The role of the Nurse Practitioner and emergency Preparedness

Christine

Pfeifer, BSN, RN, OCN Margaret Marie Cox, DNP, ANP-C, RN

Extreme events such as pandemics, natural disasters, and mass violence have put the health of communities at risk. Nurse practitioners (NPs) are critical to response and recovery efforts. Providing evidence-based emergency preparedness education in NP curriculum, having onsite simulations, and offering adaptive management skills training will give NPs the foundation to lead during a crisis. In addition, removing barriers to allow NPs full practice authority in all 50 states would accelerate response and enhance decision-making. NPs are leaders shaping the future of our healthcare system and are paramount during times of uncertainty. This paper is a position statement on the need to implement NP emergency preparedness in graduate education through the lens of Florence Nightingale’s Environmental Theory.

Keywords: nurse practitioner role, emergency preparedness, emergency response, disaster preparedness, disaster competencies, crisis communication, crisis leadership, environmental theory

The nurse practitioner (NP) role is essential to emergency preparedness. Extreme events such as pandemics, natural disasters, and mass violence have put the health of communities at risk. NPs are on the front lines providing emergent illness treatment and playing a vital role in injury mitigation, response, and recovery. They blend their expertise in diagnosing and treating health conditions to bring a comprehensive perspective and personal touch to health care (Zak et al., 2020). NPs’ contributions to disaster efforts are critical to patient survival. Educators can utilize several educational strategies to incorporate emergency preparedness into NP graduate curriculum. For practicing NPs, having onsite simulation scenario training and adaptive management skills instruction can help prepare them to lead in a crisis.

During the surge of the COVID-19 pandemic, the Coronavirus Aid, Relief, and Economic Security (CARES) Act of 2020 temporarily lifted state restrictions, waiving physician supervision and allowing NPs full practice authority (FPA) (O’Reilly-Jacob et al., 2022). Removing barriers and allowing NPs to practice independently would accelerate response and enhance

Christine Pfeifer, BSN, RN, OCN Memorial Sloan Kettering Cancer Center, New York, New York, & Adelphi University, Garden City, New York

Margaret Marie Cox, DNP, ANP-C, RN Adelphi University, Garden City, New York

decision-making in major emergencies with disaster training. Being at the forefront of patient care, NPs should incorporate crisis communication to disseminate data and situational awareness to hospital staff and the community. NPs are crucial in providing efficient patient care, especially during times of uncertainty. This paper discusses the importance of emergency preparedness education in the NP curriculum and other factors that affect NPs practicing in the clinical setting.

environmental Theory

In 1859, Florence Nightingale developed the Environmental Theory after the Crimean War. This theory defines the environment as the center of influence on human organisms and development, which favors or disfavors the progress of disease (Breigeiron et al., 2021). The Environmental Theory influences nursing to not spread diseases by organizing work through management protocols, incorporating scientific-based evidence, promoting quality education and training, stressing the importance of patient safety, and advocating for patient-centered care (Breigeiron et al., 2021). Florence Nightingale championed the significance of well-trained nursing through quality education and professional training. This theory therefore relates to the concepts of education, practice, and emergency preparedness of NPs. By providing emergency preparedness education in the graduate curriculum and

Figure 1

onsite training, professionals can be highly qualified to act in an emergency. It is a priority to invest in the curriculum so NPs can have a skilled and solid foundation to lead in public health, primary care settings, and within the community when a catastrophe emerges.

emergency Preparedness education education in NP Curriculum

Disaster education and response measures designed for NPs have increased since the COVID-19 pandemic. Most states require annual comprehensive disaster training. A sense of competency and confidence in disaster management can be linked to response efficacy (Charney et al., 2019). In NP education, incorporating crisis competencies into the curriculum provides students with improved psychological preparedness and knowledge when responding to emergencies (The International Council of Nurses [ICN], 2019). As shown in Figure 1, the The International Council of Nurses (ICN) identifies four areas and ten domains for core nursing competencies in disaster preparedness.

