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When Terror is Routine: How Israeli Nurses Cope with Multi-Casualty Terror

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Shoshana Riba, PhD, RN
Hiba Reches, MA, RN


The wave of terror that has befallen the Israeli civilian population over the past two years, striking deep into the heart of towns and cities all over the country, presents a unique challenge for the health care system in general and nursing in particular. This article has a two-fold purpose: (a) to describe discussions that took place with four focus groups consisting of emergency room nurses who had recently cared for victims of terror, and (b) to delineate recommendations for policy enhancement based upon these discussions.

Qualitative analysis of the data collected from focus group discussions revealed four stages of personal and professional involvement, each one eliciting a specific response from the nurses: call up to report for duty, waiting for casualties to arrive, caring for the victims, and closure of the event. Nurses identified numerous hardships and great anxiety along with a strong sense of professional fulfillment.

Recommendations for policy include: incorporating stress management and debriefing skills in post-basic ER training, designing workshops and drills in trauma care for non-ER nurses who float into the ER in the wake of a multi-casualty act of terror, and developing leadership seminars for head nurses in the ER departments.

Citation: Riba, S.; Reches, H. (September 30, 2002). "When Terror Is Routine: How Israeli Nurses Cope with Multi-Casualty Terror". Online Journal of Issues in Nursing. Vol. 7 No. 3, Manuscript 5. Available:

Key words: multi-casualty terror, Israeli nurses, nursing education, emotional support, nursing policy, emergency room nurses, leadership

Israeli Emergency Room (ER) nurses are well experienced in caring for victims of multi-casualty terror. Yet the terrorist attacks of the last two years on the civilian population of Israel’s cities and towns constitute a unique phenomenon that has brought in its wake unprecedented strain, both for the health care system and its respective staff.

When a civilian population becomes a target, war is no longer perceived as a matter for "soldiers only."

When war penetrates deeply into the nation’s daily routine, it stirs up profound identification with each and every victim and presents a special challenge for the professional caregivers.
When war penetrates deeply into the nation’s daily routine, it stirs up profound identification with each and every victim and presents a special challenge for the professional caregivers. ER nurses are frontline health professionals; they must tend first and foremost to the victims and their family members. In addition, they must deal with the media, as well as political figures who frequent the emergency rooms to express empathy with the victims and their families; and this is not an easy task.

The purpose of this article is (a) to present the findings of a research study that investigated perceptions, reactions and feelings of nurses who cared for victims of multi-causalty terror in the emergency room, and (b) to describe a policy recommendation for the upgrading of trauma training for nurses caring for victims of multi-casualty terrorist attacks.

The Study

The purpose of this study was to deepen our understanding of the perceptions, reactions, and feelings of nurses in the emergency room who cared for victims of terror. We felt that a qualitative approach would lend itself best to the research at hand, and chose pre-arranged focus groups consisting of emergency room nurses as the means of our data collection.

Four hospitals (one large hospital containing over 700 beds, two intermediate size hospitals, and one small hospital) all situated in the heart of the nation, in cities that underwent multi-casualty terrorist attacks, were initially chosen to host a focus group. We planned to reassess the need for meeting with an additional round of focus groups after completing the analysis of the data collected during the first four meetings. By the fourth meeting, however, although previously identified themes were broadened and deepened, no new themes surfaced. It was therefore decided not to hold any additional focus group meetings.

The first step in the process of arranging the focus groups was contacting the head nurses of the respective hospitals. We shared with them the purpose of our research and requested that they schedule a meeting with the emergency room nursing staff. It was left up to the head nurses to decide whether all staff members would be invited or only a representative number.

The head nurses of three hospitals chose to invite the entire ER staff as well as nurses from the OR, ICU and Imaging departments. Between twenty and thirty nurses participated in the meetings in these hospitals. In the fourth hospital, a representative number of fifteen nurses from the ER were invited to attend. All nurses, with the exception of one licensed practical nurse, were registered nurses certified in intensive care or emergency medicine.

