The Role of the Public Health Nurse

In Disaster

Preparedness, Response, and Recovery

APositionPaper

AssociationofPublicHealthNursesPublicHealthPreparednessCommittee

January2014

*Thisisthe2ndeditionofanAssociationofPublicHealthNurses(APHN)PositionPaper,firstpublishedin2007underAPHN’spreviousname:AssociationofStateandTerritorialDirectorsofNursing(ASTDN).The1steditionwassupportedbyASTHO'sCooperativeAgreementtoImprovetheNation'sPublicHealthInfrastructurewithStatePublicHealthAgencies/Systems,awardnumberU50/CCU313903-8-4,fromtheCentersforDiseaseControlandPrevention(seereferences).**Thisdocumentisbasedonupdatedinformationwithinputfromthefirsteditionauthors,externalreviewers,andtheQuadCouncilmembers,acoordinatingorganizationoffournursingorganizationsfocusedonpublic/communityhealthnursing:ACHNE,ANA,APHA,andAPHN.***ReferencelinksupdatedinOctober2015

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ExecutiveSummaryNosinglediscipline,agency,organizationorjurisdictioncanorshouldclaimsoleresponsibilityforthecomplexarrayofchallengesassociatedwithdisasters,whethercausedbynature,humans,orsomecombinationofboth.Eachentity,though,mustunderstanditsrespectiverole.PublichealthnursesplayanintegralroleinmeetingtheNationalPreparednessGoal.Indisasterpreparedness,response,andrecoveryoperations,publichealthnursesmustbeabletodowhattheydobest--populationbasedpracticeintheircommunities.Sometimes,though,thereisconfusionastowhatapublichealthnurseshouldandcandoinpreparedness,response,andrecoveryoperations.Thispositionpaperprovidespracticalguidanceacrossthedisasterlifecycleaswellasprovidingrespectiveresourcelinkages.Itisdesignedtoinformpublichealthnursesabouthowtoconducttheircriticalworkinadisasterwhilehelpingotherstounderstandthatwork.

Acknowledgements

TheAssociationofPublicHealthNurses(APHN)recognizesthatpublichealthnursespossessabroadrangeofpopulationbasedknowledge,skills,andnursingexpertisewhenitcomestodisasterpreparedness,response,andrecovery.Theoriginalpositionpaperontheroleofpublichealthnursesindisasterwaspublishedin2007(undertheAPHN’spreviousname:AssociationofStateandTerritorialDirectorsofNursing(ASTDN)byitsPreparednessCommitteemembershipatthetime.Usingthisprevioustemplate,the2013APHNPublicHealthPreparednessCommitteereviewedcurrentkeynationaldisasterdocuments,analyzedpublichealthandnursingdisasterrolesinrecentdisasters,analyzedthecurrentstateofcompetencyresearchandapplicablepracticemodels,andheldfocusgroupsfornursingandpublichealthinput.Theresultisthe2013TheRoleofPublicHealthNursesinEmergencyandDisasterPreparedness,Response,andRecovery.PositionPaperSubcommittee:

• SharonA.R.Stanley,PhD,RN,RS,FAANPreviousChiefNurse,AmericanRedCross,NationalHeadquarters,WashingtonD.C.andVisitingProfessor,CollegeofNursingandHealth,WrightStateUniversity,Dayton,OH-CommitteeCo-Chair

• SandraCole,RN,BA,ProgramManager,BureauofHealthEmergencyManagement,NewMexicoDepartmentofHealth,SantaFe,NM-CommitteeCo-Chair

• JudyMcGill,RN,MS,PublicHealthNurseCoordinator,OfficeofCommunityHealthSystemsandHealthPromotion,WestVirginiaDepartmentofHealth,Charleston,WV

• ClairMillet,MN,APRN,PHCNS-BC,DirectorofPublicHealthNursing,LouisianaDepartmentofHealth&HospitalsOfficeofPublicHealth,BatonRouge,LA

• DarleneMorse,RN,MEd,CHES,PublicHealthNurseProgramManager,BureauofInfectiousDiseaseControl,NewHampshireDepartmentofHealthandHumanServices,Concord,NH

Wethankallmembersofthe2012–2014PublicHealthPreparednessCommitteefortheirguidanceandinsight.WealsothankthemembersoftheQuadCouncilandothercolleagueswhoreviewedandofferedsuggestionsregardingthepaper.Aspecialthanksisdeliveredtoourtwoexternalreviewerswhoprovidedtheirexpertreviewforthefinalversion:KristineQureshi,PhD,RN,FAAN,andTenerGoodwinVeenema,PhD,RN,MPH,FNAP,FAAN.

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TableofContents

Acknowledgements…..…………………………………………………………………………………………..…. 2

Introduction….…………………………………………………………………………………………….…………… 4

PrinciplesforPHNpracticeindisaster………………………………………………………… 5

Vision...……………………………………………………….……………..………………………………… 5

Purposeanduse……………………………….………………………………………………………….. 5

PHNRoleinDisaster….………………………………………………………………..……………………..……. 5

DefinitionandscopeofPHNpractice...…………………………….……………….…….…… 5

Puttingitalltogether..……………………………….…………………………………..…….……… 6

Linkingcomponentsofthenursingprocesswiththedisastercycle…..……..…. 6

CompetencyforDisasterPractice…….…………………………...……………………………………...… 9

PublicHealthPreparednessandResponseCoreCompetencies…..…….……….… 9

ICNFrameworkofDisasterNursingCompetencies…….………………….….….……… 10

LeadershipPlanningandPolicyDevelopment..…………..………………………………………….... 11

Leadershipcollaboration…..………………………………………………………………………….. 11

Metaleadership(crisisleadership)………………..…….…..…………………………………… 12

LegalandEthicalIssues…..………………………………..………………………………………………………. 13

Licensure,geographicboundaries,anddutytorespond…….…………………………. 13

GoodSamaritanLaw..………………………………………….………………………………………… 13

Existingprotections…..…………………………………………………………………………………… 13

Summary ………………………………………………………………………………………………………….. 14

RecommendedReadingandKeyDocuments………………………………………………...…..….. 15

References …………………………………………………………………………………………………..…..…. 17

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The Role of Public Health Nurses

