Following the September 11, 2001, incident in the United States (US) and subsequent natural disasters, the US, like other countries, has focused on improving its overall disaster response capabilities. One mechanism that is under development to improve the country’s surge capacity, i.e., its ability to substantially increase the number of volunteer health care professionals available to respond during a disaster, is the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP). Registries, like ESAR-VHP, are significant tools for disaster planning and deployment. The goal of ESAR-VHP is to create a state-based registry of volunteer health professionals, verify their credentials prior to a disaster, and provide opportunities for education and training in disaster response. Each of these steps is necessary in ensuring access to patient services during an emergency, while also providing for the safety of the volunteer health professional. This article speaks to the registered nurse as a volunteer acting within these types of registries. Specifically, it addresses the development of a personal and professional response plan, and registration programs that provide the preparation needed to enable a nurse responder to work effectively within a disaster response team and facilitate preregistration with one and only one registry. The legal implications of responding are also discussed.
Key words: Credentialing, disaster preparedness, disaster registry, disaster response, emergency system, natural disaster, regulation, volunteer health professionals, weapons of mass destruction
Registered nurses are often the single largest group of responders in any major disaster.
Since September 11, 2001, disaster preparedness and response in the United States (US) and elsewhere has received significant attention, resources, and scrutiny. While there are many aspects to disaster response, such as security, transportation, and reconstruction, the medical response directly affects the people most impacted by the disaster. Provide nursing care during a disaster presents numerous challenges, such as an uncertain physical environment, scarce human and material resources, personal risk, and most certainly, patients who are at their most vulnerable. Yet, without hesitation registered nurses and other health professionals have responded during a time of need. Registered nurses are often the single largest group of responders in any major disaster. To date, nursing’s response has not necessarily been coordinated or managed within the traditional disaster planning and response framework. This article examines various aspects of the registered nurse as a disaster responder within the US. Specifically, it addresses the development of a personal and professional response plan, and registration programs that provide the preparation needed to enable a nurse responder to work effectively within a disaster response team and facilitate preregistration with one and only one registry. A variety of the legal implications of responding are also discussed. Clearly, now is the time for nursing’s response power to be harnessed, cultivated, and deliberately managed so that it can be deployed in a manner that will be of greatest benefit to this nation during a major disaster.
Key Points on Response – Be Prepared
An essential premise of a successful response is to be prepared ahead of time. All registered nurses must have a personal and professional plan in place for times of disaster. Preplanning is necessary for preparing for a disaster at home, as well as responding to a disaster within one’s own region or in another part of the country.
A personal plan addresses issues related to the family. While there is little consensus regarding the period of time for which an individual or family needs to have supplies on hand, whether it be for three days or three weeks, it is important to have items such as food, medicine, water, and batteries on hand to meet the needs of each member of the family. In addition, it is important that there be a communication plan should a disaster occur while family members are separated. There are a variety of resources available through the Department of Homeland Security (http://www.dhs.gov/) and the American Red Cross (http://www.redcross.org/) that provide detailed information and checklists designed to create a comprehensive family plan.
...spontaneous volunteers are often not able to be used during a disaster.
A professional plan addresses issues related to employment. It is especially important that health care providers reach agreement with an employer regarding how volunteering decisions will be made before a disaster occurs. The American Nurses Association (ANA) has two position statements addressing issues related to employment, volunteering, and disasters. The first, Registered Nurses’ Rights and Responsibilities Related to Work Release During a Disaster (ANA, 2002a), provides a guideline for registered nurses who wish to volunteer during a disaster and addresses considerations which need to be taken into account. A companion statement, Work Release During a Disaster – Guidelines for Employers (ANA, 2002b), provides additional information geared toward health care employers in establishing work release policies and procedures during a disaster.
