Chapter 23-The Disaster Management Cycle

Community Preparedness

Presidential Policy Directive (PPD)-8 emphasizes that true preparedness is a whole community event PPD-8 urges the strengthening of our nation's security and resilience through an integrated set of guidance, programs, and processes to implement the national preparedness goal, described earlier in this chapter (DHS, 2011).

Five mission areas by FEMA that serves as a basic understanding of emergency management

Prevention, Protection, Mitigation, Response, Recovery

he first level of disaster response occurs at

the local level with the mobilization of a team of responders such as the fire department, law enforcement, public health, and emergency services.

Each ESF includes a

oordinator function, and the primary and support agencies that work together to coordinate and deliver federal capabilities.

Healthy People 2020 Objectives Related to Preparedness

• PREP-1: Reduce the time necessary to issue official information to the public about a public health emergency. • PREP-2: Reduce the time necessary to activate designated personnel in response to a public health emergency. • PREP-3: Increase the proportion of Laboratory Response Network (LRN) laboratories that meet proficiency standards. • PREP-3.1: Increase the proportion of LRN biological laboratories that meet proficiency standards for Category A and B threat agents (http://www.bt.cdc.gov/agent/agentlist-category.asp). • PREP-3.2: Increase the proportion of LRN chemical laboratories that meet proficiency standards for chemical threat agents. • PREP-4: Reduce the time for state public health agencies to establish after-action reports and improvement plans following responses to public health emergencies and exercises.

the community must have an

an adequate warning system and an evacuation plan that includes measures to remove those individuals who hesitate to leave areas of danger. Some people refuse to leave their homes over fear that their possessions will be lost, destroyed, or looted. They also do not want to leave pets behind. Also, some people mistakenly believe that experience with a particular type of disaster is enough preparation for the next one.

Nurses should be involved in

identifying and educating communities about what effect the disaster might have on them, including helping at-risk populations to address preparedness planning. in addition to identifying high-risk individuals in neighborhoods, locations of congregate concern include schools, college campuses, residential centers, prisons, hospitals, and high-rise buildings.

Prevention

prevent, avoid, or stop an imminent, threatened or actual act

Disaster management includes four stages:

prevention (including mitigation and protection), preparedness, response, and recovery.

Prevention (Mitigation)

Activities to prevent natural/man-made disasters (increasing, strengthening public health process such as immunizations), Strengthening levees to prevent flooding, preventing communicable disease transmission, Assessing threats, vulnerabilities and capabilities, Identification and assessment of vulnerable populations (at risk)

Disaster disproportionably strikes at-risk individuals, whether their day-to-day risk is physical, emotional, or economic.

Disasters in less developed communities can also destroy decades of progress in a matter of hours, in a manner that rarely happens in more developed countries. The poor, elderly, ethnic minorities, people with disabilities, and women and children in developing communities are excessively affected and least able to rebound

Tertiary Prevention

Ensure community service linkages are available, conduct community outreach, participate in planning efforts to attain new normal

Disaster Preparedness

Occurs at national, state, and local levels. Personal and family preparedness is crucial, professional preparedness, plan stems from threats/vulnerabilities identified at prevention level, coordinated efforts, drills, different agencies

Primary Prevention

Participate in community disaster exercises, assist in development of disaster management plan for community, pre-identify vulnerable populations

Levels of Prevention

Primary Prevention Participate in community disaster exercises; assist in development of the disaster management plan for the agency/community; preidentify vulnerable populations. Secondary Prevention Assess disaster survivors; conduct rapid needs assessment; use individual and population-based triage for care; provide psychological first aid. Tertiary Prevention Ensure that community service linkages are available to individuals and families; conduct community outreach; participate in planning efforts for the community's "new normal."

Role of the Public Health Nurse in Personal and Professional Preparedness

Public health nurses play a key role in community preparedness, but they must accomplish the critical elements of personal and professional preparedness first.

he last phase, reconstruction, is the longest.

Recovery as a disaster cycle phase is addressed later in this chapter. Homes, schools, churches, and other community elements need to be rebuilt and reestablished. The goal is to return to a new state of normalcy. Community needs may still be extensive; the nurse continues to function as a member of the interprofessional team to provide and assure provision of the best possible coordinated care to the population.