In Disaster Preparedness, Response, and Recovery

APositionPaper

IntroductionPreparingfor,respondingto,andrecoveringfromdisastersisapublichealthprioritythatmustbeaddressedinanenvironmentofconstrainedresources.FlorenceNightingaledemonstratedtotheworldtheimportantroleofnursesonthefrontlinesofwar-relateddisaster,andnursescontinuetogrowthesecapabilitiesinthe21stCentury.Publichealthwasaffordedtheopportunitytogreatlyincreasecapacityacrossthedisastercycleinthecommunitysectorwithdedicatedresourcesintheearly2000s.Itwasatimeofsolidgrowthforpublichealthandpublichealthnursingintermsofassuringcommunityresilienceatthelocal,state,andnationalsectors.Publichealthmustnow,morethanever,expertlyengageitsinternalandexternalpartners,aswellasitscommunities.Nosinglediscipline,agency,organizationorjurisdictioncanorshouldclaimsoleresponsibilityforthecomplexarrayofchallengesassociatedwiththedisaster,whethercausedbynature,humans,orsomecombinationofboth.Publichealthnurses(PHNs)playanintegralroleinmeetingtheNationalPreparednessGoal,apartoftheNationalPreparednessSystem:“Asecureandresilientnationwiththecapabilitiesrequiredacrossthewholecommunitytoprevent,protectagainst,mitigate,respondtoandrecoverfromthethreatsandhazardsthatposethegreatestrisk(FEMA,2013).“Nursingand,specifically,publichealthnursingpracticemustremainaconstantacrossthenationalplanningframeworkanditsdisastercycleofpreparedness(prevention,protection,mitigation),response,andrecovery.TherecognitionofPHNs’population-basedskillsintimesofdisasterisanextremelyimportantpartofournationalcapacityforresponse.Publichealthnursesshouldnotbesimplyviewedasacutecare(i.e.,hospital)replacementsorfirstresponderextenders(e.g.,triagepersonnel)inamasscasualtyenvironment.ThisisnottosaythatPHNscannotdothesefunctionsifeducated.Indeed,allhealthprofessionalsmaybecalledupontoexpandinnon-routinepracticeareasduringacatastrophicresponse.Aboveall,though,indisasterpreparedness,response,andrecovery,PHNsarebetterusedforservicestheydobest,namelypopulationbasedpracticelikerapidneedsassessmentsofcommunitiesimpactedbytheincident,population-basedtriage,massdispensingofpreventiveorcurativetherapies,communityeducation,providingcareormanagingsheltersfordisplacedpopulationsand,ofcourse,provisionofongoingcontinuityinessentialpublichealthservices.Publichealthnursespossesstheskillsandknowledgetodevelopdisasterpoliciesandcomprehensiveplans,andtoconductandevaluatepreparednessandresponsedrills,exercisesandtrainings.Theyareintegralmembersinresponseoperationsandcommandcenters,in

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leadershipandmanagementroles,aswellasinthefieldwheretheyprovidefrontlinepopulationhealthandcorepublichealthservices.ThePHNisalsoadeptincollaboratingwithotherexperts,includingenvironmentalists,epidemiologists,laboratorians,biostatisticians,physicians,socialworkers,andothernurses.Interprofessionalpracticeisrequiredtoenhancepreparedness,response,andrecoveryatthelocal,regional,state,nationalandgloballevels.Strongsystemsandmodelsareneededtomaximizethecollaborationoffirstresponders,healthcareprofessionals,andvolunteers.PrinciplesforPHNpracticeindisaster1.Publichealthnursingrolesindisastersareconsistentwiththescopeofpublichealthnursingpracticeandarearticulatedspecificallyinthosestandardsandscope(ANA,2013).2.ThecomponentsofthenursingprocessalignwiththeNationalPlanningFrameworkphasesofpreparedness(prevention,protection,mitigation),response,andrecovery(ANA,2010;FEMA,2013).3.CompetenciesprovideaframeworkfordefiningPHNroleandstandardsofpracticeacrossthedisastercycleandthesecompetenciesincludethosefrompublichealthnursing,disasternursing,disasterpublichealth,andcompetenciesspecifictopublichealthnursespracticeindisasters(ASPH,2010;ICN2009;QuadCouncil,2011).4.Publichealthnursesbringleadership,policy,planning,andpracticeexpertisetodisasterpreparedness,response,andrecovery.VisionPublichealthnurseswhounderstandtheirdisasterrolesinlightoftheirscopeofpracticeandtheNationalPlanningFrameworkswillbereadyforpracticeacrossthedisastercycle,advocatingforandworkingbesidethewholecommunity.PurposeandusePublichealthnursingpracticefocusesonpopulationhealththroughcontinuoussurveillanceandassessmentofthemultipledeterminantsofhealthwiththeintenttopromotehealthandwellness,preventdisease,disability,andprematuredeath,andimproveneighborhoodqualityoflife(ANA,2013:2).Thispositionpapertargetsthefollowingaudiences:1)publichealthnursesatlocal,regional,andstatelevels;2)disasterpartnersinordertobettercoordinateefforts;and3)stakeholderswhoneedtounderstandPHNpracticeindisastersituations.

