The tragic events of September 11, 2001 affected the entire nation and the world. To those of us who live and work in New York, the shock of watching the World Trade Center's skyscrapers collapse into millions of tons of rubble and the fear of possibly 10,000 victims were initially paralyzing. In the headquarters building of the New York State Nurses Association (NYSNA) in upstate New York - 150 miles away, approximately 80 nurses - many from the metropolitan area - were gathered for a meeting. They and the staff of the association congregated around our television sets and wept, or sat at telephones urgently, and usually in vain, trying to reach family and friends in the immediate area. Most telephone service and electronic communications systems in lower Manhattan were disrupted, and all intact communication lines were immediately flooded with calls. The NYSNA offices on Wall Street, within a few blocks of the World Trade Center, could not be reached, so we had the additional stress of concern for the staff's safety in that area.

It was initially feared that as many as 10,000 persons might have lost their lives in the disaster. However, through the heroic evacuation efforts of the police, fire departments and thousands of employees, visitors, and bystanders, fewer than 3000 individuals died in the tragedy. The property and business damages have been estimated at over 100 billion dollars. Indirect costs related to the lost wages and benefits of employees, and the continuing medical and mental health treatment of survivors, their families, and others affected by the disaster are incalculable.

The association had never contemplated a disaster on this scale.

We were clearly not prepared to respond to a major community disaster in which the health care system - and nurses - would be a vital resource to be mobilized.

We had planned for fire or other natural disaster involving our headquarters, but we were clearly not prepared to respond to a major community disaster in which the health care system - and nurses - would be a vital resource to be mobilized. Although many nurses receive basic education in first aid, epidemiology and outbreaks of infectious disease, and perhaps some facility- based training on disaster plans related to fires, multiple vehicle accidents or train/plane crases, few (if any) educational institutions or health care facilities provide any courses or electives on mass casualties or disasters of this scale.

As the professional association for registered nurses in New York, the association's mission includes services to members and the profession at large. We have more than 150 staff in three offices, including experts in communications, the regulation of practice in the state, and information management. When the disaster occurred, senior NYSNA staff were uncertain of what role the association could serve in the recovery efforts. However, it seemed apparent that we had the resources to assist in the disaster by being a channel for information concerning the possible need for nurse volunteers. Nurses across the United States, as well as within the state, soon utilized our web site as a first point of information. Additional disaster response continued throughout the course of the disaster recovery efforts, thus showing the appropriate role of the association in this situation. The purpose of this article is to share those lessons learned, lessons about what professional associations can do in response to such disasters, in the hope that other associations can use this information to build effective disaster plans of their own.

Immediate Responses

Within an hour of the disaster, executive staff of the association organized an Emergency Response Team to assess the situation, determine priorities, and organize our work. These activities included arranging transportation; obtaining proof of licensure; establishing communications; and managing volunteers, operations and public relations.

Arrange Transportation

The most pressing requirement was to arrange for transportation back to New York City for the nurses attending our meeting in our headquarters in upstate New York.

A complicating factor was that many of the members in the building had no available documentation of their licensure status as RNs...

These nurses were experiencing a profound and urgent need to return to New York City, both to check on the safety of their families and to report to their places of employment in the City. Public transportation had ceased and private transportation was restricted from entering Manhattan. Since airlines were grounded, several members had to rent automobiles to drive back to other cities around the state. A complicating factor was that many of the members in the building had no available documentation of their licensure status as RNs or their employment in New York City, both of which were required to arrange clearance by the National Guard to travel into the affected area.

Initially, the State Police, the Fire Department, the Red Cross, and the National Guard turned down NYSNA's request to provide transportation back to New York City for the stranded nurses. Ultimately, an official from the State's Emergency Medical Services Bureau commandeered a bus and coordinated entry into the city. By this time the Borough of Manhattan and all approaches to New York City had been "locked down" and were under the control of local police, the military, or National Guard.

Obtain Proof of Identity and Professional Licensure

Members needed proof that they were registered nurses to gain access into New York City. NYSNA staff accessed the State Education Department Office of the Professions' licensure verification web site and printed a copy of each nurse's on-line licensure information. This proof of status, in conjunction with photo identification, facilitated the successful return of these nurses into New York City.