Risk Assessment

Who is at risk in community?, Have there been recent disasters?, Size/population likely to be affected, What is community disaster plan?, Warning systems in place?, Resource facilities available?, Evacuation measures, Environmental dangers

Homeland Security Presidential Directive 5 (HSPD-5) created the National Incident Management System (NIMS)

a unified, all-discipline, and all-hazards approach to domestic incident management (Naval Postgraduate School [NPS], 2014; FEMA, 2013c). The NIMS was established to provide a common language and structure enabling all those involved in disaster response to communicate with each other more effectively and efficiently.

In the honeymoon phase,

survivors may be rejoicing that their lives and the lives of loved ones have been spared. Survivors will gather to share experiences and stories. The repeated telling to others creates bonds among the survivors. A sense of thankfulness over having survived the disaster is inherent in their stories.

Disaster planning involves simplicity and realism with back-up contingencies because

(1) the disaster will never be an "exact fit" for the plan, and (2) all plans must be implementation ready, no matter who is present to start them

Nursing Role in Ongoing Community Assessment.

A major advantage of the recovery community assessment efforts is that they can be more in-depth, with greater confidence in the results. Some examples of community data points in the recovery phase include the following: ongoing illness and injuries related to the disaster; diseases related to disruption of environmental or health services; health facility infrastructure in terms of adequate personnel, beds, medical and pharmaceutical supplies; and environmental health assessment to include water quantity and quality, sanitation, shelter, solid waste disposal, and vector populations. Nurses should also be aware that postdisaster cleanup creates opportunities for unintentional injury and hazards, including those occurring from falls, contact with live wires, accidents with cutting devices, heart attacks from overexertion and stress, and auto accidents resulting from road conditions and missing traffic controls (e.g., stoplights). Nurses should also educate the public of the hazards related to carbon monoxide poisoning stemming from using lanterns, gas ranges, or generators or from burning charcoal for a heat source in enclosed areas.

Nursing Role in Disaster Communication.

A part of that communication is involved with the rapid and ongoing needs assessment just described. A lack of or inaccurate information regarding the scope of the disaster and its initial effects can contribute to mismatched resources and increased morbidity. The community needs accurate information transmitted in a timely manner. Health care personnel are the best sources for essential health information that is technical in nature. The NIMS approach uses public affairs spokespersons for formal communication. The Public Information Officer (PIO) is an individual with the authority and responsibility to communicate information to the public at large. Still, nurses are considered trustworthy sources of information and may be approached for an interview. The nurse should refer the media to the PIO representing the agency. there may be an occasion for the nurse to serve as a health consultant on the risk communication team. Risk communication includes providing critical information to the public. The information should be presented in a calm, brief, and concise manner. As a spokesperson in disaster, it is important to prepare key points in writing before speaking, verify all information is accurate, and never speculate or embellish.

Disaster Response

Activate disaster management plan, perform triage and direct those affected, coordinate evacuation, quarantine, and opening of shelters

Secondary Prevention

Assess disaster survivors, conduct rapid needs assessments, use individual and population-based triage, provide psychological first aid

Evaluation of Disaster Response

Evaluate the area, effect, and level of disaster, Create ongoing assessment, surveillance reports, Evaluate efficiency of disaster response teams, Estimate recovery time of community services (electric, water)

Disaster and Mass Casualty Exercises

Exercise categories include discussion-based simulations or "tabletops" and operations-based events such as drills, functional, and full-scale exercises (FEMA, 2013b). The latter operation types involve escalating scope and scale testing of the disaster preparedness and response network, using a specific plan. Homeland Security Exercise and Evaluation Program (HSEEP) was developed to help states and local jurisdictions improve overall preparedness with all natural and human-made disasters. It provides a standardized methodology and terminology for exercise design, development, conduct, evaluation, and improvement planning and assists communities to create exercises that will make a positive difference before a real incident

Two national preparedness documents specifically guide disaster health preparedness, response, and recovery:

HSPD-21 established a national strategy that enables a level of public health and medical preparedness sufficient to address a range of possible disasters. It did so through four critical components of public health and medical preparedness: (1) biosurveillance, (2) countermeasure distribution, (3) mass casualty care, and (4) community resilience

Phases of emotional reactions

Heroic, honeymoon, disillusionment, reconstruction

Disaster recovery starts much sooner than most nurses may think.