The moderator of the meetings was Dr. Shoshana Riba, the head nurse of the State of Israel. Ms. Hiba Reches, director of the department of licensure (Nursing Division, Ministry of Health) recorded the proceedings of the meeting. We began each meeting by explaining that the purpose of the study was to learn about the experience of caring for a victim of terror in the acute phase. We then gave all the participants an opportunity to introduce themselves and speak about their own experiences.

During the course of the meeting, Dr. Riba attempted to sharpen points that were raised, either by asking the specific nurse additional questions or inviting comments from other nurses. For example:

Dr. Riba: I understand that when a terrorist attack occurs, the entire nursing staff reports for duty, some of them even prior to the call up. What happens if you are over-staffed?

Nurse 1: There are actually two phases of activity during the intake and treatment of the victims. During the first phase, you are only concerned with saving lives and no one pays much attention to overstaffing. When things begin to settle down, we sometimes find a surplus of staff with the wounded. Often, however, at that point in time, the nurses are already emotionally involved with their patients and you can’t disengage them.

Dr. Riba: Is there a difference in the style and pace of your work during an event of this nature?

Nurse 2: We move about quicker, we feel pressured and fear the unknown- what kind of wounds will we see, of what severity….

Dr. Riba: Do you think it's possible to train people to work quickly?

Nurse 2: Nurses switch into the mode automatically.

Dr. Riba: Does the pressure and quick pace cause errors to occur in the treatment process?

Nurse 3: There is no such thing as "no errors"; they are, however, minimal. This is due in large part to high state of alert that pervades in the emergency room. An additional factor is the familiarity nurses have with respect to the protocols and procedures in the department.

Data Analysis

We did an on-going and summative content analysis of the meetings’ proceedings. The themes were identified and refined from meeting to meeting. The themes we present in this article are those that were raised by more than one nurse and in more than one institution. From the descriptions presented by the nursing staff, we crystallized four stages of involvement: call-up, waiting for the casualties to arrive, treating the victims, and incident closure.

Call Up

In order to fully appreciate the nurses’ responses, it is first important to understand how the call-up system functions in the wake of a muti-casualty attack. The Magen David Adom (MDA), the Israeli equivalent of the Red Cross, and the Police Department inform the hospital director generals immediately after the occurrence of a multi-casualty act of terror. The scope of the staff called in is based upon standing protocols that are activated by the directors according to the type and extent of the attack. Emergency room nurses and the senior managerial and professional staff are always included in the initial call up. In some of the hospitals, only senior personnel are called in directly; other staff are contacted via the telephone calling-tree procedure. In this case, an initially designated pool of emergency room staff nurses calls a number of additional staff and so on until all those needed have been contacted.

In addition, there is an intra-hospital call up whose purpose is to bolster the nursing staff in the ER. Nurses from within the various departments in the hospital, trained especially for this purpose, leave their home stations for the ER and remain until the commencement of the care for the wounded within the ER and the subsequent debriefing.

Nurses described their initial reaction to the news of an attack in terms of deep commitment and compelling need to respond at once regardless of the time of day, what they might have been doing, or the complexity involved in making arrangements for their families.

Nurses described their initial reaction to the news of an attack in terms of deep commitment and compelling need to respond at once regardless of the time of day, what they might have been doing, or the complexity involved in making arrangements for their families.
They also reported a sense of empowerment, which expressed itself in various ways: demanding from any available person or agency that they look after their children, daring to break the traffic laws while driving to the hospital, and insisting that policemen clear the road for them.

Waiting for the Casulaties to Arrive

This stage entails preparing the ER to receive the casualties. Although one might think that being caught up in the intensive activity necessary for evacuating all current ER patients to beds in the wards, as well as setting up the equipment necessary for absorbing and treating the wounded, would overshadow fear and anxiety, nurses in fact describe this interval as extremely tense and laden with emotion.