Curricula should also include making a hazard risk assessment, identifying phases of disaster management and incident management roles, ensuring multiagency emergency response communication, legal and regulatory requirements, collecting and reporting data, understanding

Care Nursing Competencies in Disaster Preparedness

 Policy development and planning for risk reduction

 Disease prevention and health promotion Mitigation/Prevention

 Education and simulations

 Communication and information sharing

 Accountability Preparedness

 Ethical and legal practice

 Psychological care of the individuals, families, vulnerable populations, and communities Response

 Short and long-term recovery of individuals, families, and communities Recovery/Rehabilitation the location of shelters, connecting survivors to available resources, and implications of the loss of community resources (Chegini et al., 2022). As NPs, becoming familiar with various emergency preparedness resources is integral to health care. The Centers for Disease Control and Prevention (CDC) offers clinicians training opportunities on how to prepare for and respond to public health threats and emergencies (Centers for Disease Control and Prevention [CDC], 2022). This can be achieved by communicating relevant information about disease outbreaks, disasters, and terrorism to the community. The Federal Emergency Management Agency (FEMA) also provides education and exercises for first responders, offering courses from the Center for Domestic Preparedness (CDP), the Emergency Management Institute (EMI), and the National Training and Education Division (NTED) in national preparedness to meet the needs at the federal, state, and local levels (Federal Emergency Management Agency [FEMA], 2022). These numerous training resources can be utilized in the NP curriculum to instill confidence in the NP to react calmly and contribute to disaster efforts.

Note: Adapted from Core Competencies of Disaster Nursing version 2.0, by the International Council of Nurses, 2019 (https://www.icn.ch/sites/default/files/inline-files/ICN_Disaster-Comp-Report_WEB.pdf).

education for Practicing Nurse Practitioners Onsite Simulation

Several educational strategies can be utilized to educate practicing NPs in emergency preparedness, such as onsite simulation and adaptive management skills. Onsite simulation prepares NPs in the clinical practice setting to be emergency ready. Evidence suggests that training for large-scale events can improve mental preparedness during disasters (Chegini et al., 2022). Crisis scenarios envision what could happen in a catastrophe and help to understand what is at stake through didactics and mock drills. This enhances response and demonstrates how to mitigate unpredictable circumstances.

For instance, in the case of an active shooter, hands-on training can be done in a healthcare environment to allow staff to practice how to spring into action in a dangerous situation. First responders are the most important players, controlling the scene and minimizing potential threats (Jannussis et al., 2021). Clear communication and having situational awareness will aid the NP in comprehending the incident, hazards, risks, and operational activities (National Fire Chiefs Council, 2022). Effective situational awareness is fundamental to the ability to make sound decisions. The three components of situational awareness are:

1. Information gathering: acquiring voice, video, and data about the events

2. Understanding information: interpreting and making sense of the information gathered

3. Anticipation: projecting how the incident might develop, and the impact of actions taken (National Fire Chiefs Council, 2022)

Furthermore, health professionals can incorporate an evidence-based framework, such as the National Response Framework, developed by FEMA to reduce risk and improve responses (Wood et al., 2020). NPs interested in enhancing their knowledge in public health response can also volunteer with the Disaster Medical Assistance Teams (DMATs). These regional teams are comprised of volunteers who are part of a more extensive National Disaster Medical System that integrates NPs’ levels of expertise into preparedness planning (Wood et al., 2020). Compliance exercises of new skills identify gaps and provide professionals with an opportunity to experiment before a crisis (Boin et al., 2017). Enhanced training and collaboration across enhanced training and collaboration across organizations give the nurse practitioners specialized skills, knowledge, and strategic planning tools to implement during all stages of a disaster. organizations give the NP specialized skills, knowledge, and strategic planning tools to implement during all stages of a disaster.

The principles of situational awareness learned from hands-on training will allow NPs to react quickly, identify changes, and use their diagnostic skills to triage patient care. NPs will rise to leadership roles with their education in practice, policy, planning, and preparation for an emergency.

Adaptive Management Skills

Adaptive management skills (AMS) are what the NP learns in simulation training and education competency courses, which they apply directly to their practice. Crisis communication is a form of AMS used in the clinical setting as an evidence-based tool for emergency preparedness when developing AMS. NPs and other healthcare providers expand their narrative to explain what happened, what is at stake, and what is being done to mitigate the situation. The story should be factually correct, offer actionable advice, show empathy, and instill confidence in the crisis response (Boin et al., 2017). During stressful times, the information can become convoluted. The NP focuses on remaining safe while ensuring all disaster responders are assigned to provide the fastest triage and best care possible (Wood et al., 2020).

Crisis and emergency risk communications (CERC) tactics use an evidence-based framework based on psychology and communication sciences that combines six principles: be first, be right, be credible, express empathy, promote action, and show respect (CDC, 2018). NPs are the leaders responsible for gathering information to keep the public and disaster teams informed about what is going on and provide guidance on patient care. They streamline data to meet the unique demands of disaster management. Utilizing AMS increases the NP’s knowledge and resilience to execute safety plans in extreme situations.