In recovery, the immediate response actions to address initial consequences subside, which could be within hours. Also, there will not be a clean break between response and recovery periods. Rather, the process is a transition. Recovery is about returning to the new normal, a community balance of infrastructure and social welfare that is near the level that it would have had if the event had not occurred The recovery phase is often the hardest part of a disaster. It involves ongoing work beyond preparedness and the response rush. Recovery is where prior community resilience has the ability to make a real difference. Although the initial disaster response phase provides an onslaught of relief aid and resources, the reality of loss and enormity of the task involved in getting back to normalcy is soon felt

Nursing Role in First Response.

In this situation, it is important to remember that life-threatening problems take priority. Triage should begin immediately. Triage at the individual level is the process of separating casualties and allocating treatment on the basis of the individuals' potentials for survival. Highest priority is given to those who have life-threatening injuries but, also, who have a high probability of survival once stabilized (Veenema, 2012). A type of triage called public health triage also exists, using a population-based approach for use in an incident undefined by a geographical location. Public health triage involves the sorting or identification of populations for priority interventions

Disasters can affect one family at a time, as in a house fire, or they can kill thousands and result in economic losses in the millions, as with floods, earthquakes, tornadoes, hurricanes, tsunamis, and bioterrorism

The American Red Cross reports that it responds to a disaster in the United States every 8 minutes, resulting in response to more than 70,000 incidents each year

The National Health Security Strategy and Community Resilience

The NHSS is designed to achieve two goals: (1) build community resilience and (2) strengthen and sustain health and emergency response systems Community resilience is a policy issue in all levels of planning (federal, state, and local) because limited resources postdisaster demand whole community resilience in order to move back into normalcy. Healthier communities, by default, will have better bounce-back ability. Community resilience is defined as the sustained ability of a community to withstand and recover from adversity (Chandra et al, 2011). Healthy individuals, families, and communities with access to health care and protective, preventive knowledge that can be used to launch timely action become some of our nation's strongest assets in disaster incidents.

The Nursing Role in Community Resilience

The public health nurse understands that a resilient community is interconnected; it has strong horizontal and vertical relationships among its residents. There is evidence that both the sense of community created by these relationships and the individual connections of those relationships help improve disaster preparedness and, by default, disaster recovery The recovery period demands that these relationships be reactivated as soon as possible. The public health nurse will have knowledge of the previously existing relationships, and must work with the population to find creative ways to reinstitute those ties.

Role of the Public Health Nurse in Disaster Recovery

The role of the public health nurse in the recovery phase of a disaster is as varied as in the preparedness and response phases, but the nurse's connection to the community puts the nurse in an incredible position of knowledge and awareness on the interprofessional recovery team. Nurses need awareness of the potential public health challenges specific to the disaster area and should monitor the physical and psychosocial environment.

The National Preparedness Guidelines (NPG) (DHS, 2007a) and the National Response Plan (NRP), which provide a national doctrine for preparedness that includes the National Response Framework (NRF), was promulgated in January 2008.

The second edition of the National Response Framework, updated in 2013, provides context for how the whole community works together and how response efforts relate to other parts of national preparedness (DHS, 2013). Each of the five frameworks covers one mission area: Prevention, Protection, Mitigation, Response, or Recovery. In that framework there are also 15 emergency support functions.

The effect of disasters on young children (Figure 23-7) can be especially disruptive

Young children may respond with regressive behaviors such as thumb-sucking, bedwetting, crying, and clinging to parents. Older children tend to re-experience images of the traumatic event or have recurring thoughts or sensations, or they may intentionally avoid reminders, thoughts, and feelings related to disaster events. Children may have heightened sensitivity to sights, sounds, or smells and may experience exaggerated responses or difficulty with usual activities.

Reconstruction

adjusting to new reality, continued rebuilding, victims start to look ahead

Honeymoon

affected individuals begin to bond and relive their experiences

The NHSS was directed by the 2006 Pandemic and All-Hazards Preparedness Act (PAHPA

an act to improve the nation's ability to detect, prepare for, and respond to a variety of public health emergencies. The PAHPA was re-enacted in 2013 and is now called the Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA). The PAHPRA funds public health and hospital preparedness programs, medical countermeasures under the BioShield Project, and enhances the authority of the Food and Drug Administration (FDA)

Nurses have unique skills for all aspects of disaster including

assessment, priority setting, collaboration, and addressing both preventive and acute care needs.

