Nurse Education in Practice xxx (2014) 1e8

Contents lists available at ScienceDirect

Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Preparing for disasters: education and management strategies

explored
Danita Alfred*, Jenifer Chilton, Della Connor, Belinda Deal, Rebecca Fountain,
Janice Hensarling, Linda Klotz

a r t i c l e i n f o a b s t r a c t

Article history: During the last half of the 20th century, the focus of nursing changed from home and field to high-tech
Accepted 16 August 2014 clinics and hospitals. Nursing in the absence of technology due to man-made or natural disasters almost
disappeared from the curriculum of many nursing schools. Numerous disaster events and threats in the
Keywords: early 21st century caused educators and practitioners to increase the emphasis on disaster nursing and
Disaster nursing those principles that guide the nurse's practice in response to disasters. This article chronicles tools used
Disaster simulation
by nurse educators to integrate disaster nursing into the didactic and clinical experiences of baccalau-
Nursing education
reate nursing students. We represent two nursing schools about 90 miles apart that collaborated to
provide students with practical application of disaster nursing concepts. Part 1: An educational journey
toward disaster nursing competencies: A curriculum in action provides an overview of the curricular
tools used to insure adequate coverage of disaster nursing concepts across the curriculum. Part 2:
Collaborative learning in Community Health Nursing for emergency preparedness relates the steps taken
to plan, implement, and evaluate two different collaborative disaster simulation events. In this manu-
script we have attempted transparency so that others can learn from our successes and our failures.
© 2014 Elsevier Ltd. All rights reserved.

Part I: an educational journey toward disaster nursing competencies: a

curriculum in action
Rebecca Fountain, Jenifer Chilton, Belinda Deal, Della Connor, Janice Hensarling,
Linda Klotz, Danita Alfred

Accepted 16 August 2014
Abstract
In the last decade, natural and man-made disasters around the
world have increased in both frequency and severity. Health care
providers and nurses in particular have expressed the need and
desire for a better understanding of disaster nursing concepts and
practice. Nursing schools have been challenged to lead these ef-
forts, to respond to calls for help during disasters and to prepare the
workforce of the future to effectively respond to all types of di-
sasters. In the U.S, the International Nursing Coalition for Mass
Casualty Education worked with the American Association of Col-
leges of Nursing to develop essential competencies for baccalau-
reate nurses. Subsequently, competencies were developed for
graduate advance practice nurses. The International Council of
Nurses Partnered with the World Health Organization to formalize
similar competencies appropriate for nurses to respond to disasters
across the globe. These core guidelines and other discipline specific
guidance served as the foundation for building a curriculum with a
strong emphasis on disaster nursing.

* Corresponding author. College of Nursing, The University of Texas at Tyler, 3900 University Blvd., Tyler, TX 75799, USA. Tel.: þ1 903/566 7019; fax: þ1 903 565 5533.
E-mail address: dalfred@uttyler.edu (D. Alfred).

http://dx.doi.org/10.1016/j.nepr.2014.08.001
1471-5953/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Alfred, D., et al., Preparing for disasters: education and management strategies explored, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.08.001
2 D. Alfred et al. / Nurse Education in Practice xxx (2014) 1e8
Keywords: Disaster Nursing, Disaster Nursing Competence,
Disaster Nursing Curriculum, Shelter, Simulation.
Globally, during the last 20 years, 2.6 billion people were
affected by 85,000 natural disasters and 2 million people were
affected by technological disasters (World Health Organization,
2011). These facts have triggered a resurgence of interest in and
demand for disaster nursing education. Global events have
increased the need for a broader perspective teaching an all hazards
approach in nursing education. The major categories of disasters
include natural (earthquake landslides, tsunami), biological
(epidemic disease, infestations of pests), technological (chemical
substance, radiological agents, transport crashes) and societal
(conflict, stampedes, acts of terrorism).
There is not one definition of disaster agreed-upon in the liter-
ature. For the purposes of this paper the definition of disaster given
by the World Health Organization and the International Council of
Nurses will be used. Disaster refers to “widespread destruction of
the environment, the economic, social and health care infrastruc-
ture, as well as loss of life, overwhelming the ability of individuals
and the community to respond using their own resources” (ICN,
WHO, 2009, p. 3). The definition of disaster nursing in this paper is,
“the systematic and flexible utilization of knowledge and skills
specific to disaster related nursing, and the promotion of a wide
range of activities to minimize the health hazards and life threat-
ening damage caused by disasters in collaboration with other
specialized fields” (Jennings-Sanders et al., 2005, p. 80).
Curriculum development
The increased emphasis on disaster nursing education has
spurred the development of both educational and practice guid-
ance related to disaster nursing. As with other skills, application of
essential elements of disaster preparedness education should be
practiced in a real or simulated situation (Kuntz et al., 2008).
Simulation techniques allow student experiences “that would be
difficult to replicate in the classroom or in a clinical setting (Carter
and Gaskins, 2010, p. 406)”. Disaster simulations require students
to quickly think on their feet and transfer acquired skills (Mills
et al., 2014). Debriefings following the exercise also allows stu-
dents to analyze the experience. This paper demonstrates how in-
ternational disaster guidelines were integrated into disaster
nursing curriculum through creative activities.
