1. DISASTER NURSING GOLDEN LECTURE
Kawkab Shishani, RN, PhD
Community Health Nursing
Kawkab.shishani@gmail.com
Jordan
Richard Garfield, RN, DrPH
Director WHO/PAHO Collaborating Center School
of Nursing, Columbia University in the City of
New York
Nicolas Padilla, MD
Universidad de Guanajuato
Mexico
Ronald LaPorte, PhD
Director Telecommunications and Disease
Monitoring; WHO Collaborating Center
University of Pittsburgh June 8, 2009
2. NURSES AND EDUCATION
Education is the most powerful
weapon which you can use to change
the world.
Nelson Mandela
3. MISSION STATEMENT
Disasters are a primary cause of morbidity and
mortality. Nurses can play an important role in
disaster mitigation, but they receive very little
training. This lecture is designed to help to
introduce to nursing the concepts of disasters
and disaster mitigation. We propose that you
teach this lecture to your nursing students to
build awareness world wide.
4. OBJECTIVES
1. Define a disaster
2. Discuss patterns of mortality and injury
3. Understand impact of disasters on health
4. Describe the factors that contribute to disasters
severity
5. Discuss role of nursing in disasters
6. Apply principles of triage in disaster
7. Analyze the WHO components of effective
disaster nursing
5. WHAT IS DISASTER
Is a result of vast ecological breakdown in the
relation between humans and their environment,
as serious or sudden event on such scale that the
stricken community needs extraordinary efforts
to cope with outside help or international aid.
7. HURRICANES
The primary health hazard from hurricanes or
cyclones lies in the risk of drowning from the
storm surge associated with the landfall of the
storm. Most deaths associated with hurricanes
are drowning deaths.
Secondarily, a hazard exists for injuries from
flying debris due to the high winds.
Nurses can be instrumental in providing direct
emergency care to drowning and head injuries.
8. TORNADOES
The primary hazard from a health perspective in a
tornado is the risk for injuries from flying debris.
The high winds and circular nature of a tornado
leads to the elevation and transport of anything
that is not fastened down. Most victims of tornadoes
are affected by head and chest trauma due to being
struck by debris or from a structural collapse. Some
individuals are injured while on the ground. Others
are lifted into the air by the tornado and dropped at
another location.
9. FLOODS
Floods may originate very quickly following a quick
rain storm, or they may develop over a short period
following an extended period of rain or quick snow
melt
The primary hazard from flooding is drowning
Longer term health concerns from flooding is the
development of disease from contaminated water and
lack of hygiene.
10. EARTHQUAKES
A significant global concern
The primary health concern:
• Injuries arising from structural collapse
• Most injuries occur amongst individuals trapped at
the time of the earthquake
Well known prevention strategy is to prevent
buildings from collapsing
There is a recognized need to develop better rescue
strategies for retrieving individuals from collapsed
buildings
11.
12. VOLCANOES
Rare, but can be catastrophic when they occur
Over the 25 year period (1972-1996), there was
an average of 6 eruptions per year, causing an
average of 1017 deaths and 285 injuries
Health outcomes are associated with volcanic
eruptions:
• Respiratory illnesses from the inhalation of
ash
• For individuals close to the volcano, some
danger exists from lava flows, or more likely
mud flows
18. MAN-MADE THREAT
Unpredictable Challenges
Disruptive
Unexpected
Targeting weaknesses
Very rare, impossible to conceive before event
Threats to Civilians, Information
Infrastructure
19. COMPONENTS OF DISASTER DEBRIS
Building Debris
Household Debris
Vegetative Debris
Problem Waste Streams
20. MYTHS ASSOCIATED WITH
DISASTERS
Any kind of assistance needed in disasters
A response not based on impartial evaluation contributes
to chaos
Epidemics and plagues are inevitable after every
disaster
Epidemics rarely ever occur after a disaster
Dead bodies will not lead to catastrophic outbreaks of
exotic disease
Proper resumption of public health services will ensure the
public’s safety (sanitation, waste disposal, water quality,
and food safety)
Disasters bring out the worst in human behavior
The majority responses spontaneous and generous
The community is too shocked and helpless
Cross-cultural dedication to common good is most common
response to natural disasters
21. PATTERNS OF MORTALITY AND
INJURY
Disaster events that involve water are the most
significant in terms of mortality
Floods, storm surges, and tsunamis all have a
higher proportion of deaths relative to injuries
Earthquakes and events associated with high
winds tend to exhibit more injuries than deaths
The risk of injury and death is much higher in
developing countries – at least 10 times higher
because of little preparedness, poorer
infrastructure.