ThePublicHealthNursingRoleinDisasterPreparedness,Response,andRecoveryDefinitionandscopeofPHNpracticePublichealthnursingis“thepracticeofpromotingandprotectingthehealthofpopulationsusingknowledgefromnursing,social,andpublichealthsciences(AmericanPublicHealthAssociation,PublicHealthNursingSection,2013,p.1).”

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Societalandpoliticalchangesleadingintothe21stcenturyhaveenhancedtheevolutionofidentifiedthreatstothehealthofthepopulation.Thesethreatshavebeenidentifiedas:(1)re-emergenceofcommunicabledisease;(2)environmentalhazards;(3)physicalorcivicbarrierstohealthylifestyles;(3)overallconcernaboutthestructureandfunctionofthehealthcaresystem;(4)modernpublichealthepidemics,suchaspandemicinfluenza,obesity,etc.;and(5)globalandemergingcriseswithincreasedopportunitiesforexposuretomultiplehealththreats(ANA,2013,pp.1-2).Thesethreatshavecreatedacrucialshifttowardspublichealthall-hazardspreparedness.Duringadisaster,PHNscontinuetoadheretotheeightprinciplesofpublichealthnursingpractice(QuadCouncil,2011)andthecorefunctionsofpublichealth(IOM,2002).PuttingitalltogetherPublichealthnursesworkattheindividual,family,community,andsystemslevelstopromotehealthandpreventdiseasewiththeultimategoalofhealthypeopleinhealthycommunities.Theybringcriticalexpertisetoeachphaseofthedisastercycle:preparedness(prevention,protection,andmitigation),responseandrecovery.Theyhaveauniqueskillsetandanabilitytolinksystemsthatarevitaltothedisastercontinuumtoinclude,butnotlimitedtodiseasesurveillance,diseaseandhealthinvestigation,casefinding,rapidneedsassessment,publichealthtriage,massprophylaxisandtreatment,collaboration,healthteachingandprovidereducation,communityorganizing,outreachandreferral,populationadvocacyandpolicydevelopment.Publichealthnursing’sabilitiesarecriticalforpopulation-basedcareacrossthedisastercycle.Publichealthnursesareknowledgeableaboutthediversecommunityresourcesthatareavailable,aswellaswhatgapsmayexistincommunityservices,before,duringandafteradisaster.Thus,thePHNhasauniqueawarenessofthevulnerablepopulationsinthecommunity,andwhomaybeatheightenedrisk.APHN’sclinicalknowledgeinmultipledeterminantsofhealthandepidemiologyandwell-honedcommunityassessmentskillsserveacrucialroleindisasterpreparedness,response,andrecovery.Resilientcommunitiesareabletorecoverfromadverseevents.Publichealthnurseshelpfurtherresilienceincommunitiesduringdisasterswiththeirdiverseskillsets.Theyassistpopulationstoovercomegreatadversityandstressthatoftenoccurindisaster(s)byfacilitatingindividuals,familiesandcommunitiestouseavailableresourcestorespondto,withstand,andrecover.LinkingcomponentsofthenursingprocesswiththedisastercycleToclarifytherelationshipbetweenPHNpracticeandphasesofadisaster,Table1illustrateshoweachstepofthenursingprocessispracticedduringeachphaseofthedisastercycle.Thistablecanbeusedtoeducateandinformnurses,partners,andstudentsaboutthepotentialroleofPHNsacrossthedisastercycle.

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Table1:THEDISASTERCYCLELINKEDTOTHENURSINGPROCESS

EXAMPLESOFEACHDISASTERPHASEALIGNEDWITHTHENURSINGPROCESSv

Preparedness,responseandrecoveryfocusesonthepublichealthinfrastructureneededtomonitortheenvironment,

assesspopulationneeds,andallocateresourcesintimesofdisaster.

vBASEDONJAKEWAY,C.,LAROSA,G.,CARY,A.&SCHOENFISCH,S.(2008).THEROLEOFPUBLICHEALTHNURSESINEMERGENCYPREPAREDNESSANDRESPONSE:APOSITIONPAPEROFTHEASSOCIATIONOFSTATEANDTERRITORIALDIRECTORSOFNURSING.PUBLICHEALTHNURSING,25(4),353-361.

DISASTERC

YCLE

DEFINITION*

*DEFINITIONSRETRIEVED

FROM:HTTP://WWW.FEMA.GOV

/MISSION-AREAS

ASSESSMENT PLANNING IMPLEMENTATION EVALUATION

PREPARED

NESS

Preparednessincludesprevention,protectionandmitigation.

Itcomprises“thecapabilitiesnecessarytoavoidand/orpreventadisaster,aswellastoreducethelossoflifeandpropertybylesseningtheimpactofdisasters.”

Eliminationofthreatsbeforeadisasterstrikes.

Assesstheregionforpopulationsatriskforaccessandfunctionalneedsduringtimesofdisaster.

Conductahazardvulnerabilityassessmentforthreatsandhazardsthatposethegreatestrisk.

Developacareplantoaddressaccessandfunctionalneedsofpopulationsduringtimesofdisaster.

Completethisassurancefunctionincollaborationwithstakeholderstoaddressneedssuchasshelteringinplace,evacuation,andmasscasualtysurgecapabilities.

Conducttraining,drillsandexercisesrelatedtothecareofindividuals,familiesandcommunitiesduringdisaster,focusingonpopulationswithaccessandfunctionalneedsinanidentifiedregion.

Evaluatethetraining,drillsandexercisesrelatedtothecareofpopulationswithaccessandfunctionalneedsindisaster,identifyinggapsandremainingneeds.

