Today’s nurses are faced with the challenges of responding to natural, manmade, and technological disasters. In the United States, disaster content is included in the National Council Licensure Examination (N-CLEX) (National Council of State Boards of Nursing, 2006), but little time is spent in teaching or learning this content during the basic nursing education program. Education at the master’s or doctoral levels fares no better.

The International Nursing Coalition for Mass Casualty Education collaborated with the National League for Nursing to survey Deans or Directors of United States (US) nursing schools as to the curriculum for emergency preparedness (Weiner, Irwin, Trangenstein, & Gordon, 2005). Results demonstrated that there is a lack of emergency preparedness content in the curriculum, with only four to five hours of disaster preparedness content taught throughout the United States during the academic years of 2000-2001 through 2002-2003.

Nursing students are not the only ones lacking in the mastery of emergency preparedness content. In the afore-mentioned survey, 74% of the respondents felt that faculty were not at all prepared or poorly prepared to teach disaster preparedness content (Weiner, Irwin, Trangenstein, & Gordon, 2005). Similar findings have been presented by researchers in Japan in relation to faculty and student learning needs (Yamamoto, 2005).

Practicing nurses are faced with similar learning deficiencies. Smallpox, for example, was thought to be eradicated during the decade of the seventies, so "baby-boomer" graduates were never taught how to give a smallpox vaccination. With today’s threats of bioterrorism, the subject of smallpox again arises, with public health agencies developing plans calling for thousands of volunteers to mass vaccinate the population against the disease. Perhaps no better example exists than the recent response efforts in the United States in response to Hurricane Katrina. While many emergency response plans were prepared, the inability to execute those plans in conjunction with a coordinated response led to the demise of such planning efforts.

All these factors contribute to the need for an enhanced curriculum for nurses in emergency planning and response. This article will describe a number of possible solutions for use by both faculty and students as they prepare for effective disaster response. The author of this article describes competencies needed for emergency preparedness identified by Columbia University, Vanderbilt University, and the INCMCE, as well as various curriculum resources for emergency planning and response and also processes to prepare nurses for emergency responses. Examples of international "Best Practices" feature programs that provide examples of innovative educational strategies for preparing nurses for emergency response are presented. The author concludes that while curriculum resources are widely available, a better centralized clearinghouse could be made available for both faculty and students.

Competency-Based Learning in Emergency Planning and Response

Today’s public is clamoring for outcomes to serve as a measure for their investments. At the same time, tuition in higher education continues to rise at the rate of 2-3% more than the rate of inflation (Ehrenberg, 2001). As a result, competency-based education has become a popular method of ensuring that a standard set of criteria are met. Educational efforts in emergency planning and response are no exception. The following section will describe the competencies developed by Columbia University, Vanderbilt University, and the INCMCE.

Columbia University

Dr. Kristine Gebbie, from the Columbia Center for Health Policy, has provided the most visible leadership in the area of competencies for emergency planning and response. She chaired the group that produced the Competency-to-Curriculum Toolkit, a resource designed to assist those involved in educating the public health workforce (Columbia University, 2002a). The document was a result of much dialogue over several years and began with competency basics, including the definition of competencies as "actions which are observable in the execution of one’s work" (p.7). These competencies describe: a) an acceptable level of performance, b) the skill needed to perform the work, and c) the actual conditions under which the work is executed today). One way of using competencies is to define what a certain type of learner needs to know (as nurses or physicians). Another method is to describe a program area such as Avian flu control, with the delineation of the roles of members on the team. Furthermore, "core" competencies can also be described that cut across all roles. Dr. Gebbie describes these as "cross-cutting" (2002, p. 11), or competencies that transcend the boundaries of the specific disciplines within public health and help to unify the practice of public health.

Core competencies for all public health workers were first developed by Dr. Gebbie and her staff in 2002 (Columbia University, 2002b) with the process described by Gebbie and Merrill (2002). After the delineation of the core competencies, she further defined role competencies for the administrator/leader, the professional, and technical/support staff. Gebbie also developed competencies for hospital workers and leaders (Columbia University, 2003). Each of these competency documents can be found on the website of the Columbia Center for Health Policy (Columbia University, 2002b).

