EMERGENCY AND

DISASTER PREPAREDNESS:
By Kristine M. Gebbie, DrPH, RN, FAAN,
and Kristine Qureshi, MSN, RN, CEN

mergencies and disasters, whether natural or man-made, are difficult to prepare for. The September 11 terrorist
attacks in New York City, Pennsylvania,
and Washington, DC, and the subsequent bioterrorist attacks with anthrax, made this
abundantly clear. Although nurses may agree that
theres a need for basic competencies in disaster preparedness and response in addition to the usual clinical skills, such training is not part of the required
undergraduate curricula at most U.S. schools of
nursing, and there is surprisingly little in the literature that addresses the role of nursing in this regard.
Its therefore imperative to identify what every nurse
needs to know to serve effectively as a member of an
emergency and disaster response team.
Emergency or disaster? The term emergency
refers to any extraordinary event or situation that
requires an intense, rapid response and that can be
Kristine M. Gebbie is the Elizabeth S. Gill Associate Professor of
Clinical Nursing, director of the Center for Health Policy and Health
Services Research, and director of the doctoral program at the
Columbia University School of Nursing in New York City. Kristine
Qureshi, a certified emergency nurse with experience in emergency
and disaster planning, is a doctoral candidate at the Columbia
University School of Nursing and a research assistant at the Columbia
University Center for Public Health Preparedness. Contact author:
Kristine M. Gebbie: [email protected].

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addressed with existing community resources.

Disaster refers to an event or situation that is of
greater magnitude than an emergency; disrupts
essential services such as housing, transportation,
communications, sanitation, water, and health care;
and that requires the response of people outside the
community affected.1 The term disaster particularly
signifies an event that carries unforeseen, serious,
and immediate threats to public health.
Natural or man-made? The World Health
Organization defines natural disaster as the result
of an ecological disruption or threat that exceeds
the adjustment capacity of the affected community.2 Such disasters include large fires, extensive
floods, hurricanes, and earthquakes. As defined by
Guha-Sapir, man-made disasters are those resulting
from events or situations that are clearly caused by
humankind, such as war and armed conflict, overwhelming environmental contamination, and significant technologic catastrophe.1
As Landesman notes, No two emergencies or
disasters are alike.3 But in each situation, regardless of cause, the competencies nurses need to possess in order to respond effectively are essentially the
same. We use the term emergency preparedness
competencies to cover both emergency and disaster
preparedness and response skills.
http://www.nursingcenter.com

CORE COMPETENCIES
FOR NURSES
What every nurse should but may not know.
An outline for action. The first step toward emergency preparedness is the identification of who
needs to know how to do what. Thus, in any setting, one of the first questions a nurse may ask is,
Whats my role in an emergency? Although there
is little in the nursing literature, specifically, that
addresses this subject, there are two articles worth
mentioning. OBrien found that nurses in Australia
play significant roles in all phases of emergency preparedness and response, including development of
disaster plans, hands-on treatment of casualties, and
evaluation of response activities.4 Shoaf and
Rottman, reporting on the 1999 University of
CaliforniaLos Angeles Conference on Public
Health and Disasters, cited four areas of focus in
emergency and disaster management: preparedness,
mitigation, response, and recovery.5 Along with a
fifth area, evaluation, these offer nurses an outline
for a plan of action to be taken when responding to
an emergency or disaster.

