Introduction
Although it is expected that the intensive scientific development and technologic advancement may facilitate the reduction of adverse consequences of disasters, the modern developmental tendencies have paved a path to the growing frequency of emergencies threatening individual lives and social well-being (Su et al., 2013). As a response to the increased risks of disaster occurrence, the international health organizations commenced the development of the system for medical, sanitary, and ecological protection of the population from natural and technological disasters.
At the initial stage of any large-scope emergency incident, there are limited opportunities for the provision of medical aid. Hence, the involvement of additional human, financial, and medical resources from the non-exposed regions or governmental reserves is required (Burkle, 2001). These factors emphasize the need for the preliminary preparation of the public health workforce capable of performing in the extreme conditions associated with a massive inflow of victims.
In disasters and consequent complication of environmental circumstances, there are many barriers to the effective provision of medical services – healthcare providers should organize their work and perform in the unusual situations which may be followed by the sharp aggravation of sanitary-epidemiologic conditions and discrepancy in present needs and available resources (Bradt, Abraham, & Franks, 2003). Therefore, the importance of a care provider’s role as an organizer and performer of all types of medical services drastically increases. Contrary to the general practice context, medical staff in disaster medicine is charged with extra duties and have more responsibilities for the development of a particular complex of competencies and practical skills which support facilitation of a more professional approach, enhancement of team coordination, and increase in work efficiency in the extreme circumstances.
The Competing Issue of Competencies
Since nurses constitute a large group of healthcare specialists, they play an important role in emergency risk reduction, disaster preparedness, and response (WHO, 2007). To provide their services effectively, nurses should have sufficient professional competence which is often defined as knowledge that enables a care provider to practice consistently and safely (ICN & WHO, 2009).
The issues of nursing competencies are of significant interest in the modern research literature, and the investigation of the professional competencies in the area of disaster medicine has both practical and theoretical implications as it may help to broaden the understanding of the issue and improve the outcomes of individual and organizational performance. Overall, the terms of competence and competencies are interrelated – they both denote the roles and skills health practitioners should perform to accomplish their professional tasks well. Gebbie and Merrill (2002) propose to regard competencies as a set of tangible skills, knowledge, behavior, and personal perceptions that allow the improvement of employee performance and facilitate the achievement of organizational sustainability. By the general definition of the concept, disaster nursing competencies are meant to ensure a high level of consistency in service provision, promote shared values, enhance team communication, and increase organizational efficiency (Alharbi, 2015).
Since there is a large number of professions in disaster medicine, there is no universal framework for the determination of competencies, but organizations use similar criteria for their identification. These criteria include individual needs in a profession, skills required to support the achievement of ideal performance indicators, the conceptual basis for competency development, contexts, and measures for the assessment of the achievement of competencies (Daily & Williams, 2013).
According to the ICN Framework of Competencies for the Nurse Specialist (2009), there are three basic groups of nursing competencies including professional, legal, ethical practice; care provision and management; as well as professional, personal, and quality development. When speaking of disaster nursing, the ICN framework extends to four key areas: disaster mitigation or prevention, preparedness, response, and recovery (ICN & WHO, 2007).
The review of the recent literature reveals that even more detailed perspectives on the issue are available. For example, Hsu et al. (2006) identify seven major competencies of a healthcare worker in emergencies: recognition of events and appropriate actions, the practice of critical event management, compliance with safety principles, comprehension of emergency operation plans, effective communication, understanding of both organizational and individual roles, and sufficient knowledge and skills.
The core competencies in emergency preparedness identified by Gebbie and Qureshi (2002) include comprehension of own role in disaster relief, awareness of the chain of command during emergencies, awareness of the emergency response plan activities, regular performance of core public health functions and responsibilities, proficient use of equipment and skills, ability to communicate with other team members, ability to identify the limits of own knowledge and practice within the scope of professional competence, engagement in the continuing process of education, evaluation of emergency response plans and individual activities, creative problem-solving skills, and psychological flexibility. It is possible to say that the perspectives on disaster nursing competencies may vary from one organization and community to another. Nevertheless, the mentioned definitions are complementary to each other, and all the functional aspects identified by different researchers should be equally addressed in staff education, training, and professional development.