Disaster response – at the best of times - is orchestrated chaos. One of the most difficult elements to handle during a disaster is the spontaneous volunteer (American Hospital Association [AHA], 2005). The success of any response is dependent on all individuals or teams understanding their roles, responsibilities, and the chain of command within the disaster response. Disaster respondents who deploy within a system that is part of the overall disaster planning usually come with the essential equipment that is needed to complete their mission and to keep the responder safe from hazards that might result from the disaster. A spontaneous volunteer who shows up on the disaster scene may not have the necessary equipment and may also easily become a distraction to those leading the response effort. While well-intentioned, spontaneous volunteers may not have been vetted through a system with regard to licensing and certification; and they may not have the proper education and training needed to provide appropriate patient care and to keep their patient and/or themselves safe. Because of this, spontaneous volunteers are often not able to be used during a disaster. If they are used, their skills, knowledge, and ability are underutilized by the disaster leadership team because they cannot be easily slotted into the existing response network (Hoard & Tosatto, 2005). This experience often leaves the individual who spontaneously deploys with a feeling of dissatisfaction, disappointment, and maybe even anger at those who are managing the response.
Hence, the time to get prepared and be ready to volunteer is not when the disaster occurs but before the disaster strikes. Respondents need the training to respond appropriately and ensure personal safety. They also need time to acquire and/or become familiar with appropriate personnel protective equipment and other necessary tools. Advance preparation enables individual skills, knowledge, and abilities to be well utilized for the benefit of the disaster casualties and other responders.
Any registered nurse who believes that he/she will want to respond at the time of a disaster should pre-register with one of the many disaster registries and response organizations that already exist. Through these registries the registered nurse’s licensure can be pre-verified and validated; he/she will have access to disaster training and drilling; and during a disaster, he/she will be deployed through a recognized system that has been incorporated into the local, state, and national response plans. When choosing the registry or volunteer response system, it is important that the registered nurse choose one deployment system that meets his/her clinical, family, and employment situation.
The next section will describe the Emergency System for Advance Registration of Volunteer Health Professionals and other organized response systems. It will also guide nurses in selecting the program best suited to their needs and interests.
Emergency System for Advance Registration of Volunteer Health Professionals
The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) is one registry available to registered nurses and other volunteer health professionals. ESAR-VHP is a national, state-based volunteer registry system that is being developed in every state under the auspices of the state health department or the state emergency response system. Following September 11, 2001, and the subsequent anthrax attacks, it became clear the United States was unprepared to respond to large scale disasters. In particular, the capacity did not exist to quickly verify health care professionals’ identity, licensing, education, and employment so that they could be used within disaster response.
In 2002, Congress passed the Public Health Security and Bioterrorism Preparedness and Response Act (Public Law 107-188). Reacting to the lack of capacity to quickly verify the names and credentials of volunteer health professionals, Congress sought to establish a system that would facilitate the ability of state and local authorities, hospitals, and other health systems to quickly utilize volunteer health professionals during a disaster (AHA, 2005). Included in this legislation was a provision that authorized the federal government to assist the states and territories in the development of a standardized, volunteer, registration system known as ESAR-VHP. The purpose of the system is to: a) give all states the ability to quickly identify and better utilize health care professionals in their state during disasters and emergencies; and b) enable the sharing of pre-registered and credentialed health care professionals across state lines and nationally.
States and territories have received federal grant funding through the Department of Health and Human Services, Human Resources and Services Administration (HRSA), National Bioterrorism Hospital Preparedness Program. Phase I of this project began in September 2004 with ten pilot states: Texas, Minnesota, Wisconsin, Missouri, Illinois, California, Ohio, West Virginia, Massachusetts, and Connecticut. Phase II began in June, 2005 and involved an additional 20 states. As of January, 2006 and the start of Phase III, all states have begun to develop an ESAR-VHP system. There are four fundamental objectives guiding the development of the ESAR-VHP program (HRSA, June 2005):
- Ensuring an adequate and competent health volunteer force
- Enabling efficient and effective emergency operations
- Allowing sharing of health volunteers across state lines
- Establishing clear protections for health volunteers, hospitals, and others
Currently, the ESAR-VHP registries are focused on the credentialing of the following health professionals: physicians, registered nurses, and behavioral health professionals (marriage and family therapists, medical and public health social workers, mental health and substance abuse social workers, psychologists, and mental health counselors). Eventually, the registries will include some 65 health and health-related occupations. At a minimum, the emergency credentialing information that will be collected on volunteer registered nurses who submit their name to the registry will include: health professional’s name and contact information; RN licensure information; degree or diploma; certifications; and information on clinical practice – active, inactive, or retired. Additional information may also be collected regarding disaster training and education.