Evaluateoperationalplansforpreparedness,responseandrecoveryforpopulationswithaccessandfunctionalneeds.

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ASSESSMENT PLANNING IMPLEMENTATION EVALUATION

RESPO

NSE

Responsecomprises“thecapabilitiesnecessarytosavelives,protectpropertyandtheenvironment,andmeetbasichumanneedsafteranincidenthasoccurred.”✜PUBLICHEALTHTRIAGE:F.M.BURKLE,POPULATION-BASEDTRIAGEMANAGEMENT

INRESPONSETOSURGE

CAPACITY

REQUIREMENTSDURING

ALARGE-SCALEBIOEVENTDISASTER.ACADEMICEMERGENCY

MEDICINE2006:13:1120.

Usepublichealth,population-basedtriagetoassesscommunicablediseaseoutbreakimpactandneededresponse(e.g.,influenza).

Populationbasedtriageinvolvingsurveillancetodividetheaffectedpopulationintosusceptible,exposed,infected,removed,andvaccinatedforexpedientandlife-savingtreatment.✜

Collaboratewithresponsepartnerstodevelopplansfortriagealgorithmsthatdetermineappropriatecareandsustenancelogisticsforpopulationsbasedontheirsymptomsandco-morbidconditions(e.g.,chronicdisease).

Identifyandplacepublichealthnursesandothersupportpersonneltoprovidecareaccordingtothedevelopedalgorithms.

Assurethatlogisticsareinplacetosupportcommunitycareduringthecrisisperiod.

Conductongoingrapidneedsassessmentsduringtheresponsephaseinordertomeetpopulationneeds.

Participateinongoingresponseplanningduringtheincident(e.g.,theIncidentManagementSystemanditsPlanning“P”).

Participateinserviceplanningandprovidereal-timeadjustmentonthebasisofreal-timepublichealthresponseevaluation.

Assureneededandnecessarypublichealthnursingcare.

RECO

VERY

Recoverycomprises“thecorecapabilitiesnecessarytoassistcommunitiesaffectedbyanincidenttorecovereffectively.”

Conductongoingrapidneedsassessmentatappropriateintervalstodeterminehealthandcriticalresourcecapacityafteranaturaldisaster(e.g.,earthquake.)

Workwithcommunitystakeholderstoplanforanylong-termhealthconcernsfollowinganincident,gettingaheadofthecurvebyidentifyingkeyresourcesandcriticalcarelogistics.

Participateinthereconstitutionofcriticalservicesandthesustainmentofthehealthandsocialinfrastructure.

Assistthecommunitytofindits“newnormal”post-disaster.

Conductevaluationofthelong-termimpactofdisasterconsequencesonthewholecommunity,promotingpublichealthessentialservicesthroughpublichealthnursing.

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CompetencyforDisasterPractice

Incompetency-basedpractice,thepublichealthnursemayhaveahardtimedecidingwhichsetofcompetenciestouse.Thechoiceisanimportantone,though,sincecompetenciesservetoinformevidencebasedpractice,standardsdevelopment,andlearningneeds(InternationalCouncilofNursing(ICN),2009).Identifyingcompetenciesisaprocessthatinvolvesthereviewofpeer-reviewedliteratureandeducationaltheory,areviewofexistingcompetencies,thesynthesisofnewcompetencies,areviewbyanexpertpanel,arefiningofnewcompetencies,andthedevelopmentofterminalobjectivesforeachcompetency(Gebbie,Hutton,&Plummer,2012).Eachoftherecommendedcompetencysetsinthissectionfollowedthatprocess.Publichealthnursesareencouragedtostudyandacquirethesecompetencies,thenapplythemtotheirownpracticeinanticipationofdisasterpreparedness,response,orrecovery.PublicHealthPreparednessandResponseCoreCompetencies(ASPH,2010)ThePublicHealthPreparednessandResponseCoreCompetenciesaretobeusedwiththeunderstandingthattheyarepracticedwithinfoundationalpublichealthcompetencies,genericemergencycorecompetencies,andposition-specificorprofessionalcompetencies.Thefourcorecompetenciesspanpreparedness,responseandrecoveryroles.PerformanceGoal:Proficientlyperformassignedprevention,preparedness,response,andrecoveryrole(s)inaccordancewithestablishednational,state,andlocalhealthsecurityandpublichealthpolicies,laws,andsystems.1.ModelLeadership

1.1Solveproblemsunderemergencyconditions.1.2Managebehaviorsassociatedwithemotionalresponsesinselfandothers.1.3Facilitatecollaborationwithinternalandexternalemergencyresponsepartners.1.4Maintainsituationalawareness.1.5Demonstraterespectforallpersonsandcultures.1.6Actwithinthescopeofone'slegalauthority.

2.CommunicateandManageInformation

2.1Manageinformationrelatedtoanemergency.2.2Useprinciplesofcrisisandriskcommunication.2.3Reportinformationpotentiallyrelevanttotheidentificationandcontrolofanemergencythroughthechainofcommand.2.4Collectdataaccordingtoprotocol.2.5Managetherecordingand/ortranscriptionofdataaccordingtoprotocol.

3.PlanforandImprovePractice

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3.1Contributeexpertisetoacommunityhazardvulnerabilityanalysis(HVA).3.2Contributeexpertisetothedevelopmentofemergencyplans.3.3Participateinimprovingtheorganization’scapacities(including,butnotlimitedtoprograms,plans,policies,laws,andworkforcetraining).3.4Refermattersoutsideofone'sscopeoflegalauthoritythroughthechainofcommand.

4.ProtectWorkerHealthandSafety

4.1Maintainpersonal/familyemergencypreparednessplans.4.2Employprotectivebehaviorsaccordingtochangingconditions,personallimitations,andthreats.4.3Reportunresolvedthreatstophysicalandmentalhealththroughthechainofcommand.