Educational competencies for registered nurses responding to
mass casualty
In August 2003, the International Nursing Coalition for Mass
Casualty Education later known as the Nursing Emergency Pre-
paredness Education Coalition, worked with the American Associ-
ation of Colleges of Nursing (AACN) to produce a report titled
“Educational Competencies for Registered Nurses Responding to
Mass Casualty Incidents (MCI)” (Task Force of the International
Nursing Coalition for Mass Casualty Education, August, 2003). The
Task Force consisted of representatives from graduate and under-
graduate nursing education, professional nursing organizations,
and practicing nurses. The work of the coalition has been
completed and the competencies and learning modules remain
available on the Vanderbilt University School of Nursing website.
http://www.nursing.vanderbilt.edu/incmce/overview.html.
AACN essentials of baccalaureate and master's education
In the United States, the AACN was in the process of revising the
essentials of baccalaureate education for professional nursing
practice and master's education to establish congruence with the
Please cite this article in press as: Alfred, D., et al., Preparing for disasters: education and management strategies explored, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.08.001
Institute of Medicine's (IOM) reports on the future of the public's
health and health professions education (IOM, 2003a, b). A number
of the revised essentials relate to the nurse's preparedness to
participate in disasters response and recovery efforts. For example,
consider the Baccalaureate Essentials VII. Clinical Prevention and
Population Health (AACN, 2008) suggests sample content in the
areas of emergency preparedness and disaster response including
self-protection for baccalaureate courses. Likewise, the Master's
Essential VIII. Clinical Prevention and Population Health for
Improving Health (AACN, 2011) suggests sample content in disaster
preparedness and management for master's courses. http://www.
aacn.nche.edu/education-resources/essential-series.
American Red Cross disaster health and sheltering
Starting in 2012, nursing programs across the U.S. could access a
blended learning course, American Red Cross Disaster Health and
Sheltering, which explores ways that nursing students can help in a
disaster response. The course helps students to become aware of
their role in disaster response efforts and provides resources and
facilitators for classroom activities including tabletop exercises
(American Red Cross, 2012). http://www.redcross.org/support/
volunteer/nurses/students.
Essential undergraduate curricular elements for disaster
preparedness
Definitive guidance for community/public health nursing
(CPHN) education is provided by the Association of Community
Health Nurse Educators (ACHNE). The ACHNE Disaster Prepared-
ness Task Force, appointed in 2007, published a white paper out-
lining critical attributes of CPHN faculty and students for disaster
preparedness (Kuntz et al., 2008). Teaching disaster nursing con-
tent is most often the responsibility of the community/public
health faculty. Due to the multi-disciplinary nature of disaster
response and the history of public health nursing response to di-
sasters, the community/public health nursing course is a logical
place for much of the basic disaster nursing content. However, no
nursing specialty area is without need for disaster nursing skills
and the competencies included in the white paper can be adapted
for use in any nursing specialty course. This framework has been
used to evaluate the effectiveness of community health course di-
dactic and clinical activities related to disaster preparedness and
response.
ICN framework for disaster nursing competencies
Perhaps the most comprehensive single document related to
disaster nursing competence is the International Council of Nurses
(ICN) framework (2009). The ICN framework is built on the
premise that nursing is the largest group of health care providers
and thus all nurses must show competence in a set of basic
disaster nursing skills. Furthermore, many of the nursing skills
needed in the provision of disaster nursing care are basic to all
nurses; however, the nurse is required to use those skills in a
chaotic environment that may have minimal resources and large
numbers of patients requiring care http://www.icn.ch/
publications/free-publications/.
The ICN used the well-known disaster management continuum
(Prevention/Mitigation, Preparedness, Response, Recovery/Reha-
bilitation) as the organizing framework for developing nursing
competencies. Guided by the four key points on the continuum, 10
competencies were developed (WHO, 2009, p. 49). These compe-
tencies acted as a framework to organize disaster education for a
University offering a baccalaureate nursing program. Creative
 D. Alfred et al. / Nurse Education in Practice xxx (2014) 1e8
activities, including a collaborative simulated medical needs shelter
between two different baccalaureate nursing programs, involved
multiple local and state agencies. The creative activities promoted
student's learning of the ten competencies, provided an opportu-
nity for agencies to meet required state expectations, and allowed
for collaborative practices between agencies. Examples reflecting
the student activities and outcomes follow the discussion of the
disaster management competencies.
Prevention/mitigation competencies
 Risk reduction, disease prevention and health promotion:
Students and faculty collaborated with other health care
professionals, community organizations, government, and
community leaders to prepare for a large scale disaster
simulation. Competencies required for disaster nursing
education include the need to “practice collaboratively
with other health care team members while providing
holistic care to clients from diverse cultural backgrounds
… .while shifting their focus from individual care to caring
for communities and at risk populations” (Kaplan et al.,
2009, p. 44). Students learned the principles and process
of isolation, quarantine, containment and decontamina-
tion through simulation modules.
 Policy development and planning:
Based on an actual previous sheltering experience, the
need for regional disaster policy was identified. Local,
regional, and state government representatives collabo-
rated with University administration and faculty to plan
the local/regional response to disasters. One identified
outcome included designating the University as an official
medical needs shelter for potential evacuees. To support
this endeavor, faculty developed “Just in Time” Training
modules. This online training program provides education
for students, healthcare providers, and volunteers inter-
ested in volunteering at a medical needs shelter (The
University of Texas at Tyler, 2010). http://www.uttyler.
edu/nursing/msns/index.php. Students completed the
“Just in Time” training modules prior to engaging in the
medical shelter simulation.
Preparedness competencies
 Ethical practice, legal practice and accountability:
Ethical challenges of disaster education are addressed
during didactic and clinical education. Many student
nurses fail to recognize the professional duty to respond
during times of disaster as well as the risk to self and
family. To support this competency, students created their
own personal emergency response plan and participated
in the disaster simulation.
