In the fall of 2005, North Central Texas became a hub of disaster relief for thousands of people following Hurricane Katrina. One local chapter of the American Red Cross estimated that over 28,000 people registered at shelters within one county following the Hurricane (Weeks, 2007). Shelters were open for seven weeks; during this time, over 34,000 Disaster Health Services contacts and over 33,000 Disaster Mental Health Services contacts were made (Weeks).

Students and faculty of the Texas Christian University (TCU) Harris College of Nursing and Health Sciences provided essential services as part of the North Central Texas efforts to provide care for survivors of Katrina. As multiple planeloads carrying persons having varying levels of healthcare needs arrived in the county, students and faculty were actively involved in the early phases of tracking and identifying these individuals in order to assist with the process of family reunification. This project was barely finished when Hurricane Rita appeared, sending thousands of Gulf Coast residents scrambling to North Central Texas for safety.

Community awareness of disaster vulnerability was heightened by this disastrous hurricane season and its aftermath, and community members became anxious to find ways to respond to such disasters in the future. Community awareness of disaster vulnerability was heightened by this disastrous hurricane season and its aftermath, and community members became anxious to find ways to respond to such disasters in the future. Having already participated in this massive disaster response, students at the TCU Harris College of Nursing and Health Sciences were eager to maintain their involvement with the community and prepare community members to better care for themselves during future disasters. Nursing faculty were aware that the region had been designated as a future hurricane evacuation site for coastal residents and that it was also vulnerable to disasters of its own, such as tornadoes, floods, and wildfires. This awareness led to the development of a community health student clinical experience focused on disaster-preparedness education. This project, consistent with the framework of action research, was designed to benefit and engage the community and, at the same time, to prepare baccalaureate nursing students to be “disaster ready.” The authors of this article describe a clinical experience that involved nursing students in a health-education project related to one community’s desire to better prepare itself for future disasters. A participatory action research (PAR) approach, which included collaboration with a community, involvement of the target community, and project evaluation, provided a framework for this disaster-preparedness initiative.

Theoretical Framework

Most disaster-preparedness research projects focus on issues facing formal healthcare facilities and frontline healthcare providers, such as public health employees, emergency medical services staff, and hospital personnel. Limited study addresses patient, family, and community needs and issues (Hinton Walker, Garmon Bibb, & Elberson, 2005), despite the fact that community members are actually the first to respond to a local disaster (Glass, 2001; Helsloot & Ruitenberg, 2004; Perry & Lindell, 2003). The health and safety of the community following a disaster of any kind, therefore, depends on the ability of its residents to be “disaster ready.” Disaster specialists recommend development of emergency-preparedness systems that minimize public health consequences (Slepski, 2005) and decrease vulnerability (McEntire, Fuller, Johnston, & Weber, 2002). When community members are apathetic toward disaster planning, ignore disaster and safety precautions, or defer personal responsibility to other entities, such as the government, disaster vulnerability increases (McEntire et al., 2002). Management of disaster vulnerability should, therefore, involve community members in efforts to become well informed about catastrophic events likely to occur in their area and to assume personal responsibility for preparing for such an event. Active community involvement is necessary for this kind of preparation. It is not enough that community members merely read disaster-preparedness web sites, such as www.ready.gov  or www.redcross.org; rather they should also be actively involved in discussions regarding scenarios of what they could expect should a disaster occur and how they would take action. Yet, descriptions of programs that illustrate community involvement are limited, as are reports of nurse involvement in community education programs. Hinton Walker, Garmon Bibb, & Elberson (2005) have noted the need for nursing to expand its involvement in preparing communities for disasters that may befall them. Programs guided by participatory action research (PAR) can begin to close this gap.

The health and safety of the community following a disaster of any kind...depends on the ability of its residents to be “disaster ready.” The PAR method allows researchers and community members to work together to define a problem, take action on the problem, and evaluate the effectiveness of the action (Kelly, 2005). A PAR project provides a means to involve a community in developing and assessing a health program. In the case of community education, PAR allows nurses to deliver health information to a targeted community audience. When taking action, nurse researchers can use information gathered during the community assessment to empower community members to create social change (Kelly). The PAR method includes collaboration, participation, and reflection, which take place during ongoing cycles of planning, acting, and review. During the planning cycle, nurse researchers and community members collaborate and discuss perceptions of a problem and potential actions needed to bring about change in the community. During the acting cycle, both of these groups participate to implement the planned actions. During the review cycle, goal reflection and reassessment takes place, and researchers collaborate with community members on interpretation of data (Kelly).

