competencies (Walsh et al., 2012) therefore have great po-
tential to be helpful in planning for emergency preparedness
education for nursing students.
Background
For several years, Texas Christian University held a seasonal
influenza immunization clinic for students, staff, and faculty using
an outside agency to contract nurses to administer vaccines.
Inconvenient hours and long lines led to low vaccination rates and
disgruntled participants. The University began to reconsider its
approach and in 2007, a member of the public health nursing fac-
ulty was approached with the request that nursing students
administer the vaccinations.
Although many nursing programs organize students to partici-
pate in an existing plan to deliver immunizations, the public health
nursing faculty recognized a service learning opportunity that
would enable senior level nursing students to plan, implement, and
evaluate a significant public health project. Participation in this
project allows students to develop expertise in public health
nursing and practice leadership and management skills, simulta-
neously meeting the needs of the campus community for an
effective, efficient vaccination clinic. The pilot clinic of Fall 2007
demonstrated to stakeholders that nursing students have the ca-
pacity to manage a large, campus-wide clinic. Since the initial pilot,
the project has grown into an annual event led by public health
nursing students that is attended by over 2500 students, faculty,
and staff. As time has gone on, it has become apparent that in
achieving the learning outcomes of the project, the nursing stu-
dents have been able to meet several core competencies for disaster
health care. Although the project is specifically designed with the
use of nursing frameworks, its learning outcomes can also be
shown to be consistent with core competencies that have been
proposed for the growing field of disaster medicine and public
health (Walsh et al., 2012).
Design
The project was developed as a service learning project capable
of meeting both student educational needs and community (Uni-
versity) health needs. The purpose of the ongoing project is to
1. Develop expertise in public health nursing leadership and
management skills consistent with disaster health care/public
health core competencies
2. Plan a community-wide influenza educational outreach pro-
gram and immunization clinic
3. Implement a community-wide influenza educational outreach
program and immunization clinic
4. Evaluate a community-wide influenza educational outreach
program and immunization clinic
Learning outcomes
In this service learning project, nursing students gain first-hand
experience in how a goal from a national public health agenda can
be facilitated through use of appropriate interventions and legal
and ethical boundaries for professional practice. Specifically, the
students refer to the immunization objective from Healthy People
2020 (United States Department of Health and Human Services,
2013) and design interventions based on a public health interven-
tion model within the boundaries of professional practice. The
 L.M. Adams et al. / Nurse Education in Practice xxx (2014) 1e5 3

interventions required to meet such learning outcomes are rooted
in the Public Health Intervention Wheel (Public Health Nursing
Section, 2001), while the boundaries in which students practice
during the project are delineated by Public Health Nursing Scope and
Standards of Practice (American Nurses Association, 2013).
While conducting the project, nursing students learn numerous
public health nursing concepts and skills and demonstrate learning
outcomes in such areas as community assessment for areas of
vulnerability, risk communication, social marketing, budgeting,
program design for people with limited English proficiency, and
emergency preparedness planning (see Table 1). Ultimately,
although the project was specifically designed with the use of
nursing frameworks, achievement of the project’s learning out-
comes is also consistent with core competencies for disaster
medicine and public health (Walsh et al., 2012). Table 1 provides a
comparison of learning outcomes with disaster medicine and
public health preparedness core competencies. The comparison
was undertaken to show how a discipline-specific public health
preparedness project can support cross-professional competencies
proposed since the inception of the project.
The students assume leadership and responsibility for assessing
the community as well as for planning, implementing, and evalu-
ating the annual clinic, although faculty are available throughout
the project to provide support and expert guidance as needed. For
example, as students explore how to obtain needed items from
potential suppliers, the faculty may provide suggestions on how
best to approach the suppliers. The faculty may also provide
advanced notice to the suppliers, letting them know that students
will be approaching them about a sanctioned university project.
The initial contact from faculty paves the way for the students’
contact to be given greater credence and gives opportunity for the
students to build relationships and practice negotiation. Another
example of faculty support and guidance involves “just in time”
training provided to additional student volunteers. The senior level
students responsible for this training meet volunteers, determine
what they would like to do at the clinic, and whether they have
passed the appropriate skills masteries to allow them to administer
intramuscular injections. The senior level students then provide a
teaching session in which the required skills are reviewed. The
teaching session includes viewing of a video and posters as well as
hands-on demonstration and return-demonstration. The teaching
modalities are approved by faculty, the teaching sessions are su-
pervised by faculty, and coaching is provided by faculty if needed;
however, the lead role in interacting with the volunteer students is
assumed by the senior students. Once the volunteer students have
completed the “just in time” training, they are placed with, moni-
tored by, and coached by a more experienced student, with addi-
tional supervision and coaching provided by faculty circulating

Table 1
Learning outcomes and related disaster health care and public health preparedness competencies.