There is none of the everyday chit-chat between staff; instead each individual is withdrawn into himself or herself, as though conserving energy for the onset of the next stage.
A foreboding silence invariably reigns and tension is often so thick, it can be cut with a knife. The familiar soothing sounds of ER activity disappear. There is none of the everyday chit-chat between staff; instead each individual is withdrawn into himself or herself, as though conserving energy for the onset of the next stage. Although the time that elapses until victims are brought in is very brief, perhaps only a few minutes long, the nurses describe it as fraught with anxiety. Nurses are afraid of what they know they are going to see. The selected quotations below illustrate this anxiety:

In the moments before the casualties start coming in you think of what horrors you’re going to be faced with. You envision in your mind the casualties of the previous incident and the fear accelerates: What injuries will I see this time and how will I stand up to it? What if I see someone I know? I’m going to save as many people as possible. And the most frightening thought of all is what if one of your own family is brought in?

This waiting period is indeed stressful.

The casualties of this last year’s terrorist attacks have been characterized by severe tissue damage and deep wounds, usually the result of the nails, iron pellets, and screws added to the bombs for just that purpose. The nurses’ fears are not unfounded; they know what to expect from their previous experiences.

Some nurses expressed thoughts such as, "I’m scared I won’t be able to function properly." This fear of not being able to perform adequately is more characteristic of younger nurses or those for whom this is only their first or second terrorist incident. One nurse described her feelings while waiting for the casualties of her first terrorist incident:

From the day I began working in the ER, I was afraid of a terrorist attack, that I wouldn’t know what to do, how to respond; I had no prior scenario to help me.

Again, the anxiety experienced in this waiting period is seen.

With cumulative experience and increased familiarity with the procedures and protocols for responding to such incidents, fear of inadequacy fades and is replaced by the knowledge that this particular challenge demands the same skills other nursing situations do. Victims of terror are in many ways similar to other casualties, only the context in which the injury occurs is different. When a nurse internalizes the principle that the treatment of these injuries is basically similar to the treatment of other injuries seen in the ER, feelings of inadequacy are considerably diminished.

A senior ER nurse described the reaction of new nurses to the announcement of a terrorist attack as one of "deep fear." She added:

The panic you see in their eyes when you are assigning each one to her station is something you never forget. They ask, "What do I do now?" And then I tell them, "You do your intake just as you would for a regular patient, you undress them and assess them." Then she says, "Oh, that’s okay, I know how to do that," and relaxes. Lowering their anxiety level enables them to recall what they already know and apply that knowledge to the situation at hand. They fall out of the helplessness mode and resume their real professional stature. My job is to bolster their spirits and get them back to their true level of functioning.

The anxiety newer nurses face during this waiting period can be lowered by insightful nurse leaders.

Yet despite all the hardship, nurses sum up treating the victims of a terrorist attack as the ultimate embodiment of their professionalism. For example, one nurse stated, "That is when your professionalism reaches its peak. When under pressure and stress, you perform at your best — there’s nothing greater." A charge nurse put it this way:

To have reached your peak level of performance, given your all, done all you are capable of doing, and done so in the context of closely knit teamwork with the other careers and out of a sense of empathy with the victims brings a feeling of the deepest satisfaction.

Although caring for patients of terrorist attacks produces anxiety, it also produces rewards.

Other comments described nurses’ participation in the event as the epitome of professional fulfillment:

The unique experience of proving yourself capable of using your clinical skills in order to save lives under such enormous stress is an almost intoxicating experience. No nurse who has experienced that feeling wants to witness another terrorist attack, but if one is announced she will move heaven and earth to be there with all the others. To participate as a nurse in these incidents is a professional need, almost a compulsion; it is the be all and end all of our profession. To be in the ER as part of the team is the ultimate. If I’m not there, if I’ve missed being there, then I’ve missed the chance of giving, of being a nurse at that special time.

Nurses describe occasions when they could not get to the ER in the wake of a call up as an unforgettably frustrating experience, whose exact circumstances they still recall: where they were, what they were doing, what they felt.

Caring for the Victims

The caring stage is a complex experience.

The caring stage is a complex experience. Nurses depict a sort of working "on automatic pilot."