THE CORE COMPETENCIES

Until now, emergency preparedness competencies
specific to nurses working in the United States
hadnt been identified. At the request of the Centers
for Disease Control and Prevention (CDC), one of
the authors of this article (Kristine Gebbie) has
[email protected]

developed a set of core emergency preparedness

competencies for public health workers.6 This
served as the model for the core competencies for
nurses outlined below.
DESCRIBE the agencys role in responding to a
range of emergencies that might arise. During an
emergency or disaster, an organization, agency, or
unit may continue functioning as usual, or it may
perform special services. Youll need to know if and
how the service line (the clinical unit or practice
area) will change or expand during an emergency.
For example, will scheduled surgeries be cancelled
to create standby capacity (in terms of both unit
space and surgery time) for trauma patients? Will a
long-term care center become a shelter for displaced
seniors? Knowing in advance exactly whats
expected of the organization during an emergency
or disaster gives the staff the opportunity to acquire
the pertinent knowledge and to practice necessary
skills beforehand. Emergency department nurses
generally know their roles through citywide trauma
plans for community disasters; nurses working in
other settings such as long-term care facilities or
home health care agencies may not have been
instructed to prepare in the same way.
DESCRIBE the chain of command in emergency
response. Effective emergency response requires
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Emergency Preparedness Information

Organization

Activities

U.S. Department of Health and Human

Services, Office of Emergency
Preparedness (OEP)
http://ndms.dhhs.gov

The lead agency for disaster health and

medical services works in close
partnership with federal agencies and
directs the NDMS.

National Disaster Medical System

(NDMS)
http://ndms.dhhs.gov/NDMS/ndms.html

A cooperative program among

government agencies and private and
voluntary organizations, it works to
ensure adequate distribution of
resources.

Federal Emergency Management Agency

(FEMA)
www.fema.gov

Works to build and support the national

emergency management system.

Centers for Disease Control and

Prevention (CDC)
www.cdc.gov

The lead federal agency for disease

prevention and control activities
provides backup support to state and
local health departments.

Joint Commission on Accreditation of

Healthcare Organizations (JCAHO)
www.jcaho.org
(For revised standards, see
www.jcaho.org/standard/stds2001_mpfrm.html.)

Accredits facilities according to

established safety and quality
standards, and revised the emergency
management standards for health care
facilities in 2001.

well-orchestrated teamwork in which each member

knows what the lines of authority and communication are. The Incident Command System (ICS),
commonly used for defining the chain of command
during emergencies, originated in the 1970s, when
local, state, and federal agencies in California
needed a well-coordinated procedure for fighting
wildfires; it has been developed further by the
Federal Emergency Management Agency (FEMA).7
(See www.fema.gov/emi/is195.htm.)
The ICS designates common titles and roles to be
used in all responding organizations and agencies.
For example, during an emergency, President Jones
of Organization A and Director Smith of Agency B
would become incident commanders with specific duties and responsibilities. The system also
organizes emergency response according to five
major components: command, planning, opera48

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tions, logistics, and finance and administration.

Depending on the scale of the emergency or disaster,
incident commanders can appoint information and
safety officers and interagency liaisons to manage
those channels. In affording diverse groups a common approach, the system facilitates communication and coordination of response efforts.
In many organizations, the nursing staff would
be deployed by the operations officer; they may also
take part in planning, logistics, or finance and
administration.
IDENTIFY and LOCATE the agencys emergency
response plan (or the pertinent portion of it). Every
nurse needs to know where the emergency response
plan can be found and to be familiar with its contents before an emergency arises. If your agency frequently responds to local emergencies, it may be
useful to outline the plan and your designated role
http://www.nursingcenter.com