One Health recognizes that the health of humans is

connected to the health of animals and the environment, and the One Health concept integration in disaster preparedness and response requires interprofessional efforts at global, national, and local levels the spread of infectious diseases and the relationships among humans, animals, and the environment are at the core of One Health

Emergency management is responsible for

developing and coordinating emergency response plans within their defined area, whether local, state, federal, or tribal. The Federal Emergency Management Agency (FEMA) coordinates comprehensive, all-hazard planning at the national level, assuring a menu of exercises and plan templates to address plausible incidents in any given community.

Psychological Stress of Disaster Workers

during an assignment, responders may be exposed to chaotic environments, long hours, rapidly changing information and directives, long wait times before getting to work, noisy environments, and living quarters that are less than ideal. According to the National Institute of Occupational Health and Safety (NIOSH, 2013), responders may not recognize the need for self-care, and to monitor their own emotional and physical health. As recovery efforts span time frames of weeks to months, there is increasing risk of adverse effects to responders. Symptoms that may signal a need for stress management assistance include the following: being reluctant or refusing to leave the scene until the work is finished; denying needed rest and recovery time; feelings of overriding stress and fatigue; engaging in unnecessary risk-taking activities; difficulty communicating thoughts, remembering instructions, making decisions, or concentrating; engaging in unnecessary arguments; having a limited attention span; and refusing to follow orders (American Red Cross, 2012). Physical symptoms such as tremors, headaches, nausea, and colds or flulike symptoms can also occur.

All-hazards mitigation (prevention, protection) is an

emergency management term for reducing risks to people and property from natural hazards before they occur. The ability to provide primary prevention through national missions of prevention, mitigation, or protection can include structural measures, such as protecting buildings and infrastructure from the forces of wind and water, and nonstructural measures, such as land development restrictions. These primary prevention measures implemented at the local government level achieve effectiveness, in an all-hazards approach to threats

public health nurses have a skill set that serves their community well in disaster, including

health education and disease screening, mass clinic expertise, an ability to provide essential public health services, community resource referral and liaison work, population advocacy, psychological first aid, public health triage, and rapid needs assessment.

Disaster Recovery

home visits, reassess health needs of affected population, provide/coordinate care in shelters, Stress counseling

Heroic

intense excitement and concern for survival, often lots of outside assistance available

National Incident Management System

is the national platform for disaster response and it includes universal protocols and language. The NIMS identifies concepts and principles that answer how to manage emergencies from preparedness to recovery regardless of their cause, size, location, or complexity. "NIMS provides a consistent, nationwide approach and vocabulary for multiple agencies or jurisdictions to work together to build, sustain and deliver the core capabilities needed to achieve a secure and resilient nation" The NIMS includes varying levels of education and training, with many organizations requiring a base level of familiarization to comply with federal funding requirements

The nurse may be involved in many roles in the primary prevention of disaster. As community advocates,

nurses promote environmental health by identifying environmental hazards and serving on the public health team for mitigation purposes. Public health nurses in particular are involved with organizing and participating in mass prophylaxis and vaccination campaigns to prevent, treat, or contain a disease. The nurse should be familiar with the region's local cache of pharmaceuticals and how the Strategic National Stockpile (SNS)

Emergency Support Function 8: Public Health and Medical

provides coordinated federal assistance to supplement state, local, and tribal resources in response to public health and medical care needs

The first goal of any disaster response is to

re-establish sanitary barriers as quickly as possible (Veenema, 2012). Water, food, waste removal, vector control, shelter, and safety are basic needs. Difficult weather conditions such as extreme heat or cold can hamper efforts, especially if electricity is affected. Continuous monitoring of the environment proactively addresses potential hazards. Disease prevention is an ongoing goal, especially if there is an interruption in the public health infrastructure. Infectious disease outbreaks can also occur in the recovery phase of disasters, and occasionally disaster workers introduce new organisms into the area.

Recovery

recover through a focus on the timely restoration, strengthening and revitalization of infrastructure, sustainable operations, as well as the health, social, cultural, historic and environmental fabric of communities affected by a catastrophic incident.