22. DISPLACEMENT OF DISASTER
VICTIMS
Mass Shelters
Shelter management:
• Organized team (chain)
• Sleeping area and necessities
• Water and food handling
• Sanitation (toilets, showers,..)
• Special care to children and elderly
• Health services (physical, mental)
23. DISASTER AND HEALTH
In a major disaster water treatment plants,
storage & pumping facilities, & distribution
lines could be damaged, interrupted or
contaminated.
Communicable diseases outbreak due to:
Changes affecting vector populations (increase
vector),
Flooded sewer systems,
The destruction of the health care infrastructure, and
The interruption of normal health services geared
towards communicable diseases
24. DISASTER AND HEALTH
Injuries from the event
Environmental exposure after the event (no
shelter)
Malnutrition after the event (feeding the
population affected)
Excess NCD mortality following a disaster
Mental health (disaster
syndrome)
25. MENTAL WELLNESS
Little attention is paid to the children
Listen attentively to children without denying
their feelings
Give easy-to-understand answers to their
questions
In the shelter, create an environment in which
children can feel safe and secure (e.g. play area)
26. MENTAL WELLNESS
In any major disaster, people want to know where
their loved ones are, nurses can assist in making
links.
In case of loss, people need to mourn:
• Give them space,
• Find family friends or local healers to encourage
and support them
• Most are back to normal within 2 weeks
• About1% to 3%, may need additional help
28. THE PHASES OF DISASTER
Mitigation:
Lessen the impact of a disaster before it strikes
Preparedness:
Activities undertaken to handle a disaster when it
strikes
Response:
Search and rescue, clearing debris, and feeding and
sheltering victims (and responders if necessary).
Recovery:
Getting a community back to its pre-disaster status
29. MITIGATION
Activities that reduce or eliminate a hazard
Prevention
Risk reduction
Examples
Immunization programs
Public education
30. PREPAREDNESS
Activities that are taken to build capacity and
identify resources that may be used
Know evacuation shelters
Emergency communication plan
Preventive measures to prevent spread of disease
Public Education
31. RESPONSE
Activities a hospital, healthcare system, or public
health agency take immediately before, during,
and after a disaster or emergency occurs
32. RECOVERY
Activities undertaken by a community and its
components after an emergency or disaster to
restore minimum services and move towards
long-term restoration.
Debris Removal
Care and Shelter
Damage Assessments
Funding Assistance
33. WHAT IS TRIAGE?
French verb “trier” means to sort
Assigns priorities when
resources limited
Do the best for the greatest
number of patients
35. ADVANTAGES OF TRIAGE
Helps to bring order and organization to a chaotic
scene.
It identifies and provides care to those who are in
greatest need
Helps make the difficult decisions easier
Assure that resources are used in the most
effective manner
May take some of the emotional burden away
from those doing triage
36. WHO DECIDES IN TRIAGE
Nurses don’t act for legal fears of being blamed
for deaths, and lack of clarity on where they fit in
the command structure
Nurses function to the level of their training and
experience.
If nurses they are the most trained personnel
the site, they are in charge.
38. HEALTH WORKER
DENSITY BY REGION
2.3
2.6
4.2
6.9
8.7
9.9
10.3
0.8
0 2 4 6 8 10 12
S ub - S aharan Af r ic a
As ia
S &C e nt ral Ame r ic a
G lo b al
M id d le E as t
We s t e rn P ac if ic
No r t h Ame r ic a
E uro p e
Workers per 1,000 population
41. ROLE OF NURSING IN DISASTERS
Disaster preparedness, including risk assessment
and multi-disciplinary management strategies at
all system levels, is critical to the delivery of
effective responses to the short, medium, and long-term
health needs of a disaster-stricken
population.