 Communication and information sharing:
To address chain of command and the role of nurses, the
incident commander from the region demonstrated the
communication process during lecture. Students partici-
pated through role-playing. This was an effective strategy
because students gained an appreciation for the difficulty
and importance of communication. One student reflection
following the simulation recognized the importance of
listening and said, “…even in the chaos, listen to your
patients”
 Education and preparedness:
Students prepared a disaster plan for an assigned case
scenario in the first session. Patients within the scenario
represent a vulnerable population with multiple medical
needs. Students worked in groups to create a disaster plan
based on state and national personal preparedness rec-
ommendations (Federal Emergency Management Agency,
Please cite this article in press as: Alfred, D., et al., Preparing for disasters: education and management strategies explored, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.08.001
3
2013; Texas Department of State Health Services, 2007).
(www.texasprepares.org and http://www.ready.gov/are-
you-ready-guide) Afterwards, students expressed a
greater understanding of the need for disaster preparations
and the special medical needs of vulnerable populations.
Several participants said “awareness” was the most useful
aspect of participation in their simulated disaster plan. The
students felt more prepared and encouraged to volunteer
during a future disaster. One student shared, “Overall, the
experience was helpful. I feel like I know what my role would
be as the nurse. I am glad that I was able to participate.”
Response competencies
 Care of the community:
Students participated in multiple health fairs at the uni-
versity and in the community and distributed disaster
preparedness information. Students passed out items pro-
vided by the public health department to help attendees
become personally prepared for emergencies and disasters.
 Care of individuals and families:
Nursing faculty prepared scenarios from de-identified
vulnerable medical patient data representing commonly
seen evacuee health issues for student use during a
disaster simulation. Shelter activation procedures and
triage assessment strategies for evacuee arrival were
taught during lecture and implemented during the simu-
lation. During the simulation debriefing, students
expressed some of the same concerns and frustrations
experienced by faculty after working in a real disaster
shelter (Deal et al., 2006). Students immediately recog-
nized how chaos can occur even with meticulous planning.
One student remarked, “I was surprised by how chaotic
things can become in a very short period of time.” In the
midst of the chaos, students struggled with identification
of critical changes in evacuee health conditions and in-
terventions were not pursued in a timely manner. Faculty
allowed these oversights to progress to the point that
students could see the implications of their failures to
respond and how this impacts evacuee and shelter safety.
 Psychological care:
Shelter simulations included evacuees with mental health
issues that students needed to identify and manage during
triage. In one case scenario, an evacuee with Alzheimer's was
not monitored and left the building unobserved. Later, she
was discovered exchanging identification bracelets with
another evacuee. A different case scenario portrayed an
evacuee diagnosed with paranoid schizophrenia. During the
simulation, he was constantly disrupting the care of other
evacuees and was threatening the student providers. The
students were prepared to meet physical needs but were
overwhelmed by their inability to meet the demands of caring
for evacuees with mental health issues. They quickly realized
the need for mental health support during stressful events.
 Care of vulnerable populations:
Students' limited experience with vulnerable populations
found it shocking that many individuals live with significant
health issues. Example scenarios included evacuees with
chronic, complicated comorbidities; such as an evacuee
with an open extremity wound secondary to diabetes. This
experience increased empathy for vulnerable populations.
Recovery/rehabilitation competencies
 Long-term individual, family and community recovery:
In addition, nursing students conducted inventories of the
shelter supplies and the community emergency stock-pile
for the regional public health department. These efforts
contributed to long-term readiness and recovery efforts in
4 R. Fountain et al. / Nurse Education in Practice xxx (2014) 1e8
the community and helped students to understand all of
the planning and practice that is required for effective
response and recovery efforts.
Nurses across specialties have increased their level of pre-
paredness for disaster response. Guidelines, frameworks, research,
and tools to measure proficiency are more readily available to the
nurse today than they were only one decade ago. The nurse
Part II: collaborative learning in community health nursing for emergency
preparedness
Janice Hensarling, Della Connor, Jenifer Chilton, Rebecca Fountain, Belinda Deal,
Linda Klotz, Danita Alfred
College of Nursing, The University of Texas at Tyler, 3900 University Blvd., Tyler, TX 75799, USA
Accepted 16 August 2014
Abstract
This article presents a collaborative disaster simulation in
multiple communities that served as a clinical experience for
nursing students from two universities in Southern Texas. With the
history of occurrences of life altering disasters members of all
communities have become familiar with the devastation that can
occur. It seems that everyone wants to know what they can do, how
they can prepare, and how they can help others in a disaster situ-
ation. Nurses should be front-runners in developing plans for
preparation before disasters occur. Nursing students should be
given the opportunity to gain first-hand experience navigating
through a disaster simulation as part of their nursing education
clinical experiences. A collaborative disaster simulation, based on
the International Council of Nurses (ICN) framework as a clinical
experience, should assist nursing students to build confidence in
their knowledge level, develop critical thinking skills, apply prin-
ciples of evidence based practice, and prepare them to be a part of a
community disaster relief team. They should also learn to prioritize
their care to patients in a disaster situation to do what is most
appropriate for the patient and the community.
Keywords: Disaster, Simulation, Collaboration, Nursing Educa-
tion, Emergency preparedness
We as a world, nation or community cannot neglect the need for
disaster preparedness. Disasters are common and will continue to
occur. To meet the global need for effective disaster response, first
responders must be educated (Kuntz et al., 2008) and feel a certain
ethical responsibility to assist. Nurses are consistently described as
reliable responders due to their education and caring characteris-
tics (ANA, 2010).
Responding to disasters and assisting communities in recovery
from a disaster is a core function of public and community health.
