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Disaster preparedness is an important part of health care workers’ training that should be a priority for the medical community (Schultz et al., 2012). Nonetheless, there is still much need for establishing core competencies standards that would drive course development. This paper will explore the role of nursing competencies and scope of practice in disaster responding.
Organizations providing public health care have been concerned with the creation of education programs that would allow the provision of better care for disaster victims since the tragic events of September 11, 2001 (Schultz et al., 2012). To this end, numerous training instructions and curricula have been developed. Their emergence has been fuelled by the increase in federal funding over the last decade (Gebbie et al., 2013). However, taking into consideration that there is no consensus concerning requirements for health care education in case of mass casualty events, the effectiveness of those programs can hardly be established (Schultz et al., 2012; Gebbie & Qureshi, 2002). According to a recent study, no evidence would confirm that federal investment has brought positive results in the area of emergency response training (Potter, Miner, & Barnett, 2010).
Competencies based training of health care professionals need a broadly accepted set of standardized core skills, knowledge, and attitudes that would help to evaluate existing teaching methods (WHO, 2006b). It will also help to make federal spending on the nation’s health more effectively and will increase accountability for emergency preparedness (Gebbie et al., 2013). Therefore, developing such a set of standards would be a significant step forward and will benefit both academia providing medical education and the general public (WHO, 2006a). Moreover, the implementation of a unified program of core competencies would translate into making the community recovery process much easier thus helping the health care sector fulfill its community obligations (Gebbie et al., 2013).
The Competing Issue of Competencies
Competence is associated with the proper application of knowledge, psychomotor, technical, and interpersonal skills as well as judgment acquired by an individual during the continual performance of their duties (ICN, 2009). It can also refer to the set of personal characteristics and attitudes required for effective practice in the medical field (ICN, 2006). The set of predetermined competencies can help to measure whether students acquired particular skills allowing them to perform within a particular area at a level that has been predefined (Littleton-Kearney & Slepski, 2008). It also allows for controlling the achievement of stated education outcomes for nursing students.
There are approximately twelve million health care professionals in the US that need to be trained for an effective response in emergencies (Hsu et al., 2006). To this end, the American Nurses Association and the American Association of Colleges of Nursing suggested initiation of programs for basic education and continued education (CE) that would regulate the training of nurse professionals (Littleton-Kearney & Slepski, 2008). However, the specific content of those programs was not defined, thus creating an issue of competing for competencies (Disaster Information Management Research Center, 2016). Some scholars suggest that to achieve certain educational outcomes, core competencies allowing objective evaluation must be included in educational programs (Littleton-Kearney & Slepski, 2008).
According to other academics, emergency preparedness must be either requisite CE or become a required step in the accreditation process for medical professionals (Littleton-Kearney & Slepski, 2008). For example, the accreditation process of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) includes an evaluation of emergency training (Littleton-Kearney & Slepski, 2008). In light of the lack of standardized criteria, JCAHO has developed its requirements necessary for the successful screening process. The Interprofessional Education Collaborative (IPEC) Institutions also developed their own set of competencies in 2009 (West et al., 2015). They were organized into four main groups: Value/Ethics for Interprofessional Practice Teams and Teamwork that were designed to guide their IPE performance (West et al., 2015).
IPEC also devised a curricular element called Disaster Day that governs a simulation exercise and includes medical professionals from the following fields: Nursing, Medicine, Pharmacy, Physical Therapy Assistants, Radiology, and Emergency Medical Technicians (West et al., 2015). The attempts to develop the standardized lists of competencies related chiefly to the nursing field have been made by the Columbia School of Nursing, the Association of Teachers of Preventive Medicine, and INCMECE/NEPEC (Littleton-Kearney & Slepski, 2008). However, the fact that no organization would validate the accuracy of competencies and establish one unified set of standards explains significant inconsistencies that exist between the competency requirements of each organization (ICN, 2015).
