NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.
National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors.
Washington (DC): National Academies Press (US); 2021 May 11.By failing to prepare, you are preparing to fail.
—Benjamin Franklin, writer, philosopher, politician
In the past decade, 2.6 billion people around the world have been affected by earthquakes, floods, hurricanes, and other natural disasters. Nurses have been and continue to be pivotal in safeguarding the public during and after these disasters, as well as public health emergencies—most recently, the COVID-19 pandemic. They educate and protect people, engage with and build trust with the community, help people prepare and respond, and foster resilience to help communities fully recover. But fundamental reform is needed in nursing education, practice, research, and policy across both health care and public health settings to ensure that all nurses—from front-line professionals to researchers—have the baseline knowledge, skills, abilities, and autonomy they need to protect populations at greatest risk and improve the readiness, safety, and support of the nursing workforce.
The increasing frequency of natural and environmental disasters, along with public health emergencies such as the COVID-19 pandemic, highlights the critical importance of having a national nursing workforce prepared with the knowledge, skills, and abilities to respond. COVID-19 has revealed deep chasms within a fragmented U.S. health care system that have resulted in significant excess mortality and morbidity, glaring health inequities, and an inability to contain a rapidly escalating pandemic. Most severely affected by these systemic flaws are individuals and communities of color that suffer disproportionately from the compound disadvantages of racism, poverty, workplace hazards, limited health care access, and preexisting health conditions that reflect the role of social determinants of health (SDOH) and inequities in access to health and health care that are a primary focus of this report. As natural disasters and public health emergencies continue to threaten population health in the decades ahead, articulation of the roles and responsibilities of nurses in disaster preparedness and public health emergency response will be critical to the nation’s capacity to plan for and respond to such events.
As described in the conceptual model framework developed by the committee to guide this study (see Figure 1-1 in Chapter 1), strengthening nurses’ capacity to aid in disaster preparedness and public health emergency response is one of the key ways to enhance nursing’s role in addressing SDOH and improving health and health care equity. This chapter explores the contribution of nurses during the COVID-19 pandemic and across sentinel historical events and describes the impact of natural disasters and public health emergencies on SDOH and health and health care equity. It also illuminates the multiple and systemic challenges encountered by nurses in these past events, and identifies bold and essential changes needed in nursing education, practice, and policy across health care and public health systems and organizations to strengthen and protect the nursing profession during and after such events. Only when equipped with the salient knowledge, skills, and abilities can nurses be fully effective in helping to protect the well-being of underserved populations, striving for health equity, and advocating for themselves and other health care workers.
The ability to care for and protect the nation’s most vulnerable citizens depends substantially on the preparedness of the nursing workforce. The myriad factors related to national nurse education and training—licensure and certification, scope of practice, mobilization and deployment, safety and protection, crisis leadership, and health care and public health systems support—together define nursing’s capacity and capabilities in disaster response. The nursing workforce available to participate in U.S. disaster and public health emergency response includes all licensed nurses (licensed practical/vocational nurses [LPN/LVNs] and registered nurses [RNs]), civilian and uniformed services nurses at the federal and state levels, nurses who have recently retired, and those who volunteer (e.g., National Disaster Medical System, Medical Reserve Corps, National Voluntary Organizations Active in Disasters, and American Red Cross [ARC]). Each of these entities plays a critical role in the nation’s ability to respond to and recover from disasters and large-scale public health emergencies such as the COVID-19 pandemic. 2
Across a broad spectrum of clinical and community settings and through all phases of a disaster event (see Figure 8-1), nurses, working with physicians and other members of the health care team, play a central role in response. Before, during, and after disasters, nurses provide education, community engagement, and health promotion and implement interventions to safeguard the public health. They provide first aid, advanced clinical care, and lifesaving medications; assess and triage victims; allocate scarce resources; and monitor ongoing physical and mental health needs. Nurses also assist with organizational logistics by developing operational response protocols and security measures and performing statistical analysis of individual- and community-level data.
Disaster nursing timeline. SOURCE: Veenema, 2018.
Beyond these contributions, nurses activate organizational emergency operations plans, participate in incident command systems, oversee the use of personal protective equipment (PPE), and provide crisis leadership and communications, often at risk to their own health. In the community, they open and manage shelters; organize blood drives; and provide outreach to underserved populations, including by addressing social needs. Nurses also assist with care for the frail elderly (Heagele and Pacqiao, 2018; Kleier et al., 2018), assist with childbirth to ensure that women have healthy babies during a disaster (Badakhsh et al., 2010; de Mendoza et al., 2012; Role of the nurse, 2012), and work to reunite families separated during response activities. Disasters place unprecedented demands on health care systems and often test nurses’ knowledge, skills, abilities, and personal commitment as health care professionals.