Mitigation

reduce the loss of life and property by lessening risks, threats, and impacts

When state resources and capabilities are overwhelmed, governors may, through provisions provided in the Robert T. Stafford Disaster Relief and Emergency Assistance Act (FEMA, 2013e)

request federal assistance under a presidential disaster or emergency declaration. crisis standards of care enable the health care operations necessary to allocate scarce resources in a different manner to save as many lives as possible (Institute of Medicine [IOM], 2012). Crisis standards need to be explored and discussed with all community stakeholders in the preparedness phase. Community engagement is key to this process.

Response

respond efficiently to save lives, protect property, and the environment, and meet basic human needs in the aftermath of a catastrophic incident

Disillusionment

responders can experience depression and exhaustion, unexpected delays

Nurses in response must consider

the psychosocial impact and the resulting emotional, cognitive, and spiritual implications. Public health nurses should identify groups/population segments particularly at risk for burnout and exhaustion, to include volunteers involved in response efforts. T hey may need breaks and reminders for nourishment. In addition, those in shock and those consumed by grief related to loss of loved ones will need compassionate care, with possible referrals to mental health counseling resources.

Professional Preparedness

the public health nurse must be prepared to advocate for the community in terms of a focus on population-based practice. The number of public health nurses available to get the job done is small when compared with those with generic or other specialty nurse preparation. Also, disaster produces conditions that demand an aggregate-care approach, increasing the need for public health nursing involvement in community service during disaster and catastrophe. The Public Health Nursing Intervention Wheel (Chapter 9) is a population-based practice model that encompasses 3 levels of practice (community, systems, and individual/family) and 16 public health interventions. it is expected that nurses know how to use personal protective equipment (PPE), operate specialized equipment needed to perform specific activities, and safely perform duties in disaster environments.

Public health nurses should help those in the affected community talk about

their feelings, including anger, sorrow, guilt, and perceived blame for the disaster or the outcomes of the disaster. Community members should be encouraged to engage in healthy eating, exercise, rest, daily routine maintenance, limited demanding responsibilities, and time with family and friends.

During the heroic phase

there is an overwhelming need for people to do whatever they can to help others survive the disaster. First responders, including health and medical personal, will work hours on end with no thought of their own personal or health needs. They may fight needed sleep and refuse rest breaks in their drive to save others. Moreover, deployed responders from outside the disaster area may be unfamiliar with the terrain and inherent dangers. Those with supervisory responsibilities need to take necessary breaks and attend to their health needs.

Response to Biological Incidents

through the Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA), several biodefense programs exist to help public health professionals mount a proactive response to these events (USDHHS, 2013b): • BioWatch is an early warning system for biothreats that uses an environmental sensor system to test the air for biological agents in several major metropolitan areas. • BioSense is a data-sharing program to facilitate surveillance of unusual patterns or clusters of diseases in the United States. It shares data with local and state health departments and is a part of the BioWatch system. • Project BioShield is a program to develop and produce new drugs and vaccines as countermeasures against potential bioweapons and deadly pathogens. • Cities Readiness Initiative is a program to aid cities in increasing their capacity to deliver medicines and medical supplies during a large-scale public health emergency such as a bioterrorism attack or a nuclear accident. • Strategic National Stockpile (SNS) is a CDC-managed program with the capacity to provide large quantities of medicine and medical supplies to protect the public in a public health emergency to include bioterrorism. The SNS is deployed through a combination of a state-level request and the public health system.

The disillusionment phase occurs as

time elapses and people notice that additional help and reinforcement are not coming as quickly as in the initial response. Fatigue and gloom can result and exhaustion starts to takes its toll on volunteers, rescuers, and medical personnel. The community begins to realize that a return to the previous normal is unlikely and that they must make major changes and adjustments.

State and local emergency planners then ensure points of dispensing (POD),

to provide prophylaxis to the entire population within 48 hours.

Presidential Policy Directive 8: National Preparedness (PPD-8)

was signed and released by President Barack Obama on March 30, 2011. PPD-8 replaced Homeland Security Presidential Directive 8 from the Bush era, and guides how the nation, from the federal level to private citizens, can "prevent, protect against, mitigate the effects of, respond to, and recover from those threats that pose the greatest risk to the security of the Nation"

National Response Framework

was written to provide an approach to domestic incidents in a unified, well-coordinated manner, enabling all responding entities the ability to work together more effectively and efficiently. The online component of the NRF Resource Center (http://www.fema.gov/national-response-framework) contains supplemental materials including annexes, partner guides, and other supporting documents and learning resources. The framework involves the entire community and is scalable, flexible, and adaptable to the given situation.