Establish Communications

The disruption of telephone, fax, and computer communications into lower Manhattan was particularly stressful. Fortunately, many staff and visitors present in our headquarters had cell phones and were eventually able to make connections to their families and employers in New York City. NYSNA staff were evacuated from the New York City office, located within blocks of "ground zero" and soon arranged a network of cellular communications among themselves and with our headquarters. Since the Executive level staff work at headquarters, it was important to establish regular communication with the New York City staff, most of whom work as field service representatives in the health care facilities of the New York City area.

Communications with disaster response agencies were very difficult since we did not have a current list of contact numbers or staff names. These agencies were inundated with their own requirements and we had to go through "back channels" to establish contact. Our headquarters staff who had working relationships with agency staff were able to contact those persons instead of the agency officials, and then to relay offers of assistance or ask urgent questions.

Manage volunteers

Within two hours of the disaster, NYSNA headquarters (upstate) was overwhelmed with calls and e-mail from nurses across the country who wanted to volunteer their services. It was necessary to assign three full-time staff to answer the telephones and e-mail and record the information. Potential volunteers (over 1000 contacts) were eager to be called on and wanted immediate and frequent follow-up telephone or e-mail contact from NYSNA.

NYSNA's Emergency Response Team contacted the State Emergency Management Office (SEMO), and NYSNA was designated as the official repository for information from nurses who could volunteer during the disaster. A system was established to respond to telephone calls and e-mails, and a database was created that included name, state of licensure, address, contact numbers, e-mail address, specialty and availability.

This information was sent to SEMO. In addition, NYSNA notified the Healthcare Association of New York State, the Greater New York Hospital Association, the New York Organization of Nurse Executives, and the nursing executives in the New York City area that a searchable list of over 1000 nurses and other healthcare workers was available. This list was also shared with the American Red Cross. State nurses associations and other groups offered to send busloads of nurse volunteers. A medical center in Vermont sent a list of all of their healthcare workers. All potential volunteers were informed that the New York State Nurse Practice Act contains an exemption for federal, state and civil emergencies. During such emergencies, RNs need not be licensed in New York State, but must bring with them evidence of current licensure in another state.

Manage operations

Not the least of our concerns was the fact that no business could be conducted from our New York City office for two weeks. Mail delivery was completely disrupted and when the office was reopened, there was an enormous backlog of work for the administrative and professional staff. Although the professional staff were able to establish contacts working from home, in many cases field service staff could not reach their facilities because of transportation disruption. It was necessary to shift all possible activity to our headquarters. Alternative office space had to be found in the event that the city office could not be reopened.

The impact of the disaster on staff was tremendous, especially among those who volunteered at the disaster site or who were evacuated from the NYC office. Nearly every staff person has experienced some form of post-traumatic stress disorder. Our Employee Assistance Program provider could not meet the need for service on this scale, so it was necessary to find additional assistance among our members and staff. Peer support meetings were organized and provided for staff for about three months.

Manage information and public relations

Many members, the press, and others called for information about the disaster and NYSNA's response. We had no communications plan for an event of this magnitude that required near constant internal and external communications with the press, agencies, members, and volunteers. Fortunately, NYSNA has an experienced communications staff, and as quickly as messages could be crafted, they were placed on our web site. Broadcast e-mail was used to keep the board of directors, other state nurses associations and ANA informed of our activities and needs.

Continuing and Long-Range Issues

By Thursday, September 13^th , the response to NYSNA and SEMO was so overwhelming that the call for nurse volunteers had to be withdrawn. It was clear there would be few survivors and that the emphasis would be on recovery, not rescue.

NYSNA members helped treat thousands of survivors who arrived at NYC hospitals. Many were admitted, but most were triaged and treated for minor injuries. While the initial onslaught of patients seemed overwhelming, hospitals never lost their ability to deliver services, largely because their own staffs instantly mobilized. Few facilities had to call any staff persons to come in - all off duty staff mobilized themselves!

By Tuesday afternoon, September 18^th, the focus shifted to helping rescue workers, as there were no more survivors expected. NYSNA members helped at the staging and family center areas, providing mental health counseling and assistance with the shelters. NYSNA staff members contacted their military reserve units, volunteered with the American Red Cross at a World Trade Center triage center, assisted with the rescue and recovery, provided emergency nursing care, donated blood, and volunteered with the Red Cross's Family Services Division.