InternationalCouncilofNurses(ICN)FrameworkofDisasterNursingCompetencies(ICNandWorldHealthOrganization,2009)TheInternationalCouncilofNurses(ICN)developeddisasternursingcompetenciestohelpclarifytheroleofthenurseinadisasterandassistinthedevelopmentofdisastereducation.AlthoughthecompetenciesdonotaddressthespecificcompetenciesrequiredforPHNpractice,theyaredesignedtoserveastheunderpinning(ICN,2009,p.7).TheICNdisasternursingcompetenciesspanfourbroadareasofcompetencies:1)mitigationandprevention;2)preparedness;3)response;and4)recovery/rehabilitation.Thecompetencydomainsare:

1. Riskreduction,diseasepreventionandhealthpromotion2. Policydevelopmentandplanning3. Ethicalpractice,legalpracticeandaccountability4. Communicationandinformationsharing5. Educationandpreparedness6. Careofthecommunity7. Careofindividualsandfamily8. Psychologicalcare9. Careofvulnerablepopulations10. Long-termrecoveryofindividuals,familiesandcommunities

Inadditiontothesecompetencysets,genericmodelsandcompetenciesforPHNpracticesuchastheMinnesotaDepartmentofHealthPHNInterventionWheel(2001)ortheQuadCouncilPHNCompetencies(2011)provideappropriatepracticemodels,whetherthatPHNpracticeisdeliveredday-to-dayorinadisaster.BycombiningboththeICNDisasterNursingCompetenciesandthePublicHealthPreparednessandResponseCoreCompetencies,thePHNfindsasolidplatformtoinformpracticeacrossthedisastercycle.BothofthesecompetencysetsarefoundintheRecommendedReadingandKeyDocumentssectionattheendofthispaper.

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LeadershipPlanningandPolicyDevelopment

“Asprioritypublichealthinitiativesevolvetoaddressemerginghealthtrends,publichealthnursestakeleadershiproles.Theyidentifyevidencebywhichnewpublichealthsystemschangesareimplementedandevaluated,anddevelopoperationalsystemsthatmaybeeffectivelydeployed.Publichealthnursingleadershipultimatelyenhancestheabilityofpublichealthsystemstoaddressthehealthissuesfacingallpeopleandcreatesconditionsinwhichpeoplecanbehealthy(ANA,2013:2).”

The2ndeditionofPublicHealthNursing:ScopeandStandardsofPractice(2013)makesitclearthatPHNsareleaders.Thisisnolesstrueinpublichealthpreparedness,response,andrecovery.LeadershipcollaborationWell-preparedPHNsbringleadershipandmanagementexpertisetoeachphaseofdisastercycle.Asanintegralpartofthehealthcaresysteminfrastructurewithintheircommunityandjurisdictions,PHNshaveestablishedlinkagestocommunityhealth-relatednetworksandresourcesthatarevitaltodevelopingdisasterpreparednessplansandpoliciesatlocal,regional,stateandnationallevels.TheseconnectionsbetweenPHNsandcommunitypartnersmustoccurinordertoaddresscomplexissuessuchasprovidingmasscareduringthechaosofadisaster,prioritizingscarceresources,supervisingspontaneousvolunteersandunlicensedhealthcareworkers,identifyingandplanningforthecareofpopulationswithfunctionalandaccessneeds,aswellasdevelopingandmaintainingeffectivesystemsofvolunteerspreparedtoassistpriortotheincident.Publichealthnursesalsocanusetheirnetworksacrossregionalandstateboundariestoachieveconsistencyintheprotocols,practicestandardsandoperationalguidelinespriortothedisasterincident.LeadershipeffortsinpolicyandplanningPublichealthnursesareleadersinpolicyandplanningtoensurethatthecommunitiestheyservereceiveprioritizedandactionablesolutionstotheirhealthandsocialproblems.AnexampleofthisistheireffortinFunctionalNeedsandSupportServices(FNSS)fordisaster-affectedpopulations(FEMA,2010).Solutionsformeetingshelteringneedsforthosewithaccessandfunctionalneedsarefoundbelow,alignedwitheachpolicyprocessstep(Stanhope,M.,2012;FEMA,2010):

1. Statementofahealthcareproblem–Childrenandadultswithdisabilitieshavethesamerighttoservicesingeneralpopulationsheltersasotherresidents.

2. Statementofpolicyoptionstoaddressthehealthproblem-Historically,resourcegapshaveexistedinplanningforandmeetingaccessandfunctionalneedsingeneralpopulationshelters.Theintentofthisplanningguidanceistoensurethatindividualsare

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notturnedawayfromgeneralpopulationsheltersandinappropriatelyplacedinotherenvironments(e.g.,“specialneeds”shelters,institutions,nursinghomes,andhotelsandmotelsdisconnectedfromothersupportservices).

3. Adoptionofaparticularpolicyoption- Keyconsiderationsinplanningforshelteroperationsarebroaderthanmedicalservices,toincludeofdietaryneeds,serviceanimals,communication,bathingandtoiletingneeds,quietspace,mentalhealthservices,dentalservices,medication,andtransportationservices.

4. Implementationofapolicyproduct(e.g.,aservice)-FunctionalNeedsSupportServices(FNSS)aredefinedasservicesthatenableindividualstomaintaintheirindependenceinageneralpopulationshelter.FNSSincludes:•reasonablemodificationtopolicies,practices,andprocedures•durablemedicalequipment(DME)•consumablemedicalsupplies(CMS)•personalassistanceservices(PAS)•othergoodsandservicesasneeded

5. Evaluationofthepolicy’sintendedandunintendedconsequencesinsolvingtheoriginalhealthcareproblem.–Ongoingthroughvariousorganizationsandagencies,toincludeRedCross’DisasterHealthServicesandnurses.