Nurses’ roles in pandemics and other infectious disease outbreaks are multifaceted and may include
supporting and advising in epidemic surveillance and detection, such as contact tracing;working in point-of-distribution clinics to screen, test, and distribute vaccines and other medical countermeasures;
employing prevention and response interventions; providing direct hospital-based treatment for impacted individuals; educating patients and the public to decrease risk for infection; providing health systems and community-based leadership; and counseling and supporting community members to assuage fear and anxiety (Veenema et al., 2020).Public health nurses have helped coordinate and implement disaster plans (Jakeway et al., 2008), and it was a school nurse working in Queens, New York, in 2009 who first observed and then notified the Centers for Disease Control and Prevention (CDC) about the H1N1 outbreak (Molyneux, 2009).
Infectious disease outbreaks have been occurring more frequently and at a higher intensity over the past few decades (Fauci and Morens, 2012; Lam et al., 2018). Both the health care system and individual front-line health care workers must be adequately prepared to respond to such events (Imai et al., 2008; Lam et al., 2018; Siu, 2010). Preparedness at the system level includes understanding the capacity of a hospital or health care system in advance of a potential public health emergency, including workforce capacity and capabilities and access to PPE, medical supplies, medical gases, and ventilators. It also requires having an action plan that includes the essential elements of managing the challenges such an event may impose on the institution (Siu, 2010; Toner et al., 2020; WHO, 2018). However, the preparedness of the U.S. health care system to manage a pediatric surge during a pandemic has been recognized as lacking (Anthony et al., 2017). Preparedness for front-line workers includes clinical skills and knowledge for providing care for patients and protecting the public from becoming ill (Lam et al., 2018; Ruderman et al., 2006; Shih et al., 2007).
Response plans and nurses’ willingness to respond will vary based on the amount of information available about the pathogen and its transmission, the severity of the disease, and the public’s attitude toward the outbreak (Chung et al., 2005; Lam and Hung, 2013; Lam et al., 2018; Shih et al., 2007). When certain aspects of the disease are uncertain or the information is inconsistent, nurses become less confident and more anxious about performing their duties during an outbreak (Lam et al., 2018; Shih et al., 2007). The more severe the disease outbreak, the more likely it is that nurses will be prone to greater anxiety and fear of infection (Koh et al., 2012; O’Boyle et al., 2006). Even if this fear does not stop them from working during the outbreak, they are more likely to have a negative attitude and decreased morale when caring for infected patients. Nurse attitudes can also be strongly impacted by the mass media and news outlets (Lam et al., 2018; Shih et al., 2009). During disease outbreaks, the media will focus on the number of deaths and the severity of the disease, making it challenging for nurses to maintain a positive attitude when working with patients. Perceptions of the disease created in the media can also cause panic in the general public, which directly affects front-line nurses both in health systems and in the community (Lam and Hung, 2013; O’Boyle et al., 2006; Shih et al., 2007, 2009).
The disaster nursing timeline (see Figure 8-1) and many state, local, and organizational response plans are based on the single occurrence of an acute event. It is important to note that infectious disease outbreaks are slow-moving disasters with multiple waves that create unique challenges for health system response. There is much to be learned from the events of 2020 and the devastating sequence of events that unfolded during the COVID-19 response.
In December 2019, the novel coronavirus known as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was first detected in China. By March 2020, the World Health Organization (WHO) had declared the COVID-19 outbreak a pandemic, which was to become the worst public health emergency in more than 100 years, with more than 120 million cases detected worldwide and 30.5 million cases confirmed in the United States as of April 1, 2021. 3 Nurses have performed a variety of roles during the COVID-19 pandemic, while health care organizations and hospitals have had to treat innumerable patients across the United States for COVID-related illness alongside other complex and serious conditions (Veenema et al., 2020).
Roles and responsibilities for nurses shifted rapidly to accommodate patient surges and the sudden unanticipated demand for health care services. Nurses were required to take on multiple new roles (e.g., non–critical care nurses asked to care for patients critically ill with COVID-19), provide end-of-life care, and serve as a means of vital communications between hospitalized patients and their families (Veenema et al., 2020). These shifts may have lowered the skill mix in intensive care units (ICUs) below required standards, with potential risks to patients’ safety and quality of care (Bambi et al., 2020). As of April 1, 2021, 552,957 people in the United States had died from COVID-19, 4 including an estimated 551 nurses. 5 Evidence gathered from nurses throughout the pandemic reveals the multiple challenges they have encountered during the pandemic response. Nurses have reported inadequate supplies of PPE, insufficient knowledge and skills for responding to the pandemic, a lack of authority for decision making related to workflow redesign and allocation of scarce resources, staffing shortages, and a basic lack of trust between front-line nurses and nurse executives and hospital administrators (ANA, 2020a,b; Mason and Friese, 2020; Veenema et al., 2020).