in a card or small notebook; include necessary contact information and update it regularly.
DESCRIBE emergency response functions or roles
and DEMONSTRATE them in regularly performed drills.
Effective emergency response requires that each
team member know what to do and how to do it.
The nurses role may be essentially unchanged or it
may entail different dutiesfor example, working
as backup staff member in the intensive care unit,
supporting families in the emergency department,
being on call at home, or reporting for duty at the
local health department. To ensure competence during an emergency or disaster, it is important that
tasks be practiced. Know which types of emergencies are likely to occur in your area and which
health conditions are likely to result from them.
Some occurrences, such as terrorist attacks, are less
predictable; still, by possessing and practicing competencies, youll be better prepared to handle all
types of emergencies.
DEMONSTRATE the use of equipment (including personal protective equipment) and the skills required
in emergency response during regular drills. All
nurses know how to safely operate equipment that
they use daily. But during an emergency, they may
be required to use unfamiliar equipment. Knowing
the setting to which youre likely to be dispatched
affords the opportunity to learn how to use such
equipment in advance. You also need to know how
to protect yourself. This requires awareness of possible contaminants and knowledge of appropriate
methods of protection. Some emergency response
activities require simple universal precautions while
others require more sophisticated protections.
DEMONSTRATE the correct operation of all equipment used for emergency communication. Teamwork and communication are essential during
emergency response. For example, a nurse may
serve as a communication link between the hospital
and health department. Professional staff members
often dont know how to use common communication equipment, and the simplest task becomes cumbersome and consumes too much time. Practicing
with the equipment beforehand can eliminate this.
DESCRIBE communication roles in emergency
response
within your agency.
with news media.
with the general public (including patients and
families).
with personal contacts (ones own family, friends,
and neighbors).
Every organization or agency should delineate
specific roles and responsibilities that apply to both
internal and external communication. Youll need
to know the communication roles of others, in addition to your own, to refer information requests
appropriately. During emergency response, [email protected]

In the Eye of the Storm

A Brooklyn hospital puts its emergency and disaster
preparedness plan to the test.
n September 11, 2001, core nursing competencies for emergency response were tested throughout my hospital. Eightyeight patients (mostly self-referred) from the site of the attacks on
the World Trade Center were seen that day. We found that our
quarterly hospitalwide drills of the emergency plan prepared the
staff to respond appropriately.
After several laboratory and administrative staff members saw
the first plane strike the south tower, the emergency response plan
went into immediate effect. Patient care rounds began at once. To
ready space for new admissions, an effort was made to expedite
patient discharges and transfers to long-term care and rehabilitation facilities (for example, by contacting private car and ambulance services for early patient pick-up), and case managers
contacted community-based skilled nursing facilities and adult
homes to find additional beds. In each department, managers
reassigned patient care activities and released staff members to
the emergency labor pool.
Department heads and those assigned to the pool met in the
executive boardroom, where, as defined by the emergency plan, a
command post was established. Run by two senior administrators,
the command post deployed staff to necessary outposts, and managed communication throughout the institution. Portable phones
with walkie-talkie components helped staff to communicate, as did
video conferencing technology, which the command post used to
contact another hospital in the network.
Meanwhile, emergency department personnel accessed disaster
supplies and equipment located in central supply. While clinicians
were preparing for incoming patients, housekeeping, clerical, and
other nonclinical staff did their best to ensure that adequate food,
water, and other supplies were available if needed. Psychiatric
and other mental health services and pastoral care were offered
to staff members directly affected by the tragedy.
Afterward, evaluations of the emergency response plan by
administrators and staff members were generally positive, yet they
revealed a few weaknesses. For example, in a revised plan to be
released within the next six months, an ambulatory presurgical
testing site will replace labor and delivery as an alternate treatand-release site. A location in the long-term care facility will
become the designated command post, and a conference room in
a nearby assisted living program will be assigned as media headquarters.
Emergency preparedness and disaster response planning have
always been an important aspect of emergency nursing practice.
Yet todays JCAHO accreditation standardswhich call for monitoring of the level of staff participation in preparation for emergencies or disastersreflect the need for organization-wide
involvement. The preparedness of our staff enabled them to perform well, despite the fact that many were personally affected by
the loss of family and friends.Cathy Norton Lind, MSN, RN,
CEN, FN, Director of Emergency Services, The Brookdale
University Hospital and Medical Center, Brooklyn, NY