Meta-leadership(crisisleadership)Nursesarefamiliarwiththeconceptofmeta-research,wheremanyareasofresearcharoundatopicarepulledtogetherforanewlookatacomplexproblemandnewsolutions.Duringadisaster,atypeofleadershipthatisincreasinglycalledforincrisiscomplexityismeta-leadership.Meta-leadershipisnotjustatwo-dimensionalrelationshipbetweenasupervisorandemployeeorincidentcommanderandthechainofcommand;rather,itoccursacrossnumerousentitiesandinmanydirections:up,down,andsideways.Meta-leadershipisdefinedasafive-dimensionalabilitytoworkwithincross-boundaryintegrationofanorganization’scapabilitiesintothecommunity(Rowitz,2013).Inordertodothat,anindividualmustunderstandself,theproblemathand,theirorganization,theirsupervisorsandhowtoleadup(i.e.,satisfythebosswhilemakingsuretherightthinggetsdone),andtheconnectivityofthedefinedcommunity,bothitsorganizationsanditsagencies(Marcusetal.,2009).Thesefivedimensionsofmeta-leadershipalignperfectlyintopublichealthnursingpractice.Metaleaders,likepublichealthnurses,motivate,inspire,andgivetoensurethatthecommunitiestheyservejoininthesolution.Althoughin-depthcoverageofhowtoleadindisastercannotbecoveredinthispositionpaper,theMarcusetal.(2007)materialsincludedintherecommendedreadingsectiontoenablethePHNtodevelopfamiliaritywithmeta-leadershipprinciples.

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LegalandEthicalIssues

Licensure,geographicboundariesanddutytorespondPublichealthnursesshouldbefamiliarwiththenursepracticeactoftheirstateanditsinformationaboutthepracticeofnursingindisasters.IfanurseislicensedbyaNurseLicensureCompactstate,theycanalreadypracticeacrossstatelinesinmemberstates(NCSBN,2013).Duringlarge-scaledisastersthatcrossstateborders,licensednursesmaybeallowedbyfederaland/orstatelawordeclarationstopracticeinotherstates.Manystateshavenoweliminatedhardcopylicensesasthepapercardscanbetamperedwithanddonotreflectcurrentdisciplinarystatus.Licensureisnowoftenverifiedonlineatstateboardsofnursingsites,evenduringdisasters.TheNationalCouncilofStateBoardsofNursing(NCSBN)providesthecapacityforbulklicenseverificationthroughitsNursysdatabaseonbehalfofresponseorganizations.Nurseswhovolunteertoprovidedisasterservicesshouldclarifytheexpectationsforlicensureandliabilityprotectionwiththeorganizationtheyplantovolunteerin.Priortovolunteering,PHNsmustbefamiliarwiththeiremployer’splansforstaffwhowishtorespondandwhattheirdutyexpectationsaretotheirorganization,bothlegallyandethically.Publichealthnursesalsoneedtoclarifyhowtheyarewrittenintoexistingresponseplansfortheirorganizationandregion.Inadditiontotheemployer,regionalplanningbodiesorstatesmayidentifycertaingroupsofnursesandpre-definetheiruseinresponseandrecovery.Writtenpolicyshouldassureprotectionsandmakecleartheexpectationsoftheregisterednurse,theemployer,andthegovernmentresponsesystemsbeforethedisasteroccurs(ANA,2010).GoodSamaritanLawGoodSamaritanlawsgenerallyprovideliabilityprotectiontoindividualsforsituationswhereemergencycareisrenderedusingreasonableandprudentjudgmentforthecircumstances.MoststateshaveenactedsomeformofGoodSamaritanlaw,butmanydonotexplicitlyrecognizepubliclydeclareddisasters(Courtney,Priest,&Root,2012).TheGoodSamaritanlawappliestosituationsinwhichthecareoraidrenderedwasagood-faitheffortandasavoluntaryact.ThismeansthatGoodSamaritanlawsdonotprotectaproviderworkingasanemployeeorasanorganizationalvolunteer.Also,GoodSamaritanlawsdonotprotectagainstnegligenceorgrossmisconduct.ExistingprotectionsThereiscurrentlynocomprehensivenationallegalprotectionforhealthcareprovidersworkinginthedisastercycle.FederallawssuchastheFederalPublicReadinessandEmergencyPreparednessActandtheFederalVolunteerProtectionActandstatelawssuchasStateVolunteerProtectionActs,ModelStateEmergencyHealthPowersActs,andStatePublicHealthandEmergencyManagementProvisionsareinplace.Somebelievethatthepatchworkofprotectionforhealthcareworkershasbecomemuchstrongerinitsproviderprotections(Courtney,Priest,&Roost,2012).