International Council of Nurses (2006)
42. NURSES’ ROLES IN DISASTERS
Determine magnitude of the event
Define health needs of the affected groups
Establish priorities and objectives
Identify actual and potential public health
problems
Determine resources needed to respond to the
needs identified
Collaborate with other professional disciplines,
governmental and non-governmental agencies
Maintain a unified chain of command
Communication
43. COMMUNICATION IS A SUCCESS
KEY
Nursing organizations must have a
comprehensive and accurate registry for all
members
Have a structured plan:
• Collaborate and coordinate with local authorities
• Have a hotline 24x7
• Inform nurses where to report and how (keep
records)
• Make sure have a coordinator to prevent chaos
• Ensure ways to maintain communication between
nurses and their families
44. THE NEED FOR DISASTER NURSING
TRAINING
11 million nurses world wide:
• Form the backbone of the health care system
• Are the frontline health care workers who are
in direct contact with the public
• Contribute to health of individuals, families,
communities, and the globe
Schools of nursing offer little or no information
on disaster nursing (WHO, 2008)
Shortage of trained instructors/faculty (WHO,
2008)
45. CORE COMPETENCIES IN DISASTER
NURSING TRAINING
Ethical and legal issues, and decision making;
Care principles;
Nursing care;
Needs assessment and planning;
Safety and security;
Communication and interpersonal relationships;
Public health; and
Health care systems and policies in emergency
situations
(WHO, 2008)
46. TOPICS THAT MUST BE COVERED
BY DISASTER NURSING TRAINING
Basic life support
System and planning for settings where nurses
work
Communications (what to report and to whom)
Working in the damaged facilities and with
damaged equipment
Safety of clients and practitioners
Working within a team (understand each
member’s role and responsibility)
Infection control
Mental and psychosocial support
(WHO, 2006)
51. “Most of all, if gains in health and nutrition during
emergencies are to be sustained, graduates need to
understand the importance of capacity building of
national staff and institutions.”
Salama et al, Lessons Learned from Complex Emergencies
52. DISASTER NURSING SUPERCOURSE
o To join the Nursing Supercourse, please visit
www.pitt.edu/~super1
or e-mail
super2@pitt.edu.
o Membership in the Global Health Network
Supercourse will allow you to receive free
Supercourse CDs, just in time lecture, and annual
prevention lectures
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from PowerPoint slide show mode
53. More information
This lecture is available at:
http://www.pitt.edu/~super1/lecture/lec35051/index.htm
Please fee free to e-mail at:
kawkab.shishani@gmail.com
Hinweis der Redaktion
Over the past few decades, disasters have been on the rise. Millions of people have been affected, lost homes and family members, or displaced. No one is immune against disasters. However, what makes a difference is the degree of preparedness. Nurses are the largest health care professional group, yet, they are not well prepared for disasters. Disasters pose threats to physical as well psychosocial wellbeing. Nurses view health as a state of physical and psychosocial wellbeing. In this context nurses who receive disaster training can contribute significantly in disaster mitigation both at ground zero and throughout the country. This lecture intends to provide basic information on disasters and describe nurses’ roles in disaster management on the three levels of prevention.
There are millions of nurses, and many thousands of nursing schools that teach nothing on disasters –especially in places exposed to continuous natural disasters. The teachers at these countries are in need for teaching material on disaster management. A Nursing Supercourse will empower faculty members and instructors at nursing schools world wide by providing them with state of art ready to teach lectures on disaster management.
Noji: www.pitt.edu/~super7/20011-21001/20351.ppt
Nurses are the main health professionals in touch with the community. They have exceptional knowledge of the most vulnerable populations, and this information can be immediately used in a disaster. Nursing recognizes the physical and the psychosocial impact of disasters on well being of individuals, families and community. Nurses deal not only with the physical stresses of a disaster, but potentially more importantly the fear, dangers, stress and uncertainties of disasters.
Nurses in disasters provide support and help the public in regain confidence in rebuilding their lives and living through hard times. Understanding and finding a meaning to suffering helps in healing and in reducing impact on physical health.
Nurses can save lives and reduce public's fear and assist in mitigation measures such as equipped shelters. Nurses play key roles in disaster preparedness. Nurses can help in initiating or updating emergency plans at their work settings as well as being knowledgeable about the disasters that their areas are vulnerable to. Nurses can inform the public about the shelters available in the area and the importance of having an emergency family plan especially when there are family members who have special health needs.
Nurses play a key role as preventionists in assisting in maintenance of proper sanitation measures, proper control of vector populations, and control of infectious disease through public education.
Head and chest injuries and fractures are common in earthquake victims. Nurses poses clinical skills that can save lives when they assist in searching and retrieving trapped individuals. Also the injury rate is high for first responders, and nurses can play a major role in protecting the rescue teams. In fact all rescue teams should have at least one nurse.
The column to the left demonstrates that people who live in lower middle income countries are at higher risk of being exposed to earthquakes. The column to the right confirms that the same countries have higher death rates compared to other countries. Nurses in these countries need to take leadership role and be actively involved in planning and implementing national preventive strategies. Deans of schools of nursing should ensure that curricula provide sufficient training and that nursing graduates are competent and posses necessary critical skills.
