Inspiring, progressing and promoting the profession of nursing in disaster health
The 44th Patricia Chomley
Inspiring, progressing and promoting the
profession of nursing in disaster health
Mr Jamie Ranse RN FRCNA
BN; GCertClinEpi; GCertClinEd; MCritCarNurs
26th May 2010
2010 Nursing Summit
Realm Hotel, Barton, Canberra, ACT
The 44th PaTricia chomley memorial oraTor
Mr Jamie Ranse RN FRCNA
BN; GCertClinEpi; GCertClinEd; MCritCarNurs
Throughout his nursing career, Jamie has
held various clinical, education, research and
management roles, primarily within the critical
care environment. Jamie is currently employed
as a Clinical Manager of the Emergency
Department at Calvary Health Care ACT. In this
role Jamie contributes to elements of clinical
leadership and research facilitation. Jamie guides
and mentors staff in research design and writing
for publication. Additionally, Jamie is employed
as a Research Associate at the Flinders University
Research Centre for Disaster Resilience and
Health. His research interests are in the areas of
disaster and mass gathering health. To date, his work has been supported by competitive research
grants, published in peer-reviewed journals and presented at national and international conferences.
Jamie volunteers with St John Ambulance Australia, holding the high-level strategic position of
Chief Nurse. In this role, Jamie develops nursing policy and guidelines, and provides strategic advice
on clinical and professional topics to the organisation. Additionally, Jamie promotes internally and
externally, to professional nursing organisations and government, the variety of roles and activities
nurses undertake in the pre-hospital environment.
Jamie is an Associate Editor for the Australasian Emergency Nursing Journal, holding the pre-hospital
portfolio, and peer-reviews for a number of national and international journals relating to disaster,
emergency and primary health care. Additionally, Jamie has a close affiliation with the University of
Canberra where he holds an adjunct position.
The PaTricia chomley memorial oraTion
Established in 1966, the Patricia Chomley Memorial Oration has become part of tradition at Royal
College of Nursing, Australia and has been presented annually to honour Miss Patricia Chomley,
the first director of RCNA.
Appointed in 1949, Miss Chomley was director until her retirement from the position in 1964.
During the 15 years of Miss Chomley’s leadership, some six hundred students undertook
courses. Many of those nurses subsequently held responsible positions throughout Australia and
were instrumental in important developments in the nursing profession and in upgrading the
quality of patient care.
Miss Chomley passed away on 24 October 2002 and the Patricia Chomley Memorial Oration is a
fitting tribute to her leadership and contribution to RCNA.
inSPirinG, ProGreSSinG anD PromoTinG The
ProFeSSion oF nUrSinG in DiSaSTer healTh
Associate Professor Stephanie Fox-Young – President; Debra Cerasa – Chief Executive Officer;
Rosemary Bryant – Chief Nurse and Midwifery Officer of Australia and the President of the
International Council of Nurses; Fellows and Members of the Royal College of Nursing, Australia;
distinguished guests and colleagues; ladies and gentlemen.
Firstly, I wish to acknowledge the traditional custodians of the land we are meeting on, the
Ngunnawal people. I wish to acknowledge and respect their continuing culture and the contribution
they make to the life of this city and this region. I would also like to acknowledge and welcome other
Aboriginal and Torres Strait Islander people who may be attending this week’s event.
Secondly, thank you for the opportunity to speak with you today. When preparing for this oration,
I looked back upon the type of orators, and their presentation content from previous years. It was
only at this point in time that I realised the extent of the privilege and honour it is to be invited to
deliver the 44th Patricia Chomley Memorial Oration. More so, as it falls in the International Year of the
Nurse. International Year of the Nurse, highlighting the centennial year of the death of the founder
of modern nursing, Florence Nightingale (1820 – 1910). Additionally, this privilege and honour is of
significance to me as it is held in my home town of Canberra, where I have grown my family and
The title of this oration ‘Inspiring, progressing and promoting the profession of nursing in disaster
health’ is about acknowledging and highlighting the various roles Australian nurses play in disaster
health. For this oration I will outline my growing interest in disaster health, define disasters, highlight
some significant disasters in Australia and the region, illustrate the role of nurses in disaster, discuss
disaster preparedness and finish with various challenges facing the nursing profession in disaster
GROWING INTEREST IN DISASTER HEALTH
I will try to articulate how my interest in nursing developed, and more so, how my passion for
a better understanding of disaster health has evolved. This will hopefully provide some context
for the remainder of my discussion.