Nurses have experienced significant psychological and moral distress during the pandemic (Altman, 2020; Labrague and De Los Santos, 2020; Pappa et al., 2020; Shechter et al., 2020). Results of a survey conducted by the American Nurses Association (ANA, 2020a) reveal that 87 percent of nurses were afraid to go to work, 36 percent had cared for an infectious patient without having adequate PPE, and only 11 percent felt well prepared to care for a patient with COVID-19. A follow-up survey conducted by ANA (2020c) revealed that intermittent shortages of PPE for nurses persisted 7 months into the pandemic, particularly for those working in smaller rural hospitals, home care, and palliative care. Nurses were asked to extend and reuse N95 masks long after CDC’s recommended guidelines, leading ANA to request that the Defense Production Act (DPA) be invoked to produce N95 masks (Lasek, 2020). In particular, nurses working in long-term care facilities, home care, palliative care, and small rural hospitals were particularly vulnerable as caregivers in environments with high risk and high mortality (ANA, 2020c).
The mental health burden of the pandemic on nurses has been profound (see Chapter 10). Nurses of Asian/Pacific Islander (API) descent have experienced discrimination from patients who have refused care from them or made disparaging remarks about their ethnic origins. The Asian Pacific Policy and Planning Council released a report on August 27, 2020, detailing 2,583 incidents of discrimination against APIs in the United States from March 19 to August 5, 2020 (Attacks against AAPI community, 2020). The psychological and mental health implications for nurses of API descent represent one of the many challenges nurses have faced during the pandemic.
In addition to natural disasters and public health emergencies, the United States is currently experiencing significant increases in gun-related violence, civil unrest against systemic racism, and social upheaval associated with growing political polarization (see Box 8-1). Active shooters in hospitals, school shootings, and random acts of foreign and domestic terrorism have forced a widening aperture for national preparedness, and nurses are involved in responding to the care needs of victims of these events (Lavin et al., 2017).
Pulse Nightclub Shooting.
A disaster is defined as “a serious disruption of the functioning of a community or a society at any scale due to hazardous events interacting with conditions of exposure, vulnerability and capacity, leading to one or more of the following: human, material, economic and environmental losses and impacts” (UNISDR, 2017). More than 2.6 billion people globally have been affected by natural disasters, such as earthquakes, tsunamis, and heat waves, in the past decade, and these disasters have led to massive injuries, mental health issues, and illnesses that can overwhelm local health care resources and prevent them from delivering comprehensive and definitive medical care (WHO, 2020). During 2019 alone, the United States experienced 14 separate billion-dollar disasters, including inland floods, severe storms, two hurricanes, and a major wildfire event (Smith, 2020). Disaster planning for emergency preparedness is, then, imperative. In the near future, such factors as climate change and climate change–related events, including global warming and sea-level rise; the depletion of resources and associated societal factors; and the growth of “megacities” and populations shifts (IFRC, 2019; UN, 2016) are likely to converge to increase the risk of future disasters (IPCC, 2012, 2014; Watts et al., 2018). Human-caused disasters, such as school and other mass shootings and random acts of terrorism, create additional hazards for human health.
While disasters impact populations, research has shown that those impacts are not equally distributed. Disasters often amplify the inequities already present in society and harm high-risk and highly vulnerable communities far more than others (Davis et al., 2010). Although every person who is exposed to a disaster is impacted in some form, the disproportionate impact on high-risk and highly vulnerable populations, including the elderly, individuals with disabilities, the immunosuppressed, the underserved, and those living in poverty, is unequivocal (Maltz, 2019; UNISDR, 1982). Severe and morbid obesity, the complex causes of which are rooted in SDOH, also creates increased vulnerability to disasters. In fact, the intersection of SDOH, severe or morbid obesity, and disaster vulnerability is postulated to create “triple jeopardy” for these individuals (Gray, 2017).
Health and health care disparities, such as lack of access to primary care and specialty providers, the presence of comorbid conditions, and lack of health insurance, together with poverty, not only put people at increased risk for injury or death during disasters but also are often exacerbated during a disaster. For example, more than 4,600 excess deaths are believed to have resulted from Hurricane Katrina because of interruptions in medical care and basic utilities, which especially impacted those with chronic conditions who required medical equipment powered by electricity (Kishore et al., 2018). This number was much higher than the number of people who died as a direct result of the hurricane and indicates how quickly chronic conditions can revert to acute medical emergencies, greatly increasing the mortality of those most underserved.