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Disastersinvolveresourceconstraints,undesirableenvironments,andmasscasualtysurgeneeds.Disasterincidentsstressplanningandpreparations,providechallenges,andmayinvolveunforeseensituationsdemandingimmediateresponseinthemiddleofchaos.Evenifthehealthcareproviderhassignificantdemandsplacedonthemtothepointthatthecarebecomesqualitativelydifferentfromthatprovidedinnormalcircumstances,professionalliabilityhasandwillbedecidedagainsttherelevantfactsofthesituation(Courtney,Priest,&Roost,2012).Legalprotectiongaugeswhatareasonablyskillfulandprudentproviderwoulddoinasimilarsituation(i.e.,indisaster).Thereisacontinuedneedforcompetency-basedtrainingandanunderstandingbythePHNoftheprofessionalscopeandstandardsofpracticetoassurepreparationasahealthprofessional.Indeed,mostethicalandlegalconflictscanbeavoidedwithdisastertrainingandfamiliaritywithdisasterplans,toincludehands-ondisasterdrillsthatincludebothmedicalandethicaldecisionmaking(Pou,2013).Publichealthnurseswillneedtheabilitytomakeconsistentjudgmentsanddecisionsbasedondisasterplansandpolicies,sometimesinspiteoftheirpersonalbeliefs.SummaryIfpublichealthnursescannotconveytheirdisasterpracticeexpertisetoothers,theywillmostlikelybeunderused,misused,and/orunabletoparticipateintheleadershipthattheyemployforcommunityadvocacy.Nursesremainthelargesthealthcareprovidergroupavailableforpreparedness,response,andrecovery.Itisimportantthatpublichealthnursesunderstandandpromotetheirdisastercapabilitiesasmembersofthepublichealthandhealthcareteambefore,during,andaftertheincident.Disasterpreparedness,response,andrecoveryisacriticalcomponentofpublichealthnursingpractice.Publichealthnurseswillalwaysbeneededwhounderstandthepopulation-basednatureofadisasterresponseandpossesstheknowledgeandskillstorespondinatimelyandappropriatemannertoanytypeofdisaster.

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RecommendedReadingandKeyDocuments

AmericanNursesAssociation(ANA).2010.ANAissuesbrief:Whowillbethere?Ethics,thelawandanurse’sdutytorespondindisaster.http://nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/DPR/Disaster-Preparedness.pdf

ANA.2008.Adaptingstandardsofcareunderextremeconditions:Guidanceforprofessionalsduringdisasters,pandemics,andotherextremeemergencies.http://nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/DPR/TheLawEthicsofDisasterResponse/AdaptingStandardsofCare.pdf

AssociationforCommunityHealthNursingEducators(ACHNE)TaskForceonDisasterPreparedness.2008.Disasterpreparednesswhitepaperforcommunity/publichealthnursingeducators.http://www.achne.org/files/public/DisasterPreparednessWhitePaper.pdf

AssociationofSchoolsofPublicHealth(ASPH).2010.Publichealthpreparedness&responsecorecompetencymodel.http://www.cdc.gov/phpr/documents/perlcpdfs/preparednesscompetencymodelworkforce-version1_0.pdf

CentersforDiseaseControlandPrevention(CDC).2013.2013-2014nationalsnapshotofpublichealthpreparedness.http://www.cdc.gov/phpr/pubs-links/2013/

CDC.2011.Anationalstrategicplanforpublichealthpreparednessandresponse.http://www.cdc.gov/phpr/publications/A_Natl_Strategic_Plan_for_Preparedness.htmCDC.March2011.Publichealthpreparednesscapabilities:Nationalstandardsforstateandlocalplanning.http://www.cdc.gov/phpr/capabilities/dslr_capabilities_july.pdfFederalEmergencyManagementAgency(FEMA).2013.PresidentialPolicyDirective(PPD)8components:Nationalpreparednessgoal,nationalpreparednesssystem,nationalplanningframeworks.https://www.fema.gov/learn-about-presidential-policy-directive-8FEMA.2010.GuidanceonplanningforintegrationofFunctionalNeedsSupportServices(FNSS).http://www.fema.gov/pdf/about/odic/fnss_guidance.pdfFEMAEmergencyManagementInstitute(EMI).2013.Independentstudyprogram(ISP).http://training.fema.gov/IS/NIMS.aspxInternationalCouncilofNurses(ICN)andWorldHealthOrganization(WHO).2009.ICNframeworkofdisasternursingcompetencies.http://www.icn.ch/images/stories/documents/networks/DisasterPreparednessNetwork/Disaster_Nursing_Competencies_lite.pdf

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InstituteofMedicine(IOM).2013.Crisisstandardsofcare:Atoolkitforindicatorsandtriggers.http://iom.nationalacademies.org/Reports/2013/Crisis-Standards-of-Care-A-Toolkit-for-Indicators-and-Triggers.aspxIOM.2012.Crisisstandardsofcare:Asystemsframeworkforcatastrophicdisasterresponse.http://www.nap.edu/catalog.php?record_id=13351Marcus,L.J.,Dorn,B.C.,Ashkenazi,I.,Henderson,J.M.,&McNulty,E.2010.Meta-leadership:Aprimer.http://npli.sph.harvard.edu/wp-content/uploads/sites/8/2013/04/meta-leadership_primer.pdfNationalCommissiononChildrenandDisasters.October2010.2010Reporttothepresidentandcongress,AHRQPublicationNo.10-M037.http://archive.ahrq.gov/prep/nccdreport/nccdreport.pdfQuadCouncilofPublicHealthNursingOrganizations(QuadCouncil).(2011).Corecompetenciesforpublichealthnurses(CCPHN).http://www.phf.org/resourcestools/Pages/Public_Health_Nursing_Competencies.aspxRESOLVE,Inc.2012.Transformingpublichealth:Emergingconceptsfordecisionmakinginachangingpublichealthworld.http://www.rwjf.org/en/research-publications/find-rwjf-research/2012/06/transforming-public-health.htmlTrustforAmerica’sHealth.December2012.Readyornot:Protectingthepublicfromdiseases,disasters,andbioterrorism.http://www.healthyamericans.org/report/101/Veenema,T.G.2012.Disasternursingandemergencypreparedness:Forchemical,biological,andradiologicalterrorismandotherhazards,Thirdedition.NewYork,NewYork:SpringerPublishingCompany.U.S.DepartmentofHealthandHumanServices(DHHS).2012.ImplementationplanforthenationalhealthsecuritystrategyoftheUnitedStatesofAmerica.http://www.phe.gov/Preparedness/planning/authority/nhss/ip/Documents/nhss-ip.pdfU.S.DepartmentofHomelandSecurity.(2013)Overviewofthenationalplanningframeworks.http://www.fema.gov/media-library-data/20130726-1914-25045-2057/final_overview_of_national_planning_frameworks_20130501.pdf______________________________________________________________________________

