Overview: One Year Later: The Impact and Aftermath of September 11

Much has been written about the horrific events of a fateful sunny Tuesday morning in New York City, Washington, D.C., and Somerset County, Pennsylvania, one year ago, September 11, 2001. The stories vary, ranging from selfless heroism and triumph to poignant tales of loss, from gritty determination and strength to an outpouring of both support and outrage from peoples around the world. Our spirits were buoyed by the extraordinary generosity and compassion of our nation and the global community, yet our hearts broke anew with the next victim's name.

One year later the emotions of many remain raw. A year's worth of tears have been shed. Memorials have been held and grief, that at times has seemed unbearable, has been experienced. Children have been left without a mother or a father, a spouse without their life partner, parents without their sons or daughters. A war has begun. Faith has been tested. The power of hate - and of prayer - has been felt. Kindnesses have been shown. Debris has been cleared. Mass-casualty and bio-terror drills have been run. Our homeland environment in the United States has been altered. And daily life has slowly fallen back into a routine that can never again be considered normal. There have been explanations, analyses, and critiques of the actions and behaviors of the many players involved in this tragedy, and yet we are still left with an emptiness, and struggle with the question "Why?"

A search for meaning is generally constructed within a context of the past, the present, and the future. Meanings attributed to the events of Fall 2001 will largely depend on an individual's history, their belief systems or philosophies, and their experiences. Though terrorist acts have occurred throughout the ages, the events of last Fall brought to the United States new types of threats and violence, causing people to question their safety and creating feelings of vulnerability and powerlessness, lessons well-known by millions of men, women, and children in other parts of the world.

With the one year anniversary upon us, many yearn for a closure that is elusive. Some people say that the events are never far from their thoughts while others are experiencing 9/11 fatigue. Barely healed wounds have re-opened with the constant barrage of news and print stories that relive the moments of destruction and loss, rescue and recovery, and, in some cases, the moving on. Meaning has not come easily. Maybe it is true . . . maybe following a tragedy of such magnitude, one year is not enough time to make sense of the senseless . . . to put it into the past and gain some historical perspective or context.

And in the midst of our own search for meaning, we, as health care providers, must prepare for a future, a future we would not have anticipated a year ago. We learned many things last Fall. We learned that though our trauma care and public health systems are excellent, additional resources and training are needed to be properly prepared for potential future terrorist or bioterrorist acts and mass-casualties. We witnessed tireless and selfless effort on the part of our rescue workers, health care personnel, and construction crews. Yet these courageous souls suffered tremendously, and they, like the victims and their families, need formal and informal support and emotional care, both during and after their work has been completed. We learned that nurses are among the first responders to disasters and that there is a critical need for emergency, trauma, and critical care, public health, and psychiatric-mental health nurses, a situation made even more ominous because of the growing shortages of nurses worldwide.

The manuscripts in this volume present historical reviews of the events of September 11 and its aftermath, the struggles that health care personnel and professional organizations have faced when dealing with mass-casualties, and recommendations regarding disaster preparedness for the future. In the first article Jameson presents a detailed accounting of the violent acts of September 11. Glimpses into the courage, emotion, and loss experienced by individuals in the air and on the ground that day and during the weeks to follow are included. Ways in which our lives changed as a result of the terrorism, such as loss of freedoms and increased airport security, are discussed.

Orr, in her article, frankly observes that the New York State Nurses Association (NYSNA) had never planned for a disaster of the magnitude of that which occurred September 11. She describes some of the unique problems its personnel faced that day, particularly with the New York office located near the World Trade Center. Within hours of the terrorist attacks the NYSNA mobilized an Emergency Response Team that had to address issues related to transportation, proof of identity and licensure, communication, management of volunteers, and disruption of normal business. In the days that followed, NYSNA personnel and volunteers along with New York City Hospitals had cared for thousands of survivors, aided rescue and recovery operations, and provided mental health counseling and assistance at staging and family center areas. Orr speaks to how NYSNA evaluated the entire experience and describes the current development of a comprehensive disaster plan, including the need for support and mental health care for health care personnel responding to disasters. Website resources are listed that can provide information for professional organizations wishing to prepare disaster plans.