Many professional and academic studies emphasize the significance of disaster preparedness and awareness as the major factors affecting the efficiency of nurses’ service. It is observed that prior experiences in disaster response are positively associated with more efficient nursing activities (Noguchi, Inoue, Shimanoe, Shibayama, & Shinchi, 2016). However, appropriate nursing education programs may foster success in the development of disaster preparedness at both individual and organizational levels.
According to the World Health Assembly (WHA) resolution on Emergency Preparedness and Response (WHO, 2006), there is an overwhelming need for strengthening national disaster mitigation, preparedness, response, and recovery programs, as the disaster nursing competencies in many countries are underdeveloped and will not be able to cope with large-scale emergencies efficiently. The weak awareness of disaster preparedness is defined by nurses’ inadequate perceptions of their roles in disaster medicine, required knowledge, and priorities in emergency care provision (Loke & Fung, 2014). The findings emphasize the significance of education in the efforts to meet the increasing demand for high-quality service during frequently happening emergency events – enhancement of disaster management process, development of cultural competence, and provision of the global nursing workforce with sufficient ethical, technical, and theoretical knowledge for the improved community service.
Scope of Practice
The work of disaster medical assistance teams is coordinated at the national level, and it means that they should always be prepared for the provision of emergency medical aid in any national and global region (Aitken et al., 2011). The disaster medical practice is of planned character and implies the preliminary arrangement of workforce and resources, integrated coordination of national and international disaster response services, development of strategies for resource allocation, staff training, etc. Based on this, administrative, legal, and institutional factors determine the scope of nursing practice in disasters as they may either support the achievement of positive outcomes in disaster response endeavors or impose limitations on nursing practice. Some legal elements of response, such as state laws and the imposition of compliance obligations on nurses, do not help specialists to feel comfortable and confident about their responding procedures and creates additional constraints for practice (Aliakbari, Hammad, Bahrami, & Aein, 2015). In this way, the terms of the legal scope of practice may significantly vary in different regions. However, it is possible to say that the professional scope of practice in disaster medicine remains universal across the globe.
The scope of practice in disaster nursing is interrelated with the definition of public health nursing which denotes the complex of practices for promotion and protection of the health of populations through the application of the interdisciplinary knowledge derived from social and medical studies (Association of Public Health Nurses [APHN], 2014). To cope with challenges associated with service during disasters, nurses need to practice the core principles of public health nursing attempting to improve community health. They should implement relevant knowledge throughout every phase of the disaster cycle: pre-event or preventive phase, crisis, and early response phase, post-event, or rehabilitation phase (Karadag & Hakan, 2012). And at each of the disaster cycle phases, a nurse should apply a wide range of skills and competencies including assessment, surveillance, treatment, collaboration, teaching, referral, advocacy, etc. (APHN, 2014). Moreover, all these skills should be integrated with ethical and legal considerations of population-based care and the awareness of the vulnerable populations to increase the efficiency of response and recovery activities.
Ethics
A critical role in the provision of timely medical aid during large-scale disasters is given to international professional collaborations. However, nowadays the approaches to healthcare significantly vary in many countries, and, as a result, the methods implemented by one group of specialists may not be suitable for the representatives of other cultural, social, and ethnic communities. For example, Japanese public health nurses hold a different set of responsibilities than U.S. registered nurses, and their practice is primarily focused on community-based service (Kako & Mitani, 2010). Respect for diversity in people is one of the major values in nursing (Australian College of Nursing, 2008). Thus, disaster nursing service should necessarily be rooted in the accounting practice and consideration of both role differentiation among international specialists and the interests of patients from diverse cultural backgrounds.