This problem creates substantial obstacles for planning that is necessary for appropriate resource allocation (WHO, 2006b; WHO and ICN, 2009). The competing issue of competencies also means that educational content for nurses and other health care professionals is not incorporated in all existing courses. According to a study conducted by the National Organization of Nurse Practitioner Faculties, there are many areas where nurses have to receive additional training such as decontamination, incident command system, and quarantine (Littleton-Kearney & Slepski, 2008). Moreover, the data from the same study suggests that the majority of educators are not able to teach emergency preparedness content (Littleton-Kearney & Slepski, 2008).
The role of nurse practitioners (NP) in Australia is being governed and regulated by the government (Chapman & Arbon, 2008). To improve health care delivery in the country, virtually all Australian states developed separate legislative arrangements designed to establish regulatory bodies for nurses. The Australian Nursing and Midwifery Council (ANMC) devised a set of competency standards that is common for all NPs. (O’Connell & Gardner, 2012). After their implementation in 2006, all curricula were guided by generic benchmarks thus creating a system for the assessment of nurse professional and their eligibility to work in the field (O’Connell & Gardner, 2012).
However, there is no unified set of measurements that would help to guide education or training assessment of emergency nurse practitioners (ENP). According to O’Connell and Gardner, Australian ENPs cannot adopt the system of the formal clinical competencies devised by the American Emergency Nurses Association because of the numerous legislative and practical differences between the two countries (2012). Therefore, it can be concluded that there is a pressing need for the development of the national competency standards for ENPs that would facilitate the evaluation of their performance.
The nurse practitioner title in Canada is protected by legislation. Achievement of specific competencies is controlled by accreditation bodies and organizations such as the Canadian Nurse Association (O’Connell, Gardner, & Coyer, 2014). However, in the United Kingdom, no legislation would guarantee the protection of the nurse practitioner title; therefore, there are significant variations in their training (O’Connell et al., 2014). A recent study reveals that there is no particular system regulating disaster nursing competencies in Japan (Kako & Mitani, 2010). The authors of the research discovered that disaster nursing in the country covers an extremely broad area making the need for comprehensive benchmarks for the assessment of NPs even more pressing. According to Kako and Mitani, the efforts of WHO committee members could help to develop a central competency core program for disasters; however, it would require significant resources from the professional community (2010).
Expanding Scope of Practice
The scope of practice is associated with strictly defined practice boundaries and restrictions related to decision-making and accountability within a particular medical profession (Fealy et al., 2015). A majority of developed countries have established regulatory organizations that are concerned with the creation of guidelines controlling the scope of practice of nurses and midwives (Fealy et al., 2015).
The Nurses and Midwives Act issued in 2011 by the Ireland government established a special organization having a role of regulatory authority for nursing practitioners—the Nursing and Midwifery Board of Ireland (Fealy et al., 2015). After conducting a comprehensive national consultation process, it created the Scope of Practice Framework that serves as a basis for establishing the professional competence of NPs (Fealy et al., 2015).
New South Wales established the traditional NP role in Australia in 2000 (Lowe, 2015). Even though there are only around 400 nurse practitioners in the country, their number is consistently increasing (Lowe, 2015). It can be argued that the role of NP is not static and fluctuates by various clinical demands (CRNBC, 2016). Taking into consideration the dynamic nature of the nursing profession, it is hard to establish a specific scope of practice. Even though ANMC has developed competency guidelines, there are significant variations in the ENP roles that are dictated by differences in clinical structures (Lowe, 2015). According to the Nursing and Midwifery Board of Australia (NMBA), “some professional colleges may establish professional programs that set benchmarks for their relevant nurse practitioner scopes of practice” (2015, para. 10).
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It can be argued that the scope of practice is an ever-evolving measure that changes with each organizational structure. Nonetheless, there is a need for a system that would address “medico-legal aspects of clinical practice” and would help to expand its scope (Lowe, 2015 p. 75). Considering that the ENP role that was implemented in ED settings is largely successful, it is necessary to develop a model that would consider the following issues: flexibility that would allow natural evolution of the ENP role; clinical support for ENPs that have to cope with increased workloads; a clear demarcation of ENR clinical practice and care for those patients that do not fit current CPG model (Lowe, 2015).