Studies show that although the majority of Americans are considered unprepared for the occurrence of a disaster, those of lower socioeconomic status (SES) and lower educational attainment are generally less prepared than their wealthier and more educated counterparts in part because of the costs associated with preparedness actions, such as obtaining insurance and taking measures to prepare for earthquakes (SAMHSA, 2017). In a national household survey, for example, 65 percent of respondents said they had no disaster plans or had plans that were inadequate (Petkova et al., 2016). And according to national survey data from the Federal Emergency Management Agency (FEMA), fewer than half of Americans are familiar with local hazards, less than 40 percent have created a household emergency plan, and only about half (52 percent) have disaster supplies at home (FEMA, 2014).
When communities are warned about impending disasters, research shows that those of lower SES may be less likely to respond because of the cost and resources associated with evacuation (Thiede and Brown, 2013). When a disaster strikes, a range of impacts continue to affect those of lower SES compared with those of higher SES more severely, including homelessness, physical injuries, and financial effects. Families of lower SES are more likely to experience greater impacts from disasters, including damage to their homes from strong winds, floods, or earthquakes because of their homes’ lower construction quality and increased likelihood of being located in flood-prone areas; lack of insurance coverage; insufficient savings; and lack of understanding of the governmental systems that provide aid to victims (Hallegatte et al., 2016). They may not know how to access aid and may feel uncomfortable working with these systems, especially if they are undocumented immigrants in fear of being deported. Families may even be unable to reach assistance centers because of a lack of transportation and child care or the inability to miss work. Those of lower SES are more vulnerable to homelessness after a disaster and experience extreme difficulty in obtaining housing loans to help them rebuild their damaged homes (SAMHSA, 2017). This plethora of hardships experienced by people of lower SES and people of color during and after a disaster also leads to an increased likelihood of experiencing depression and posttraumatic stress.
Health inequities seen in natural disasters and infectious disease outbreaks are often directly related to race and ethnicity. The COVID-19 pandemic has had a disproportionate effect on Black, Hispanic, and American Indian populations, who have experienced greater levels of suffering and death. Long-standing racial and ethnic inequities in access to health care services prior to the pandemic have translated into disparities in access to COVID-19 testing and treatment (Duke Margolis Center for Health Policy, 2020; Poteat et al., 2020). Zoning laws and low income levels have disadvantaged some racial and ethnic groups and contributed to living conditions that have made it difficult for individuals to socially distance (Davenport et al., 2020). The added burdens of chronic disease and persistent underfunding of American Indian health systems have resulted in the nation’s Indigenous population being at high risk of poor outcomes from the disease (AMA, 2020). COVID-19-related unemployment and economic devastation have impacted all communities, with Black and Hispanic workers experiencing the highest rates of COVID-19 infection (BLS, 2020). Box 8-2 describes how one county in Texas became a COVID-19 “hotspot.”
COVID-19 in Hidalgo County, Texas.
In the future, nurses could play a role in helping to address these disparities before, during, and after a disaster. Community resilience, which “refers to community capabilities that buffer it from or support effective responses to disasters,” is of growing importance in disaster preparedness, particularly in underresourced areas (Wells et al., 2013, p. 1172). This concept engages the community in disaster planning, such as creating “community emergency response teams” and helping families compile their own disaster preparedness kits (Wells et al., 2013). When adequate in number, public health and school nurses can help with these community engagement activities and advance preparedness in at-risk populations, such as low-income families and the homebound elderly (Spurlock et al., 2019). Some disasters may not call on nurses to use technical clinical practice skills, but rather their skills in networking, communications, creation of partnerships, resource identification, and assessment, as well as their understanding of SDOH that result in increased vulnerabilities to a disaster event. Disasters often limit or eliminate access to transportation; access to care, food, and shelter; and employment. By understanding how these factors affect a person’s health and well-being and related potential resources, nurses can help build community resilience (Heagele, 2017). Additionally, nurses can play a role in advocating for a health equity approach in preparation for future pandemics that addresses historical and current structural as well as systemic racial prejudice and discrimination that result in health disparities.
Equitable access to and distribution of tests, treatments, contact tracing, and vaccines especially for underserved populations, is instrumental to the success of the response to COVID-19 as well as future pandemics. Nurses’ capacity to advance health equity in the United States includes supporting fair, equitable, and transparent allocation of vaccine during the nation’s COVID-19 vaccine campaign and future infectious disease emergencies. Nurses’ awareness of the relationship between the historical experience of individuals and communities and how SDOH impact trust in the health care system and vaccine hesitancy is a precursor to the critically important work of framing community health education and messaging to counter misinformation. With this understanding, nurses can be trusted sources of health information and work actively to educate their communities, particularly in the areas of preventing disease spread and dispelling vaccine-related misinformation. Nurses should be able and willing to participate in all of these activities during an ongoing pandemic (Martin, 2011).