If the disaster exceeds local resources, the county or city emergency management agency (EMA)

will coordinate activities through an Emergency Operations Center (EOC). The EOC provides central functions at a strategic level to oversee the emergency situation. In general, local responders within a county sign a regional or statewide mutual aid agreement to allow the sharing of needed personnel, equipment, services, and supplies.

Populations at Greatest Risk for Disruption after Disaster

• Seniors • Vision and/or hearing impaired • Women • Children • Individuals with chronic disease • Individuals with chronic mental illness • Non-English-speaking • Low income • Homeless • Tourists; persons new to an area • Persons with disabilities • Single-parent families • Substance abusers • Undocumented residents

Four community phases as seen in Figure 23-8 are commonly recognized:

1) heroic, (2) honeymoon, (3) disillusionment, and (4) reconstruction

Disasters

An event that causes human suffering and demands more resources than are available to the community (man-made, naturally occurring, combination of both)

Stress Reactions in Individuals.

A traumatic event can cause moderate to severe stress reactions. Individuals react to the same disaster in different ways depending on their age, cultural background, health status, social support structure, and general ability to adapt to crisis. people who are affected by a disaster often have an exacerbation of an existing chronic disease. For example, the emotional stress of the disaster may make it difficult for people with diabetes to control their blood glucose levels. Grief results in harmful effects on the immune system.

Disaster Recovery

Begins when danger no longer exists, and needed agencies available, Lasts until economic/ civil life community is restored, Monitor disease and sanitation controls, PTSD and Delayed stress reactions are normal. Can affect caregiver and victims

Stress Reactions in the Community.

Communities reflect the individuals and families living in them, both during and after a disaster incident.

Disaster Planning

Develop plan based on possible threats, Identify warning system and communication center, how to access, Community first responder disaster plan, Identify agencies who are part of disaster management, Identify specific roles of personnel, Locate equipment as supplies needed, Check equipment, Evaluate efficiency, response time, and safety.

The NRF includes the 15 emergency support functions (ESFs) (FEMA, 2014d):

ESF #1: Transportation ESF #2: Communications ESF #3: Public Works and Engineering ESF #4: Firefighting ESF #5: Information and Planning ESF #6: Mass Care, Emergency Assistance, Temporary Housing and Human Services ESF #7: Logistics ESF #8: Public Health and Medical Services ESF #9: Search and Rescue ESF #10: Oil and Hazardous Materials ESF #11: Agriculture and Natural Resources ESF #12: Energy ESF #13: Public Safety and Security ESF #14: Long-Term Community Recovery ESF #15: External Affairs/Standard Operating Procedures.

Nursing Role in Rapid Needs Assessment.

Elements of a rapid needs assessment include the following: determining the magnitude of the incident, defining the specific health needs of the affected population, establishing priorities and objectives for action, identifying existing and potential public health problems, evaluating the capacity of the local response including resources and logistics, and determining the external resource needs for priority actions (Stanley et al, 2008). The Community Assessment for Public Health Emergency Response (CASPER) is a toolkit developed to assist public health practitioners and emergency management officials determine the health status and basic needs of the affected community. The CASPER guides in the collection of health and basic need information (CDC, 2012b). Noji (1997) points out that disaster assessment priorities relate to the type of disaster.

Nursing Role in Sheltering.

General population shelter management is often the responsibility of the local Red Cross chapter within their ESF-6 colead function. In catastrophic disaster, however, governmental authority may establish "mega shelters" housing thousands. Nurses, because of their comfort with delivering aggregate health promotion, disease prevention, and emotional support, make ideal shelter managers and team members. Nurses in shelter functions are involved in providing assessment and referral, health care needs (e.g., prescription glasses, medications), first aid, and appropriate dietary adjustment; keeping client records; ensuring emergency communications; and providing a safe environment Basic measures that can be taken by the shelter nurse include the following: listen to shelter residents tell and retell their disaster story and current situation; encourage residents to share their feelings with one another if it seems appropriate to do so, especially those suffering from similar circumstances; help residents make decisions; delegate tasks (e.g., reading, crafts, and playing games with children) to teenagers and others to help combat boredom; provide the basic necessities (e.g., food, clothing, rest); attempt to recover or gain needed items (e.g., prescription glasses or medication); provide basic compassion and dignity (e.g., privacy when appropriate and if possible); and refer to a mental health counselor or other sources of help as the situation warrants. To help assist these individuals, Functional Needs Support Services (FNSS) are implemented to aid individuals in maintaining their independence with the general population shelter. Required FNSS include reasonable modification to policies, practices, and procedures to accommodate individuals with functional needs as well as access to durable medical equipment within the shelter environment (e.g., walkers, beds, ventilators), consumable medical supplies (e.g., ostomy supplies, dressings). Alternate care centers may be used to shelter patients with medical needs designated as "Non-ambulatory care/Hospital overflow," for example, care of nonambulatory patients with less intense medical needs.