This article will describe a community health-education project that focused on disaster preparedness and was implemented in a manner consistent with the PAR framework. The overall aim of this project was to promote active involvement of baccalaureate nursing students in working with community partners to plan, implement, and evaluate a community-based, health-education program directly related to a community’s desire to be prepared to respond to future disasters. This project can serve as a model for other community and university partnerships.

Initial Steps

In this project the initial steps included assessing the community and developing the community partnership. Each will be described in turn.

Assessing the Community

Following the massive influx of New Orleans residents into the North Central Texas region following Hurricane Katrina, members of various faith communities expressed frustration at their inability to respond effectively to the needs of these their guests. Many of these faith communities are geographically clustered and include multiple churches and schools. One example is a two-mile stretch along a major road in North Central Texas that is home to two schools, five churches, a mosque, and a cloistered community. The second author is both a member of one of these faith communities and a community health faculty member of the TCU Harris College of Nursing and Health Sciences. Because of her faculty position, she was approached by a few church leaders and asked to “bring [some] nursing students here to teach us how to provide care for disaster survivors."

As the second author became aware of this community’s desire to become disaster response volunteers, she consulted with nursing faculty colleagues, including the first author, to determine how best to incorporate the church’s request into a meaningful community health clinical experience for baccalaureate nursing students. The first author, who had been a trained disaster response volunteer, expressed concern that the faith community was thinking of providing disaster relief only in the context of Hurricane Katrina, which had brought survivors to an area otherwise unaffected by the disaster. This author pointed out that all disasters begin at a local level and therefore require preparedness at a local level. Given the risk for disasters in the North Central Texas region, it seemed appropriate to prepare for the possibility that the next disaster might directly affect the community members and, in turn, affect their ability to respond as disaster volunteers. We shared this concern with the community members, explaining that their desire to become disaster response volunteers before they developed personal disaster-preparedness plans was premature. The challenge was to convince well-meaning people that the first step in providing effective assistance to others during a disaster was to become personally prepared. We proposed offering basic education for community leaders. This would serve as a basis for dialog about the need for personal disaster preparedness prior to becoming disaster-response volunteers. This education would take place during a “stakeholders’ meeting” that would provide the initial step in working with community partners.

Developing the Community Partnership

At the beginning of the students’ clinical experience, the community health faculty member organized this stakeholders’ meeting for community leaders including school nurses and principals, faith community nurses, ministers, and church staff members. The leaders invited were identified by the various faith communities as being “key” members. Members of five churches and staff of the two schools responded to the invitation.

A major goal of this meeting, conducted as a seminar with invited speakers, was to educate the community members on basic concepts of disasters. The speakers described disasters the community was likely to face, potential dangers related to such disasters, the emotional impact of a sudden crisis, research related to disaster preparedness, and roles of community members and first responders in time of disaster. A second goal was to bring the community leaders together in a central location to begin developing relationships with the nursing students who would be working with them. The schedule for the day-long meeting included a meal during which the students served as hosts and met their community partners for the first time on a one-to-one basis. Having the students and community members attend the seminar together ensured that they received the same information about disasters.

At the end of the day, the students gave their community partners a list of potential disaster-preparedness activities to prioritize in order of their perceived importance. This assessment formed the basis for development of the educational intervention and provided the transition into the planning cycle that is consistent with PAR. This collaborative approach is consistent with the concepts of “community as partner” and “empowerment” advocated by community health practitioners (Lasker & Weiss, 2003; Reutter, et al., 2005; Tibbetts, 2003).

Planning Cycle

Students enrolled in the community health nursing course were excited to become involved in a project they saw as practical and meaningful. Students enrolled in the community health nursing course were excited to become involved in a project they saw as practical and meaningful. Most of them had participated in care for Katrina survivors either in shelters or in hospitals and recognized that the survivors were still in process of recovery from one of the worst natural disasters they could remember. Several students had family or friends in Houston who had very recently evacuated from the path of Hurricane Rita. Such close brushes with disaster increased their awareness of vulnerability and heightened their own interest in becoming prepared. This project provided an opportunity to enhance the community’s health, as well as their own, through disaster preparedness.