During disasters, nurses staff shelters that house people displaced by these events. Shelters are critical in disaster response, providing temporary housing for those displaced by such events as earthquakes and hurricanes (see Box 8-3). During Hurricanes Gustav and Ike in 2008, more than 3,700 patients were treated by nurses in shelters for acute and chronic illnesses (Noe et al., 2013). After Hurricane Katrina in 2006, nearly 1,400 evacuation shelters were opened to accommodate 500,000 evacuees from the Gulf region (Jenkins et al., 2009). People who receive care in shelters, including children, the elderly, and those with chronic medical conditions, are often economically disadvantaged and highly vulnerable to a disaster’s health impacts (Laditka et al., 2008; Springer and Casey-Lockyer, 2016). For example, one study of evacuees living in Red Cross shelters after Hurricane Katrina found that nearly half lacked health insurance, 55 percent had a preexisting chronic disease, and 48 percent lacked access to medication (Greenough et al., 2008). Nurses can help ensure that such evacuees receive appropriate care, including for physical and mental illnesses, and help prevent unnecessary deaths that may result from disruptions in health care services.
Lessons Learned from Nurses’ Role in Evacuation During Hurricane Sandy.
After a disaster, people must often spend extended periods in shelters until they can find alternative housing, greatly affecting their social, mental, and physical well-being. For example, studies have found that disaster victims are at increased risk for posttraumatic stress disorder, and the close proximity to others in which they must live in shelters, combined with poor infection control, greatly increases the potential for infectious disease outbreaks in these settings. The health needs of those residing in shelters long-term are often much greater than the needs of those who suffer acute injuries, such as traumas (e.g., penetrating wounds, bone fractures), from the disaster itself. For example, a review of more than 30,000 people treated in shelters after Hurricane Katrina found that most of the care provided was “primary care or preventive in nature, with only 3.8 percent of all patients requiring referral to a hospital or emergency department” (Jenkins et al., 2009, p. 105). An assessment conducted after Hurricanes Gustav and Ike identified similar postdisaster health care needs within shelters (Noe et al., 2013).
Historically, nurses have delivered care to shelter populations, perhaps most familiarly in working with ARC. For example, ARC nurses at a shelter housing Hurricane Katrina evacuees set up hand sanitizing stations to help prevent infectious disease outbreaks. ARC nurses have worked to understand the functional, physical, and mental health needs of displaced persons; ensure that shelters are safe environments; and “maximiz[e] the effectiveness of nurses and other licensed care providers in disaster shelters” (Springer and Casey-Lockyer, 2016).
Critical lessons learned during the response to prior infectious disease outbreaks, such as the 2003 severe acute respiratory syndrome (SARS) coronavirus outbreak, the 2009 H1N1 influenza pandemic, and the Ebola virus outbreak in West Africa, were not applied to workforce planning for future infectious disease outbreaks such as COVID-19 (Hick et al., 2020). These prior public health emergencies illuminated glaring gaps in emergency preparedness and workforce development and the harmful effects on nurses, and multiple calls to improve nurse readiness for pandemic response have been issued (Catrambone and Vlasich, 2017; Corless et al., 2018; Veenema et al., 2016a).
Basic knowledge about health system emergency preparedness is generally lacking among nurses, including school nurses, who, as discussed above, are expected to play key roles during public health emergencies (Baack and Alfred, 2013; Labrague et al., 2018; Rebmann et al., 2012; Usher et al., 2015). For example, in a survey of more than 5,000 nurses across the Spectrum Health system, 78 percent of respondents said they had little or no familiarity with emergency preparedness and disaster response (ASPR, 2019). Similarly, studies evaluating curricular content in U.S. schools of nursing (Charney et al., 2019; Veenema et al., 2019) and globally (Grochtdreis et al., 2016) disclose a notable absence of health care emergency preparedness content and little evidence that the few students who receive instruction in this context achieve competency in these skills. Furthermore, the willingness of individual nurses and other health care providers to respond to disasters is variable, and research suggests that many feel unequipped to respond (Connor, 2014; Veenema et al., 2008) or to keep themselves safe (Subbotina and Agrawal, 2018).
This educational gap is striking given that studies have shown that the more knowledgeable nurses are about infectious disease manifestation, transmission, and protection, the more confident and successful they will be when working during an outbreak (Liu and Liehr, 2009; Shih et al., 2009). Moreover, nurses who have previous experience working with an infectious disease outbreak are more confident and better prepared during a subsequent outbreak (Koh et al., 2012; Lam and Hung, 2013; Liu and Liehr, 2009), more knowledgeable about infection control and prevention measures, and more skilled in treating those with such infectious diseases. Nurses with a strong sense of their professional value—those who believe their role as a nurse is not just a job but a responsibility to serve and protect the public—are more likely to work during an infectious disease outbreak (Koh et al., 2012). Their outlook often causes them to struggle in balancing their duty as a nurse to provide care with their personal safety and health during an outbreak (Chung et al., 2005).