Nurses depict a sort of working "on automatic pilot." Their actions are goal-oriented, stripped of thought and emotion, consisting of total concentration on the task at hand and extreme precision in its execution. They use expressions such as "working mechanically, just doing," "switching one’s brain on automatic, as though you were in a play and nothing mattered but giving your best performance," and "you give it all you’ve got….you are on sort of a high...."

In the face of an overwhelming situation, nurses describe instinctively divorcing themselves from their emotions. This mechanism enables them to work automatically and efficiently without the interference of their cognitive and emotional selves. Thoughts and feelings remain in the background and surface when the acuity of the situation begins to dissipate. One nurse reported:

I am always deathly afraid my instincts will fail me and I won’t detach myself...that I will be unable to function at the most critical time…until the acute phase is over there must be no tears, no running about, no hysteria. When it’s over, then everything can come out.

These nurses recognized a time for detachment and a time for expressing emotions.

Nurses also report a sharpening of the senses. This sharpening of the senses is described as follows:

At the time, you see everything, you hear every sound, and most of all you smell every smell. Every sense is maximally sensitive. The image of burnt, blackened bodies, the sound of a baby screaming, the smell of scorched flesh remains deeply imbedded in our minds.

Sense perceptions become more intense during this period of overwhelming stress.

As soon as the last casualty has been treated and evacuated, the emotions switch on again.

As soon as the last casualty has been treated and evacuated, the emotions switch on again.
An overwhelming flood of emotions often typifies the immediate transition from the intensely demanding situation to the ordinary routine. "I didn’t even have the strength to even get in the car and drive home," commented one of the nurses. Many nurses pointed out the need for some time-out with their peers for debriefing and mutual support.


The phase of closure begins as soon as the last patient is discharged from the ER, but its duration fluctuates, lasting as long as each nurse needs to recover. Senior members of the managerial staff of the respective hospitals quickly came to the realization that it is unwise and unfair to send nurses home without an opportunity to verbalize thoughts and feelings regarding the event. Nurses are often left with pangs of frustration and even guilt, especially if, despite all their efforts, their patients died. At times a nurse fears that not everything that could be done was in fact done.

It became accepted practice to hold group support sessions, structured or unstructured, soon after an incident.

The debriefing process provides the opportunity to reconstruct the process of treatment..
These sessions included anything from sharing a cup of coffee together to structured sessions led by professional group therapists. The debriefing process provides the opportunity to reconstruct the process of treatment. Often information shared during this time enables nurses to understand why certain patients, for example, those with major vital organ damage, could not be saved

In addition, some of the nurses said that treating their patient made them more sharply aware that only by the grace of God do they find themselves standing by the treatment table instead of lying upon it.

some of nurses said that treating their patient made them more sharply aware that only by the grace of God do they find themselves standing by the treatment table instead of lying upon it.
Many verbalized the fear of one day becoming a victim of terror or of this happening to one of their children. One nurse stated:

After a terrorist attack your view of life and death changes. I realized that it’s like Russian roulette, anyone can get hit. People leave the house and they don’t know if they’ll be coming back. Nowadays, I get into all sorts of arguments with my kids because of my anxiety regarding their safety.

The stress of caring for victims of terror lingers on, long after the terrorist attack is over.

Venting the emotions as soon as possible after an incident is therapeutic, but not enough to bring nurses back to normality. Many report restlessness, sleeplessness and nightmares. Lavie (2000) stated that these disturbances experienced by witnesses to any traumatic event can last up to four weeks. Nurse responses included the following descriptions of these disturbances:

When I get home after a terrorist attack, I can never fall asleep. I take a shower and start to clean the house. What you experience is so powerful it takes several days to get back to a normal sleep routine; when I get into that hyperactive state, I try to give it a positive twist by doing extra work in the garden; another nurse I know starts baking cakes.

These descriptions illustrate the depth of the trauma experienced by the nurses.