My mother was a registered nurse and midwife who worked for the Bush Church Aid Society in
remote Australia in the 1970s. I recall her telling me a story of her abseiling down a large opal mine,
in the middle of the night, to rescue a mine worker who had fallen and injured themselves. In
addition to this, she tells of working with various organisations, such as the Royal Flying Doctor
Service, to achieve optimal patient outcomes. She also tells of acting as the local vet and providing
health care to animals, as no vet was stationed in the town. These stories typify to me the multiplicity
and diversity in what constitutes ‘nursing work’ and the varying operational environments of nursing.
It was such stories that initially generated my interest in health care.
My father was a member of the Australian Federal Police for many years, primarily with a community
policing focus. I recall growing up and watching as my father would be called out to assist in the
community to investigate a murder case, to negotiate with people in extenuating circumstances,
or to investigate major incidents, such as the ‘implosion’ of the Royal Canberra Hospital. It was from
observing this work that motivated me, not only to enter a health profession, but to enter one that
was community based.
I recall as a five-year-old, at school on the monkey bars attempting a backwards one-and-a-half
somersault in the pike position, a routine I had completed successfully on many occasions. However,
this time I was unsuccessful – landing on my arm which resulted in a fracture. Whilst painful, it was
exciting to have an ambulance arrive at my school and subsequently transport me to the emergency
At the age of thirteen I decided that I wanted to be a paramedic. With this in mind, I pursued avenues
to undertake a first aid course. I was told that I was too young to do a public first aid course; however,
I could join St John Ambulance Australia as a cadet and learn first aid – which I did. I would attend
major public gatherings in Canberra and the region, volunteering hundreds of hours each year.
This strengthened my willingness and desire for a career in health care.
I focused on university studies, completing my Bachelor of Nursing in 2002 and subsequently gained
employment at a local emergency department. A few years later, I was persuaded into part-time
employment at the Research Centre for Nursing and Midwifery Practice at the University of Canberra
and Canberra Hospital, whilst continuing to work in the emergency department. This would be
a change in my career trajectory. My passion grew for research and a desire to generate a better
understanding of ‘what we do’. Since then, I have found myself moving between employment in the
areas of emergency and intensive care, and at various times undertaking aspects of clinical, research,
education and management. My current employment arrangements combine elements of clinical
management in the Emergency Department at Calvary Health Care ACT, and research through the
Flinders University Research Centre for Disaster Resilience and Health – this is not a partnership
position, but an arrangement I have organised.
At some level I think that the medical profession has got this right. In the medical profession you
can be the clinical leader of a department or unit, and in this role you can be engaged with hands
on clinical practice, you can be undertaking research, you can be engaged with academia through
your local university where you hold an academic appointment, and by virtue you are engaged in
education and training medical staff. Why in nursing is it so hard to be employed in a position that
combines a couple of these elements [clinical, research, education, management or leadership]?
Whilst some appointments in nursing may be expanded across more than one of these elements,
it would not be a common occurrence. As a profession we need to think about how we better
engage nurses in the workforce, and I would propose that a model with mixed elements is one
option. My experience however, is that clinical institutions would consider elements other than
clinical nursing, for a clinical nurse; or management, if you’re the manager, as being non-productive.
Nursing needs to get creative about the types of employment models that underpin our work,
and the issue of engagement with staff requires more attention. We may ask staff about why they
joined our team, perhaps why they are thinking about leaving – however, I think the more important
question is: why do you stay? Once we know this, this is the area we should focus our time and
energy to engage staff.