Community health courses in nursing school curriculums tradi-
tionally provide disaster instruction. This first time exposure to
disaster training may make the difference of whether a student will
or will not respond to future disaster needs of a community when
the student becomes a nurse.
Traditional didactic education does not always provide the role
playing that simulations can offer. In a study by Bartley et al. (2006)
a combination of disaster exercise and educational process were
Please cite this article in press as: Alfred, D., et al., Preparing for disasters: education and management strategies explored, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.08.001
educator has both the privilege and responsibility to implement
creative strategies for insuring that future nurses are well grounded
in disaster nursing. These guidelines have formed the background
foundation for students' education and for our collective profes-
sional ability to respond to disasters in our communities and
beyond.
the most beneficial for individuals and departments involved in the
disaster exercises. Instructors need creative strategies that include
simulation to facilitate competency development in this important
area. With these thoughts in mind, two nursing schools in Texas
formed a partnership to instruct Community Nursing students on
ways to assist communities in disaster preparedness through a
complex disaster simulation.
Literature review
Nursing students' role in and understanding of emergency
preparedness has not been well defined. Schmidt et al. (2011) found
that nursing students across the United States were lacking in
knowledge concerning preparedness for disasters, impact of di-
sasters on student nurses, and strategies to assist student nurses.
The authors recommend that nurse educators develop emergency
management strategies to prepare nursing students for their role in
emergencies and suggest the use of the American Red Cross sup-
plied templates as a guide (Schmidt et al., 2011).
Nursing schools have developed innovative ways to prepare
undergraduate nursing students for the emergency disaster role.
Atack et al. (2009) developed an eight-week online, interactive,
interprofessional course in disaster management that included
participation with professional staff in a disaster simulation. Stu-
dents who completed this course indicated that they had
increased awareness of the different roles in a multi-disciplinary
team and an increased understanding of disaster management
content (Atack et al., 2009). Kaplan et al. (2012) developed a
simulation utilizing patient simulators, task trainer mannequins,
and live actors to simulate an assisted-living facility that had been
destroyed by a tornado. The baccalaureate students who partici-
pated in the simulation gave positive survey responses for
increased understanding of disaster preparedness, working in
teams, their ability to handle disaster situations and working more
effectively in their future place of employment (Kaplan et al.,
2012).
These recent innovations in student emergency preparedness
showcase the benefit of including emergency preparedness in
health care curriculum. The simulation described in this article is
yet another facet of collaborative emergency preparedness that can
be utilized in preparing student nurses for their role in
emergencies.
 R. Fountain et al. / Nurse Education in Practice xxx (2014) 1e8
Developing a collaborative disaster simulation
Students learn about taking care of patients through didactic
course work, skills practice sessions, simulation labs, feedback from
instructors and other students, and post conferences to discuss,
“what went right and what went wrong”. Two schools of nursing in
the Southern region of the U. S. collaborated on a disaster simula-
tion event to role model collaboration and to provide a unique
experience in disaster education.
Several educational and practice guidelines were reviewed to
determine the guideline and framework for the disaster simulation.
The Essentials of Baccalaureate Nursing Education for Entry Level
Community/Public Health Nursing developed by the Association of
Community Health Nursing Educators (ACHNE) (2009) was utilized
as a guideline. The 10 competencies of the disaster management
continuum (Prevention/Mitigation, Preparedness, Response, Re-
covery/Rehabilitation) developed by the International Council of
Nurses acted as a framework (WHO, 2009). The ICN 2009, 10
competencies for this disaster simulation are discussed in more
detail in (Fountain et al., 2014).
Collaboration between universities
Two professors from different universities discussed the chal-
lenges of keeping community nursing courses relevant to students.
This simple conversation blossomed into an elaborate disaster
simulation event between universities and communities. Each
professor offered different skill sets. One had experience creating
patient scenarios and moulaging. Moulage is the application of
various makeup techniques to create the appearance of age varia-
tions, injuries, and wounds or “victims” who participate in life-like
practice scenarios used to train responders. The other instructor
had skills in medical needs sheltering. The professors agreed to the
following: 1) design a collaborative disaster simulation to occur in
the fall and spring; 2) play reciprocal roles 3) accept responsibility
for funding as the host university. The plan was that in the fall
semester one university would host a disaster simulation (Fall
Simulation) and then reciprocate roles for the spring semester
(Spring Simulation).
The initial disaster scenario (Fall Simulation) involved an evac-
uation of medical needs patients from the region due to massive
out of control wild fires. The role of evacuees was depicted by
nursing students from the visiting school. The ‘evacuees’ met at
their college to be moulaged and to load buses. Departure was at
9:00 AM for a scheduled arrival at approximately 11:00 AM. As this
was occurring, the nursing students from the host school received
this message, “The medical needs shelter is being initiated e report
to the Auxiliary Gym at 09:00 AM sharp”. All senior level com-
munity nursing students and nurse practitioner students arrived on
site. The goals were to set-up and prepare the medical needs shelter
before the evacuees arrived.
Host students received prior training by viewing “Just in Time
Training Modules”. Two students were previously elected as inci-
dent commanders (IC) and were given additional guidance by an
expert faculty member. The tasks for the ICs were to mobilize the
medical needs shelter efficiently. Once the ‘evacuees’ arrived the
goal was to admit, assess, and provide care based on specific
medical needs training protocol and the medical needs of each
victim.