Advanced practice can be described as an extension of the traditional scope of practice with the help of integration of nursing skills and knowledge aimed at maximizing professional development. It is associated with a high level of autonomy, authority, and accountability granted to a practitioner (Lowe, 2015).
According to Manley, Mantzoukas, and Watkinson, the advanced practice encompasses many medical roles such as practitioner, educator, researcher, and consultant on the multidimensional level (as cited in McConnell, Slevin, & McIlfatrick, 2013). That is, the advanced practitioner should distinguish between nursing and medical roles (McConnell et al., 2013). According to the review of the clinical practices in the UK, the role of ENPs is significantly influenced by the needs of stakeholders (McConnell et al., 2013). Moreover, Tye and Ross argue that the scope of practice of a nurse practitioner is determined by the ethos of the majority of clinical settings (as cited in McConnell et al., 2013). There is evidence suggesting that “acquisition of clinical skills” is the key element for Accident and Emergency practice (McConnell et al., 2013). The study conducted by Noris and Melby’s suggests that almost 97 percent of nurses believe that clinical experience is more important than mentorship, management, and research skills (as cited in McConnell et al., 2013).
It is a challenging task to develop a structural approach that would allow the slow and steady transformation of the existing clinical system. The issues such as the role of promotion and integration of practitioners as well as the creation of guarantees for both patients and medical care professionals have to be addressed to achieve the best possible health outcomes. To this end, there has to be a strong “nursing representation” during the process of developing a structured progression of the scope of practice for ENPs (Lowe, 2015, p. 81).
A code of professional conduct is a set of rules and norms regulating the nursing profession that establishes a standard of behavior and serve as a point of reference for numerous situations occurring during the care process (Dobrowolska et al., 2007). The members of the national organizations regulating the activities of NPs collect those standards and adjust them according to the expected norms of conduct in their societies (Dobrowolska et al., 2007). As a result, there are significant variations between the codes of professional conduct of different countries. Therefore, the opponents of professional ethics claim that codes of behavior for medical professionals can be considered as relative (Dobrowolska et al., 2007).
According to the ICN Code of Ethics for Nurses, all competencies should correspond with the set of norms that it describes as well as the employer’s code of conduct (ICN, 2009). It relays the main tasks that should be performed by nurses: promotion of health, prevention of diseases, alleviation of suffering, and improvement of health (Dobrowolska et al., 2007). It also mentions the concern for the principle of non-violation of human rights. Moreover, the ICN Code of Ethics for Nurses provides recommendations for the proper use of the ethical principles by managers and employees of health care organizations. The norms of the ICN code are very general and are designed to be a reflection of traditional values for the profession. Therefore, numerous ethics codes for nurses in other countries have been built on it (Dobrowolska et al., 2007).
The objectives of the NMC Code of Professional Conduct are two-pronged: informing the practitioners about specific standards of conduct that are usually associated with professional accountability and letting the public know the norms of professional conduct that guide the behavior of health care workers (Dobrowolska et al., 2007). The code emphasizes that nurses “must” uphold the following seven principles: respect for every patient; obtaining consent from clients or their families before initiating any treatment procedure; partnership with other members of a team; guarantying protection of personal information; maintaining the level of professional competence; trustworthiness; striving to identify and keep to a minimum all potential obstacles to the successful provision of patient care (Dobrowolska et al., 2007, p.174).
The Irish Code of professional conduct for each nurse and midwife describes its aim as the provision of a sufficient foundation for the decision-making process by practitioners (Dobrowolska et al., 2007). Other objectives include present nurses with a framework for responsible conduct.