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nication within an agency genlevel of care. For example, in

erally follows the usual chain
the case of a patient with
of command. Communication
crushing chest pain, you would
with the news media is usually
arrange his immediate transfer
delegated to a single office or
by ambulance to the ED.
APPLY creative problem-solvperson.
ing skills and flexible thinking
Communication with the
to the situation, within the conpublic occurs at various levels
fines of your role, and EVALUATE
of formality. For example, disthe effectiveness of all actions
cussion with patients and their
taken. No matter how well prefamilies tends to be conversaThe first step
pared in the core competencies
tional and informal; a someyou are, there will be times
what more formal, scripted
when youll need to think on
exchange would take place
toward emergency
your feet. Situations wont necover a telephone hotline. Each
essarily arise and develop
nurse must be prepared to perexactly as the preparedness
form a role in communication
preparedness is
plan describes. Systems, equipat this level. For example, stayment, or plans may fail. Creaing current with CDC (see
tive problem solving entails
www.cdc.gov) or health dethe identification
addressing a situation with
partment information regardwhatever resources are availing anthrax will help ensure
of who needs to
able at the moment; nurses tend
that the information you disto be good at this because its a
pense is accurate.
skill also used under ordinary
Personal communications
know how to
circumstances. Once you take
also must be considered.
action, you should evaluate its
Because the nurse wont be
effectiveness on an ongoing
able to focus on emergency
do what.
basis. If you refer a problem
response duties if worried
elsewhere, follow up to see that
about the safety of family
it was appropriately addressed.
members, significant others,
For example, suppose an
friends, and pets, provisions
for them should be planned in advance. An overall emergency plan calls for the use of mobile telefamily emergency plan can be useful and is easily phones for internal communication, but when a disdeveloped using the suggestions developed by aster occurs, reception may be interrupted. The
the American Red Cross (ARC) and FEMA nurse manager decides to assign a runner to handcarry messages to and from the facilitys command
(www.fema.gov/library/yfdp.pdf).
IDENTIFY the limits of your own knowledge, skills, post until the reception problem is corrected. She
and authority, and identify key system resources for also checks regularly on the status of the mobile
referring matters that exceed these limits. During an communication system.
RECOGNIZE deviations from the norm that might
emergency, nurses often perform tasks outside their
usual domain. But because nurses are generally seen indicate an emergency and DESCRIBE appropriate
as being exceptionally versatile, theyre likely to be action. Regardless of setting, most patients spend
asked to perform tasks or to assume roles that are more time with nurses than with any other health
far beyond that domain. For example, a nurse who professional. Because nurses are so familiar with
ordinarily works with adults may be asked to work normal patterns of health and illness in the comwith children, although she may not be familiar munities and organizations they serve, theyre
with pediatric medication concerns. Its important well positioned to recognize deviations in them.
both to recognize when one is past the limit of ones Early detection of such a change and prompt
knowledge, skills, or authority and to know where notification of the proper authorities can enable
to direct the request or need so that appropriate early warning of an impending emergency or disanswers or services can be provided. In other words, aster, or of a shift in community needs during the
be clear with yourself and others about what you response.
For example, suppose a school nurse notes a
know and what you do not know.
A nurse working in a disaster shelter should be large number of similar complaints not common
able to recognize the presence of an acute illness or in the community or season and reports the findinjury and know how to arrange the patients trans- ing to her supervisor, who in turn notifies the epifer to a facility that can provide the appropriate demiology office at the local hospital. The finding
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may indicate the beginning of an infectious disease outbreak, and an emergency response may be
warranted.
PARTICIPATE in continuing education to maintain upto-date knowledge in relevant areas. As environmental, political, or societal conditions change, the
nature of emergencies and disasters will also
changeand so must the plans, methods, and technologies used in emergency response. Regular continuing education in specific areas can help nurses
keep abreast of these changes. For example, when
biological threats such as bovine spongiform
encephalopathy (mad cow disease, which has
been implicated in cases of Creutzfeldt-Jakob disease in humans) and anthrax loomed recently,
providers found that they needed to know more
about emerging infections. Many such resources
exist. For example, an electronic subscription to
the Morbidity and Mortality Weekly Review
(www.cdc.gov/mmwr), which is free, offers information on seasonal disease trends and other community public health matters. Professional
association meetings and hospital-based journal
clubs are other good sources of current information.
Remember that its important to consider the reliability of the source of information, especially in
regard to new types of emergencies or potential disasters. When emergent events are covered by both
the lay press and professional journals, the most
credible sources of information for application to
clinical practice should be sought.
Furthermore, any kind of changeof ones role
in an organization, of equipment, or of technique
is likely to affect how one responds. A staff nurse
who becomes a supervisor will need to acquire new
management competencies; for example, shell need
to know the protocol for communicating with the
emergency medical services team during an emergency response. All nurses must keep abreast of
changes in personal protective equipment and isolation techniques.
PARTICIPATE in evaluating every drill or response
and IDENTIFY necessary changes to the plan. Most
emergency response plans are works in progress.
As conditions change in an organization, community, or nation, the emergency response plan will
have to evolve. Each drill or response provides
information that can be used to improve the plan.
Nurses should be fully involved in the ongoing
evaluation process.
After each drill or response, there is usually a
meeting for the purpose of identifying what went
well and should be kept in or added to the emergency plan, and what needs improvement and
should be practiced or revised. This gives every
nurse the opportunity to review the emergency
response experience and to contribute to the development of the plan.
[email protected]