Running parallel to my nursing career is my activities within St John Ambulance Australia. I had an
opportunity to attend, from a health perspective, mass gatherings such as the Sydney Olympics
and World Youth Day. However, my interest in disasters grew as I had the opportunity to assist in the
establishment of the health service at an evacuation centre during the Canberra bushfires of 2003,
and more recently during the Victorian bushfires of 2009, where I was engaged in a high-level
So, emergency nursing, an association with disaster research through Flinders University, and
continued engagement with St John have increased my interest and understanding of disaster
DISASTER HEALTH CARE
There is no widely accepted definition of disaster. However, most definitions describe an element of
disruption to a community. The World Association for Disaster and Emergency Medicine defines a
disaster as an event that interrupts the normal functioning of a community, resulting in the need
for external human and/or physical resources to assist in a response beyond that of the normal
day-to-day operational capacity for that community (TFQCDM/WADEM, 2002).
A community could be described as: a group of people, a suburb, a town, and so on. As such, the
application of the term disaster in this context is somewhat broad – but different from the way
the term is used within the media. The media commonly describe an ‘event’, such as a bushfire
or hurricane as a disaster; rather than using the term ‘disaster’, which is the result of the bushfire
Disasters in Australia and the region
In recent Australian history, there have been numerous disasters at a community level. For example:
� Cyclone Tracy ,
� Granville train crash and bridge collapse ,
� Ash Wednesday ,
� Newcastle earthquake ,
� Canberra bushfire , and more recently
� Black Saturday and Victorian bushfires .
Arguably, the Australian health care system is familiar with the impact of events such as bushfires,
earthquakes and transport accidents as outlined above. And in more recent times, has managed
sufficiently the initial health impact of these events (Richardson & Kumar, 2003; Cameron, et al., 2009).
This is primarily due to factors such as; delayed and staggered patient arrival and that most survivors
sustain minor injury.
There have been a number of disasters in the Asia-Pacific region that have required a health response
from Australia, of particular note these include:
� Bali bombings [2002, 2005],
� Sumatra-Andaman earthquake and tsunami , and more recently
� Samoan tsunami .
This demonstrates that the impact of terrorism and natural disasters on neighbouring shores,
and its impact on the Australian health care system have more recently become well known.
We have learnt key lessons from these events, and from recent Australian research. For example,
prior to the Bali bombings, if you had asked each state and territory their transport capacity of burns
patients, they would have cited a number well above the actual capacity – this occurred as states and
territories were counting on the same aircraft to transport patients around the country. Additionally,
we have learnt, that you cannot mobilise health care professionals to a disaster area without
adequately equipping them with basic needs, such as shelter and food. Otherwise, resources are
diverted from those directly affected by the disaster to cater for these health care professionals.
As a result of some recent Australian research we know a little about the personal protective
equipment which is available to staff. We know about the willingness of staff to assist during
chemical, biological and radiological incidents (Considine & Mitchell, 2008). We know about H1N1
Influenza 2009 and its impact on Emergency Department and Influenza Assessment Clinic Workload
(Ranse, et al., 2010a). However, much is still unknown, as most disaster scholarship to date is of a
I would argue that the likelihood of a public health care emergency on Australian shores, larger than
those we have previously experienced is not unrealistic. And that our health capacity to respond
would not be adequate. This is a view that is supported by others (Templeman & Bergin, 2008).
Nursing role in disasters
Commonly, if a disaster occurs, the health system relies on health care professionals from outside a
given jurisdiction to sustain an adequate level of service. I want to use two case studies to highlight
some of the roles of nurses, and provide a snapshot of challenges that exist in disaster response.
The first case is the Sumatra-Andaman earthquake and tsunami , and the second is Black
Saturday and the Victorian bushfires .
Sumatra-Andaman earthquake and tsunami
As events unfolded around the Sumatra-Andaman earthquake and tsunami on Boxing Day 2004,
health care professionals within Australia were provided with an opportunity to assist in the
health response. Initially, health teams were put together at short notice and in an ad-hoc manner
(Robertson, et al., 2005). Members of these teams would undertake various roles; such as welfare,
clinical activities and liaison.