Examples of learning outcomes Related disaster health care and public health preparedness competencies

Community & Population Assessment: Core Competency 8: “Demonstrate knowledge of public health principles and
Assessed campus community to identify at risk populations practices for the management of all ages and populations affected by disasters
Assessed trends of circulating influenza virus in greater community and public health emergencies” (Walsh et al., 2012, p. 50)
Leadership Skills:
Assessed, planned, organized, and implemented annual immunization clinic for
campus community
Assessed, planned, organized, and implemented pre-event educational
campaign
Assessed, planned, organized, and implemented social marketing campaign
Developed just-in-time training program for clinic volunteers
Assumed leadership of project, offering direction and guidance to the
collaborating stakeholders while maintaining control of the project
development
Collaboration: Core Competency 2: “Demonstrate knowledge of one’s expected role(s) in
Worked with stakeholders to ensure clinic, education program, and marketing organizational and community response plans activated during a disaster or
met needs of all parties public health emergency” (Walsh et al., 2012, p. 50)
Developed plan of action for clinic with stakeholders
Health Promotion & Risk Reduction: Core Competency 4: “Communicate effectively with others in a disaster or
Developed and delivered health education initiatives (examples: cough public health emergency “ (Walsh et al., 2012, p. 50)
etiquette, hand washing, influenza prevention train-the-trainer program for
Resident Advisors, educational posters)
Performed outreach to at-risk and key community members (examples: health
literacy needs addressed for ESL community members, prevention program
provided for student leadership)
Developed emergency communications plan including “silent operations”
through use of color-coded flags to initiate response
Information & Health Care Technology: Core Competency 5: “Demonstrate knowledge of personal safety measures that
Searched for current research and guidelines related to project can be implemented in a disaster or public health emergency” (Walsh et al.,
Integrated current evidence and guidelines into project (examples: gloveless 2012, p. 50)
procedure, intramuscular injection technique, adverse reaction response) Core Competency 7: “Demonstrate knowledge of principles and practices for the
clinical management of all ages and populations affected by affected by disasters
and public health emergencies” (Walsh et al., 2012, p. 50)
Delegation: Core Competency 6: “Demonstrate knowledge of surge capacity assets,
Developed just-in-time training program for volunteers consistent with one’s role in organization agency, and/or community response
Mentored volunteers until assured of practice and understanding of clinic plans” (Walsh et al., 2012, p.50)
routine
Treated clinic as a Point of Distribution
Implemented creative solutions to maximize availability of physical resources
while minimizing expense (examples: modified and refurbished library cart
adapted for use as a mobile supply cart, dollar store items used for
organization of administration tables, obtained in-kind services or financial
assistance from community partners)