Vanderbilt University and the International Nursing Coalition for Mass Casualty Education

The INCMCE first met during the spring of 2001 at Vanderbilt University with sponsorship from the U.S. Department of Health and Human Services (U.S. DHHS) (INCMCE, n.d.). The Coalition was designed to have organizational representatives from schools of nursing, government agencies, nursing specialty organizations, and nursing accrediting agencies. Early in the development of the INCMCE, international representation was limited, but has now grown to ten non U.S. members. Individuals who were interested in mass casualty education were requested to submit curriculum vitae so that their expertise in either emergency planning or response could be used when needed.

One of the early activities of the INCMCE was to develop competencies for all nurses, regardless of the level of their education. Dr. Joan Stanley (2005) chaired the Task Force and has described the process used by the group to develop the competencies. The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing [AACN], 1998) provided the framework for organizing the competencies. However, as Dr. Stanley (2005) noted, there was a general consensus that all RNs currently licensed to practice and all nurses educated from now on should have some basic level of knowledge and skill related to mass casualty events.

The resulting list has sixty-four competencies and can be found at the INCMCE (2003) website. While philosophically noting that all nurses should master the entire list of competencies, INCMCE members have acknowledged that some of the competencies can be considered very basic, or "core" to an interdisciplinary team. Knowing that nursing faculties typically teach a full curriculum, the Competency Task Force also described ways to integrate mass casualty content into an already existing curriculum (Stanley, 2005). In addition, the INCMCE has directed development of competencies for advanced practice nurses (in conjunction with the National Organization of Nurse Practitioner Faculty). These competencies will define the higher-level triage, diagnosis, and treatment capabilities that are within the scope of advanced practice nursing.

It is important to note that the INCMCE competencies were based on the categorical headings of the Essentials (AACN, 1998) document, thus resulting in a longer list of competencies than those developed at Columbia. There are, however, similarities in some of the basic skills that can be taught during interdisciplinary preparedness activities. These skills are likely to benefit nurses regardless of where they are employed, thus transferring a skill set to a variety of agencies. The Table identifies those items considered "basic" competencies by the INCMCE. This list more closely resembles the Columbia competencies. The advantage to interdisciplinary education is that teams can prepare and learn together, resulting in smoother team performance when an actual crisis occurs. At any rate, all of the competencies have yet to be validated during a "live" event. For example, one could assess whether these competencies were actually needed by those who responded to the Hurricane Katrina event and/or whether additional competencies were also needed. Only then could any gaps be identified for future curriculum.

None of the competencies is promoting that nurses be educated in isolation. In fact, team education is preferred, and it was response teams that were requested (rather than individuals interested in volunteering) during the Katrina response. Nurses were urged to join local Medical Reserve Corps teams or serve as a member of a team that had trained together as a unit. It should be noted, though, that one of the limitations to team training has been the lack of adequate curriculum resources designed for use by teams.

Curriculum Resources for Emergency Planning and Response

A variety of curriculum resources are available to help nurses and other team members enhance their emergency preparedness skills. These include online modules, pre-packaged materials, and electronic journals.

Online Modules

The INCMCE competencies were divided and placed into a curriculum grid that served as the blueprint for development of online modules (INCMCE, 2006a, 2006b). Leadership for the online development was provided by Dr. Elizabeth Weiner, a multimedia developer and the Associate Director for the INCMCE. Funding for four of the six modules has been received from the Agency for Healthcare Research and Quality (AHRQ) and from the Health Resources and Services Administration’s (HRSA) Bioterrorism and Curriculum Development Program.

A unique aspect of these online modules is that when all are completed, the vast majority of the INCMCE competencies will be met. (The exceptions are those competencies requiring a return demonstration of skills.) Furthermore, the development has used the "How People Learn" framework, a process resulting from a national review of the literature by the American Research Council in understanding how best people learn (National Research Council, 1999). As these modules are completed, they are made available free of charge on the INCMCE (2006b) website. Other federal resources have also been used to stimulate the development of learning materials in emergency preparedness and response for nurses.

Centers of Excellence

The Centers for Public Health Preparedness (CPHP) was initiated in 2000 to strengthen terrorism and emergency preparedness by linking academic expertise to state and local health agency needs within the US. The program has grown to 52 CPHPs which serve as an important national resource for the development, delivery, and evaluation of preparedness education (U.S. DHHS, 2006a). The primary focus of the CPHP program activities centers on the delivery of education, training, and dissemination of information related to enhancing emergency preparedness and response. Examples of activities include: courses, train-the-trainer programs, conferences, workshops for emergency preparedness curriculum development, internships, and training exercises/drills. To maximize the dissemination of educational materials, the U.S. Centers for Disease Control and Prevention (CDC) has collaborated with the Association of Schools of Public Health (ASPH) to develop an online CPHP Resource Center (U.S. DHHS, 2006b). This site allows the user to search by material types, audience (such as nurse), topics, institution, and/or keywords. For example, a search for all material types, targeted for nurses across all topics and institutions, returned 419 resources. Some of the resources actually link to the resource itself; others require the user to contact the originating Center for further information.