The Spring Simulation between the universities took place in
the spring of 2013. This disaster simulation involved several com-
munities and community partners using multiple sites to evaluate
their own community disaster preparedness. The scenario involved
a multi-vehicle accident on a prominent freeway due to fog. Due to
the high number of victims, patients were diverted to regional
Please cite this article in press as: Alfred, D., et al., Preparing for disasters: education and management strategies explored, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.08.001
5
hospitals. Vehicles involved in the accident included an 18-wheeler
carrying toxic chemicals, a bus full of junior high students, and
random persons in single cars. Community nursing students from
both universities enacted the victim and nurse roles.
Collectively, 130 Community Health nursing students from both
universities participated in the Spring Simulation. The simulation
included seven different health care facilities. Student preparation
included assigning roles and preparing students to work within a
particular agency. The host students received their role through
random selection. The students were expected to carry out their
role as realistically as possible. Students were divided into six
groups and assigned to one of the seven designated health care
facilities. Each of the groups elected a student as the nurse coor-
dinator. These nurse coordinators attended the regional planning
meetings and disseminated the information to their group mem-
bers. The groups were expected to function effectively in the
assigned hospital as a member of the team. They were to receive
and triage the ‘victims’. This was particularly difficult because the
student nurses were not informed of the type of injuries or
numbers of victims to expect. The students had to apply their
nursing knowledge in a controlled but chaotic situation. This is not
unlike a real disaster. Student nurses, in the role of a nurse, reported
to the health care facilities the morning of the event and waited for
victims to arrive.
The preparations from the visiting university were not as
extensive, but did require planning for an intense experience. Pa-
tient scenarios were created by the host school. Visiting students
were assigned a patient role based on these scenarios. Scenarios
were divided equally so comparisons between victim experiences
were possible. Injuries for the Spring Simulation included chemical
burns, broken bones, impaled objects, lacerations, and amputa-
tions. The students in the Fall Simulation simulated patients with
chronic diseases and who were on multiple medications. This
required the student victims to study the chronic disease symp-
toms, understand medication side effects, and act appropriately for
the type of injury and comorbidity. Student victims had to syn-
thesize a tremendous amount of knowledge to accurately portray
the victim, and they received clinical credit for their preparation
time and for the actual event.
Faculty members of the visiting university for both simulations
required students to report to the skills labs 1.5 h prior to departure
for final preparation. Moulage is a skill and none of the visiting
school faculty had experience with these techniques. Training and
supplies are expensive and due to time constraints could not be
obtained. However, due to the internet, several helpful sources
were discovered. A moulage cookbook and several you tube videos
enabled faculty to provide needed supplies and techniques inex-
pensively. Student victims came to their university dressed in
character, checked in for administrative details, and were assigned
a lab room for specific injuries. Faculty members were assigned
‘victims’ with certain injuries and became the moulage ‘expert’ for
that injury. As students arrived, they helped each other moulage
with faculty guidance. These activities had to be completed before
the bus departed. The bus driver was warned about the appearance
of his passengers, but was still shocked when he met them. As this
was occurring, one faculty member handled the paperwork
required by both universities. Student victims were ready and
departed as planned. Students were on the bus for a time period of
1.5e2.5 h depending on the location of their assigned hospital or
area.
Collaboration with community agencies
Planning this event was complex and required the competencies
of care of the community, individuals and families, psychological
6 R. Fountain et al. / Nurse Education in Practice xxx (2014) 1e8
care, and care of vulnerable populations (WHO, 2009) in the
community and population planning (Callen et al., 2009). An
assumption regarding the leadership role of community educators
in disaster preparedness is that disaster preparedness requires an
organized, multi-sector approach (Kuntz et al., 2008). Organizing
this event exemplified this assumption. This collaboration was also
an example of (WHO, 2009) competencies of risk reduction, disease
prevention, and health promotion.
All communities in the region have had episodes when their
resources were taxed by major disasters such as hurricanes, tor-
nadoes, fires, flooding, train wrecks, major chemical spills etc.
Various community members were requested to participate in the
disaster simulation. Communities, schools, hospitals etc. are
required to have periodic disaster drills. Regional Area Councils
(RACs) are required by the state of Texas to plan disaster drills at the
community wide level. Southern Texas is made up of many small to
medium sized communities with the role of disaster preparedness
focused within the local county hospital district. The members of
the RAC were contacted to determine the level of collaboration
needed. Multiple meetings were attended to discuss and plan the
community wide disaster simulations.
In the Spring Simulation, there were 6 hospitals and one surgery
center participating as local disaster planning partners in 4
different cities. The Reserve Officers' Training Corps (ROTC) from
the host university participated in roles of security and crowd
control in the rural communities. Each community developed their
own disaster scenario to meet the needs of disaster training in their
community but all scenarios were similar and ‘victims’ were
treated at the local health care facilities. Victims included those
with chemical burns that had to be decontaminated (some in
shower tents outside the ER doors), amputations, pregnant woman
in labor, mentally unstable conditions, impaled wounds, burns,
“road rash”, respiratory and circulatory shock and even a deceased
victim. Student victims were delivered either via bus or by ambu-
lances with local EMS treating them as they would normally treat
and transport victims. The disaster simulation taxed the disaster
preparedness and resources of local health care facilities, emer-
gency medical systems, fire departments, security teams, media,
and disaster preparedness teams.
When working with community agencies, funding was an issue
with both simulations. Both schools worked together on a wish list
of needs for the first event. A key faculty member structured the
funding request specifically for funds from the regional agency
responsible for distribution of disaster preparedness funding. In the
Fall Simulation, the agency agreed to pay for the transportation and
a lunch after the event. This cost was approximately $3000. The
local health department donated meal replacements, MREs (Meals
Ready to Eat) for evacuees and provided an ambulance bus to
transport 20 of the evacuees. An external evaluator from the state
was provided from the local health department to evaluate the
event. Funding for the Spring Simulation involved the trans-
portation of students as well as the post conference meal for over
200 people. This was provided by local host organizations. The
media was contacted by both schools and a collaborative story was
broadcast in both regions.