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4 L.M. Adams et al. / Nurse Education in Practice xxx (2014) 1e5
through the clinic. As senior students identify needs for perfor-
mance improvement on the part of student volunteers, faculty are
available to consult on the best method to provide feedback.
Although faculty will intervene if necessary, the senior level stu-
dents take the lead as much as possible. In essence, the faculty have
created an infrastructure and safety net within which the project
occurs, allowing the students to take on leadership roles as well as
learning roles.
Project outcomes
The student-led annual clinic provides opportunity for students,
staff, and faculty to receive the influenza vaccine. The clinic has
grown so that over 2500 doses of seasonal influenza vaccine are
administered within 6e7 h each year, with an average queue time
of 5 min or less. Participant evaluations indicate satisfaction with
the process. Additionally, through a variety of educational outreach
opportunities and social marketing strategies devised by the
nursing students, the community learns about the importance of
vaccination and other influenza prevention methods.
Discussion
The clinic and accompanying educational programs evolve with
each new student cohort. Each cohort approaches the project
differently, with new learning opportunities, improvements, and
innovations taking place each year based on previous years’ eval-
uations and creative thinking on the part of the new cohort. Ex-
amples of student-suggested improvements and innovations
include
 Encouraging participation in the clinic through entry into a
drawing for a substantial incentive item such as a football ticket
prize package
 Utilizing an evaluation tool to assess effectiveness of marketing
and educational programs
 Utilizing the evaluation process as an opportunity to delay
participants’ leaving in order to assess them for adverse reaction
post-vaccination
 Encouraging participation in the evaluation process through use
of small incentive items such as pocket-size hand sanitizers
 Providing an “I was vaccinated” sticker to participants to
heighten awareness of the event throughout the campus and to
make assessment of the participant easier in the event of a
reaction
 Developing multi-stage inventory assessment timelines and
guidelines
 Developing effective “Just In Time” training for additional stu-
dent volunteers
 Establishing silent operations with color-coded flags to initiate a
response (for example, “white” indicates need for supplies at a
station, “blue” indicates immediate response needed from fac-
ulty and/or emergency medical services personnel)
Faculty who facilitate the clinic annually have discovered that
students often have a difficult time building upon work of previous
student cohorts due to ethical concerns that doing so will be
considered cheating The students are unaccustomed to projects
that allow or even require them to build on previous practices.
Unless they are explicitly given permission to use strategies that
have been effective in past clinics, students are likely to try to build
the clinic from the ground up rather than be accused of cheating.
Faculty now openly discuss with students how “building upon the
past” can be done appropriately and effectively through dissemi-
nation of historical information, collaboration, seeking permission
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Nurse Education in Practice (2014), http://dx.doi.org/10.1016/j.nepr.2013.12.004
to replicate as needed, and improving processes as needed. Process
improvement requires critical evaluation of previous strategies for
inclusion or exclusion, and students also need permission to drop
or modify elements of previous clinic versions that they do not
believe to be effective. Faculty also encourage students to develop
ownership of the project, so each group of students make an effort
to develop a unique brand for “their” clinic, whether in the form of
a logo or slogan for each year.
In recent years, the project has included explicit emergency
preparedness training into the immunization clinic. As students
become familiar with the Public Health Nursing: Scope and Standards
of Practice (ANA, 2013), they identify the boundaries of practice as
well as the legal and ethical parameters of working in the com-
munity during times of disaster or emergency. As the students
consider the concept of immunization from a national health
strategy perspective, they look to Healthy People 2020 (US DHHS,
2013), which addresses immunizations, infectious diseases, and
emergency preparedness. The students pay particular attention to
objectives that focus on increasing influenza vaccinations (IID 12.5)
and identify agencies that support this effort, specifically the Cen-
ters for Disease Control and Prevention (CDC) and the Occupational
Safety and Health Administration (OSHA). The students also review
the topic area of Preparedness (P4), which they ultimately use as a
basis for evaluation of the current project and recommendations for
the future.
Faculty members have created a simulation scenario that com-
bines planning for an annual event with essential elements of
emergency preparedness. While they plan the project, students are
expected to respond to a scenario in which the local Public Health
Department has announced an influenza pandemic and has
requested the College of Nursing to open a Point of Distribution
(POD) on the campus with the goal of dispensing up to 4000 doses
of vaccine safely, effectively, and efficiently during a 1-day opera-
tion. The students are expected to address all the logistics, social
marketing, and community education that allow this goal to be met
within the limitations of parameters established by the faculty.
Parameters specifically address clinic budget, number of assigned
students, queue time, maintenance of a calm clinic environment,
administration procedure, orchestrated intake and throughput
process, and effective documentation, Because it is an emergency
scenario, time and funding are of the essence and students must
develop creative solutions for simple to complex concerns. Addi-
tionally, the nursing students must quickly meet the educational
requirements to protect the community until vaccines are deployed
and simultaneously meet the marketing and clinic development
requirements to make the mass immunization clinic a success.
When the clinic is completed, the students develop a mock “after
action” report that includes recommendations for improvement
based on the Preparedness (P4) recommendation. The addition of
this scenario encourages translation of the current “today” activity
of immunization to a “tomorrow” skill for the futuredplanning to
participate in emergency preparedness and response as a health
professional.
Conclusions
The annual student-led project encompassing outreach educa-
tion for influenza prevention and seasonal influenza immunization
clinic has been successfully sustained since 2007. It has evolved into
an ongoing example of a combination of service learning with
public health nursing that enables students to take leadership for a
comprehensive program requiring attention to evidence, safety,
effectiveness, and efficiency. The project was designed within a
nursing framework and is also consistent with cross-professional
core competencies for disaster medicine and public health
 L.M. Adams et al. / Nurse Education in Practice xxx (2014) 1e5
preparedness proposed since the project’s inception. This consis-
tency provides support for the relevance of core competencies in
the educational process for emergency preparedness.
Acknowledgments
The authors wish to acknowledge the nursing students who
have contributed to this student-led project since 2007.
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