To begin planning education for the community, the students referred to the results of the assessment they had completed with their community partners on the day of the stakeholders’ meeting. They identified the disaster-preparedness needs that had been most frequently cited by key community members and used them as the basis for an educational intervention. The three needs most frequently cited were to learn how to (a) develop an emergency communication plan, (b) maintain an emergency food and water supply for the home, and (c) protect important documents. In order to address these needs, the students chose to develop a poster presentation since it was cost effective, portable, reusable, attractive, and could be readily duplicated. It was also a presentation style that could be easily managed within the community. In addition to planning the content and presentation, the students also determined the location and times for making the presentations, specifically before and after services at each church in the faith community.

Acting Cycle

To prevent information overload for community members during this first acting cycle, students limited the poster content to the three top needs cited by community members. Students prepared posters to describe development of an emergency communication plan, maintenance of an emergency food and water supply for the home, and protection of important documents. The posters bullet-pointed important information, such as type and amount of items to be included in a food supply for four people, and types of documents that needed to be protected or copied. They also included graphics, such as completed communication plans. The posters were further enhanced by sample displays of food and water supplies and document protection systems including a fire safe.

The presentations were set up in high-traffic areas at each of the five churches and all service attendees were invited to view the posters. Students met with viewers to answer questions and offer suggestions on disaster preparedness. Viewers also received take-home handouts  to remind them of key disaster-preparation points and templates for a communication plan that they could complete for themselves.

Review Cycle

The review cycle of this initiative included both a project evaluation of the effectiveness of the disaster-preparedness teaching and an analysis of the outcomes for the community and for the students. Both aspects of this review cycle will be discussed below.

Project Evaluation

To explore the effectiveness of the educational intervention (namely the teaching that occurred during the poster presentation) to increase knowledge regarding personal disaster preparedness, a survey was designed and administered to a portion of the faith community members before and after they viewed and discussed the information presented by the students. As well as providing an evaluation of this project’s success, such an evaluation could be used later with members of the lay public in similar situations where education is offered (Adams, Canclini, & Bradley, 2007). Examples of these similar situations include disaster preparedness education presentations provided for members of other community or church groups, and health and safety fairs that include a disaster-preparedness component. This approach also provided the nursing students with an introduction to the research process. The students assisted in preparing the survey instrument for use and were prepared to assist in obtaining informed consent after completing self-study on human subject’s protection as required by the TCU Institutional Review Board.

The participants. All adults 18 or older attending services at one church in the faith community on the day of a poster session were eligible to participate in the evaluation process. Forty-one men and women participated in the study designed to evaluate the program, representing approximately 12% of the 350 adults who attended.

Data collection. The TCU Institutional Review Board approved the study’s protection of human subjects. Participants were recruited through an announcement in the church’s bulletin and an announcement made during each church service. Potential participants reviewed the approved consent form for an explanation of the study’s purpose, risks, benefits, and privacy and confidentiality precautions. The participants were assured that their participation was totally voluntary, without financial incentives, and could be withdrawn at any time.

Before viewing the posters and discussing content with the student presenters, the participants completed a researcher-designed survey consisting of demographic items and closed-ended questions related to 12 disaster-preparedness activities frequently cited in the literature. Examples included: “Do you have an emergency food supply?” and “Do you have an emergency communication plan for your family and/or significant others?” Most of the activities were directly related to personal disaster preparedness. “Have you taken first aid training?” relates both to personal preparedness and to more formal preparation as a disaster response volunteer. “Have you taken disaster response training?” and “Have you joined a voluntary disaster organization?” are directly related only to a more formal disaster response activity and not to personal preparedness. These questions were included in this survey based on the fact that community members had originally requested training to become disaster response volunteers. We therefore felt it was important to obtain preliminary data on whether any community members had actually pursued these activities. For the purpose of this study, a “yes” response indicated preparedness for that item and a “no” response indicated lack of preparedness. For any questions answered “no,” the participant was asked to rate the possibility of undertaking the action on a 5-point Likert scale from “not at all” to “definitely.” For the purpose of this study, “possibility” is defined by the respondents’ self-reported rating on the Likert scale. After viewing the poster session, the participants completed a survey consisting of the same questions related to personal disaster preparedness. While this design did not allow assessment of whether behaviors were carried out, it did show how individuals viewed the possibility of taking these actions in the future.

Evaluation of the approach to presenting the educational intervention was also of interest. A brief evaluation form was developed so that all community members who viewed the posters at the church where the pilot study was completed could also rate the presentation on a 5-point Likert scale ranging from “not helpful at all” to “very helpful.” Approximately 70 community members viewed the posters and completed the evaluation, including the 41 people who participated in the study. All found the poster presentation either “helpful” or “very helpful.”