Gaps in education and training are evident in nursing leadership as well (Knebel et al., 2012; Langan et al., 2017; Veenema et al., 2016b, 2017). Nurse leadership, an important component of nurses’ roles (see Chapter 9), is essential in any organization experiencing a disaster (Samuel et al., 2018). Thus, greater effort to develop and evaluate training programs for nurse leaders is warranted. Such programs can cultivate communication, business, and leadership competencies, and these nurse leaders, in turn, can improve health care’s response, outcomes for patients, staff well-being, and the financial stability of hospitals (Shuman and Costa, 2020). Results of the April 2020 ANA survey indicated gaps in crisis leadership resulting in a lack of trust between nursing and hospital leadership and front-line nursing staff.
Areas in which action needs to be taken to advance national nurse readiness for responding to disasters, including pandemics, are detailed below. First, however, it is critical to identify and understand the gaps in the U.S. health care system both within and outside of the nursing workforce that have contributed to an ongoing lack of disaster readiness (Veenema et al., 2020). A range of factors that influence nursing workforce development and nurses’ safety and support during disasters extend across the governmental, system (e.g., large regional health systems), and organizational (e.g., individual hospitals, clinics, and other types of health care settings) levels. Aggressive actions taken now to transform nursing education, practice, and policy across health care and public health systems and organizations can improve the readiness, safety, and support of the national nursing workforce for COVID-19 as well as future disasters. The factors reviewed below that affect nurse preparedness include government strategies, research funding, education and accreditation, responsibilities of hospitals and health care organizations, and the role of professional nursing organizations. The interactions among nurses, health care institutions, and government have been identified as crucial to an effective pandemic response (Lam et al., 2018).
The federal government has wide-ranging responsibilities for disaster preparedness and response across various agencies. The Office of the Assistant Secretary for Preparedness and Response (ASPR) within the U.S. Department of Health and Human Services (HHS) “leads the nation’s medical and public health preparedness for, response to, and recovery from disasters and public health emergencies” (HHS, 2019). ASPR’s many roles during these events include coordinating the HHS Emergency Support Functions, overseeing the National Disaster Medical System, supporting the Hospital Preparedness Program, and maintaining and distributing the Strategic National Stockpile. 6 ASPR’s strategies for identifying risks and informing preparedness and response efforts also include the National Biodefense Strategy and the National Health Security Strategy. Federal response strategies and frameworks beyond those of ASPR include FEMA’s National Response Framework and CDC’s Public Health Emergency Preparedness and Response Capabilities.
Concern has been expressed that the above federal strategies may not accurately reflect and incorporate the capacity of the nursing workforce to respond to disasters. Veenema and colleagues (2016a) identify the need for a systematic review of national policies and planning documents addressing disasters to ensure that they elevate, prioritize, and address the practice of disaster nursing in federal, state, and local emergency management operations. For instance, the 2017–2022 Health Care Preparedness and Response Capabilities provides a framework for health care coalition capabilities, including health care and medical readiness, health care and medical response coordination, continuity of health care service delivery, and medical surge (ASPR, 2016). Noteworthy, however, is that many of the capabilities outlined in this framework depend on a trained nursing workforce.
Ensuring that nurses are educationally prepared and available will be instrumental to success in mass vaccination and other disaster-related efforts. In terms of local government decisions, for example, school nurses are responsible for safe reentry of children to K–12 education during disasters. Lessons learned from the reopening of schools in other jurisdictions and other countries, as well as CDC guidance, can inform the incorporation of such practices as pandemic public health interventions into schools. The roles and responsibilities expected of nurses within existing local, state, and federal preparedness and response strategies need to be clarified to equip nurses with the knowledge, skills, and abilities needed to execute those roles safely and to build and maintain them across the nursing workforce. Additionally, nursing expertise that draws on both clinical and public health nursing knowledge can actively inform policy makers from the local to the federal levels to ensure nurses’ robust preparation for and response to disasters.
Scientific evidence is foundational to the delivery of safe, high-quality nursing care to individuals and communities affected by a disaster, yet data suggest that this evidence base is underdeveloped (Veenema et al., 2020). Research gaps have been identified (Stangeland, 2010), and priorities related to disaster nursing have been articulated (Ranse et al., 2014). A 2016 consensus report articulates specific recommendations for advancing research on disaster nursing, including the articulation of a research agenda based on a needs assessment to document gaps in the literature, nursing knowledge and skills, and available resources; expansion of research methods to include interventional studies and use both quantitative and qualitative designs; and an effort to increase the number of PhD-prepared nurse scientists serving as principal investigators on disaster research projects (Veenema et al., 2016a).
