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Ne smith 2006.defining disasters

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    • Educator’s ForumDefining ‘‘Disasters’’ with Implications for NursingScholarship and PracticeElizabeth G. NeSmith, RN, MSNNurses have long been a part of disaster care, yetthe nurses’ unique approaches to disaster victimshave not been reported in the nursing literature.This situation raises the questions, ‘‘How doesdisaster nursing differ than general nursing?’’ and‘‘What defines the specialty care of disasternursing?’’ An analysis of the term ‘‘disaster’’ andthe concepts that have been used to builda theoretic base for disaster nursing arepresented.Disasters tend to be described in terms ofcause (e.g., natural forces or human-made)and effect (e.g., events that overwhelm andsuspend the productive function of a community orsociety). Historically, nurses always have been a partof the response to care for victims of various types ofdisasters, and nursing scholars search for answers tothe question, ‘‘What separates disaster care from theeveryday emergencies that nurses face?’’ Is disasternursing a form of specialized care that is composed ofunique knowledge and skills? The purpose of thisarticle is to explore the concept of disaster usinga framework provided by Walker and Avant1and toidentify concepts that are used to define disasternursing.Defining DisastersOrigins of TermThe secular use of the term ‘‘disaster’’ has French,Italian, Latin, and Greek origins referenced as earlyas the year 1297.2The French root desastre (1564)and the Italian root disastro both mean ‘‘ill-starred,’’from dis-, ‘‘away, without’’ plus astro, ‘‘star, planet.’’The Latin and Greek roots of the word originatefrom L. astrum and G. astron. The sense is astrolog-ical, of a calamity blamed on an unfavorable positionof a planet.2A modern interpretation of this root is that the oc-currence of a disaster is outside human control. Theword ‘‘disaster’’ has many synonyms that collectivelyadd conceptual significance to the definition in com-municating misery, death, destruction, helplessness,sudden reversal of what is expected, and unhappy res-olutions to distressing events.2These synonyms aresummarized in Table 1.Themes in the LiteratureThe literature is rich with illustrations of disasterthemes (Table 2). Newspapers, magazines, and otherpublications catalog past and present accounts of di-sasters such as fires, floods, hurricanes, tornados,earthquakes, droughts, disease and famine.3-5Fic-tional accounts of disaster survival, such as the filmversion of ‘‘Gone With the Wind,’’ vividly depict thepersonal dramas experienced as a result of these cata-strophic events.6-8Professional Definitions of DisasterInternational disaster health organizations, such asthe Centre for Research on the Epidemiology of Disas-ters9-11and the World Association for Disaster Emer-gency Medicine,11have provided definitions thatinclude attributes and outcomes of events that helpto distinguish an event as a disaster (see Table 3). Di-sasters also can be described in terms of antecedentsand consequences and are summarized in Table 4.Disaster Nursing as a SpecialtyDefining NursingProfessional nursing is recognized by its practiceand scholarship. The American Nurses Association12A modern interpretation of this root is thatthe occurrence of a disaster is outsidehuman control.Elizabeth G. NeSmith is a Doctoral Nursing Student, MedicalCollege of Georgia, Augusta.Reprint requests: Elizabeth G. NeSmith, Medical College ofGeorgia, School of Nursing, EB-218, 1120 15th St, Augusta,GA 30912; E-mail: bnesmith@students.mcg.eduDisaster Manage Response 2006;4:59-63.1540-2487/$32.00Copyright Ó 2006 by the Emergency Nurses Association.doi:10.1016/j.dmr.2006.01.004DMRApril-June 2006 Disaster Management & Response/NeSmith 59
    • defines nursing as ‘‘the diagnosis and treatment of hu-man responses to actual or potential health problems.’’The Canadian Nurses Association13states that nursing‘‘exists in response to a need of society’’ and ‘‘directsits energies toward the promotion, maintenance andrestoration of health; the prevention of illness, the al-leviation of suffering and the insurance of a peacefuldeath when life can no longer be sustained.’’ Such def-initions tend to be general because nurses practice ina variety of settings (e.g., institutional, community,and field care) and under a variety of conditions. Nomention is made of the specific knowledge and skillsthat are required to successfully practice in a givensetting or situation.Defining Disaster NursingRecently, the definition of disaster nursing has be-come the topic of much discussion because practicingunder disaster conditions is what makes disaster nursingunique. Disaster nursing requires new concepts of whatconstitutes good care. For instance, in a disaster, nursesknow to shift from the usual assessment and treatmentgoals of care, that is, providing care to the sickestpatients first, including those with a comparatively lowTable 1. Disaster synonyms2Synonym Origin Date MeaningMischance Old French 1297 Bad luck, calamityTragedy Old French 1375 Unhappy endingWrack Middle Dutch 1390 Misery, punishment,damage, destructionQualm Old English 1530 Death, plague,destructionCatastrophe Greek 1540 Reversal of whatis expectedEmergency French 1631 UnforeseenoccurrenceDebacle