Full Practice Authority

Executing FPA throughout the 50 states would allow NPs to be leaders in their domain, equivalent to chiefs in fire and police departments. During a disaster, NPs can gather data and generate situational awareness reports utilizing adaptive management skills increases the nurse practitioner's knowledge and resilience to execute safety plans in extreme situations. for the healthcare system and the local community. With the COVID19 pandemic, states lifted collaborative practice agreements for physician supervision of NPs (Wood et al., 2020). State governing bodies temporarily removed NP practice barriers to increase access to health care. NPs were able to certify home healthcare services for Medicare beneficiaries and lifted telehealth restrictions, expanding the pool of telehealth providers (O’Reilly-Jacob et al., 2022).

When Hurricane Michael, a Category-5 hurricane in Florida, caused massive destruction that collapsed the health infrastructure, the need for NPs amplified to provide health care in devastated communities. Amid this intense hurricane, barriers to FPA were lifted, enabling NPs to prioritize patients and provide immediate care to patients with life-threatening chronic conditions (Wilson, 2020). This practice change gave NPs more independence to manage patient care and respond successfully to meet patient needs during a crisis. Expanding the SOP of the NP and providing disaster response training will help the NP to be prepared to serve the community.

Implications for Practice

Education in emergency preparedness in the NP graduate curriculum and NP practice, as well as FPA, will improve NP responses in disaster situations. Although FPA is discussed in this paper and its relevance to emergency preparedness for NPs, it is a topic that needs further exploration and more data to support legislation to change practice.

Emergency preparedness significantly impacts the NP’s role. As seen with the COVID-19 pandemic, establishing data collection, and utilizing a succinct structure will guide state and local authorities. The use of jurisdictional systems that automate data collection via electronic health records, bed management, or inventory systems should be encouraged. Such systems reduce the data collection burden and increase data quality (Raske, 2021). Healthcare providers, hospitals, clinics, and public health departments must submit reports on unusual patterns of illness to answer the pleas for relief of human suffering (DeNisco, 2021).

NPs who can factually state what is happening and use CERC techniques in planning and responding to emergencies will be successful. The NP will gather information, provide two-way communication with active listening to assess the situation, evaluate the risk and resources available, and then can take action (CDC, 2018).

Incorporating evidence-based disaster training into the curriculum and at-work training sessions will give NPs the foundation to lead during a crisis. NPs can now be equipped with preparedness, situational awareness, crisis communication, and incident management competencies. The combination of advanced clinical knowledge and emergency preparedness skills will lay the groundwork for NPs to play an intricate role in a disaster.

Future Preparedness

The pandemic has forced NPs and nurse leaders to become expert strategic planners. Most providers receive little training in the leadership and management skills that can be the difference between life and death for patients (Blanding, 2022). The pandemic has shown that NPs could benefit from leadership skills and disaster training. Emergency preparedness and response can include pandemic flu planning, preparedness campaigns, mass dispensing of vaccinations, shelter operations and support, first-responder rehab, and mass casualty incident response (DeNisco, 2021).

In addition, hospitals need to have enough resources for personal protective equipment, a plan for surge hospital capacity, emergency department volume and acuity, supply of blood products, and adequate safe staffing (Raske, 2021). A more informed learning process is required, upgrading crisis management performance in a more fundamental forwardlooking fashion (Boin et al., 2017). This will create stability when a disaster arises. Emergency preparedness training can empower NPs to utilize the knowledge and skills they learn in graduate education and onsite clinical practice education to advance patient care.

Conclusion

Florence Nightingale’s Environmental Theory is a vital component of emergency preparedness in graduate education and onsite training. The theory emphasizes the importance of a solid foundation for a skilled workforce and its leaders. As seen during the COVID-19 pandemic, nursing teams have sought innovation in care and made crucial decisions during a rapidly changing environment. The significance of the NP’s clinical knowledge associated with their work and role as a leader has been evident (Breigeiron et al., 2021).

Disaster education can catapult providers from chaos to confident crisis leaders. Incorporating emergency core competencies into curricula and providing onsite workplace exercises with AMS training provides NPs with skills to take charge when disaster strikes. This expertise is essential in assisting communities during and after a catastrophe. NPs can distribute data efficiently and have the resources to empower clear critical decisionmaking during an incident. Early detection means faster deployment of resources, which can save lives and accelerate patient care. NPs can now break out of reactive mode and respond more proactively to crises (Boin et al., 2017). This lays the foundation for constructing our healthcare system’s infrastructure during an emergency.

NPs can make a difference in the lives of the community by being empowered to deal with the challenges of momentous disasters. NPs have become crisis leaders of multidisciplinary teams. They are the linchpin to improving patient outcomes during extreme events.

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