The ICN Code of Ethics for Nurses (2012) describes four basic principles of ethical conduct: respect of human dignity, recognition of autonomy, beneficence, and nonmaleficence, and equity. It is also mentioned that a nurse should demonstrate the values of responsiveness, respectfulness, trustworthiness, and compassion and follow the major ethical rules of confidentiality, informed consent, and integrity (ICN, 2012). When combined, all these rules and principles constitute the ethical coordinates that define the moral status of an individual in the system of social relationships in which he/she finds oneself when dealing with a disease or injury.
Medical aid in an emergency context aims to maintain the welfare of society as a whole, and it thus should support the reduction of the number of casualties (Falkenheimner, 2015). To fulfill these objectives, care providers implement the system of medical triage which is meant to facilitate the accurate identification of patients who need the most urgent treatment and those who can wait for a little longer (Smith, 2012). However, triage does not eliminate the opportunity for the violation of some patients’ rights and freedoms. For example, in military conflicts, health practitioners may regard the intervention of soldiers’ conditions as a priority to quicken their return to a military operation, while the treatment of other patient populations may be postponed.
Despite the character of the situation in which medical service is provided, nurses need to comply with the basic ethical principles reported by many proficient health organizations. However, the environment in which the healthcare workforce operates may also create barriers to the realization of these universal ethical principles.
According to WHO (2015), the dignity of each person should be respected independently of his/her racial, religious, social, and other multicultural backgrounds. Human dignity is one of the universal values which should be protected and maintained by all governmental institutions including the public healthcare system. Therefore, when the scope of healthcare service in emergency contradicts cultural or religious perceptions of individuals, their rights for the protection of human dignity may be violated. To mitigate the risks of conflict development, nurses should develop multicultural awareness and sensitivity as the lack of sufficient knowledge about particular customs, traditions, and beliefs may provoke adverse impacts on the character of patient communication and treatment, and may even result in the refusal of critical medical aid (Almutairi, McCarthy, & Gardner, 2015).
The notions of beneficence and nonmaleficence are used to define a set of actions aimed to promote the welfare of others; this principle implies an appropriate balance between negative and positive influences (Powell-Young, Baker, & Hogan, 2006). It means that the medical aid should enhance well-being and minimize the probability of any harm to patients – potential positive impacts of nursing practice should prevail over potential risks. But nurses’ cultural incompetence may adversely impact the psycho-emotional state of individuals. A low level of cultural competence is associated with health disparities, inhibited disaster response, and recovery (Danna, Pierce, Schaubhut, Billingsley, & Bennett, 2015). In agreement with these findings, significant attention should be given to the promotion of culturally competent interventions among nurses and the achievement of sustainability in the performance of culturally sensitive service.
The principle of patient autonomy in decision making is performed only in case if he/she consciously gives consent for the implementation of medical manipulation techniques selected by a healthcare provider (Cook, Mavroudis, Jacobs, & Mavroudis, 2015). However, in emergencies, a person may be unconscious, and a nurse may not have time for discussing an intervention plan. The ethical issue is linked to the fact that by making a decision independently of patients’ preferences, nurses violate the individual right for autonomy and potentially threaten the vital interests of a patient (Aliakbari et al., 2015).
Throughout a life course, each person develops own religious and social identity which influences his/her perceptions and health beliefs. The consideration of cultural identity and potential ethical controversies is especially important when the cultural backgrounds of patients and care providers differ. Although the obtainment of informed consent may not be easy to observe in disaster nursing, the researchers and healthcare practitioners agree that the basic ethical principles should still be practiced despite the chaotic nature of a situation. Aliakbari et al. (2015) recommend disaster nurses to communicate their decisions in a concise and empathetic manner to establish trust. In this way, a nurse will minimize the risks of harming patients’ well-being and will demonstrate competence and credibility.
The principle of justice implies equity in resource allocation and access to health care (ICN, 2012). Nevertheless, during disasters, this principle may frequently be not observed due to resource scarcity. Wherein, the requirement for social justice and the need for the identification of patients’ needs may contradict each other. The casualty triage cannot eliminate these ethical risks to a full extent but can significantly mitigate them. It may not be able to achieve a completely error-free practice, but by equipping staff members with information and skills in patient categorization, organizations may facilitate the performance of the principle of justice.