A code of ethics that every nurse must observe poses an ethical obligation on professionals providing health care. However, following this set of standards might become a challenge in a disaster setting (Hick, Hanfling, & Cantrill, 2012). The practical implications of ethical issues that might arise in the emergency setting are different from those in everyday practice. In a disaster situation the following problems have to be considered and dealt with: allocation of limited resources, working without supervision, impossibility to obtain informed consent, and keeping privacy (Aliakbari et al., 2014). Moreover, all nurses have to act within certain legal constrictions when responding to disaster situations (Aliakbari et al., 2014).
Therefore, not only do they have to know legal boundaries that regulate their professional conduct on a day-to-day basis, but they also have to be aware of national and international laws governing their behavior during a disaster (Aliakbari et al., 2014). Therefore, it is extremely important to ensure that nurses, who make an invaluable contribution to every disaster relief effort, should receive a sufficient amount of training that would allow the provision of the best possible care regardless of numerous constraints posed by natural and other types of disasters. According to the International Council of Nurses Position Statement on Nurses and Disaster Preparedness, the cross-disciplinary approach to disaster preparedness is essential for the reduction of life-threatening damage and sustainable community development (Yan et al., 2015).
Considering that nurses are critical for the provision of disaster response, it is necessary to provide them with sufficient professional and legal training that would help them to ensure that disaster outcome is the least harmful. Therefore, there is a pressing need for the collaborative effort of governmental organizations that would help to create a unified set of training programs and include them in nursing education (Yan et al., 2015).
Ability to Respond
The ability to respond to catastrophes defines the outcome of the victims’ health; therefore, the issue of nursing competencies plays a significant part in the disaster preparedness training (Loke & Fung, 2014). Many factors are influencing the results of emergency care operations; however, the most important are the nurse’s perception of clinical competence and personal safety (Al Thobaity et al., 2015). It is necessary to realize, that sometimes nurses have to respond to disaster events occurring overseas thereby exposing themselves to disordered and difficult situations. Moreover, they often have to perform operations that are beyond their usual scope of practice (Daily, Padjen, & Birnbaum, 2010).
Therefore, all nurses responding to disasters must have a sufficient level of knowledge and skills that would allow them to minimize the negative health consequences of a catastrophic event without causing significant damage to their physical and psychological health (Joes &Dufrene, 2014) To this end, it is necessary to ensure that training of health care professionals has a broadly accepted set of standardized core skills, knowledge, and attitudes that would help to evaluate existing teaching methods of health care practitioners.
According to a study conducted by Chapman and Arbon, the effects of both natural and made-made disasters could be significantly exacerbated by the lack of proper education of health care professionals (2008). The researchers argue that adequate disaster response training can improve communication and coordination between responding units (Chapman & Arbon, 2008). Moreover, they claim that proper implementation of disaster preparedness competencies will result in the increase of nurses’ confidence levels and improvement of their attitudes thus leading to the improvement of their capacity to cope with catastrophic events.
Disaster preparedness training is an important part of health care workers’ education that should be a priority for the medical community. Therefore, there is a pressing need for the creation of a unified system of core competencies that could drive health care course development. The establishment of a general set of core skills for nurses would help to evaluate the existing teaching methods and create new ones that would help to provide a more effective approach to disaster response training.
It can be argued that special regulatory bodies controlling the scope of practice could bring a significant improvement in the field of emergency nursing. The system able to increase the flexibility of the ENP role as well as guarantee provision of clinical support for health care practitioners would prove invaluable for managing hazardous results of natural and man-made disasters. Even though the expansion of the nurses’ scope of practice is a challenging issue requiring, the steady transformation of the existing clinical system, it can be accomplished by the concerted effort of the country’s health care organizations and medical community.
Various codes of ethics provide nurses with a framework for responsible conduct thereby guiding their behavior within and outside emergencies. Taking into consideration that principles presented in such codes are essential for the provision of patient care, it is necessary to ensure that all ethical challenges facing health care practitioners during a disaster response are addressed by them.
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