Our web site described how nurses were responding to the terrorist attack and how to volunteer. Information was also supplied about hotlines, grief-counseling services, and suggested charities for donations. On a daily basis the need for supplies or opportunities for volunteering were identified. NYSNA shared stories from nurses providing care near the World Trade Center and provided an online opportunity for nurses to comment on the national crisis. Also on the web site were recommendations from the New York Committee for Occupational Safety and Health (NYCOSH) about air and environmental hazards that might affect those involved in rescue, recovery and clean-up operations.

The association utilized staff of our Statewide Peer Assistance Network to provide individual and group opportunities to discuss the feelings of grief and anger that were so prevalent.

For months following the disaster, the primary needs for nurses were for specialists in mental health care (children and adults) and burn care. NYSNA facilitated access to lists of qualified providers in these areas. Post-Traumatic Stress Syndrome was evident in many volunteers and staff of the association. The association utilized staff of our Statewide Peer Assistance Network to provide individual and group opportunities to discuss the feelings of grief and anger that were so prevalent. First-hand accounts of conditions at "Ground Zero" were shared by staff who volunteered at the site. Through our communications department, the association also collected nurses' stories of their experience. Some of these stories were printed in a special issue of The Journal of the New York State Nurses Association (The Journal of NYSNA,2002).

One very special concern was the fact that the Association's centennial convention and celebration was scheduled in less than six weeks - in a New York City hotel.

...the decision to proceed with the convention (and to deny terrorism that acknowledgement) was quickly made.

Questions about our intent to hold the convention - and members' willingness to attend - surfaced almost immediately. With enormous cancellation penalties looming, the decision to proceed with the convention (and to deny terrorism that acknowledgement) was quickly made. By action of our Voting Body at convention, a special task force was created to examine our preparedness to meet the disaster-related needs of our communities, especially for provision of mental health care.

The Future - Getting Ready For Any Disaster

NYSNA held an "after-action" review of the entire experience and formulated plans for future work. These were our goals:

1. Establish a comprehensive disaster plan. The plan should, at a minimum, include internal policies for responding to various levels of emergencies and disasters; policies for interaction of the association with federal, state and local authorities; alternate communications channels; evacuation plans; plans for maintenance and restoration of business operations.
2. Develop guidelines for communication and information that should be provided for members and the public through various communication vehicles. Designate a specific spokesperson to respond to the press.
3. Develop and maintain a master list of contact numbers and staff names for SEMO, FEMA, American Red Cross (state and city offices), Salvation Army, and mental health providers. Establish and develop relationships with these resource persons. Update the list every 3-6 months.
4. Develop an understanding of the functions (and coordination) of FEMA and SEMO, and relief agencies. (Some Directors of Nursing told us that they were required to get nurses from FEMA in order for the federal government to reimburse for the costs of these nurses.) Determine the best way to integrate assistance from the association into these other groups' activities.
5. Address the educational needs of members regarding disaster preparedness, training for volunteer work in disasters, bioterroism, and employee rights when absent due to a federal, state, or local emergency.
6. Explore the possibility/advisability of establishing permanent photo identification cards for health personnel.
7. Keep in mind that history is occurring during a disaster and keep a record for historical purposes. First hand accounts of nurses' involvement in disaster relief should be invited and recorded.
8. Understand that SNA staff are experiencing the disaster even while having to respond. Plan for provision of staff support.

A "permanent" staff team was created to develop the disaster plan and make recommendations for implementation activities. The plan is nearing completion and includes sections on life safety, property protection, staff communications, administration and logistics, community outreach and disaster response, recovery and restoration of operations, policies regarding interruption of mail and telecommunications, and handling of suspicious mail.

Alternate office space has been identified.

Offsite storage of the association's critical databases has been arranged, with electronic backup every evening.

Offsite storage of the association's critical databases has been arranged, with electronic backup every evening. American Red Cross pamphlets and checklists for personal/home disaster preparation have been distributed to all staff. Primary and alternate communications "trees" (including telephone, e-mail, and cell phone numbers) have been developed and will be distributed to all management staff.