Provision of medical aid with reliance only on the professional competence and technological knowledge of a care provider and exclusion of patients’ beliefs and values from the consideration may lead to the violation of ethical principles. However, it is possible to presume that the absolute compliance with ethical regulations and performance of professional values may be facilitated through the adequate organization of disaster response and recovery efforts. In this way, nurses should be encouraged for the development of leadership strategies and comprehension of leadership roles aimed to enhance work structuring, planning, and coordination.
Ability to Respond
It is found that the major factors influencing the competency of disaster response and management are age, experience in disaster relief, disaster-related training, formal education, and professional rank (Luo et al., 2013). It means that the increased job duration allows nurses to gain professional knowledge and experience fostering the ability to cope with psychological stress and a shift toward a more reflective, holistic, and strategic approach to victims. As mentioned by Gebbie, Hutton, & Plummer (2012), nurses’ flexibility regarding their professional roles, schedules, and expectations, as well as the ability to perform outside their comfort zone and without substantial support and direction are of significant importance in the challenging work environment.
It is possible to say, that the sufficient level of flexibility in the approach to disaster response procedures may be achieved merely with the increase in age and practical experience. However, disaster nursing education and the development of specialized knowledge play an essential role in the formation of health practitioners’ ability to respond in the event of a disaster, create leadership strategies, and enhance work management (ICN & WHO, 2009). Therefore, disaster-related training may help to build a greater competency in disaster response and provide substantial support to the inexperienced nurses during their first tours of duty
According to Daily, Padjen, and Birnbaum (2010), “Education and training are the cornerstones of disaster preparedness” (p. 388). However, the lack of standardized approach to nursing education and selection of best practices, as well as insufficient consistency regarding core nursing competencies across communities and schools may impede coordination of disaster response activities in the international environment and provoke the occurrence of professional conflicts due to the absence of a universally accepted model of professional behavior.
Team coherence, integrity, shared values, and vision is of great importance in national and international efforts in handling the consequences of emergencies. Moreover, the outcome of disaster response largely depends on the manner of plan establishment and organization (Thobaity, Plummer, Innes, & Copnell, 2015). The key role in the enforcement of shared values and deepening understanding of plan among team members is given to leadership that is considered a decisive factor that defines the organizational and national ability to cope with and recover from a crisis (Knebel, Toomey, & Libby, 2012). Leadership qualities and nurses’ competencies of collaboration and professional communication help to increase time-efficiency, improve the overall patient outcomes, and facilitate the stress resistance of every team member.
Based on the findings identified in the literature, the success of professional collaboration and ability to respond at both individual and whole-organization level largely depends on the following performance characteristics: nurses’ qualification, strict work regulation, comprehension of emergency plan procedures and individual responsibilities, leadership, experience, and in-depth understanding of ethical and professional principles of conduct.
Conclusion
Nowadays, the success of disaster response inhibited by nurses’ inadequate knowledge regarding disaster medicine and practices and insufficient awareness of their professional roles, and disaster nursing education and training are regarded as the main tools for the enhancement of the present situation in emergency management. Disaster nursing practice bases itself upon the core public health functions, values, and principles. But since it is larger in scope than general public health service, it requires the development of more competencies and greater knowledgeability regarding the peculiarities of work in the adverse circumstances. In emergencies, nurses encounter significant professional, legal, and ethical challenges, and the need for skills supporting efficient decision making is required. The competencies identified in the paper aim to ensure nurses’ compliance with safety, ethical, and professional principles, improvement of professional communication, subordination, and facilitation of accomplishment of tasks in a well-organized and consistent manner.
Identified nursing competencies play a key role in the improvement of disaster preparedness, response, and recovery activities. Thus, further research on disaster nursing competencies and factors affecting nurses’ performance in disasters is of significant practical and theoretical value. It may allow the development of a standardized approach to nurses’ training and, in this way, it may affect the international ability to address emergencies and their consequences in a positive way.
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