One avenue to register interest was via the Federal Government’s Tsunami Volunteer Hotline.
This hotline collected information from potential volunteers regarding their clinical background,
experience and preparedness to respond. A retrospective analysis of data collected via this hotline
demonstrated that many potential volunteers were underprepared for international travel, as they
lacked a current passport and their immunisation status was not sufficient. Additionally, the majority
had no prior disaster or military experience (Arbon, et al., 2006).
An alternate way to volunteer in this disaster response was somewhat circumstantial. Imagine if a
phone call was received in an Australia emergency department requesting the assistance of one
nurse and one medical practitioner from that department who could be available in a short time
frame to depart Australia. The nurse who is likely to be deployed to the disaster is the person who
answered the phone, and the medical practitioner likely to be deployed to the disaster is the person
standing beside the nurse who answers the phone. The preparedness of these staff, at this point in
time was largely unknown. As a result these clinicians were taken out of their somewhat controlled
clinical environment and placed into unfamiliar environments within an unfamiliar country, culture
and health system.
Now, I don’t want to play down the systems at that time that were in place for a coordinated
approach to disaster health care response from Australia, as these were in place, and at some
level worked well, deploying civilian and defence personnel in medical and public health teams
(Templemen, 2004). However, the response required from Australia was greater than what had
previously been anticipated or experienced and as a result it was a somewhat haphazard approach
to the deployment of health care professionals at this time.
Black Saturday and the Victoria bushfires of 2009, is an example of an event that required additional
health care support, within an Australian jurisdiction.
Whilst this was not considered a health care disaster for Australia, nor was it really a health care
disaster for the state of Victoria - as they were able to manage the workload capacity within their
major tertiary referral centres and in particular their burns centres (Cameron, et al., 2009). However,
at the community level, of those areas directly affected by the bushfire, this was indeed a disaster. It
is important that we reflect on this event, and pay homage to those who lost their lives, recognising
that nurses were amongst them.
Nurses played an important role in the response to the Victorian bushfires. Nurses were deployed in
teams as part of the Victorian Medical Assistance Teams under the State Health Emergency Response
Plan, primarily to support hospital staff in rural and regional areas. Additionally, nurses were deployed
in the pre-hospital environment as volunteers with St John Ambulance Australia (Ranse, et al., 2010b).
St John is an organisation with a multitude of activities. However, a focus is on the provision of clinical
services at mass gatherings or major at public events, and during emergencies such as the Black
Saturday and the Victorian bushfires . St John is a volunteer based organisation that consists
of laypersons with first aid and advanced first aid skills, knowledge and experience. At major public
events and emergencies these laypersons are supported by an additional clinical tier. This additional
clinical tier is health care professionals, and by numbers, primarily nurses.
During the response to the Black Saturday and Victoria bushfires, 55 nurses volunteered with St John,
contributing to over 1,500 combined hours. Nurses undertook roles across three distinct domains:
clinical, command and auxiliary. Clinical relates to clinical care or clinical support; command relates to
liaising with external organisations, logistics and commanding clinicians; whilst auxiliary roles related
to activities such as administration. Most undertook multiple roles, with seventy-percent undertaking
a clinical role and fifty-percent undertaking an administrative role. It is of interest that half undertook
an administration role – I would argue that this is probably not the most effective use of nursing time.
Of those that undertook a clinical role, they performed clinical activities in varying settings; cared for
a diversity of populations, and worked with a various health care professionals. To me this exemplifies
the ability and diversity of nurses in extenuating circumstances such as them.
For me, the term preparedness relates to a nurse’s ability to perform at an adequate level within
a given environment. I believe it is built from elements such as previous experience, attitude,
education, knowledge and skills. Little is known about the preparedness of nurses who have assisted
in the health response to disasters.