Many of the survivors, rescue personnel, health care professionals, and construction workers involved with September 11 have experienced post-traumatic stress disorder (PTSD) symptoms. Based upon data collected following the bombing of the Federal Building in Oklahoma City, one in three people directly affected by the terrorism of last Fall can be expected to develop PTSD (North et al., 1999). This number does not take into account those indirectly affected and may be even higher because of the magnitude of harm and destruction, the subsequent bioterrorist-related attacks, and ongoing threats of further physical, biological and chemical violence. In her article White describes the initial organizational response of the American Psychiatric Nurses Association (APNA), and that of some of its members, to the events of September 11. Psychiatric-Mental Health Nurses (PMNH) from the APNA answered crisis calls, provided support and grief counseling, and supplied information to assist families, especially those with children, in dealing with the aftermath of the tragedy. The various stress reactions and disorders most often seen following exposure to violence and traumatic events are discussed. APNA plans for addressing mental health promotion in light of possible future terrorist attacks and the role of Psychiatric-Mental Health Nurses are explored.

Bioterrorism is a relatively new type of traumatic event, particularly for Americans, considering that these acts had not been perpetrated in such an organized manner in the United States until recently. It is an intentional, random, human act, meant to cause large scale harm or death. Berkowitz points out the multiple challenges public health nursing and the public health infrastructure face in preparing for bioterrorism-related acts and threats. Issues associated with communication, authority, information technology, funding, and workforce are just some of the challenges that exist for local, state, and national health officials in preparing for bioterrorism. The critical need for training and expertise in prevention and detection, diagnosis, and management of the effects of biological and chemical agents is highlighted. Berkowitz also lists the eight domains of core competencies and skills necessary for providing essential public health services and preparing for bioterrorism and details the vital role of public health nursing in responding to bioterrorist acts.

In the final article Riba and Reches offer a unique perspective of Israeli emergency nursing, borne of experience, in a country exposed to unpredictable and regular terrorist attacks on civilians. The authors speak of the many hardships the Israeli professional caregivers experience, from over-identifying with civilian targets of terrorist attacks, who are injured as they go about their daily routine, to managing mass casualties in the emergency room. The contexts for preparing nurses for the special demands of multi-casualty emergencies are described. The authors also discuss findings from focus group research on the personal and professional issues faced by emergency room nurses treating victims of terrorism on a consistent basis. The nurses describe their sense of personal responsibility when summoned to the emergency room, the emotion and tension they experience as they wait for casualties to arrive, and their fear that their skills may not be enough or that they may know the victim. The nurses talk of being on "automatic pilot," of how their concentration and senses are heightened when caring for victims, yet their emotions are turned off. And, when the work is completed and the emotions have switched back on, the caregivers speak of being flooded with overwhelming feelings or of carrying home the sights, sounds, and smells of the injured. Though structured and unstructured support group sessions follow all mass casualty incidents, many nurses still experience sleep disturbances and hyperactivity. Riba and Reches also note the importance of incorporating input from emergency staff into the policy-making process.

Nursing brings unique skills and perspectives to the care of victims of natural and manmade disasters. In the Spring of 2002 the National Institute of Nursing Research (NINR), along with the National Institute of Allergies and Infectious Diseases (NIAID), and the Office of Behavioral and Social Science Research (OBSSR), convened a multidisciplinary workgroup to examine nursing research needs and opportunities in biodefense. (Biodefense is not exclusively bioterrorism, but includes trauma resulting from events such as natural disasters and flu panendemics). Nursing and interdisciplinary research related to biodefense can take many forms, including detection, mechanisms and effects of toxic agents, biobehavioral responses to threat and injury, evaluation research, biodefense planning and response capacities, and the study of learning and behavioral changes, especially under stressful conditions. The full report on increasing research opportunities in biodefense can be viewed at NINR's website <www.nih.gov/ninr> under news-info/publications.

Those reading the articles in this journal may be affected in some way by the complexity of the issues surrounding the events and/or aftermath of September 11. The editors encourage authors to express their responses in Letters to the Editor or submit manuscripts to OJIN that will further the discussion of the Topic of September 11th.

Author

Stephanie J. Woods, PhD, RN

Stephanie Woods is an Assistant Professor at The University of Akron College of Nursing. She participated in the Spring 2002 multidisciplinary science work group, sponsored by the National Institute of Nursing Research (NINR) and The Office of Rare Diseases at NIH, that examined nursing research needs and opportunities in biodefense. She is currently investigating the relationship between post-traumatic stress disorder, lifetime trauma, the stress hormone cortisol, and immune function in battered women in a project funded by NINR. She holds a PhD in Nursing from Wayne State University and a Master and Bachelor of Science in Nursing from Edinboro University of Pennsylvania.