However, funding for this work has been insufficient. Support for public health emergency preparedness and response (PHEPR) research in general has repeatedly stopped and restarted, resulting in an evidence base comprising one-off studies. There has been little funding for academic public health emergency programs since 2015, with the exception of CDC’s Center for Preparedness and Response’s Broad Agency Announcement for Public Health Emergency Preparedness and Response Applied Research, and no funding for academic disaster nursing. Overall funding for disaster research has declined since 2009 (NASEM, 2020). A report recently released by the National Academies (NASEM, 2020) concludes,
A report recently released by the National Academies concludes the public health emergency preparedness and response (PHEPR) response field is currently “relying on fragmented and largely uncoordinated efforts,” (NASEM, 2020, p. 7) often with no clear linkage to overall system goals. Collectively, these deficiencies have contributed to a field based on long-standing practice not evidence-based practices (NASEM, 2020). To address these deficiencies, the PHEPR field needs a coordinated intergovernmental, multidisciplinary effort with defined objectives to prioritize and align research efforts and investments in a research infrastructure to strengthen the capacity to conduct research before, during, and following public health emergencies (NASEM, 2020).
In 2017, the Centers for Medicare & Medicaid Services (CMS) enacted the Emergency Preparedness Rule, which established requirements for planning, preparing, and training for emergencies (CMS, 2016, 2019). The rule was intended to advance health care preparedness, but it did not address the preparedness of the nursing workforce. The rule was designed to promote preparedness at the health care organization level, allowing the organization flexibility in testing and training for staff, including nurses. Accreditors are required to ensure that the criteria for the rule are met, but they do not evaluate the level of knowledge among staff or require additional training or workforce development. Gaps in nursing’s emergency preparedness within these organizations can occur even if they have met the CMS emergency preparedness criteria.
Maintaining adequate and safe staffing levels during a disaster needs to be a key consideration in the development of a workforce emergency strategy. The Joint Commission has a vested interest in nursing workforce issues, viewing nursing as part of its mission to support high-quality and safe care for the public. The Joint Commission has produced recommendations designed to increase the professionalism of nursing and diversify the nursing workforce, and it has implemented measures to improve the safety and quality of nursing care practices. While The Joint Commission does not specifically require reporting of nurse-to-patient ratios, it does have some related metrics around patient outcomes (The Joint Commission, 2020). The lack of metrics that specifically measure whether facilities have the plans, procedures, and human resources needed to surge the workforce during a disaster leaves them vulnerable to staffing shortages and increases the likelihood that they will need to turn to a crisis standards of care staffing model.
Fundamental and seismic change also is required in nursing education if the profession is to keep pace with the increasing numbers of natural disasters and public health emergencies. The major threats to global human health (climate change, air pollution, influenza, emerging infectious diseases, vaccine hesitancy) (WHO, 2019) receive minimal coverage in most nursing school curricula. COVID-19 represents a harbinger of public health emergencies to come, highlighting the vital role of disaster response education and training for nurses. Yet, repeatedly, empirical evidence shows that nurses are ill prepared to respond to these events (Charney et al., 2019; Labrague et al., 2018; Veenema, 2018). Overall, the preparedness of the nursing workforce is a factor in prelicensure education and lifelong learning inclusive of training (e.g., regular drills and exercises). Nursing preparedness requires that all organizations employing nurses, from schools of nursing to hospitals to other health-related organizations, engage in this agenda. To equip nurses to respond to future disaster events, schools of nursing need to produce nurses capable of providing culturally meaningful care, using data to drive health decisions, and addressing SDOH to optimize population health outcomes (Duke Margolis Center for Health Policy, 2020). And as noted earlier, PhD-prepared nurse scientists are essential to conduct disaster research and educate a cadre of future nurse researchers and educators to sustain and advance the field. Nursing curricula need to be updated to reflect the realities of these increasing threats to human health.
The American Association of Colleges of Nursing (AACN) establishes the standards for curriculum for academic nursing programs through a series of Essentials documents that are currently being revised and are targeted to be released in early 2021 (see Chapter 7 for more detailed information). Population health competencies that specifically address disaster response are included in the revised Essentials, and their addition has the potential to drive transformational change across academic programs. Greater emphasis on disaster and public health emergency response competencies and skills should have beneficial effects for nurses during disasters, including greater resilience, increased practical and theoretical knowledge, a broader view of the “clinical and organizational big picture,” and reduced psychological impact in case of sudden reassignment to a different clinical setting (Bambi et al., 2020). While all schools need to increase content in general disaster preparedness, it is also worth considering incorporating additional hazard-specific content to build capacity for nurses to respond to the kinds of emergencies that are most likely in the geographic area where they will live and practice. Schools of nursing can expand their use of educational technology, including telenursing and virtual simulations to increase interprofessional disaster training opportunities in partnership with community disaster response agencies.