NYSNA has received a grant from the Department of Health to provide disaster preparedness training for nurses. We hope to receive some additional funding to create and maintain a statewide database of nurses who are trained and ready to provide disaster related services. NYSNA has developed and posted an on-line continuing education course on exposure to biological agents (bioterrorism) and plans to offer additional courses on disaster preparedness. (www.nysna.org/PROGRAMS/NED/HOME.htm)

Organized Nursing's Response

NYSNA believes that a national, coordinated plan and mechanism for mobilizing the profession's large resource pool should be developed. It is important to ensure the availability and involvement of volunteer professional nurses for the emergency organizations and agencies that respond to emergencies and disasters such as earthquakes, hurricanes, fires, storms, tornadoes, epidemics, nuclear reactor accidents, biological hazards, and acts of violence and terrorism.

For this reason, NYSNA, in collaboration with several other state nurses associations, submitted a resolution to the 2002 House of Delegates of The American Nurses Association (ANA) to urge ANA to provide ongoing leadership for the profession on the need to develop and maintain an adequate number of nurse volunteers available to the organizations and agencies that provide emergency, rescue and disaster services. We believe ANA must also provide direction to individual volunteer professional nurses in order that these nurses may proactively plan their own responses in a coordinated way that enhances the necessary relief and rescue efforts.

The specific recommendations submitted to ANA were as follows:

1. Provide leadership for the profession on the need for nurses to volunteer their services to assist in the activities of the agencies and organizations that offer rescue, relief, and disaster services.
2. Promote workplace initiatives that support nurses volunteering during periods of local, state, and federal emergencies and disasters.
3. Provide leadership for the constituent member associations in planning for state, regional and national disaster services.

The resolution was passed nearly unanimously by the House of Delegates in 2002.

Several state nurses associations have already begun their own work in planning for disasters. The Georgia Nurses Association, for example, in collaboration with the American Red Cross, the Georgia Board of Nursing, the Georgia Department of Human Resources, and the Georgia Nurses Foundation, has established a network of volunteer nurses who will make up part of a statewide emergency response team(Robinson, 2002). Work on disaster preparedness has also been done by the Florida, Oklahoma. Virginia, and Washington Nurses Associations.

Clearly, professional associations should be prepared to respond to even unimaginable disasters - to mobilize resources, maintain their vital business operations, facilitate communications, and support nurses in the exercise of their professional responsibility. One excellent resource to assist associations in planning is a special publication of the Federal Emergency Management Agency's "Emergency Management Guide for Business and Industry"(Wahle & Beatty, n.d.). This publication contains sections on plan development and suggestions for communications, community outreach, life safety, and other business recovery information. The Guide is available in both HTML and as a PDF file from the Preparedness, Training and Exercises Room of the FEMA online library (www.fema.gov/library/).

Another excellent resource is a special issue of a Joint Commission on Accreditation of Healthcare Organizations (JCAHO) publication, "Emergency Management in the New Millenium." (JCAHO, 2001). Although framed in terms of emergency management within health care facilities, several of the articles contain recommendations for emergency management that are applicable to associations. Subscribers can obtain this issue online at www.jcrinc.com/.

Summary

Nursing's organizations have an opportunity and obligation, as part of the profession's social contract, to identify our appropriate roles in the event of natural or manmade disasters.

Sadly, it appears that continued threats of terrorism and mass destruction will be a presence in our society for the foreseeable future. Nursing's organizations have an opportunity and obligation, as part of the profession's social contract, to identify our appropriate roles in the event of natural or manmade disasters. It is a given that such disasters will be disruptive of the normal systems needed to respond to large-scale disasters, including communications, transportation, supply lines, and decision-making systems. Strategic planning must be utilized to identify alternate scenarios for response. Finally, the impact of disasters upon the emergency response personnel and their families must be understood and provision made to care for the caregivers. Ready or not, disasters happen. Registered nurses - and their professional organizations - can be leaders in recovery efforts.

Authors

Martha L. Orr, MN, RN, CAE
e-mail: martha.orr@nysna.org

Martha Orr received both her bachelor and master's of nursing degrees from Emory University in Atlanta, GA. She is certified by the American Society of Association Executives (Certified Association Executive). Ms. Orr has been Executive Director of NYSNA for 17 years. NYSNA is the oldest and largest of the ANA constituent member associations. With a staff of more than 160 persons located in three offices, Ms. Orr has had numerous experiences managing organizational crises, though none involving a community disaster of these proportions. When asked to comment on experiences that might have assisted her in responding, Ms. Orr credits her training in nursing assessment, care planning, and evaluation. Multi-tasking skills are highly developed in professional nurses and association executives!

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