Other Organized Response Systems
In addition to the ESAR-VHP, there are many other organized response systems that facilitate the use of volunteer health professionals (some of which are listed in the Table). For instance, within the National Disaster Medical System (NDMS) are the Disaster Medical Assistance Team and the National Nurse Response Team. The NDMS is a part of the Department of Homeland Security within the Federal Emergency Management Agency. NDMS’ purpose (NDMS, 2006) is to "design, develop, and maintain a national capability to deliver quality medical care to the victims of – and responders to – a domestic disaster." The Disaster Medical Assistance Teams (DMAT) are highly organized and trained teams of health professionals dedicated to providing medical care during a disaster. The National Nurse Response Team (NNRT) is a specialty team of registered nurses dedicated to providing chemoprophylaxis, managing a mass vaccination program, or responding to a use of a weapon of mass destruction that requires surge capacity of registered nurses.
The Medical Reserve Corps (MRC) includes teams of local volunteer medical and public health professionals who can be used to supplement existing emergency and public health resources. While the MRC national office functions under the auspices of the U.S. Surgeon General, the MRC units are organized and managed at the community level.
The American Red Cross is also a well-known humanitarian organization that provides relief to victims of disasters while also working to prevent, prepare for, and respond to emergencies. As with the other organized response systems identified, the Red Cross provides significant opportunities for training in a variety of response missions.
Questions to Ask Yourself
It is important to evaluate your level of commitment to serving as a disaster response volunteer...
It is important to evaluate your level of commitment to serving as a disaster response volunteer by considering the following questions:
- How involved in disaster response do you want to become?
- Are you interested in extensive training with the opportunity for frequent deployments?
- Are you more interested in only responding during a time of major national emergency?
- Do you have significant family responsibilities that will limit your ability to be deployed to another part of the country?
- Do you need to be paid during your deployment?
- Do you have portable liability insurance? Or, does the system through which you are deploying provide you with such coverage?
- Is your employer amenable to having you be deployed? Have you discussed with your employer the circumstances under which you will be available to be deployed?
Based on the answers to these questions, a registered nurse may consider a variety of different programs through which to register, receive training and education, and be deployed. If someone is interested in potentially frequent deployments and extensive training, then the Disaster Medical Assistance Teams (DMATs) operated through the National Disaster Medical System may be of interest. Or, the American Red Cross may also provide extensive volunteer opportunities. On the other hand, if someone is interested in local deployments, the local Medical Reserve Corps may provide the type of volunteer opportunity of this nature.
...it is critically important that an individual only register through one system.
One final note, when registering it is critically important that an individual only register through one system. In disaster planning, knowing what type and how many resources are available is extremely important to a successful response. An individual who has registered through multiple systems is considered to be an available asset to each system. But, the reality is that an individual can only be deployed through one system at a time. Multiple registrations means that an asset is repeatedly counted even though this asset may not be available when needed because deployment through another system may have already occurred.
Legal Implications of Responding
There continues to be significant legal and regulatory barriers that can hamper the ability of registered nurses to respond. Unless a volunteer is deployed through a federal response effort, such as the DMATs or NNRT, or under the state implemented Emergency Management Assistance Compact (EMAC) as a designated asset, issues related to licensure recognition, civil liability, and right to re-employment remain.
Practicing without a license - even during an emergency - could leave the volunteer open to civil or criminal charges.