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SilverSpring,Maryland:Author.AmericanPublicHealthAssociation,PublicHealthNursingSection.(2013).Thedefinitionand

practiceofpublichealth2013.Retrievedfromhttp://www.apha.org/~/media/files/pdf/membergroups/nursingdefinition.ashx

AssociationofSchoolsofPublicHealthandCentersforDiseaseControlandPrevention PublicHealthPreparednessandResponse.(2010).Publichealthpreparedness& Responsecorecompetencymodel.Retrievedfrom

http://www.cdc.gov/phpr/documents/perlcPDFS/PreparednessCompetencyModelWorkforce-Version1_0.pdf

Brewer,K.(2010).Whowillbethere?Ethics,thelawandanurse’sduty

torespondindisaster(ANAIssueBrief).RetrievedJuly1,2014fromhttp://nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/DPR/Disaster-Preparedness.pdf

Courtney,B.A.,Priest,C.,&Root,P.(2012).Legalissuesinemergencyresponse.In M.P.Couig&P.W.Kelley,(Eds.),Annualreviewofnursingresearch:Disastersand humanitarianassistance(Volume30,pp.67-88).NewYork,NewYork:Springer PublishingCompany.FederalEmergencyManagementAgency.(2013).PresidentialPolicyDirective 8components:Nationalpreparednessgoal,Nationalpreparednesssystem, Nationalplanningframeworks.Retrievedfrom https://www.fema.gov/learn-about-presidential-policy-directive-8FederalEmergencyManagementAgency.(2010).Guidanceonplanningforintegrationof functionalneedssupportservices(FNSS).Retrievedfrom http://www.fema.gov/pdf/about/odic/fnss_guidance.pdfGebbie,K.M.,Hutton,A.,&Plummer,V.(2012).Updateoncompetenciesandeducation.In M.P.Couig,&P.W.Kelley,(Eds.),Annualreviewofnursingresearch:Disasters andhumanitarianassistance(Volume30,pp.169-192).NewYork,NewYork: SpringerPublishing.

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InstituteofMedicine.(2002).Thefutureofthepublic'shealthinthe21stcentury.WashingtonDC:DepartmentofHealthandHumanServices.Retrievedfromhttp://iom.edu/Reports/2002/The-Future-of-the-Publics-Health-in-the-21st-Century.aspx

InternationalCouncilofNursing&WorldHealthOrganization.(2009).ICNframeworkof disasternursingcompetencies.Geneva,Switzerland:Authors.Retrievedfrom http://www.wpro.who.int/hrh/documents/icn_framework/en/ Jakeway,C.,LaRosa,G.,Cary,A.&Schoenfisch,S.(2008).Theroleofpublichealthnurses

inemergencypreparednessandresponse:ApositionpaperoftheAssociationofStateandTerritorialDirectorsofNursing.PublicHealthNursing,25(4),353-361.Retrievedfromhttp://onlinelibrary.wiley.com/doi/10.1111/j.1525-1446.2008.00716.x/abstract

Kuntz,S.W.,Frable,P.,Qureshi,K.,&Strong,L.L.(2008).AssociationofCommunityHealth

NursingEducators(ACHNE):Disasterpreparednesswhitepaperforcommunity/publichealthnursingeducators.PublicHealthNursing,25(4),362-369.Retrievedfromhttp://onlinelibrary.wiley.com/doi/10.1111/j.1525-1446.2008.00717.x/abstract

Marcus,L.J.,Ashkennazi,I.,Dorn,B.C.,&Henderson,J.M.(2007).Nationalpreparedness andthefivedimensionsofmeta-leadership.Retrievedfrom

https://www.medicalreservecorps.gov/File/Promising_Practices_Toolkit/Guidance_Documents/Emergency_Preparedness_Response/Meta_Leadership_One_page_primer_March_2007.pdf

MinnesotaDepartmentofHealth,DivisionofCommunityHealthServices,PublicHealth NursingSection.(2001).Publichealthnursinginterventionwheel.Retrievedfrom http://www.health.state.mn.us/divs/opi/cd/phn/docs/0301wheel_manual.pdfNationalCouncilofStateBoardsofNursing.(2013).Nurselicensurecompact.Retrievedfrom

https://www.ncsbn.org/nlc.htm

Pou,A.(2013).Ethicalandlegalchallengesofdisastermedicine:Areyouready?SouthernMedicalJournal,106(1),27-30.Retrievedfromhttp://www.medscape.com/viewarticle/777544

QuadCouncilofPublicHealthNursingOrganizations(QUADCOUNCIL).(2011).Core

competenciesforpublichealthnurses(CCPHN).Retrievedfromhttp://www.phf.org/resourcestools/Pages/Public_Health_Nursing_Competencies.aspx

Rowitz,Louis.(2013).Publichealthleadership:Puttingprinciplesintopractice,3rded. Burlington,Massachusetts:JonesandBartlettLearning,LLC.Stanhope,M.(2012).PublicHealthPolicy.InM.Stanhope&J.Lancaster,(Eds.),Public

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Retrievedfromhttp://www.fema.gov/media-library-data/20130726-1914-25045-2057/final_overview_of_national_planning_frameworks_20130501.pdf