Analysis and findings. Prior to the intervention, few participants reported having an emergency supply of food (37.8%) or water (43.2%), copies of important documents (27.8%), an emergency communication plan for their family and significant others (21.6%), or a disaster kit for the home (13.5%) or car (13.9%). Nearly all participants (92.7%) indicated that they would like to learn more about disaster preparation. Table 1 presents data describing the number and percentage of participants who had performed specific disaster-preparedness activities before the poster presentation. Participants who indicated they had not performed the activities were asked to rate the possibility of undertaking the action based on a 5-point Likert scale. The mean possibility score for each activity was calculated before and after the presentation. Possibility scores increased for all activities following the poster session (Table 2); and paired sample t-tests performed on the pre- and post-test possibility scores showed significant pre- and post-test differences for the activities related to “disaster kit for home,” “disaster kit for car,” and “joined a voluntary disaster organization.” Although these activities were not highlighted in the educational intervention, it is possible that being asked about them heightened participants’ awareness. This increased awareness may have led to their increased willingness to consider performing the activities. Follow up with these participants was not feasible, although a future study that would look at actual actions taken over time would be of interest.

Analysis of Outcomes for the Community and the Students

The introductory seminar on disaster-related concepts...provided an opportunity for community members to build collegial relationships among themselves...Kelly (2005) has explained that outcome evaluation can be used to describe changes in the community, health conditions, and participants. Consistent with the PAR framework, the researchers and community members reviewed the project in a variety of ways to assess the project outcomes. This section will describe outcomes for both the community members and the nursing students involved in the project as well as subsequent benefits for both the community and a new group of students.

Community outcomes. The introductory seminar on disaster-related concepts, including disasters likely to be faced by this community, dangers related to disasters, and roles of responders and community members during disasters, provided an opportunity for community members to build collegial relationships among themselves that did not previously exist. Evidence of these relationships included collaboration between the parochial schools in developing a disaster plan for both schools. This collaboration began as school administrators sat together at the seminar. As they talked during that day, they realized they had much in common, including the need to update their disaster plans. They decided to begin working together to develop a complementary disaster plan and noted to the community health faculty member that they “could support each other” by making a disaster plan that could work for both schools. Additionally, one church sponsored a health fair that included a disaster-preparedness booth to which all members of the faith community were invited.

The students reported that their own personal preparedness improved because of their participation in the project. Student outcomes. An overall aim of the project was to promote active involvement of baccalaureate nursing students in working with community partners to plan, implement, and evaluate a community-based, health-education program directly relevant to a community’s desire to respond to future disasters. The students were able to meet the objectives of their community health nursing course effectively by partnering with the community. Not only did they learn more about important ways to prepare for a disaster and the role of community members and healthcare professionals in the process, they also developed a greater understanding of the research process as it relates to disaster preparedness and education. The students reported that their own personal preparedness improved because of their participation in the project. They reported satisfaction with being able to learn in “real time” while participating in the project, and described it as their first positive experience with taking an idea from concept to reality.

Subsequent benefits. This initial project served as a basis on which to build continued community partnerships in disaster preparedness. At the end of the project, all involved concluded that the educational intervention would be more effective if it were expanded for presentation at a community health fair or a “Disaster-Preparedness Fair.” Based on this conclusion, the community health faculty member brought another group of nursing students into the same community to continue the partnership. As this new group of students began working with the community, they heard the community members continuing to ask for more information related to disaster preparedness. Hence, this second group of students and their faculty member collaborated with the two parochial schools in the community to develop a “Safety and Disaster-Preparedness Fair” for children and their parents. Like the first project, the fair was received positively by participants.

Limitations and Recommendations

Since the evaluation portion of the project served as a pilot study, the sample size was intentionally small. A longer-term study with a larger sample size that would allow for the assessment of changes in preparedness behavior over time would be valuable. This would allow continuation of students’ active involvement in the research process and allow them to see how action research and program evaluation in collaboration with community representatives leads to further planning.

The community members were eager to learn about disasters at least in part due to the recent (and ongoing) experience of Katrina recovery. It is possible that a community with less contact with a large-scale disaster would not be as receptive to such a program. It is also important to remember that the community members did not initially place a high priority on personal disaster preparation. Their initial priority was learning how to take care of those affected by disaster—not necessarily considering that they themselves might be directly affected by a disaster. Dialog between the faculty and key community members was crucial in encouraging the community to consider the importance of personal disaster preparedness prior to pursuing disaster volunteer activities.