French 1848 Violence, to ‘‘un-bar’’Table 2. Disaster themes/examples in theliteratureDisaster themes Examples in the literatureAct of God; eventoutside humancontrolNoah’s ark and thebiblical flood, fires,hurricanes, earthquakes,and other naturaldisasters4,5,18Large loss of human,environmental, and/orfinancial resourcesStock Market Crash of1929,19Exxon ValdezOil Spill,20tsunami tragedyPotential preventionand ignorance ofwarning signsTitanic,21Hindenburg,22Space Shuttle disasters23Personal drama ‘‘Gone With The Wind,’’6,7Titanic,21‘‘Drought,’’8‘‘TheYear of Disaster &Disgrace’’24Nursing response Story of Clara Barton andthe origin of the AmericanRed Cross,25nurses inWWII,26inscription onVietnam Nurses Memorial,27reports of nurses caringfor victims of the WorldTrade Center disasters28Table 3. Defining attributes/empirical referentsDefining attributes Empirical referentsNegative impact eventof natural, financial,technologic, or human-made origin, forexample, armedconflict3-5,11,18,20,25,29Notification of emergencyservices personnel (toinclude nursingcomponent) of anoccurrence that isdeemed likely tooverwhelm theresources necessary toeffectively manage theeventEvent that disrupts thehealth of and occursto a collective unit ofa society or community11Activation of theinstitutional, community,or regional EmergencyOperations PlanEvent overwhelmsavailable resources andrequires outsideassistance formanagement andmitigation9,10Initiation and use of theIncident CommandSystem within acommunity or institutionto access and coordinateadditional resourcesRepresents tremendousrelative human losses9Conduction of on-scenetriage and treatment tomitigate casualty lossesRepresents a breakdownin the relationshipbetween man and hisenvironment10Subsequent investigationreveals turning pointevent that causeddisasterTable 4. Antecedents of disaster/consequencesof disasterAntecedents ofdisasterConsequences ofdisasterNormal community orsocietal functioningprior to the eventRelatively widespreadhuman casualties withan overwhelming needfor physical and/orpsychological health careassistance9,10Negative proportionalpreparation incomparison to size ofsubsequent event29Losses exceed the resourcesand ability of society/community to manage orcope and result in seriousdisruption in the functioningof the population affected11Citizens ignore orbecome ordesensitized topreventive warningsigns, if they arepresent21-23,29Requirement ofunprecedented cooperationand communication amongvictims, others in thecommunity, and those whoarrive to assist associatedwith a need for prioritizationand rationing of availablehealth care resourcesDMR60 Disaster Management & Response/NeSmith Volume 4, Number 2
    • probability of survival, to ‘‘doing the greatest good forthe greatest number.’’14This means that victims witha low probability of survival may receive comfort mea-sures only, making more resources available for victimswho potentially could benefit most. Disaster nurseswho are specialists in this type of care will knowwhen to make this paradigm shift from emergency to di-saster nursing practice. Nursing scholarship is chal-lenged to define additional concepts that represent theunique roles of nurses who prevent, plan for, respondto, and help others recover from disasters. From multi-ple concepts, scholars can build theories that guidenursing practice.Use of nursing theory. Historically, nursing theo-ries generally address 4 central concepts: person, envi-ronment, health, and nursing.15Disaster nursingpractice also encompasses these domains. Disasternurses care for the ‘‘person’’ by diagnosing and treat-ing the physical and psychological response to disas-ter of individuals, families, and communities.Environment may refer to the usual physical surround-ings, personal circumstances, or even the humanbody. Environment also refers to the setting in whichnursing care is delivered15and is expanded in disasternursing practice from the usual institutional and publichealth settings to include field and impact zonesettings, as well as Incident Command System (ICS)posts. Health, known as ‘‘a person’s state of well-being,’’15is profoundly changed as result of disaster.Nurses promote, maintain, and restore health throughcareful disaster planning, activation of the EmergencyOperations Plan, and by prioritizing and rationing ofavailable health care resources following the event.Creating new concepts. A concept is defined asa characteristic that is used to define a phenomenon,and the concept of disaster nursing has not been aswell defined. Efforts have been made to define disas-ter nursing on the basis of minimum competencies.16In an attempt to demonstrate how these concepts16can be put into operation, the disaster paradigm as de-scribed in the Advanced Disaster Life SupportCourse17has been used here to provide a frameworkfor specific examples of disaster nursing practice.These examples include, but are not limited to thefollowing:DdDetectionNurses are aware of and involved in the planningand implementation of local (community or institu-tional), regional, or national emergency responseplans and participate in subsequent disaster drillsand disaster continuing education. Disaster nursingpractice also includes the planning, early recognition,and coordination of assistance for the needs ofvulnerable victims following events that are