Collaboration within the university
This activity was unusual because of the collaboration that
occurred within the College of Nursing (CON) between senior level
nursing faculty, graduate level faculty, senior level nursing stu-
dents, and graduate level nurse practitioner (NP) students. The
WHO (2009) competencies of education and preparedness were
integrated for both courses which contributed to new connections
in learning. Community nursing faculty asked Leadership Nursing
Please cite this article in press as: Alfred, D., et al., Preparing for disasters: education and management strategies explored, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.08.001
faculty to allow clinical hours for participation in the community
event. Leadership faculty was willing to do this because the simu-
lation provided a unique opportunity to expand leadership skills
beyond the acute care setting. The Leadership students assumed
leadership responsibilities and made work assignments for
everyone. The students were required by the circumstances to
collaborate with each other. Faculty supported students throughout
the process, but did not make operational decisions at the event.
Another unique aspect involved the addition of nurse practi-
tioner students. The NP faculty also gave NP students clinical hours
for participating. NP students operated a medical clinic onsite with
the assistance of undergraduate students. It was a beneficial
experience for undergraduates to see an expanded role of nursing.
NP's reported the disaster simulation as a valuable learning tool and
requested inclusion in other events. The NPs involvement made the
experience richer for all.
Collaboration occurred between the College of Nursing (CON)
and the university. In the Fall Simulation, the university required
specific actions to reserve the identified location. Room reservation
initially had to be negotiated between the facilities director,
basketball coaches, and the nursing faculty. Finding a place to host
the event was challenging. Contacts were made in person rather
than through email. This direct approach put a face to the request
and helped facilitate the process.
Security and police force were included in the planning
stages. Police determined where supplies for the shelter could be
left on campus the night before as well as where the large ve-
hicles could stop and unload ‘evacuees’. Parking was an issue
and without their help unloading buses could have been very
complicated. Security unlocked the building and helped manage
basic concerns. They were also present in case something un-
usual occurred. For example, the patient scenarios included pa-
tients with mental health issues. The students playing these
roles actually “escaped” on campus. This could have caused a
security concern based on the way the evacuees were fulfilling
their roles. The actual students from the university who were
unaware of the disaster simulation scenarios could have
mistakenly thought some of the situations were really occurring.
In the second scenario the ROTC which is a part of the host
university were eager to participate in this interdisciplinary
disaster simulation project and agreed to be a participant in
future project plans.
The multimedia program at the host university in the Spring
Simulation also became involved as their students posed as ‘re-
porters’ who were attempting to “get information” and pictures of
the disaster simulation. This was with the approval of one of the
local hospitals with clear HIPPA guidelines followed. This added a
new component to make the disaster simulation even more “life-
like”.
Discussion
All participants at both scenarios were invited to come to the
de-briefing (After Action Plan) in the host community. This de-
briefing met the competency guidelines for communication and
information sharing (WHO, 2009). Members of the Regional Area
Council (RAC) Team including the Regional Disaster Planning
Coordinator were present at the “After Action” debriefing. Nursing
faculty attended the post conference and all nursing students who
participated as either the nurse, charge nurse or the victims
attended the post conference. Nursing students who had been
designated as “Incident Commander” at each health care facility
were asked to make summary comments on what went right and
what went wrong in each community disaster simulation. Each
health care facility was assigned a “scribe” to make notes about
 R. Fountain et al. / Nurse Education in Practice xxx (2014) 1e8
what went right and what went wrong. Community members
who had donated funds to pay for transportation, supplies and
refreshments including a meal for all participants were invited to
the post conference and “After Action Plan” meeting. The ROTC,
who participated as security and crowd control at some of the
rural hospitals, attended and were asked for their input. There was
constructive feedback that was very helpful to all the participants
of the disaster simulations and discussion of what was learned and
how productive this was for all contributors. The overall discus-
sion at the ‘After Action Plan’ post conference was very positive as
to the importance of the involvement of nursing students in
disaster preparedness planning in each community and health
care facility. This reflective activity which addresses the (WHO,
2009) competencies of long-term individual, family, and com-
munity recovery provides extensive plans for disaster prepared-
ness. There was identification of areas that went right and areas
that went wrong and what could be modified in future disaster
simulations.
Lessons learned by the host students
The host students learned many valuable lessons. The foremost
concern was the unknown and feeling out of control. They did not
know the number of patients or specific health conditions that
were in route to the shelter. They did not know if they would be
able to meet the needs of the patients, or even if and how, the
patients would act and react to them and their nursing
interventions.
The benefit of using nursing students to play the victim role is
that nursing students understand the complexity of problems and
health complications, and are able to accurately portray the con-
dition. They also understand assessment and what should be
happening. Host nursing students were forced to take action and
learned to “think like a nurse”. We hope this improved their critical
thinking skills and the characteristic of being flexible. These skills
were challenged because the students did not know each other. It
was hard for the nurses to decipher the role's being played versus
the authentic person. This ambiguity presented unexpected chal-
lenges by stretching communication skills. Communication skills,
according to Callen et al. (2009) are ‘fundamental to a public health
practice’. This opportunity supported basic communication com-
petencies proposed by Callen et al. (2009).
One lesson tied to the objectives of ethical practice, legal prac-
tice and accountability (WHO, 2009) was for nursing students to
become individually prepared for disaster. After this experience
one student said, “I finally get why I need to become personally
prepared”. The intense three-hour drill of running the shelter
demonstrated the difficulties of caring for others in chaos. The leap
to ‘what if this was real’ and ‘what would happen to my family’ hit
home.