I now want to focus on the factor of educational preparedness of nurses who respond to a health
care disaster. Nationally, various disaster education programs are offered through various institutions
and organisations. However, it could be argued that existing disaster education for nurses is
somewhat haphazard and fragmented, and that the required competencies of a nurse to adequately
perform in a disaster are not well understood. In the United States, core competencies for nurses in
emergencies and disasters have been suggested (Gebbie & Qureshi, 2002); however, these are not
necessarily applicable to the Australian context. Therefore, a need exists to develop a structured
approach to train and educate the most appropriate nurses to the most appropriate level. Work has
recently commenced on a proposed disaster education and training framework for the Australian
context (FitzGerald, et al., 2010). However, this is in its infancy and requires further development and
buy-in prior to implementation. Similarly, the World Health Organization and International Council of
Nurses have developed a set of ‘disaster nursing competencies’ which will assist to progress this need
(WHO & ICN, 2009).
Emergency departments, and more specifically emergency nurses, are commonly amongst the
first health care professionals to assist in a disaster. However, the preparedness through education
and training of emergency nurses regarding disaster nursing roles, responsibilities and processes
is not well understood. A project currently being undertaken through the Flinders University
Research Centre for Disaster Resilience and Health, in collaboration with academics and clinicians
in emergency nursing, aims to describe the disaster content of Australian postgraduate emergency
nursing courses as a means of better understanding emergency nurses’ educational preparedness
for disaster. The preliminary findings of this project, suggests that the type and amount of disaster
content in postgraduate emergency nursing courses varies across the country (Ranse, et al., 2010c).
Whilst this highlights the need for core competencies and consistency in disaster education,
it also raises the point that not all postgraduate emergency nursing courses are similar. From my
perspective as an emergency clinician, I believe it would be of great benefit to know that if an
individual nurse has completed a postgraduate program from one institution that they would have
an equal or about equal level of competence as if they had obtained it at an alternative institution.
This would improve our ability to credential specialties such as emergency nursing. From a disaster
response perspective, it would allow us to have a better understanding of the competencies of
graduated students, and identify suitable potential clinicians for deployment. It should not only
be isolated to emergency nursing, but across most or all postgraduate course, such as critical care,
peri-operative, paediatrics, and so on.
I now want to outline another couple of challenges not yet described above. That being:
� cross border response considerations,
� considerations for replacing or supplementing an exhausted workforce, and
� getting the right nurse, to the right disaster, at the right time.
Cross border response
A challenge for nurses during an Australian response is the process to be registered in another state
or territory. Both the Canberra bushfire of 2003, and Black Saturday of 2009, occurred on a Saturday.
As you would appreciate, state or territory nursing registration boards don’t have office hours on a
weekend. This provided the first hurdle in nurses obtaining registration for interstate deployment.
In my capacity as Chief Nurse for St John, I previously wrote to each state and territory nurses board,
requesting an understanding of the process that would be required to register nurses from interstate
during a disaster. Most boards understood the need for mutual registration within a short timeframe,
on a short term basis. Additionally, most made reference to the Australian Nursing and Midwifery
Councils guideline on “the responsibilities of nurses and midwives in the event of a declared national
emergency”, which states:
“... Should a nurse or midwife decide to volunteer in a second or subsequent state or
territory where they do not hold current registration, it is required that they first clarify their
authority to practise with the relevant state or territory’s regulatory authority. Where this is
not possible due to lack of time, it is recommended that the nurse or midwife carry their
current practising certificate with them, together with some form of photo identification,
for the duration of the declared emergency...” (ANMC, 2008: p3).
However, other boards stated that the nurses would need to be registered to practise in their state or
territory and on occasions this could take up to forty-eight hours, or would only occur during office
hours. From a timely disaster response perspective, this is not sufficient. The introduction of national
registration in July this year is sensible, and well overdue from a disaster response perspective.
An exhausted workforce
What happens when a disaster occurs that overwhelms the health system, when our nursing
workforce is overworked and overstretched, more so than normal, who do we rely on to provide
additional clinical support? One option as we have already described is to rely on nurses from
other states and territories, or organisations. However, this is somewhat limiting as most have
commitments within their existing jurisdictions.