In a replication of the study, we would consider using the word “probability” to measure the community members’ intent to perform disaster-preparedness activities. We used the term “possibility” on the pre- and post-test because the word had been used previously in literature exploring community preparedness (Helsloot & Ruitenberg, 2004). Upon reflection, we recognize that the word simply means it is “possible” for an individual to perform an activity. It does not imply that the individual actually expects to do so. In contrast, “probability” suggests the individual’s intent to perform an activity and would therefore be a more descriptive term.

One of the lessons learned from Hurricane Katrina was that special populations have special needs that must continue to be met during and after a disaster. A limitation of the original phase of the educational intervention was that the poster presentations were based only on the top three preparedness needs identified by community members (how to maintain emergency food and water supply for home, develop a family emergency communication plan, and protect important documents). Therefore, important information about meeting needs for special populations such as those with chronic conditions was not initially addressed. One of the lessons learned from Hurricane Katrina was that special populations have special needs that must continue to be met during and after a disaster. Effective disaster planning requires communities to be alert to areas of vulnerability, including specific populations who may be at greater risk following a disaster (Adams, 2008). Upon expansion to a disaster-preparedness fair, the students were able to include information about the need to plan for availability of medications or specialized equipment during disaster. To plan the most effective disaster-preparedness education during future acting cycles, it will be important for the faculty and students to review literature for key topics and priorities and to utilize “lessons learned” from previous disasters.

Working in faith communities presented a challenge for nursing students because the communities tend to gather on weekends. To teach the majority of the community members, therefore, students needed to complete many of their clinical requirements on the weekend. It will be important for other faculty using this model to explain clearly the need for weekend activities to students at the beginning of the clinical experience. Additionally, some nursing students experienced difficulty understanding the beliefs of the various religious traditions. Faculty pursuing clinical experiences in a faith community must be very deliberate in guiding nursing students to learn about religious traditions and cultural norms prior to venturing out into the field. An unintended, yet valuable, learning experience for the student was, and can be, the non-judgmental acceptance of various religious faiths.

Conclusion

The overall aim of the project was to promote active involvement of baccalaureate nursing students in working with community partners to plan, implement, and evaluate a community-based, health-education program directly relevant to a community’s desire to respond more effectively to future disasters. The positive outcomes from the project suggest that schools of nursing have a crucial role to play in preparing the community for disasters. This project can serve as a model for community-university partnerships in disaster preparation, as well as for other health-promotion activities. Such a model can be used in a variety of settings with a variety of populations. Collaboration with other organizations, such as the local chapter of the American Red Cross, Community Emergency Response Teams (CERT), and public health departments, may also produce valuable synergy in promoting community health and preparedness for disaster.

Acknowledgments:

This project was partially funded through a 2006 Texas Christian University Vision in Action grant. The authors wish to thank Dr. Patricia Bradley, DNS, RN, for assistance with development of the project and review of the manuscript; Dr. Gail Davis, EdD, RN, for review of the manuscript; and the Community Health Nursing students who actively participated in this project.

Authors

Lavonne M. Adams, PhD, RN, CCRN
E-mail: L.adams2@tcu.edu

Lavonne M. Adams is an Assistant Professor in the Texas Christian University Harris College of Nursing & Health Sciences. From 2006-2008, she was the chair of Tarrant County Voluntary Organizations Active in Disaster (VOAD). She has been a volunteer and trainer for Adventist Community Services Disaster Response (ACS-DR) since 2003, ACS-DR representative to Tarrant County VOAD since 2004, and a Disaster Health Services Volunteer for the American Red Cross since 2005. Dr. Adams’ clinical background includes critical care and emergency nursing. She holds a PhD with a focus in leadership, and a MS degree from Andrews University (Michigan), a BSN degree from Wright State University (Ohio), and an AS degree from Kettering College of Medical Arts (Ohio).

Sharon B. Canclini, MS, RN, FCN
E-mail: S.canclini@tcu.edu

Sharon B. Canclini is a Clinical Lecturer in the Texas Christian University Harris College of Nursing & Health Sciences, teaching community health nursing. She is also a faith community nurse in Arlington, TX. Her clinical background includes community health and maternity nursing. Ms. Canclini received her diploma in nursing from Samuel Merritt Hospital (California), her BSN degree from the University of Texas Health Science Center, and her MS degree in Nursing from Wright State University (Ohio).