La Porte: www.bibalex.org/Supercourse/SupercoursePPT/21011-22001/21601.ppt
This slide indicates that there has been almost a doubling in the rates of natural disasters. This could be due to: improved reporting, and/or the major increase in populations living in dangerous areas. This alerting trend mandates increase in level of preparedness among health care workers. Nurses are in frontline and are trained to provide emergency direct care to individuals under normal conditions. Disasters result in massive causalities and responsiveness can be often challenging. Under such critical circumstances nurses can be more effective when receive adequate training in preparedness and responding to disasters.
The increase in number of disasters has been accompanied by increase in numbers of people affected. Consequences of disasters include: displacement, losing employment and income, physical and mental health disabilities. Therefore, responding to the needs requires working as a team. Multidisciplinary teams serve a wide range of affected populations. Nurses are often under estimated when dealing with disasters. This lecture demonstrates that nurse involvement in disaster management can be beneficial at local, national and international level.
Vulnerable populations such as people with chronic health conditions are in great danger in disasters due to the risk of occurrence of an acute critical event. Individuals with chronic conditions, e.g. cardiovascular disease, diabetes, renal failure, etc. need to be monitored and have their health conditions managed with care.
The circles demonstrate overlapping the concentration of water emergencies. More money means more abilities which means that responses to disasters are improving. Higher risk of water events means more need. How well a country is organized determines the level of vulnerability, hence the importance of preparedness and training for nurses.
Deaths per year have actually declined over the long period, these data are from Centre for Research on the Epidemiology of Disasters. There are fewer conflicts, and the conflicts have a smaller number of deaths, but this is only an accounting of battle deaths.
Asia is at higher risk for disasters and Africa for complex emergencies. Connolly A, Gayer M, Ryan M, Salama P, Spiegel P, Heyman D. Communicable diseases in complex emergencies: impact and challenges. The Lancet, 364, 9449: 1974 – 1983, 2004
We need to focus on each of the components of man-made threats. The Supercourse model has done this as evidenced with Natural, Asymmetric attacks. Supercourse has significant number of lectures specific disaster focus. Shortly after the building of the Supercourse we realized that it had exceptional potential in the area of disasters. We had the idea if a disaster were to occur we could rapidly develop a network of people from out network interested in helping and to develop a Just-in-Time (JIT) lecture. This was established by:
Rapid Contact of Expert Supercourse Network
Lecture Created by Experts with Vetting
Rapid JIT Development of Customized lectures
Rapid Dissemination
Continuously updated learning as crisis enfolds
With the same vision, building Nursing Supercourse can serve faculty at schools of nursing well by empowering them with an innovative educational teaching model.
Chotani RA, LaPorte RE, Linkov F, Dodani S, Ahmed D, Ibrahim KM. Just-in-time lectures: SARS. Lancet. 2003 Jun 7;361(9373):1996
La Porte: www.supercourse.cn/SupercoursePPT/29741.ppt
Severe injuries can be caused by disaster debris. Clean up of debris is the authorities responsibility but nurses can assume the role of educators by increasing public’s awareness to hazards of debris and precautionary measures to protect their own and their families safety. Nurses also a major role in long term mitigation such as with land minds or rebuilding.
Noji: www.pitt.edu/~super7/20011-21001/20351.ppt
Knowing the patterns of mortality and injuries associated with particular disasters can be most beneficial when providing training. This can result in effective preparedness and ensure better outcomes. It is important to bring this to the attention of nurses in developing counties especially that their countries at higher risk for disasters and causalities.
Immediate response is mostly concerned with saving lives and eliminating immediate threats. However, what is substantial too is working with survivors with minimal or no physical injuries. These groups are usually displaced in shelters to meet their survival needs. Survivors vary according to age groups or health conditions. These shelters are expected to work in a systematic way to ensure high performance. Lay professional volunteers can assume the role of organizing and management of the shelter. Nurses can be spared for other important tasks such as taking care of the affected people, assessing their health conditions and any special needs and use the available resources to attend to these health needs. Nurses can be responsible for establishing mental services, counseling and providing social support especially that under such circumstances people need to make meaning of what happened and how to adjust in order to be able to continue their lives. Pediatric nurses have the most burden because children unlike other populations need to have an outlet for their energy, have their own ways of understanding and coping to unusual conditions.
Community/public health nurses can serve vulnerable populations during a disaster and assist communities in recovery. This requires expansion of their knowledge by providing state of art training in disaster preparedness.
Infection control is an important strategy in eliminating infectious diseases (e.g. cholera, etc.). Nurses receive training in infection control during their undergraduate or as part of continuing education. Public education about preventive strategies in times where water is contaminated can be a determinant factor in eliminating any epidemic.
Disasters consequences range between short and long-term. Effective assessment can establish the base for appropriate actions. This can serve well in lessening the burden of disaster and enhancement of coping. Nursing education acknowledges mental wellness by itself an outcome , however, it is also looked as the key for physical well being.