Skills practiced by students included negotiation, conflict reso-
lution, active listening, cultural sensitivity, and utilization of
appropriate media to disseminate health information. Several stu-
dents interacted with the media and provided good health infor-
mation to the public.
Lessons learned by visiting students
The visiting students learned several valuable lessons from the
very beginning of this learning experience. During the preparation
of moluage and accompanying props to use to fulfill their roles,
students received some first-hand lessons about how it feels to be a
“patient” in a disaster simulation. They went from young energetic
college age students to their assigned roles of elderly men and
women with multiple disfiguring and disabling injuries. Some
Please cite this article in press as: Alfred, D., et al., Preparing for disasters: education and management strategies explored, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.08.001
7
portrayed younger patients with multiple health conditions
including mental health issues that exacerbated during the stress of
the disaster and subsequent evacuation. They learned how it feels
to be nauseated because they were riding in an ambulance bus
riding for more than an hour with 19 other “victims” placed in
wheel chairs, using canes, with bandaged body parts and strapped
on stretchers where they had little control of their environment or
how they were treated. They were frustrated in their role as a pa-
tient who was “admitted and tagged” by the intake personal, asked
the same questions repeatedly as they were triaged, treated and
then left on a cot in a gymnasium full of other “evacuees” on cots.
Lessons learned by nursing faculty
Some of the participating instructors have included disaster
simulations in local community clinical experiences but the
magnitude of this collaborative simulation and the logistics to bring
it all about was definitely a challenge and some valuable lessons
were learned. One identified issue was that not enough planning
had taken place for the magnitude of this event. The events were
planned in less than three months. The simulations were successful
but the stress level due to planning issues was very high. It is
suggested 12 months or more is needed to plan this type of event to
decrease anxiety on all participants. The unanticipated amount of
support, funds and coordination of the many agencies was a
dilemma at times also.
The instructors were very impressed by the “evacuee” visiting
students as well as the host “Nurse and NP” students in both events.
The debriefing, which was directed by RAC, helped instructors,
nursing students and NP students, as well as other participants,
review the day's events together.
As mentioned previously, the impetus for this collaboration
occurred through a conversation at a graduation celebration. Each
party agreed upon expectations. Assignments were delegated and
completed as assigned. Since this was a new collaborative event,
each side understood flexibility as an important characteristic for
success.
A new undertaking of this magnitude was bound to have un-
foreseen problems. Instead of reacting with frustration, both sides
were able to make accommodations graciously. Joint credit was
shared between all parties. A unique outcome of the ability to share
credit was the development of collaborative writing teams related
to this event. A list of potential articles was generated and collab-
orative teams were created with opportunities to rotate first
authorship. This signifies a winewin for everyone involved. If one
person had claimed all the credit, this opportunity would not have
occurred.
Nursing implications
Simulations are a life-like clinical situation where students can
participate and learn is a very positive atmosphere. It is an oppor-
tunity for students to identify patients in a situation where they see
first-hand how volatile the patient encounters are when they have
little or no prior information about the patient's health care prob-
lems. Nurses do not rely on what they have been told by another
nurse in report but make split minute decisions based on their
critical thinking skills, evidence based practice, their knowledge
and sometimes their “gut feeling” to do what is best for the patient
and the community. They learn to prioritize their care to patients
and in a disaster situation this can change from moment to
moment. The nurse may have stabilized the patient and moved on
to another patient only to look back at that “stabilized” patient, who
within a matter of seconds could have gone from stable to critical
because of an injury or chemical exposure. The student nurse will
8 R. Fountain et al. / Nurse Education in Practice xxx (2014) 1e8
learn how to become involved in the community realizing that the
health status of a community in a disaster situation is only as strong
as the preparedness of the community partners.
As nursing instructors we have learned the importance of
partnering with others to make for even better clinical experiences
for nursing students. The ACHNE states in another assumption for
nurse educators: “community and public health nurses serve as
role models to students and faculty through both professional and
community service activities” (Kuntz et al., 2008; p. 364). We role
modeled a macro approach to disaster preparedness education for
students, faculty, university administrators, and communities. This
event provided an example for others to follow that may help
ensure a robust disaster response and community assistance by
future nurses.
Future plans
At the debriefing session, all parties indicated that the disaster
simulation experience was valuable and should be continued. In-
structors agreed to have a reciprocal event the following semester
with the roles of victims and nurses to be reversed. All of us are
aware that our world is becoming ‘closer’ because of increased
population, information, transportation and communication. The
possibilities of more disasters occurring are not a case of “if it will
happen but rather when it will happen”. How ready will we be as
nurses to face the challenges of various disaster situations? We, as
nursing faculty, must develop innovative approaches to prepare our
students to be competent nurses in disaster situations.
Based on the positive feedback from the RAC, all stakeholders
and participants, plans are underway to continue collaborative
simulations in future semesters. Nursing students have expressed
that this was a great learning experience, it was thinking “outside
the box” in the clinical practice area, it was very challenging for
them and they enjoyed the participation with so many different
entities.
In addition, more research studies are needed to determine if
this type of simulation is effective for teaching disaster compe-
tencies for nursing students. The feedback from students is positive
so it appears to be effective; it just needs to be quantified. It is also
important to investigate individual preparedness of nurses and
nursing students. There is potential to develop multiple evidenced
based interventions based on this collaboration.