Most state boards of nursing have established a procedure for swift licensure recognition during a disaster. However, if the state board of nursing in the affected state is unable to function due to power outage or other ramifications of the disaster, even these minimal procedures may be difficult. For a registered nurse interested in volunteering, it will be important to know what licensure rules are in place at the time of an emergency. Practicing without a license – even during an emergency – could leave the volunteer open to civil or criminal charges.
Civil liability refers to the "potential responsibility of a person or entity for actions that result in injuries or losses to others" (HRSA, September 2005). Some federal and state laws provide protection from civil liability through immunity or indemnification. These protections may be limited to individuals responding under the auspices of a registry or identified disaster response organization. Good Samaritan statutes may provide limited protection from civil liability; however, whether protection exists and the level to which it provides protection will be dependent on the state in which the action occurred. If a volunteer is responding through a disaster relief organization, the deploying organization may also provide some liability coverage to the volunteer. If the volunteer carries professional liability insurance, it will be important to know if that policy covers actions taken during a disaster.
If the volunteer carries professional liability insurance, it will be important to know if that policy covers actions taken during a disaster.
As already mentioned, responding under designated federal response systems or through EMAC, provides some guarantee that the volunteer has the right to reemployment following their deployment. An individual who chooses to respond as a spontaneous volunteer cannot necessarily expect a right to re-employment unless this is agreed upon by the employer.
Specific to licensure reciprocity and civil liability, the ANA has been collaborating with the National Conference of Commissioners on Uniform State Laws (NCCUSL) to develop uniform state legislation that will create a better legal environment for volunteer health professionals. At its meeting in July, 2006, NCCUSL approved an initial uniform state act, Uniform Emergency Volunteer Healthcare Practitioners Act, which state legislatures will be able to consider as they address concerns related to volunteer health professionals. This Act addresses concerns related to licensure reciprocity and the use of registries. The NCCUSL intends to continue its consideration with regard to civil liability and workers’ compensation protection, with final action expected on these areas in July 2007.
The Time Is Now – Be Prepared
Neither the Unites States, nor any nation, can remain complacent about the ability to respond to a disaster. Registered nurses, as the largest group of health professionals across the country, are a significant element of any successful response. The time is now for all registered nurses to seize the role of disaster responder. All registered nurses should plan for and be ready to respond should a disaster occur. Planning for and being ready means that individual registered nurses have a personal and professional plan that address issues related to family preparedness and continuing employment. Nurses interested in volunteering should register with an organized response system, receive the appropriate education and training, and be deployed through the established disaster response channels so that their skills, knowledge, and abilities can be used appropriately to care for those injured during the disaster. It is essential that any volunteer registered nurse know the legal and regulatory framework regarding the disaster for which they are volunteering.
Cheryl A. Peterson, MSN, RN
Cheryl A. Peterson, MSN, RN, is a senior policy analyst for the American Nurses Association (ANA) responsible for researching and developing association policy related to preparing for and responding to a disaster, whether man-made or natural. Since 1998, Ms. Peterson has been actively involved in disaster planning at the federal level. In addition, she coordinated ANA’s response to the Tsunami disaster in Southeast Asia and to hurricanes during the 2005 U.S. hurricane season. Ms. Peterson spent 13 years in the Reserve Army Nurse Corps and in 1990, was deployed during Desert Storm. She also spent 7 years as an active volunteer in the Kensington Volunteer Fire Department (Montgomery County, Maryland). Ms. Peterson received her BSN from the University of Cincinnati and her MSN from Georgetown University.
Article published September 30, 2006
American Nurses Association. (2002a). Registered nurses’ rights and responsibilities related to work release during a disaster. Retrieved May 15, 2006, www.nursingworld.org/responsibilitiesdisasterps.aspx.
American Nurses Association. (2002b). Work release during a disaster – guidelines for employers. Retrieved May 15, 2006, www.nursingworld.org/workreleaseps.
Health Resources and Services Administration. (June 2005). Emergency system for advance registration of volunteer health professionals (ESAR-VHP) program – Interim technical and policy guidelines, standards, and definitions.