Management response includes:

How many affected?, How many injured or dead?, Fresh food/water available?, Areas of risk/sanitation problems?, Classified by type, level, and scope.

Nursing Role in Disaster Response Ethics.

In disaster surge the nurse may no longer be focused on the care of individual clients, but on the entire community. In extreme conditions, traditional ethics of doing the best for every patient may shift to a utilitarian framework where nursing's goal becomes to do the "greatest good for the greatest number of individuals" (American Nurses Association [ANA], 2008, p. 10). In these circumstances, each patient may not receive all the care that would occur under normal conditions. Instead, the focus is on providing care that maximizes the benefit to the greatest number of people. In addition to limited resources, nurses may be faced with situations that personally put them in harm's way.

Future of Disaster Management

Nurses must continue to plan and train in an all-hazards environment, regardless of their specialty practice. PHNs are especially critical members of the multidisciplinary disaster health team, given their population-based focus and specialty knowledge in epidemiology and community assessment. Staying current in disaster training requires the PHN's commitment in community planning activities, exercise participation, and actual disaster work.

Personal Preparedness.

One way a nurse can feel assured about family member protection is by working with them to develop the skills and knowledge necessary for coping in disaster. For example, long-term benefits occur by involving children and adolescents in activities such as writing preparedness plans, exercising the plan, preparing disaster kits, becoming familiar with their school emergency procedures and family reunification sites, and learning about the range of potential hazards in their vicinity to include evacuation routes.

Level of Disaster Prevention

Primary, secondary, and tertiary

Role of the Public Health Nurse in Disaster Response

Public health nurses bring leadership, policy, planning, and practice expertise to disaster preparedness and response (Association of Public Health Nurses [APHN], 2014). One thing is certain about disasters: continuing change. Public health nursing roles in disaster are generally consistent with the scope of public health nursing practice, but that practice is often provided in chaotic surges.

The Nursing Role in Psychosocial Support.

Referrals to mental health professionals should continue throughout the recovery phase and as long as the need exists. The role of the nurse in case finding and referral remains critical during this phase. In the end, it is the leveraging its resiliency that will help the community progress into its new normal. The public health nurse is the community and client advocate that ensures resilience is fostered in partnership with the population.

Nurses who seek increased participation or who seek a better understanding of disaster management can become involved in any number of community organizations.

The National Disaster Medical System (NDMS) provides nurses the opportunity to work on specialized teams such as the Disaster Medical Assistance Team (DMAT). The Medical Reserve Corps (MRC) and the Community Emergency Response Team (CERT) provide opportunities for nurses to support emergency preparedness and response in their local jurisdictions. The American Red Cross offers training in disaster health services and disaster mental health for both local response and national deployment opportunities.

Homeland Security Act of 2002

The U.S. Department of Homeland Security (DHS) was created

Nursing Role in Epidemiology and Ongoing Surveillance.

The need to collect surveillance data is heightened during a disaster. To detect adverse effects on the community, data are collected related to deaths, injuries, and illnesses. This information allows public health to determine impacts of disaster and assess for potential problems related to response and recovery. Surveillance includes disease tracking, injury trends, and vigilance for the potential for disease outbreaks. These data allow decision-makers to plan and allocate resources. Ongoing assessments or surveillance reports are just as important as initial assessments. Surveillance reports indicate the continuing status of the affected population and the effectiveness of ongoing relief efforts. Surveillance continues into and through the recovery phase of a disaster,

Protection

protect employees, citizens, residents, visitors and assets against threats and hazards