References
Association of Community Health Nursing Educators [ACHNE], 2009. Essentials of
Baccalaureate Nursing Education for Entry Level Community/Public Health
Nursing (Available from: Association of Community Health Nursing Educators,
10200 W44th Avenue, Suite 304, Wheat Ridge, CO 80033).
American Association of Colleges of Nursing, 2008. The Essentials of Baccalaureate
Nursing Education for Professional Practice. Author, Washington, D.C. http://
www.aacn.nche.edu/education-resources/essential-series.
Please cite this article in press as: Alfred, D., et al., Preparing for disasters: education and management strategies explored, Nurse Education in
Practice (2014), http://dx.doi.org/10.1016/j.nepr.2014.08.001
American Association of Colleges of Nursing, 2011. The Essentials of Master's Edu-
cation in Nursing. Author, Washington, D.C. http://www.aacn.nche.edu/
education-resources/essential-series.
American Nurses Association, 2010. Who will be there? Ethics, the law, and a
nurse's duty to repond in a disaster.
American Red Cross, 2012. Nursing Students: New Nation-wide Student Nurse Disaster
Response Course. http://www.redcross.org/support/volunteer/nurses/students.
Atack, L., Parker, K., Rocchi, M., Maher, J., Dryden, T., 2009. The impact of an online
interprofessional course in disaster management competency and attitude to-
wards interprofessional learning. J. Interprofessional Care 23 (6), 586e598.
http://dx.doi.org/10.3109/13561820902886238.
Bartley, B., Stella, J., Walsh, L., 2006. What a disaster?! Assessing utility of simulated
disaster exercise and educational process for improving hospital preparedness.
Prehospital Disaster Med. 21 (4), 249e255.
Callen, B.C., Block, D., Joynce, B., Lutz, J., Schott, N.B., Smith, C.M., 2009. Essentials of
Baccalaureate Nursing Education for Entry Level Community/public Health
Nursing. Association of Community Health Nursing.
Carter, M., Gaskins, S., 2010. Incorporating bioterrorism content in the nursing
curriculum: a creative approach. J. Nurs. Educ. 49 (7), 406e409 doi: 10:3928/
01484834-20100217-08.
Deal, B.J., Fountain, R.A., Russell-Broaddus, C.A., Stanley-Hermanns, M., 2006.
Challenges and opportunities of nursing care in special needs shelters. Disaster
Manag. Response 4 (4), 100e105.
Federal Emergency Management Agency, 2013. Are You Ready? An in-depth Guide
to Citizen Preparedness. http://www.ready.gov/are-you-ready-guide.
Fountain, R., Chilton, J., Deal, B., Connor, D., Hensarling, J., Klotz, L., Alfred, D., 2014.
Preparing for disasters: education and management strategies explored. Nurse
Educ. Pract. http://dx.doi.org/10.1016/j.nepr.2014.08.001.
Institute of Medicine, 2003a. The Future of the Public's Health in the 21st Century.
National Academies Press, Washington, D.C.
Institute of Medicine, 2003b. Health Professions Education: a Bridge to Quality.
National Academies Press, Washington, D.C.
Jennings-Sanders, A., Frisch, N., Wing, S., 2005. Nursing students' perceptions about
disaster nursing. Disaster Manag. Res. 3 (3), 80e85. http://dx.doi.org/10.1016/
j.dmr.2005.04.001.
Kaplan, B., Connor, L., Ferranti, E., Holmes, L., Spencer, L., 2009. Use of an emergency
preparedness disaster simulation with undergraduate nursing students. Public
Health Nurs. 29 (1), 44e52. http://dx.doi.org/10.1111/j.1525-1446.2011.00960.x.
Kaplan, B.G., Connor, A., Ferranti, E.P., Holmes, L., Spencer, L., 2012. Use of an
emergency preparedness disaster simulation with undergraduate nursing stu-
dents. Public Health Nurs. 29 (1), 44e51. http://dx.doi.org/10.1111/j.1525-
1446.2011.00960.x.
Kuntz, S.W., Frable, P., Qureshi, K., Strong, L.L., 2008. Association of community
health nursing educators: disaster preparedness white paper for community/
public health nursing educators. Public Health Nurs. 25 (4), 362e369. http://
dx.doi.org/10.1111/j.1525-1446.2008.00717.x.
Mills, J., West, C., Langtree, T., Usher, K., Henry, R., Chamberlain-Salaun, J.,
Mason, M., 2014. Putting it together': unfolding case studies and high fidelity
simulation in the first-year of an undergraduate nursing curriculum. Nurse
Educ. Pract. 14 (1), 12e17. http://dx.doi.org/10.1016/j.nepr.2013.06.003.
Schmidt, C.K., Davis, J.M., Sanders, J.L., Chapman, L.A., Cisco, M., Hady, A.R., 2011.
Exploring nursing students' level of preparedness for disaster Response. Nurs.
Educ. Perspect. 32 (6), 380e383.
Task Force of the International Nursing Coalition for Mass Casualty Education,
August, 2003. Final Report: Educational Competencies for Registered Nurses
Responding to Mass Casualty Incidents. http://www.nursing.vanderbilt.edu/
incmce/overview.html.
Texas Department of State Health Services, 2007. Ready or Not? Have a Plan. http://
www.texasprepares.org/.
The University of Texas at Tyler, College of Nursing, 2010. Medical Needs Shelter,
Just-in-time Online Training, p. 2012. http://www.uttyler.edu/nursing/msns/
index.php.
World Health Organization and International Council of Nurses, 2009. ICN Frame-
work of Disaster Nursing Competencies. ICN, Geneva, Switzerland. http://www.
icn.ch/publications/free-publications/.
World Health Organization, 2011. Disaster Risk Management for Health Overview
Fact Sheet. WHO Global Platform, United Kingdom. May 2011.