Hospitals vary in the long-term support structure provided for their ER staff. Some of the nurses reported that when they experienced emotional overload, they needed to geographically distance themselves from the hospital and enjoy a change of scenery. A senior nurse who had been involved in the treatment of many victims of terror in her hospital ER recounted the following reaction:

Last Independence Day I said to myself I’m getting away, I can’t bear to see any more, I’m not going to be here. I need to collect myself and take off to the Dead Sea, to feel that I’m in my own country and a free agent. You feel you need air, space and time-out, and it had to be far away, so that if something happened I really couldn’t get there, I was definitely out of touch.

Bleich & Kutz (2002) stressed the necessity of taking care of carers who have been exposed to painful sights and incidents in order to avert the dangers of accelerated burn-out and secondary traumatization. Some of the measures they recommended included ensuring that staff get the necessary rest periods and providing consultation facilities, emotional support, and opportunities to get away from "it all," either individually or in a group.

Trauma Training: State of the Art

In order to enable the reader to fully appreciate our policy recommendations for enhancing trauma training for nurses, we will first briefly describe the current status of both formal education and ongoing training.

Formal Education

Both the registered nursing level as well as the post-basic certification level include formal education in trauma. All registered nursing programs, both academic and diploma, must receive the approval of the Nursing Division of the Ministry of Health (Ministry of Health, Nursing Division, 1999) and all graduates must pass the national licensure examination. These programs include in their core curriculum a theoretical course in emergency nursing and trauma and also 150 hours of clinical experience in an Emergency Medicine department.

On the post-basic level, programs in Advanced Public Health Nursing include training in Pre-Hospital Trauma Life Support (PHTLS). Programs in Emergency Nursing consist of 530 hours of specialty training (310 hours of theory and 220 hours of clinical experience) including Advanced Trauma Life Support (ATLS). The Ministry must also approve these programs, and graduates must pass the qualifying examinations in the respective clinical specialties. Post-basic programs are currently undergoing academization and will soon be upgraded to the MSN level.

Ongoing training

Additionally ongoing training is carried out by the Ministry of Health's Emergency Preparedness Division (EPD) (Ministry of Health, Nursing Division, 2001). This body invests great effort and resources in preparing nurses for the special demands of multi-casualty incidents. Its mandate includes designing protocols for the effective management of multi-casualty emergency situations and the planning and executing of elaborate drills in which all the bodies involved in the life-saving processes must participate. The latter includes a yearly emergency drill of a specific multi-casualty scenario in every major hospital. The drill involves the MDA, the police, the Israel Defense Forces (IDF), and local government authorities. During the drills, the EPD staff is on the scene observing how the various personnel function. They write up a structured report that is utilized to fine-tune the protocols. Hospitals are of course updated in this regard. The EPD drills both empower nurses by providing hands-on experience in coping with the demands a multi-casualty incident will make upon them and also put into focus areas in which additional knowledge and skill development are still necessary.

Policy Recommendations for Enhancing Trauma Training

As will be recalled, nurses generally described themselves as competent caregivers to trauma victims. The nurses attested to frequent review of standing protocols and emergency procedures during routine work-days. They found this practice extremely helpful in times of emergency. Head nurses and nurses responsible for quality assurance on the emergency room scene during times of crisis also attested to the high level of cooperation, organization and performance of the nurses. This perception was generally backed up by the reports of senior hospital personnel as well as the data accumulated in the registries on multi-casualty victims kept by the respective hospitals. Our study has nevertheless crystallized certain aspects of training that need to be enhanced.

First, nurses with relatively little experience in caring for trauma victims expressed, as will be recalled, less confidence and relatively higher levels of anxiety compared to their more experienced counterparts. This was especially true for the nurses called into the ER from other departments in the hospital to bolster the regular staff. We recommend that post-basic courses in emergency medicine and trauma be expanded to include emergency room logistics, stress management techniques, and debriefing strategies. In addition, for the specific cadre of nurses floating in from other departments, we recommend a yearly series of workshops and drills tailor-made for nursing staff that do not handle emergency on a regular basis.

Another finding that emerged from our study was the critical role played by the ER charge nurse.