College of nursing, university of Hyogo: http://www.coe-cnas.jp/english/index.html
Everyone has a role identity in family and community; when they lose everything and are then taken care of with emergency assistance, they may be turned intopassive receivers and lose that role identity. We can help themrecover their sense of purpose and worth along with helping themexpress and process the loses.
Nurses assume multiple roles with different populations. Nurses are highly skilled health care workers trained to work with vulnerable groups. Therefore, they are essential team players in any emergency preparedness team.
Nursing can contribute to prevention, mitigation, preparedness, response, and recovery. Nurses work systematically by gathering data, planning according to priorities to target all who might benefit, working skillfully to promote health of the community, and evaluating the outcomes.
Keith: www.queens.edu/pdf/upload/nursing/
In triage causalities are categorized according to severity of injury. The color red requires immediate and quick attention because it means life threatening injury. On this level nurses focus on airway, breathing, and circulation and based on that decide the level of intervention needed.
Triage aims to:
To sort patients based on needs for immediate care
To recognize futility
Assumption: Medical needs will outstrip the immediately available resources
Additional resources will become available given enough time
How Does Triage Manage Resources?
By preventing the use of excessive resources on patients who are likely to die no matter what we do for them
By preventing the use of excessive resources on patients who have minor injuries and require little to no treatment
By focusing resources on those patients with severe injuries and high survivability rates
Worldwide nurses receive minimal training on disaster preparedness. The World Health Organization (WHO) report 2006 acknowledges that nurses lack knowledge and skills in disaster and recommends that nurses to be involved in planning, policy-making for disaster preparedness and response. Furthermore, WHO demonstrates that training nurses will have a great impact on risk reduction and response to a disaster.
WHO (2006). The Contribution of nursing and midwifery in emergencies: report of a WHO consultation, WHO, Geneva. http://www.who.int/hac/events/2006/nursing_consultation_report_sept07.pdf
Nursing and midwifery densities across the Region are found in the slide. Note particularly low densities of each in PNG, Cambodia, etc, and also, what isn‘t apparent in the density table, rural/urban inequities, with nurses/midwives, other health professionals concentrated in urban areas.
Geography is modified by the relative size of the nursing population in these bubble charts. According to the size of the bubbles, there are more nurses in the developed countries.
Again, the bubbles size in this slide demonstrates that there are more resources and more nurses in the richer countries, but the majority of deaths due to disasters occurs in the poorer countries. So nurses are even more important in developing countries.
Nursing curricula, starting from the first year equip nurses with clinical skills to assess, plan, implement, and evaluate the health needs of individuals and groups. They also are trained to work in the context of team work. This workforce must be prepared for disaster management and integrated into each country’s national emergency team.
Nursing organizations have the responsibility of coordinating with the officials in having clear understanding in nurses' roles during disaster and taking all measures to speed nurses’ involvement in crisis times.
Nurses can integrate into an existing team or lead one if there is not yet one on site. And document what they do for continuity with each patient, or record where the injured are sent.
World Health Organization (2008). Integrating Emergency Preparedness and Response into Undergraduate Nursing Curricula. Geneva, Switzerland
To build national and international capacity of nurses, the WHO proposed a set of competencies that are essential in disaster preparedness training program.
World Health Organization (2006). The contribution of nursing and midwifery in emergencies. Geneva, Switzerland
Question: What is the best way to improve global health and science training?
Answer: Improve lectures.
Question: How do we improve global health and science lectures:
Answer: Faculty worldwide share their best PowerPoint lectures:
Question: Will faculty share lectures?
Answer: Yes, The Supercourse has 64.000 faculty from 172 countries who created an open source Library with 3500 lectures. We have collaborators from over 1200 medical and public health schools using our lectures. In the last 12 months we taught over 1 million students world wide.
Nursing Supercourse will serve as educational model for instructors at schools of nursing to ensure effective training of nurses worldwide in disaster management based on the competencies proposed by the World Health Organization. These competencies give a clear picture on the skills that are essential when preparing nurses for disaster management. Capacity building is the core of disaster management. Training of nurses can have significant impact on the degree of harm inflicted by disasters. Training will also expand the scope of practice and augment the role of other healthcare workers.
Nursing Supercourse will also establish a solid foundation for building a global network of nurses before the disaster occurs, which would lead to much better coordination.
We, at the Nursing Supercourse project look forward to collaborating with you. So join us and let the one thousand mile journey start with this first step toward bringing together nurses in the world to promote healthier life on this planet.