An alternative, which hasn’t currently been explored in the context of disasters, is to utilise
unregulated workers. In particular, I am referring to undergraduate health care professionals. More so
I am referring to those undergraduate nursing students who may have already undertaken a clinical
placement, of some description, within the clinical institution that is now overwhelmed. However,
to make this a possibility, what we would require is an element of disaster awareness embedded
within undergraduate nursing curriculum. Currently, I am unaware if disaster awareness, or education,
or training, exists in undergraduate nursing programs. However, I would assume that the answer
would be that there is none or very little. And if there is, it would most definitely not be consistent
across the nation. At some level, there needs to be a discussion about options for supplementing
nurses during disasters, as nurses constitute the largest health care workforce.
Right nurse, to the right disaster, at the right time
The discussion so far has somewhat focused on meeting the challenge of getting the right health
care professional to the disaster area within an appropriate timeframe. However, the questions are
– in responding to a disaster, what do we really want in a health care professional? And how do we
I would suggest that there is a common set of skills and attributes we would want someone to have,
such as being; linguistically diverse, culturally aware, appropriately immunised, educated and trained
about disaster response and recovery, holding a current passport, possibly having previous disaster
experience, and so on.
In identifying appropriate health care professionals for disaster response, some states and territories
have a well established process. However, this process is not well grounded throughout the nation.
The example given earlier regarding nurses responding to the Sumatra-Andaman earthquake
and tsunami , highlights that the identification of appropriate clinicians was haphazard. The
approach to the Samoa tsunami  was more appropriate, with the deployment of teams from
those states that had well-established processes, and somewhat prepared Medical Assistance Teams.
However, if an earthquake and subsequent tsunami occurred in Samoa tomorrow – who would be
sent? I would argue that we should send those people who responded to the 2009 event, as they
have disaster response and recovery experience, and now an understanding of what it is like to work
in that environment and work within that culture. However, I would suggest that this is unlikely
to occur. What about those states and territories where a well established process does not exist?
What if, in these states or territories the most appropriate clinicians existed, they were just currently
unidentifiable? My solution is to have a national, rather than state based disaster health care database
or registry. Or as a minimum a national disaster nursing database or registry. This is not a new idea;
it was outlined many years ago within a forum held by the Australian Health Protection Committee.
However, this idea has not been progressed.
I believe it is timely with the introduction of national registration to have an additional or adjunct
database that could be used to identify the most appropriate nurse for disaster response. My vision
would be that this database complements the Nursing and Midwifery Board of Australia’s database,
is electronic, online and self administered by nurses who subscribe to it. Automatic reminders could
be sent to the subscribers when key dates are approaching, such as an expiring passport or out-of-
date immunisations. Additionally, users could be made aware of what level of education or training,
and other elements of preparedness are required to be a considered candidate for disaster response.
Perhaps this is an initiative that the Royal College of Nursing, Australia could lead to promote nurses
as the leading health care professionals in the disaster environment.
I hope that this oration has provided some insight into the roles and challenges of disaster nursing.
I want to reiterate that some suggest Australia will see a health care disaster in the future, larger than
what we have previously experienced. Whilst I have outlined the role of nurses in disasters, such as:
welfare, clinical, administration, commander and liaison, we need to have a better understanding
of disaster nursing competencies for the Australian context, complemented with an entrenched
national disaster education and training framework for health care professionals. We need a well
recognised structure and arrangement for supplementing an overwhelmed nursing workforce,
such as the use of undergraduate nursing students, together with disaster awareness education
in undergraduate programs. Whilst I highlighted that national nursing registration was overdue
from a disaster response perspective, I want to emphasise the need for a structured approach to
identifying appropriate clinicians to deploy to disasters, such as the implementation of a national
nursing disaster database.
In closing, I want to thank you for taking the time to listen to my discussion and I hope this oration
has provided ideas to inspire, progress and promote the profession of nursing in disaster health.
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Views and opinions expressed in this paper are those of the author