likely tooverwhelm available resources. Examples include par-ticipation in disaster planning committees, initiation ofthe disaster plan when necessary, and educating newnurses regarding how to implement disaster plans.IdIncident CommandNurses command, work within, and foster team-work within the carefully designed and complex ICS.Practice examples include receiving scene assess-ments from field workers and directing the coordina-tion of available personnel and equipment resourcesto appropriate sites to mitigate the effects of thedisaster.SdSafety and SecurityNurses are alert to all potential hazards at the pri-mary scene of the incident and/or within secondarycare perimeters, such as a triage area or hospital. Anexample of practice in this area would include themaintenance of a high index of suspicion for hazardssuch as chemical, biologic, or nuclear contaminationof a scene or victims received from a scene.AdAssessNurses assess for the presence of hazards at the pri-mary or secondary disaster sites (sites that receive di-saster victims). Nurses provide for the safety ofhealth care providers through the distribution and cor-rect utilization of personal protective equipment.Nursing practice would include training and educationon the correct process for choosing, donning, andworking within specific personal protective equip-ment for different exposure situations.SdSupportNurses act as a support link in the successful mitiga-tion and management of the incident. Acting as a sup-port link may include provision and/or maintenanceof essential nursing or other personnel, supplies, facil-ities, and resources and/or providing direct nursingcare to victims according to their specific injuries orcomplaints. This role may include participation in orcommand of the ICS, as well as functioning as thecharge nurse on duty at the scene or the receivinginstitution during a disaster incident. It also couldinclude coordination of resources at the scene as partof the response team.Disaster nursing requires new concepts ofwhat constitutes good care.The Advanced Disaster Life Support Course hasbeenusedheretoprovideaframeworkforspecificexamples of disaster nursing practice.DMRApril-June 2006 Disaster Management & Response/NeSmith 61
    • TdTriage and TreatmentNurses work within the parameters of the NursePractice Act to move, assess, sort, and treat the variousconditions of victims and serve as a communication linkto describe conditions of individual and groups ofpatients between the field and receiving institutions,as well as within the boundaries of the receiving hospi-tals themselves. This would include the work of the tri-age nurse in the receiving emergency department or inthe field.EdEvacuationNurses may participate in the planning and imple-mentation of a disaster evacuation and accommoda-tion plan for victims and their families either at thescene or following receipt of the individuals at desig-nated institutions. Coordination of this function wouldbe carried out most appropriately by the charge nurseon duty and by senior, more experienced staff nurseswho receive patients and families requiring care.RdRecoveryNurses provide physical and psychological care toaffected individuals, which includes providing care torescue and treatment personnel. Nurses provide thiscare while being sure to address the long-term care im-plications and costs. Nurses work within the establishedstructure to minimize the impact of the event on thecommunity, state, nation, and environment. Advancedpractice nurses, including psychiatric clinical nurse spe-cialists and nurse practitioners, as well as nurses work-ing in a case management or rehabilitation role, areexamples of nurses involved in this type of care.Future ImplicationsNurse leaders, scholars, and practitioners will bechallenged to further develop the conceptual, theo-retic, and practical foundations for disaster nursing.To advance the specialty of disaster nursing, scholarswill need to involve theory synthesis, theory testingthrough research, and transition of research resultsinto practice. Providing care to vulnerable personsall over the world demands responsible and carefulnursing scholarship and practice.SummaryThe concept of disaster has developed over time,and the origin of terms demonstrates a changing beliefregarding the causes of disasters. Nurses historicallyhave been a part of disaster care, and with the ad-vancement of scientific basis for practice, there is in-terest in developing an emerging specialty of disasternursing. Further conceptual refinement and construc-tion of a framework to guide future disaster researchand practice is needed.Acknowledgment: I extend special thanks toDr Shelia Bunting, Professor, Department of HealthEnvironment and Systems, Schools of Nursing andGraduate Studies at the Medical College of Georgia,for assistance with the conceptualization and criticalreview of this manuscript.References1. Walker LO, Avant KC. Strategies for theory constructionin nursing. 4th ed. Upper Saddle River (NJ): PearsonPrentice Hall; 2005.2. Harper D. Online dictionary of word origins (ETYMOL-OGY) [online, Nov 2001, cited 2004 Sept 23]. Availablefrom: URL: http://www.etymonline.com3. Andreas AT. History of Chicago from the earliest period tothe present time [online, 1884, cited 2004 Sept 20]. 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