Pre-packaged Materials

Nurses who work within the infrastructure of the armed forces have typically had more experience than civilian nurses in emergency response. They also have greater access to handbooks and other resource materials that delineate the algorithms to be used based on the situation.

Dr. Tener Veenema (2003) edited the most comprehensive textbook for disaster education for nurses. In addition, she used the structure of the chapters to organize curricular materials in the format of content outlines with developed PowerPoint programs that can be customized by faculty (Veenema, 2005). Calling her curriculum "Ready RN," she also added a companion, purse-sized handbook that is marketed through Logical Images.

Electronic Journals

The two major journals in emergency planning and response for health care workers both started out as print journals but have recently converted to electronic journals for easier access across the world. Disaster Management and Response is an official journal of the U.S. Emergency Nurses Association (ENA). The journal is published quarterly and focuses on health care management of issues associated with natural or manmade disasters, such as weapons of mass destruction, hurricanes, biological warfare, and other public health emergencies (ENA, 2006). As of the writing of this article, the journal is open to the public in a free trial period.

The second journal has more of an international influence. The Journal of Prehospital and Disaster Medicine is the official medical journal of the World Association for Disaster and Emergency Medicine (WADEM) and the Nordic Society for Disaster Medicine (WADEM, 2006). An added feature of the journal is that all references used by authors are placed in a reference clearing house. However, the clearing house was still under construction as of the writing of this article, at which time it still contained older citations. WADEM as an organization consists of individual members. During the 2005 World Congress, the first subspecialty group consisting of nurses was organized (Andress, 2005).

Regardless of the choice of curricular materials, it is possible to design learning activities in a variety of ways. Pre-assigned didactic material could form the basis of a tabletop or full exercise. Competencies could then be observed "in action" and weaknesses identified. Online learning materials could be assigned via identified modules. A "skills marathon" with return demonstration of selected skills would complete the package.

Educating Volunteer Nurses for Emergency Response

Educating volunteer nurses creates its own set of unique challenges. In some situations, nurses simply show up at the scene and expect to receive "on-the-job" education, or "just-in-time" learning materials. While there may be important remediation materials to be used on-site, volunteers are encouraged to register through organized teams and complete learning activities prior to the emergency event. This pre-registration process also allows for credentialing prior to the event response, therefore ensuring appropriate scope of practice and clarification of legal liabilities. The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) is one mechanism states can use to register their healthcare volunteers (HRSA, 2006). Other local communities are organizing as Medical Reserve Corps units, and can provide educational activities prior to an emergency event (Medical Reserve Corps, 2006). Peterson's (2006) article describing advance registration of volunteer health professionals is available in this September 30, 2006 OJIN topic.

One of the benefits of better preparation for emergency events has been improved coordination between the public health and hospital-based sectors. Prior to the "anthrax scares," reporting between public health departments and hospitals had been isolated to disease specific issues. Many of the federal funds were made available to strengthen the public health infrastructure, a system that before the "anthax scares" had been allowed to decay to the point that some local health departments did not even own a fax machine. Responses can now be sent electronically and many databases have been designed for local responses that collect data that can be useful for both public health and hospital leaders. Leaders in both sectors have learned to consistently manage emergency events, using the standardized national incident management system.

International "Best Practices" in Educating Nurses for Emergency Planning and Response

A number of different schools currently offer programs in disaster preparedness and management. A recent article by Veenema (2006) lists these schools and details of their programs, including the web addresses for 20 schools. Two programs outside the United States deserve additional recognition for their efforts in disaster education. These programs have been presented at various international meetings, including the International Council of Nurses.

The University of Glamorgan (in Wales) has collaborated with other schools in the United Kingdom to offer a comprehensive curriculum delivered in an online fashion using WebCT (University of Glamorgan, 2006). Survival training is offered during the summer months along with simulations. Clinical placements are found around the world in disaster and emergency situations so that students are prepared in real-life events rather than solely in simulated experiences. A Master’s of science degree in disaster health care relief is offered, as well as a postgraduate certificate or postgraduate diploma. This program was modeled after the University of Ulster program, which was the first academic program available for nurses in disaster nursing.