Another finding that emerged from our study was the critical role played by the ER charge nurse.
The quality of her personality and leadership and her correct use of a nurse support network filters down quickly to all the staff nurses. Her critical role lends support to Bennis and Manus’s assertion (1985) that "leadership is like the Invisible Snowman: he is never seen but his footprints turn up everywhere." There is a direct correlation between the charge nurse’s charisma and authority and her nurses’ level of commitment, self-confidence, sense of belonging and desire to contribute. It is of utmost importance that the charge nurse be a source of direction and strength, offer answers to professional questions, and provide on-the-spot solutions to on-the-spot problems. She must first and foremost, however, be a rock of emotional support to her staff during and in the aftermath of the traumatizing circumstances such as multi-casualty emergencies.

In light of the above, we recommend that charge nurses, as a special group, be given special training in leadership and group dynamics. According to Goldberg (2001), the leadership role of ER Charge Nurses needs nurturing. After surveying 1642 charge nurses in 99 hospital departments, she concluded that the charge nurse exercises a great influence on the professional development of her subordinates. Her critical role in times of emergency only reinforces that finding and demands a response at the policy-making level. Candidates with leadership potential should be looked for at early stages of professional assessment and given the appropriate leadership training.

Concluding Remarks

This article had two purposes: to share with the reader the lived experiences of nurses tending to victims of terror during a multi-casualty attack and to draw conclusions to inform policy regarding the training of nurses for this difficult task. Sixty nurses shared with us their personal experiences of caring for the wounded in the ER. From a qualitative analysis of the data, we identified four main stages that characterize all incidents: call up, waiting for the casualties to arrive, caring for the victims, and closure.

The main recommendations for policy were fine-tuning drills for less experienced nurses, broadening the formal post-basic education to include logistic and psychosocial aspects of emergency trauma, and giving special attention to charge nurses, a most valuable link in the chain of care. We see maintaining open discussion with focus groups as an excellent tool for understanding the processes of nursing care and how they can be improved.


Shoshana Riba, PhD, RN

Dr. Riba serves as National Head Nurse and Director of the Nursing Division of the Israeli Ministry of Health. In this capacity, she is responsible for making and overseeing all policy related to nursing education, professional guidelines and development. In addition, she is consultant to the government ministries as well as overseas bodies (including the World Health Organization) on all matters concerning the nursing profession and is the national representative of the nursing profession. She has delivered numerous professional papers all over the world on various facets of the nursing profession and is a member of many professional committees involved in promoting nursing and general health care.

Hiba Reches, MA, RN

Hiba Reches is Director of the Department of Nursing Licensure of the Israeli Ministry of Health’s Nursing Division. In this capacity, she is responsible for the contents and quality of the generic nursing education, including setting performance standards and updating programs on a regular basis. Ms Reches was the first editor of the professional journal Oncology Nursing in Israel and has both coordinated nursing curricula and taught various nursing courses at the Tel Aviv University


Bennis, W.G., & Manus, B. (1985). Leaders: Strategies for taking charge. New York: Harper & Row.

Bleich, A., & Kutz, E. (2002). Chemical and biological terrorism: Psychological aspects and basic principles for psychiatric preparatory measures. Refuah, 171 (5), 111-117. (In Hebrew).

Goldberg, S. (2001). Nursing leadership in an era of reform in the health care system: Evaluation of the head nurse leadership style in relation to the effectiveness of the department. Unpublished Doctoral dissertation. Ben-Gurion University of the Negev, Israel.

Lavie P. (2001). Sleep disturbances in the wake of traumatic events. New England Journal of Medicine, 345(25), 1825-1832.

Ministry of Health, Nursing Division. (1999). Compulsory core curriculum for emergency nursing course. Jerusalem, Israel: Author. (In Hebrew).

Ministry of Health, Nursing Division. (2001). Nursing division annual activity report for 2001 and its objectives for 2002. Jerusalem, Israel: Author. (In Hebrew).

© 2002 Online Journal of Issues in Nursing
Article published September 30, 2002

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