The Commission on Collegiate Nursing Education (CCNE) Standards and Professional Nursing Guidelines Standards for Accreditation of Baccalaureate and Graduate Nursing Programs are applied at accreditation site visits to schools of nursing (AACN, 2011) to confirm that academic programs align with Essentials. CCNE evaluators’ confirmation of the adoption of the new Essentials standards on incorporating disaster response content into education and training programs could produce evidence of graduates’ related clinical competence (Veenema et al., 2020).
Disasters, including such events as the COVID-19 pandemic, interrupt academic progression and student mastery of clinical competencies and can delay graduations. Schools of nursing and state boards of nursing would be well served to establish options for supporting clinical rotations in the health care setting, such as expanding the role of virtual or simulated learning and alternative, nontraditional sites for clinical placements. Working with clinical and community partners, schools of nursing would benefit from establishing back-up plans to ensure that academic programs continue during public health emergencies. A particular emphasis on addressing health care equity in the face of disaster would be of prime importance.
The COVID-19 pandemic has revealed profound problems with the financing and delivery of American health care, presenting both challenges and opportunities for nursing, and has exposed systemic vulnerabilities that afflict the well-being and resilience of nurses and other health professionals. Hospitals and other organizations employing nurses, nurse leaders, physicians, and others have a responsibility to create a safe working environment for nurses, ensuring adequate staffing levels, access to appropriate levels of PPE, and physical and mental health support services for protracted disaster events. Hospital administrators and nursing and medical executives need to be held accountable for having policies in place to ensure a safe working environment for nurses during disaster response. Hospital disaster plans need to accommodate changes in clinical duties and nurse staffing to meet demand, and identify alternative nurse staffing resources to aid in the response. Long-term care facilities, home care agencies, and community health clinics need to include the same accommodations.
Nurse executives in various health and health care organizations across communities can work together to plan for circumstances that may require surging nurses across settings to meet emerging health care needs. Nurses well educated in addressing SDOH would be of particular value in contributing to the development and implementation of preparedness and response strategies that meet the needs of diverse high-risk, high-vulnerability populations. Stockpiling and procurement of adequate supplies (e.g., testing supplies, PPE, medical gases) are critical for keeping nurses safe at work. Health system leaders, mandated to have emergency management response plans in place, can ensure that all disaster and pandemic response plans address training content, including issues of health equity and communication with and protection of their workforce.
Professional nursing organizations have an important role in ensuring that their members and the profession at large have the expertise and support to respond to unanticipated events that threaten the health of the public. These organizations have advocated for the support and protection of nurses during past disasters and continue to do so today. The Tri-Council for Nursing (Tri-Council) is an alliance of five nursing organizations focused on leadership for education, practice, and research. Working with specialty nursing organizations, such as the Emergency Nurses Association and the Council of Public Health Nursing Organizations, the Tri-Council could advocate for a broad and forward-thinking national plan to advance disaster nursing and PHEPR. A special emphasis should be the care of individuals, families, and communities that are disproportionally affected by disasters. Nursing organizations uniting around the COVID-19 response can use this experience to establish a foundation for preparing the profession to meet future disaster-related challenges.
COVID-19, while historic, is but one example of the significant burden imposed by disasters and public health emergencies on the health of populations, health care professionals, and nurses in particular. The pandemic has created multiple challenges, particularly for managing its effects across diverse and highly vulnerable populations, and exacerbated existing health inequities. Future natural disasters and infectious disease outbreaks will present similar, if not greater challenges for the nursing profession. Bold, anticipatory action is needed to advance nurse readiness for these events.
Conclusion 8-1: The nation’s nurses are not currently prepared for disaster and public health emergency response.
Conclusion 8-2: A bold and expansive effort, executed across multiple platforms, will be needed to fully support nurses in becoming prepared for disaster and public health emergency response. It is essential to convene experts who can develop a national strategic plan articulating the existing deficiencies in this regard and action steps to address them, and, most important, establishing where responsibility will lie for ensuring that those action steps are taken.
Conclusion 8-3: Rapid action is needed across nursing education, practice, policy, and research to address the gaps in nursing’s disaster preparedness and improve its capacity as a profession to advocate for population health and health equity during such events.
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This chapter was commissioned by the Committee on the Future of Nursing 2020–2030 (Veenema, 2020).
For the sake of brevity, the term “disaster” is used throughout the remainder of this chapter to refer to both natural disasters and public health emergencies.