Hyogo University has been designated as a 21^st Century Center of Excellence in their country of Japan (Yamamoto, 2004). The focus of their center of disaster nursing in a ubiquitous society focuses on preparing for disasters, the period immediately following a disaster, and the mid-to long-term consequences of disasters. Based on their experiences following the Great Hanshin-Awaji earthquake in 1995, faculty divided the needs of their center into four areas. These areas related to the health of the people, nursing care, education (for specialists, researchers, and community), and human network and information systems. Their purpose is to develop self-care abilities of communities and individuals to regenerate and recover from the consequences of disasters. Central to their efforts is a research focus addressing the development of an information base, the establishment of a nursing support network throughout Asia and the world, and the development of nursing care strategies which includes the Education/Training Program Development Project. This five year project holds promise to move important educational and research issues forward for the international nursing community.

An additional collaborative effort which merits discussion as a "Best Practice" model is The European Master in Disaster Medicine (EMDM, 2006), although the majority of the participating students are physicians. The University of Eastern Piedmont School of Medicine, Novara, Italy, and the Free University of Brussels School of Medicine, Brussels, Belgium, together are the founding universities and actually provide the degree. Associate universities include the Centre for Teaching & Research in Disaster Medicine and Traumatology (Linkoping, Sweden), Centre Hospitalier Universitaire Vaudois (Lausanne, Switzerland), the International Emergency Medicine and Disaster Medicine Sections, Harvard Medical School (Boston, Massachusetts, United States of American [USA]), Yale New Haven Center for Emergency Preparedness and Disaster Response (New Haven, Connecticut, USA), and the Vanderbilt University School of Nursing and National Center for Emergency Preparedness (Nashville, Tennessee, USA). Didactic content is presented in an online format for three months prior to the two week live-in course venue. The live-in venue takes place in a selected site in Italy, where interactive exercises culminate in a community-based drill. This year marks the sixth edition of the course, and nursing content was presented for the first time during 2006. Students attend from around the world and have the unique opportunity to better understand their global colleagues in disaster relief.

Conclusions

Competency-based learning provides an infrastructure on which to base educational activities for nurses in emergency planning and response. A number of different competencies exist for use depending on the role expectations for the intended learners. After selecting the appropriate competencies, a variety of learning resources have recently been developed that are available for use by those who persevere in finding the actual resources themselves instead of simply the citations. A major challenge will be to integrate, rather than add, additional content into an already full nursing curriculum. Faculty development is important because they, too, need to have the confidence in their knowledge base in order to provide the academic leadership as well as the much needed supervision of students in responding to local events.

A more centralized resource for the learning resources would be helpful for both faculty and students. A recent example is through the National Nurse Emergency Preparedness Initiative (U.S. Department of Homeland Security, 2005). Through a collaboration of the George Washington University and George Mason University, the Department of Homeland Security has funded efforts to centralize online resources for nurses. These resources are organized according to the type of employment of nurses (hospital, hospice/home health, school, public health, nursing home, occupational health, and ambulatory care). Keeping these resources current will require continued funding. Efforts to collaborate, nationally and internationally, in other learning endeavors have also recently gained momentum. While these efforts do require funding as well as personnel time, they also provide a more comprehensive picture of possible global response efforts. After all, it is during times of disaster that we all best understand humanity’s needs, regardless of political influences. We should all do our best to be prepared to respond.

Author

Elizabeth Weiner, PhD, RN, BC, FAAN
E-mail: Betsy.Weiner@vanderbilt.edu

Elizabeth Weiner is the Associate Director of the International Nursing Coalition for Mass Casualty Education (INCMCE), an organization hosted by the Vanderbilt University School of Nursing. Dr. Weiner is currently implementing a bioterrorism curriculum development grant from the Health Resources and Services Administration (HRSA) as well as an educational evaluation grant from the Agency for Healthcare Research and Quality (AHRQ). She has over 30 years of experience in developing multimedia programs in the Health Sciences, and collaborates with her development team and Little Planet Learning, Inc. to develop online learning modules. The INCMCE has developed standardized competencies for all nurses in emergency response, and these are being met with the online curriculum development. Dr. Weiner speaks nationally and internationally on the INCMCE activities. She is the Senior Associate Dean for Educational Informatics and Professor in Nursing and Biomedical Informatics at Vanderbilt.