ADDITIONAL CORE COMPETENCIES

These competencies are specific to nurses who have
managerial or leadership responsibilities.
ENSURE that there is a written plan for major
categories of emergencies. Nurse administrators
must be sure that the unit, department, or organization theyre responsible for has a written
emergency preparedness plan. Unit and departmental plans must be compatible with the organizations plan, and the organizations plan must
be practicable for individual department and
unit implementation. Nurses should be represented on the organizations emergency preparedness committee.
ENSURE that all parts of the emergency plan are
practiced regularly. Emergency preparedness and
response plans that are never practiced or that are
poorly understood will probably be useless. The
Joint Commission on the Accreditation of
Healthcare Organizations requires regular emergency management drills at least annually (specific requirements vary by type of facility), and
some states mandate biannual drills. Practice can
take the form of either actual drills or tabletop
exercises using either spoken or written scenarios
and responses. This allows nurses to practice performing their roles, to give critiques of each
others performances, and to assist with plan
improvement.
ENSURE that identified gaps in knowledge or skills
are filled. Once a drill or an emergency response has
been executed, both that which went well and that
which wants modification must be identified and
then addressed. What works in a drill may not work
well during a real emergency.
REFERENCES
1. Guha-Sapir D. Overview of types of hazards and disasters,
and their consequences. In: Landesman LY, editor. Disaster
preparedness in schools of public health: a curriculum for the
new century. Washington (DC): Association of Schools of
Public Health; 2000. Sect. 1.0, 1.1.
2. Lechat MF. Disasters and public health. Bull World Health
Organ 1979;57(1):11-7.
3. Landesman LY. Public health management of disasters: the
practice guide. Washington (DC): American Public Health
Association; 2001.
4. OBrien K. The role of nurses in disaster planning and management [report]. School of Nursing, La Trobe University,
Bendig, Australia. 1997 Mar. http://redgum.bendigo.latrobe.
edu.au/~obrien/nursdisast.pdf.
5. Shoaf KI, Rottman SJ. The role of public health in disaster
preparedness, mitigation, response, and recovery. Prehospital
Disaster Med 2000;15(4):144-6.
6. Columbia University School of Nursing. Center for Health
Policy. Core public health worker competencies for emergency preparedness and response. 2001 Apr.
http://cpmcnet.columbia.edu/dept/nursing/institute-centers/
chphsr/COMPETENCIES.pdf.
7. Federal Emergency Management Agency. Emergency
Management Institute. IS 195 - Basic Incident Command
System. 2001. http://www.fema.gov/emi/is195.htm.

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